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diff --git a/39157-8.txt b/39157-8.txt new file mode 100644 index 0000000..fb2bb13 --- /dev/null +++ b/39157-8.txt @@ -0,0 +1,65891 @@ +The Project Gutenberg EBook of A System of Practical Medicine by American +Authors, Vol. I, by Various + +This eBook is for the use of anyone anywhere at no cost and with +almost no restrictions whatsoever. You may copy it, give it away or +re-use it under the terms of the Project Gutenberg License included +with this eBook or online at www.gutenberg.org/license + + +Title: A System of Practical Medicine by American Authors, Vol. I + Volume 1: Pathology and General Diseases + +Author: Various + +Editor: William Pepper + Louis Starr + +Release Date: March 15, 2012 [EBook #39157] + +Language: English + +Character set encoding: ISO-8859-1 + +*** START OF THIS PROJECT GUTENBERG EBOOK A SYSTEM OF PRACTICAL *** + + + + +Produced by Ron Swanson (This file was produced from images +generously made available by The Internet Archive/Canadian +Libraries) + + + + + + +A SYSTEM OF PRACTICAL MEDICINE. + +BY AMERICAN AUTHORS. + + + + +EDITED BY + +WILLIAM PEPPER, M.D., LL.D., + +PROVOST AND PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE AND OF +CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA. + + +ASSISTED BY + +LOUIS STARR, M.D., + +CLINICAL PROFESSOR OF DISEASES OF CHILDREN IN THE HOSPITAL OF THE +UNIVERSITY OF PENNSYLVANIA. + + + + +VOLUME I. PATHOLOGY AND GENERAL DISEASES. + + + + +PHILADELPHIA: + +LEA BROTHERS & CO. + +1885. + + + + +Entered according to Act of Congress, in the year 1885, by LEA +BROTHERS & CO., in the Office of the Librarian of Congress. All rights +reserved. + + + + +WESTCOTT & THOMSON, _Stereotypers and Electrotypers, Philada._ + +WILLIAM J. DORNAN, _Printer, Philada._ + + + + +PREFACE. + + +The present work has been undertaken in the belief that by obtaining +the co-operation of a considerable number of physicians of +acknowledged authority, who should treat subjects selected by +themselves, there could be secured an amount of practical information +and teaching not otherwise accessible. It was determined to restrict +the selection of authors to those of this country--including +Canada--not from any want of recognition of the importance of the +studies of certain special subjects by European investigators, but +because it was felt that the proper time had arrived for the +presentation of the whole field of medicine as it is actually taught +and practised by its best representatives in America. + +It is a matter of importance also that a comprehensive study shall be +made of the various forms of disease as occurring among our highly +composite population and under our varied and peculiar climatic +influences. Of course, in the present work comparative studies of this +kind must occupy a subordinate position; yet it cannot fail to enhance +both its interest and its value to have the various forms of disease +as they occur in this country discussed by those among us who are +confessedly the most competent and experienced. + +The force of these observations must have been felt by the +distinguished men to whom I made application, for with scarcely an +exception they joined cordially in the laborious undertaking. I take +the greatest pleasure in testifying to the courtesy which has marked +all our relations, and which has lessened materially the labor and +strain inevitable in the production of such a work. + +To ensure greater accuracy in the revision of the large amount of +proof-sheets, as well as to relieve me of some of the details +connected with the editorial work, I associated with myself Dr. THOMAS +HOLMES CATHCART, and, after sudden illness had cut short his very +promising career, I was fortunate in securing the assistance of Dr. +LOUIS STARR for the same purpose. + +In order to render the work as valuable as possible to the general +practitioner, its scope has been made as comprehensive as could be +done without exceeding the limits prescribed by the nature of the +undertaking. This will be particularly noted in the section on +Gynaecology, where is presented a series of articles by eminent +specialists upon the subjects of chief importance to the general +practitioner, written with special reference to their constitutional +relations and their bearings on associated morbid conditions, while, +among the general diseases, a full article on puerperal fever has +properly been included. Important articles will also be found on +Tracheotomy, the Diseases of the Rectum and the Anus, and those of the +Bladder and the male sexual organs. Comprehensive sections have +further been provided, from the pens of distinguished specialists, +upon medical ophthalmology, medical otology, and on skin diseases, +presenting these large and complicated subjects in a clear and +practical light and with special reference to their relations to +general medical practice. In the presentation of such subjects as +hydrophobia, glanders, and anthrax care has been taken to ensure the +full discussion of these affections, not only as occurring in man, but +also in the lower animals, since it is highly important to provide the +physician with authoritative information on at least such points of +Veterinary Science as have a direct practical bearing on morbid +processes in man. + +In view of the intimate relations of all questions of hygiene to the +causation and prevention of disease, in regard to which medical men +are constantly consulted, and are, indeed, often obliged to assume +weighty responsibilities, interesting articles on Drainage and Hygiene +have been provided. + +In order to avoid repetition and confusion, and at the same time to +secure a comprehensive presentation of the subjects of General +Pathology and of General Etiology, Symptomatology, and Diagnosis, +considerable space has been devoted to their full discussion. The +chapter on General Morbid Processes will be found to convey distinct +and conservative teaching on all points included under that +comprehensive title, and will thus supply a solid basis for the +subsequent discussions of special morbid conditions. In any work on +General Medicine at the present day frequent allusion must be made to +the relations of various low organisms to morbid processes. This +question--or rather the series of questions which arise in connection +with this subject, and which at present form the most fruitful topic +of discussion and of investigation--will be found treated by different +authors in various places and from various standpoints. No attempt has +been made to secure uniformity of views upon a matter which is still +_sub judice_, and which demands much more skilful and critical +investigation before its true scientific position has been finally +determined. It has even been felt to be desirable to allow a certain +amount of repetition, which has naturally resulted from the +introduction of this discussion, not only in the chapter on General +Etiology, but in connection with the causation of scarlatina, +diphtheria, hydrophobia, pyaemia, puerperal fever, and phthisis. + +Throughout the work the chief purpose of the editor and of his +collaborators, to furnish a concise and thoroughly practical system of +medicine, has compelled the omission of bibliographical lists, of +numerous references, and of extended discussions of theoretical views +or of controverted questions, in order that more space might be +devoted to clear descriptions of disease and to a full presentation of +the subjects of diagnosis and treatment. If it should seem, in +consequence, that inadequate recognition has been made of the labors +of others, it must be borne in mind that ample quotations and numerous +references were inadmissible in such a work as the present. + + * * * * * + +The classification and nomenclature which have been adopted are those +recommended by the Royal College of Physicians of England and by the +American Medical Association. Charts and tables have been inserted +wherever they were needed to elucidate the text, but after mature +reflection it was felt necessary to omit all illustrations that were +not imperatively required, although many original drawings and +paintings of high value were offered with the articles. + +THE EDITOR. + +OCTOBER, 1884. + + + + +CONTENTS OF VOL. I. + + + PAGE +PREFACE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 + + + GENERAL PATHOLOGY AND SANITARY SCIENCE. + +GENERAL MORBID PROCESSES. By REGINALD H. FITZ, M.D. . . . . . . . 35 + +GENERAL ETIOLOGY, MEDICAL DIAGNOSIS, AND PROGNOSIS. By HENRY + HARTSHORNE, M.D., LL.D. . . . . . . . . . . . . . . . . . . . . 125 + +HYGIENE. By JOHN S. BILLINGS, A.M., M.D., LL.D. (Edin.) . . . . . 173 + +DRAINAGE AND SEWERAGE IN THEIR HYGIENIC RELATIONS. By GEORGE E. + WARING, JR., M. Inst. C.E. . . . . . . . . . . . . . . . . . . 213 + + + GENERAL DISEASES. + +SIMPLE CONTINUED FEVER. By JAMES H. HUTCHINSON, M.D. . . . . . . 231 + +TYPHOID FEVER. By JAMES H. HUTCHINSON, M.D. . . . . . . . . . . . 237 + +TYPHUS FEVER. By JAMES H. HUTCHINSON, M.D. . . . . . . . . . . . 338 + +RELAPSING FEVER. By WILLIAM PEPPER, M.D., LL.D. . . . . . . . . . 369 + +VARIOLA. By JAMES NEVINS HYDE, M.D. . . . . . . . . . . . . . . . 434 + +VACCINIA. By FRANK P. FOSTER, M.D. . . . . . . . . . . . . . . . 455 + +VARICELLA. By JAMES NEVINS HYDE, M.D. . . . . . . . . . . . . . . 481 + +SCARLET FEVER. By J. LEWIS SMITH, M.D. . . . . . . . . . . . . . 486 + +RUBEOLA. By W. A. HARDAWAY, A.M., M.D. . . . . . . . . . . . . . 557 + +ROTHELN. By W. A. HARDAWAY, A.M., M.D. . . . . . . . . . . . . . 582 + +MALARIAL FEVERS. By SAMUEL M. BEMISS, M.D. . . . . . . . . . . . 589 + +PAROTITIS. By JOHN M. KEATING, M.D. . . . . . . . . . . . . . . . 620 + +ERYSIPELAS. By JAMES NEVINS HYDE, M.D. . . . . . . . . . . . . . 629 + +YELLOW FEVER. By SAMUEL M. BEMISS, M.D. . . . . . . . . . . . . . 640 + +DIPHTHERIA. By ABRAHAM JACOBI, M.D. . . . . . . . . . . . . . . . 656 + +CHOLERA. By ALFRED STILLE, M.D., LL.D. . . . . . . . . . . . . . 715 + +PLAGUE. By JAMES C. WILSON, A.M., M.D. . . . . . . . . . . . . . 771 + +LEPROSY. By JAMES C. WHITE, M.D. . . . . . . . . . . . . . . . . 785 + +EPIDEMIC CEREBRO-SPINAL MENINGITIS. By A. STILLE, M.D., LL.D. . . 795 + +PERTUSSIS. By JOHN M. KEATING, M.D. . . . . . . . . . . . . . . . 836 + +INFLUENZA. By JAMES C. WILSON, A.M., M.D. . . . . . . . . . . . . 851 + +DENGUE. By H. D. SCHMIDT, M.D. . . . . . . . . . . . . . . . . . 879 + +RABIES AND HYDROPHOBIA. By JAMES LAW, F.R.C.V.S. . . . . . . . . 886 + +GLANDERS AND FARCY. By JAMES LAW, F.R.C.V.S. . . . . . . . . . . 909 + +ANTHRAX (MALIGNANT PUSTULE). By JAMES LAW, F.R.C.V.S. . . . . . . 926 + +PYAEMIA AND SEPTICAEMIA. By B. A. WATSON, A.M., M.D. . . . . . . 945 + +PUERPERAL FEVER. By WILLIAM T. LUSK, M.D. . . . . . . . . . . . . 984 + +BERIBERI. By DUANE B. SIMMONS, M.D. . . . . . . . . . . . . . . . 1038 + + +INDEX . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1045 + + + + +CONTRIBUTORS TO VOL. I. + + +BEMISS, SAMUEL M., M.D., + Professor of Theory and Practice of Medicine and Clinical Medicine + in the University of Louisiana, New Orleans. + +BILLINGS, JOHN S., A.M., M.D., LL.D. (Edin.), + Surgeon U.S. Army, Washington. + +FITZ, REGINALD H., M.D., + Shattuck Professor of Pathological Anatomy in Harvard University, + Boston. + +FOSTER, FRANK P., M.D., + New York. + +HARDAWAY, W. A., A.M., M.D., + Professor of Diseases of the Skin in the St. Louis Post-Graduate + School of Medicine and in the Missouri Medical College, St. + Louis; President of the American Dermatological Association. + +HARTSHORNE, HENRY, M.D., LL.D., + Late Professor of Hygiene in the University of Pennsylvania, + Philadelphia. + +HUTCHINSON, JAMES H., M.D., + Physician to the Pennsylvania Hospital and to the Children's + Hospital, Philadelphia. + +HYDE, JAMES NEVINS, M.D., + Professor of Skin and Venereal Diseases in the Rush Medical + College, Chicago. + +JACOBI, ABRAHAM, M.D., + Clinical Professor of Diseases of Children in the College of + Physicians and Surgeons, New York, etc. + +KEATING, JOHN M., M.D., + Visiting Obstetrician and Lecturer on Diseases of Women and + Children to the Philadelphia (Blockley) Hospital; Surgeon to the + Maternity Hospital; Physician to St. Joseph's Hospital, + Philadelphia. + +LAW, JAMES, F.R.C.V.S., + Professor of Veterinary Science in Cornell University, Ithaca, + N.Y. + +LUSK, WILLIAM T., M.D., + Professor of Obstetrics and Diseases of Women and Children in the + Bellevue Hospital Medical College, New York. + +PEPPER, WILLIAM, M.D., LL.D., + Provost and Professor of the Theory and Practice of Medicine and + of Clinical Medicine in the University of Pennsylvania, + Philadelphia. + +SCHMIDT, H. D., M.D., + Pathologist to the Charity Hospital, New Orleans. + +SIMMONS, DUANE B., M.D., Yokohama, Japan, + Late Director, Physician, and Surgeon-in-Chief of the Government + Hospital, also Consulting Surgeon to Prison and Police Hospitals + at Yokohama, Japan. + +SMITH, J. LEWIS, M.D., + Clinical Professor of Diseases of Children in the Bellevue + Hospital Medical College, New York. + +STILLE, ALFRED, M.D., LL.D., + Emeritus Professor of Theory and Practice of Medicine in the + University of Pennsylvania, Philadelphia. + +WARING, GEORGE E., JR., M. Inst. C.E., + Engineer of Sanitary Drainage, Newport, R.I. + +WATSON, B. A., A.M., M.D., + Surgeon to the Jersey City Charity, St. Francis, and Christ + Hospitals, Jersey City, N.J. + +WHITE, JAMES C., M.D., + Professor of Dermatology in Harvard University, Boston. + +WILSON, JAMES C., A.M., M.D., + Physician to the Jefferson Medical College Hospital and to the + Philadelphia Hospital, Philadelphia. + + + + +ILLUSTRATIONS. + + +FIGURE PAGE + 1. MICROCOCCI . . . . . . . . . . . . . . . . . . . . . . . . . 142 + + 2. BACTERIA . . . . . . . . . . . . . . . . . . . . . . . . . . 142 + + 3. BACILLUS MALARIAE . . . . . . . . . . . . . . . . . . . . . . 143 + + 4. BACTERIA FROM GELATIN SOLUTION . . . . . . . . . . . . . . . 143 + + 5. VIBRIOS IN GELATIN CULTURE-FLUID . . . . . . . . . . . . . . 144 + + 6. PROTOCOCCUS FROM SLIDES EXPOSED OVER SWAMP-MUD . . . . . . . 144 + + 7. BACILLI FROM SWAMP-MUD . . . . . . . . . . . . . . . . . . . 145 + + 8. BACILLI FROM SEPTICAEMIC RABBIT . . . . . . . . . . . . . . . 145 + + 9. BACILLI FROM HUMAN SALIVA . . . . . . . . . . . . . . . . . . 146 + +10. BACILLUS ANTHRACIS . . . . . . . . . . . . . . . . . . . . . 146 + +11. BACILLUS TUBERCULOSIS . . . . . . . . . . . . . . . . . . . . 147 + +12. CHART OF TYPICAL RANGE OF TEMPERATURE IN TYPHOID FEVER, AFTER + WUNDERLICH . . . . . . . . . . . . . . . . . . . . . . . . 282 + +13. CHART SHOWING RECRUDESCENCE OF FEVER FROM INDISCRETION OF + DIET. . . . . . . . . . . . . . . . . . . . . . . . . . . . 283 + +14. CHART SHOWING FALL OF TEMPERATURE FROM INTESTINAL HEMORRHAGE + IN TYPHOID FEVER . . . . . . . . . . . . . . . . . . . . . 284 + +15. PULSE-TRACING IN RELAPSES OF TYPHOID FEVER . . . . . . . . . 304 + +16. CHART OF TEMPERATURE IN TYPHOID FEVER WITH RELAPSE.--ORIGINAL + ATTACK . . . . . . . . . . . . . . . . . . . . . . . . . . 306 + +17. CHART OF TEMPERATURE IN TYPHOID FEVER WITH RELAPSE.--RELAPSE 306 + +18. TEMPERATURE CHART OF TYPHOID FEVER.--ABORTIVE ATTACK, + FOLLOWED BY TYPICAL ATTACK . . . . . . . . . . . . . . . . 308 + +19. SPIRILLUM FROM THE BLOOD IN A CASE OF RELAPSING FEVER . . . . 374 + +20. TEMPERATURE CHART OF TYPICAL CASE OF RELAPSING FEVER, WITH + THREE RELAPSES TERMINATING IN RECOVERY . . . . . . . . . . 379 + +21. TEMPERATURE CHART OF TYPICAL CASE OF RELAPSING FEVER, + TERMINATING IN RECOVERY . . . . . . . . . . . . . . . . . . 380 + +22. TEMPERATURE CHART FROM A CASE OF THE BILIOUS TYPHOID OR GRAVE + SUBINTRANT FORM OF RELAPSING FEVER . . . . . . . . . . . . 397 + +23. TEMPERATURE CHART SHOWING THE LAPSE OF A REMITTENT FEVER INTO + AN INTERMITTENT . . . . . . . . . . . . . . . . . . . . . . 600 + +24. CHARTS SHOWING THE TEMPERATURE CURVE IN TYPHO-MALARIAL FEVER: + PART I., SHOWING PREDOMINANCE OF TYPHOIDAL ELEMENT; + PART II., SHOWING PREDOMINANCE OF MALARIAL ELEMENT . . . . 617 + + + + +GENERAL PATHOLOGY. + + +GENERAL MORBID PROCESSES. + +GENERAL ETIOLOGY. + +HYGIENE AND QUARANTINE. + +DRAINAGE AND SEWERAGE IN RELATION TO THE PREVENTION OF DISEASE. + + + + +{35} + +GENERAL MORBID PROCESSES.[1] + +INFLAMMATION; THROMBOSIS AND EMBOLISM; EFFUSIONS; DEGENERATIONS; +TUBERCULOSIS; MORBID GROWTHS. + +BY REGINALD H. FITZ, M.D. + +[Footnote 1: In the preparation of this subject full and free use has +been made of the following works: _Die Cellular Pathologie_, Virchow, +4te Auflage, Berlin, 1871; _Handbuch der Allgemeinen Pathologie_, Uhle +und Wagner, 7te Auflage, Leipzig, 1876; _Handbuch der Allgemeinen +Pathologie als Pathologische Physiologie_, Samuel, Stuttgart, 1879; +_Vorlesungen uber Allgemeine Pathologie_, Cohnheim, 2te Auflage, +Berlin, 1882; _Lehrbuch der Pathologischen Anatomie_, +Birch-Hirschfeld, 2te Auflage, 1er Band, Leipzig, 1882; _Lehrbuch der +Allgemeinen und Speciellen Pathologischen Anatomie_, Ziegler, 1er und +2er Theil, Jena, 1882 and 1883.] + + +GENERAL MORBID PROCESSES. + + +Disease is to be regarded as representing the result of a series of +processes called morbid or pathological, from the fact that they are +manifested by disturbances in the organism. + +The processes concerned are the same in kind as those essential to +health, but they are modified in time, place, or quantity. + +Morbid processes, therefore, are to be considered as modified +physiological processes tending to cause disease. + +All physiological processes are subject to certain variations which +tend to produce disturbances in the functions of the body. In the +healthy organism this tendency is checked by the automatic regulators +of the functional activity of the various organs, to the importance of +which Virchow[2] long ago called attention. By their action the +influence of external agents is controlled within certain limits. The +lids close and prevent injury to the eye. Sneezing, coughing, and +vomiting bring about the expulsion of noxious irritants. Sweating aids +in neutralizing the injurious effects of exposure to high +temperatures. Rapid respiration permits a sufficient cleansing of the +blood in rarefied atmospheres. When the limits, within which the +regulation of physiological processes is possible, are exceeded, such +processes become pathological and disease begins. A morbid process, +therefore, is usually incapable of recognition till disease is +present. It may exist and disease be unsuspected and denied. A +diminished blood-supply may be one link in the process which +eventually leads to the production of disturbances. {36} Another link +is to be found in the fatty degeneration resulting from this lack of +blood. + +[Footnote 2: _Handbuch der Speciellen Pathologie und Therapie_, +Virchow, 1er Band, p. 15, Erlangen, 1854.] + +Such a degeneration may have long existed in the walls of a +blood-vessel, and yet the individual appear in the best of health. The +sudden rupture of the weakened wall results in death or disease. With +the manifestation of the disturbances which render the condition of +the vessel obvious the individual is said to be diseased. + +In most instances, however, the morbid process makes itself early +apparent. Disturbances of nutrition, formation, or function soon +become sufficient in quantity to attract attention from the resulting +discomfort, and the presence of disease is then recognized. The latter +is thus essentially a conventional term, and begins when the morbid +processes occasion a sufficient degree of inconvenience. + +The process is never at a standstill. It either tends toward a return +to the physiological conditions, or its course is in the direction of +their destruction. As physiological processes are absolutely dependent +upon the vitality of the elements of the tissues, so those which have +become pathological cease to exist with the death of such elements. In +the dead body there is no disease, although its results remain, and +furnish the most efficient means of identifying the processes which +occasioned them. + +In the study of morbid processes, therefore, one must appreciate the +normal conditions and manifestations of life in the individual. +Physiological laws govern pathological phenomena, and the latter must +always be submitted to the tests furnished by the former. + +Just as little, however, as the study of anatomy familiarizes the +student with the anatomical changes resulting from diseased processes, +does the study of physiology accustom the student to the features of +disease. Pathological processes must be studied by themselves and for +themselves, although the means which are employed may be the same as +those used in physiological research. + +It is evident that the exactness of method which is the demand of the +physiological investigator cannot be secured by the pathologist. The +material of the latter lies farther, beyond his control. Nevertheless, +much of the ground to be gone over is common, and the object sought +for is essentially the same--the knowledge of the conditions necessary +to maintain life. + +In an introduction to the study of disease there are certain processes +which deserve early recognition. They are both the cause and the +result of disease, and may occur in various diseases, either limited +to one organ or present in a series of organs. Their treatment at +present obviates the necessity of repetition, and prepares the reader +for the special consideration of their occurrence in the various +structures and systems of the body. + +These processes are named in virtue of some prominent characteristic, +and each is made up of a complex series of conditions and +disturbances. In part, they represent modifications in the circulation +of blood and lymph; in part, they consist of nutritive derangements, +whose consequences appear as the various degenerations, or as the +additions to the body, the new formations. + +The processes and groups of processes in question are those included +under the following heads: inflammation; thrombosis and embolism; +effusions; degenerations; tuberculosis; and morbid growths. + + +{37} Inflammation. + +Inflammation is characterized now, as in the time of Galen, by the +presence of redness, heat, swelling, and pain. The disturbance of +function, added to modern definitions, is to be regarded either as a +result or a cause, or both, of the variously modified physiological +processes whose sum is the inflammation. + +The redness of inflammation is obviously dependent upon the presence +of an increased quantity of blood. This is readily apparent in the +direct observation of the blood-vessels of an inflamed, transparent +part of the body, as the mesentery of the frog or rabbit, or the +tongue and webbed foot of the former animal. The redness of +inflammation consequently demands the presence of blood-vessels in the +affected region, and becomes all the greater the more vascular the +part--_i.e._ the richer it is in such vessels. + +Redness does not suffice for the existence of inflammation, for it may +be found in the absence of other evidence of the latter. The diffused +redness, often extensive, of birth-marks, that from venous obstruction +or temporary congestions, from vaso-motor disturbances--the section of +the sympathetic furnishing a well-known instance--are examples of +non-inflammatory redness. Inflammation may even be present without +redness, as may be constantly observed in the occurrence of +parenchymatous inflammation and of the chronic interstitial varieties. + +The heat of inflammation is one of the most important clinical +features, yet not indispensable, as appears from its absence in +chronic interstitial forms of inflammation. In the acute varieties of +inflammation an elevated temperature is constant, and its observation +and record furnish a most valuable means of determining the beginning +and progress of an inflammation, which, for a time, may furnish but +little additional evidence. + +The heat of inflammation is the prominent characteristic of +inflammatory fever, and it is the study of this variety of fever of +late years which has resulted in an intelligible and relatively +satisfactory theory concerning fevers in general. Information of much +value is to be found in the recent work of Wood,[3] which contains +abundant historical information, as well as extensive original +observations and conclusions. + +[Footnote 3: _Fever: A Study in Morbid and Normal Physiology_, H. C. +Wood, A.M., M.D., Philadelphia, 1880. (Reprint from the _Smithsonian +Contributions to Knowledge_, No. 357.)] + +Inflammatory fevers are distinguished from idiopathic forms. The +latter variety includes the occurrence of fever as an attribute of the +disease concerned, the more characteristic symptoms of which follow +the febrile outbreak. Local inflammatory processes may take place +during the progress of the disease with its fever, but such processes +are co-effects of the cause of the latter, rather than its cause. Most +of those diseases in which fever occurs as one of the joint effects of +the cause of the disease, are included among the infective or zymotic +classes. + +The inflammatory fevers are those attending an acute inflammatory +process, and are secondary to, and occasioned by, the latter. The type +of this variety is seen in the fever occurring during the progress of +a wound, whether its course is toward healing or extension. Such {38} +traumatic fevers are characterized as septic or aseptic; the former +including the conditions of septicaemia and pyaemia. The aseptic +traumatic fevers, as described by Volkmann,[4] are those which pursue +their course with an elevated temperature, but without most of the +other febrile phenomena. + +[Footnote 4: _Beitrage zur Chirurgie_, Leipzig, 1875, p. 24; _Sammlung +Klinischer Vortrage_, No. 121, Genzmer und Volkmann.] + +Fever in general is characterized by a combination of disturbances in +the physiological processes of the body. Such processes are those +concerned in the production and dissipation of heat, in respiration +and circulation, digestion and secretion, and in mental, motor, and +other sensorial action. Such disturbances are manifested by a +persistent elevation of temperature, an increased destruction of +tissue, a quickened and modified pulse, accelerated breathing, +increased thirst, diminished appetite, and diminished quantity and +altered quality of the secretions. The sensorial disturbances include +wakefulness and stupor, headache, delirium, twitchings, cramps, and +other symptoms indicative of functional impairment of the nervous +system. + +Of all these manifold evidences of fever, the elevation of temperature +is the one whose cause, range, and results have been most carefully +and critically investigated. No record of a case in which fever is +present is regarded as complete without the chart of the daily +variations in temperature, respiration, and circulation. The practical +value of such records is thus admitted, and in the experiments +relating to the origin of animal heat the observations of temperature +are as essential as the chemical analyses, each of which supplements +the other. + +The more accurate determination of the heat produced in the body is +obtained either by the use of the calorimeter (an apparatus for +measuring the collected heat liberated from the body) or by estimating +the quantity of heat produced in the destruction of the constituents +of the body from quantitative analyses of the discharged carbonic acid +and urea. The results of such investigations are regarded by +Rosenthal[5] as possessing only a relative value, but justify the +conclusion that most of the heat produced in the organism results from +the oxidation of its constituents. + +[Footnote 5: _Hermann's Handbuch der Physiologie_, Leipzig, 1882, iv. +2, 375.] + +For the preservation of health it is essential that this heat should +be removed from the body in such quantity that the temperature of the +latter shall not vary to any considerable extent, for any considerable +time, from 37.2 degrees C. (98.4 degrees F.). The removal of the heat +is mainly accomplished by its radiation or conduction into a +surrounding cooler medium, and by the evaporation of moisture from the +surface of the body. Too great a removal of heat results in death from +freezing, while too great an accumulation of heat terminates fatally +from the effects of an unduly elevated temperature. To ensure the +normal range of temperature, constantly changing relations must exist +between the production of heat and its dissipation. The cooler the +surroundings, the more must heat be produced, or the less must heat be +evolved from the body. + +An increased production of heat is obvious under conditions of climate +demanding prolonged exposure to low temperature. An abundantly fatty +diet promotes the formation of heat, while suitable clothing checks +its dissipation. Although it is claimed by Liebermeister that sudden +exposure to cold stimulates heat-production, Rosenthal[6] disputes +this {39} statement, and maintains that it is still to be regarded as +doubtful whether the production of heat can be varied to suit the +demands of sudden and temporary changes of temperature. With the +admission of this doubt, the regulation of the temperature of the +body, under the circumstances just referred to, is mainly accomplished +through the influence of agencies favoring or checking the loss of +heat. Since heat is largely brought to the surfaces of the body by the +circulating blood, modifications in the fulness and rapidity of this +superficial current produce corresponding differences in the amount of +heat and moisture presented. Such variations are considered to be +accomplished through the action of the vaso-motor nervous system, +whose differing effects are apparent in the pale, cool skin and the +flushed, warm surface. + +[Footnote 6: _Op. cit._, 413.] + +The search for the regulation of such vaso-motor action has led to the +view that the production of heat, as well as its dissipation, may be +influenced from a nervous centre. Wood[7] claims that the result of +experiments made by him proves the existence of such a heat-centre in +or above the pons. Although admitting the possibility of its being a +muscular vaso-motor centre, he regards it rather as an inhibitory +heat-centre, which acts, as suggested by Tscheschichin, by repressing +the chemical changes in the constituents of the body through which +heat is produced. + +[Footnote 7: _Op. cit._, 254.] + +This view is objected to by Rosenthal,[8] on the ground that the facts +are not universally agreed upon, and their interpretation is somewhat +vague. Even the increased production of heat as determined by Wood, if +admitted, may be regarded as the result of a modified circulation. + +[Footnote 8: _Op. cit._, 442.] + +The preservation of a normal range of temperature in general is to be +recognized as the result of variations in the relation of +heat-production to heat-dissipation. The causes which influence this +relation may act from without or from within, and are regarded as +producing their effect by means of the vaso-motor nervous system. The +causes which act from within are those concerned in the febrile +elevation of temperature. Whether the latter is associated with, or +independent of, inflammatory processes, the question of first +importance relates to the modification of physiological conditions. +The causes of the physiological production of heat and its dissipation +have already been referred to, and the same elements demand +consideration in the pathological range of temperature so striking in +fever. + +Relatively accurate inductions with regard to the origin of febrile +heat were first rendered possible by the experiments of Billroth and +Weber. These observers found that the introduction of putrid material +into the circulation of animals produced fever. It was afterward shown +that various substances, not necessarily of a putrid character, might +produce the same result. + +From measurements with the calorimeter of the heat produced, it was +concluded by Wood[9] that in the fever of pyaemic dogs more heat was +produced than in healthy, fasting dogs, although less than in +high-fed, healthy dogs. An increased production of heat in the fevered +animal is thus obvious, as his capacity to receive and assimilate food +is considerably less than that of a high-fed, healthy dog. The +calculations of Sanderson, referred to by Wood,[10] based upon the +analyses of eliminated carbonic {40} acid and urea, show that the +febrile human subject produces very much more heat than the fasting, +though less than the fully-fed, healthy, man. + +[Footnote 9: _Op. cit._, 236.] + +[Footnote 10: _Op. cit._, 239.] + +An increased production of heat in fever is generally admitted, +although it alone is not to be regarded as the essential feature in +the elevated range of the temperature. The fasting man or animal under +ordinary circumstances is not febrile, and an increased production of +heat from full feeding in health, equal to that observed in fever, not +being associated with fever, it is apparent that the retention of the +produced heat is of importance for the existence of fever. Although it +has been shown by various observers that more heat is dissipated +during fever than in health, this increased loss is not in proportion +to the increased production of heat. A persistent elevation of +temperature is the necessary result. This elevation is subject to +daily and hourly differences, as is the temperature of the healthy +individual. These variations in the range of the febrile temperature +are apparently due to an agency like that which dominates the course +of normal temperatures--viz. a varying action of the vaso-motor +nervous apparatus, as well as of that controlling the secretion of +sweat, now permitting, now checking, the dissipation of the produced +heat. + +For the existence of the elevated temperature of fever, therefore, +there is demanded the presence of an agent within the body which, as +stated by Wood,[11] shall act "upon the nervous system which regulates +the production and dissipation of animal heat--a system composed of +diverse parts so accustomed to act continually in unison in health +that they become, as it were, one system and suffer in disease +together." It may be that there exists, as claimed by Wood and +Tscheschichin, a heat-centre independent of the vaso-motor and other +centres, through which heat is dissipated, or it may be, as maintained +by Rosenthal, that the vaso-motor system alone is concerned in the +regulation of temperature. Such action may be inhibitory or excitant, +according to the views of the one or the other author, without +affecting the main question as above stated. + +[Footnote 11: _Op. cit._, 255.] + +The elevation of temperature suffices to explain for the most part +certain of the other phenomena of fever, as thirst, digestive +disturbances, increased respiration, and emaciation. A coincident +affection of various cerebro-spinal centres is demanded to explain the +altered action of the heart and the numerous nervous symptoms which +are to be found in fever. The agent producing such manifold effects is +obviously no unit. It may be introduced from without or it may arise +within the body, and its transfer to the nervous centres is +undoubtedly accomplished through the circulation. + +Among those agents which act from without are to be included the +specific causes of infective diseases. It is probable that these +produce the fever, as they occasion other symptoms of the disease, and +their action may be regarded as direct, or indirect through the +secondary products of their own vital changes. In the light of the +existing facts the products of minute organisms developed outside the +human body may give rise to fever when introduced, without the +organism, into the body. The history of septicaemia contains numerous +illustrations of the pyrogenetic properties of material produced in +connection with wounded surfaces of the body exposed to the action of +minute organisms. The introduction of blood of the same, or of a +different animal, into the {41} circulation of a given animal is +followed by fever, as is the injection of considerable quantities of +water into the blood-vessels. The same is true of various chemical +substances. + +It is further obvious that the agents producing fever may arise within +the body. The fever resulting from the deprivation of water, and from +the destruction of tissues, are instances of the probable origin of +pyrogenetic substances from the rapid metamorphosis of tissues. + +It is suggested by Samuel[12] that under given circumstances the fever +may be sanatory. This view is based upon the probability that certain +parasitic organisms are destroyed at such temperatures as may be +produced within the body. The growth of the bacillus of malignant +pustule takes place most vigorously at a temperature of 30.5 degrees +C. (95 degrees F.), while its development is feeble at 40 degrees C. +(104 degrees F.). The bacillus of tuberculosis, as shown by Koch, +thrives at temperatures between 37 degrees C. (98.6 degrees F.) and 38 +degrees C. (100.4 degrees F.), but its growth ceases at temperatures +above 41 degrees C. (105.8 degrees F.). The spiral fibre of relapsing +fever, which is present in the blood in great abundance at the +beginning of the febrile onset, disappears at the close, the +temperature being 42 degrees C. (107.6 degrees F.). It is not to be +found in the intervals between the febrile paroxysms, but reappears a +few hours before the recurrence of the fever. The history of +intermittent fever suggests a similar relation between its cause and +the febrile periods. + +[Footnote 12: _Op. cit._, 155.] + +The value of pain as evidence of inflammation is merely relative. Its +existence depends upon the presence of sensitive nerves, and those +inflammations are the least painful which occur in parts where such +nerves are fewest. + +The pain of inflammation is attributable to the pressure upon the +nerves of that product of the inflammation known as the exudation. +This pressure becomes all the greater the more abundant the exudation, +or the greater the obstruction offered to its diffusion throughout the +inflamed part. The intense pain resulting from inflammation of the +fascia or of the periosteum is thus explained, while an inflammation +of the loose connective tissue may be diffused over a wide area with +little or no pain. In the chronic varieties of inflammation, where the +exudation is but scanty, and its accumulation extended over a long +period of time, there may be no pain during the entire course of the +inflammation. + +Swelling remains for consideration as the most important of the four +cardinal symptoms. Like the others, its presence is not absolutely +essential. It may exist at one time in the course of the inflammation, +and may be absent at another. Even a diminution in the size of an +organ may suggest the existence of an inflammation, for the yellow and +cirrhotic atrophies of the liver give evidence, respectively, of an +acute and chronic inflammation of this organ. + +The swelling of an inflamed part is due to the presence of an +increased quantity of blood, and lymph, and to the exudation. These +constituents of the swelling are not of equal importance. Although the +quantity of blood in the part is increased, no considerable swelling +is produced, provided the flow of blood and lymph from the part be +unobstructed. The current of lymph through the larger lymphatics may +be greatly increased, yet a decided swelling be absent, unless there +is an obstruction to the passage of lymph from the inflamed region. + +{42} The exudation is the most essential element of the swelling, and +our knowledge of its origin and fate includes the most important +features of the general pathology of the processes concerned. + +The inflammatory exudation is represented by the accumulation, outside +the blood-vessels, of material previously within them. The prevailing +views concerning the manner of origin of this exudation, and its +relation to inflammatory processes, are essentially due to the +rediscovery by Cohnheim of the forgotten observation of Addison, that +white blood-corpuscles pass through the apparently intact walls of the +blood-vessels. + +In the observation of the mesentery or other transparent part of a +suitable animal, the changes taking place in inflammation are, at the +outset, limited to the blood-vessels and their immediate vicinity. The +vessels become dilated and the rapidity of the flow within them is +soon diminished. In the veins particularly the white blood-corpuscles +separate in considerable numbers from the general current and line the +wall in constantly-increasing numbers, while the red corpuscles are +borne along the middle of the stream. The white corpuscles stagnate, +stick to the wall for a longer or shorter time, and often change their +place, while the red corpuscles are in constant and progressive +motion. In the capillaries a considerable number of white corpuscles +are found in contact with the wall, but numbers of red corpuscles are +associated with them. The formation of the exudation now begins by the +passage of white corpuscles through the apparently intact wall of the +veins and capillaries, especially of the former. Limited numbers, +under ordinary circumstances, of red corpuscles also make their way +through the walls of the capillaries. This is the phenomenon of +emigration, and is associated with the amoeboid movements of the white +corpuscles. + +With the passage outward of the white and red corpuscles there is also +the effusion of liquid material. Both the liquid and solid +constituents continually escape and spread in all directions beyond +the wall, following the course of the least resistance. It is probable +that this course is defined by the pre-existing spaces within the +tissues of the part, the lymph-spaces. The exudation is more abundant +in parts richly provided with blood-vessels and in those containing +the larger spaces; it is diminished where the vessels are less +numerous or the surrounding parts more resistant, with smaller and +fewer lymph-spaces. The resulting swelling is the less when ready +opportunities for the diffusion and removal of the exudation by +lymphatics and veins are presented, and when the material appears upon +surfaces over which it may flow away. + +The liquid portion of the exudation represents something more than the +transuded blood-serum, and a certain practical importance results from +the distinction drawn between an exudation and a transudation. Such a +distinction is especially called for when the inflammatory or +non-inflammatory origin of considerable quantities of fluid in the +larger cavities of the body is concerned. From a recent contribution +to our knowledge of this subject by Reuss[13] the following +information is derived: The percentage of albumen is always greater in +exudations than in transudations, and is more constant in the former +than in the latter. It increases with the severity of the +inflammation, being highest in the ichorous forms, less in the +purulent, and least in the serous exudations. When an {43} +inflammatory exudation is found to contain less albumen than usual, +the existence of a transudation with secondary inflammation is +suggested, or the exudation may have taken place in a hydraemic +individual. A sufficient number of exceptions are met with, however, +to interfere with the absolute nature of this test. + +[Footnote 13: _Deutsches Archiv fur Klinische Medicin_, 1879, xxiv. +583.] + +The coagulation of an inflammatory exudation apparently depends upon +the contained white blood-corpuscles; the more numerous (within +certain limits) these are in a serous exudation, the more abundant is +the formation of fibrin. The cellular element likewise is that which +in abundant liquid exudations characterizes them as purulent. Although +it is generally agreed that most of the corpuscles of pus are +emigrated white blood-corpuscles, it is not necessary to admit that +all are of this nature. The cells present in an inflamed part include +those pre-existing, as well as those which escape from the vessels. +The former are the wandering cells of the connective tissues, as well +as the fixed variety, the epithelial cells of the surface of a mucous +membrane in addition to the subjacent connective-tissue cells. +Amoeboid cells outside the blood-vessels have been seen to divide, and +it is possible that such duplication may serve as the method of +formation of a certain number of pus-corpuscles. The statements +concerning the proliferation of the fixed connective-tissue cells and +of epithelium are derived from appearances, and are interpretations of +these appearances, not observations of a process. + +The changes taking place along the walls of the blood-vessels being +the feature of prime importance in the observation of the progress of +an inflammation, numerous investigators have directed their attention +to the determination of the nature of the changes in the vessel wall +by means of which the escape of the corpuscles is permitted. Arnold +represents the most strenuous advocates of the stomata theory, +according to which the leucocytes pass through canals normally +existing in the wall. By means of the silver method of staining, and +by injections of various insoluble pigments into the blood-current, +certain results are met with, which give color to the view that pores +and canals are present upon and in the walls of the vessels, analogous +to those found in the diaphragm. As the latter have been shown to be +in direct communication with the lymphatic system of tubes and spaces, +so the walls of the blood-vessels have been assumed to present similar +channels of communication. + +The prevailing views at the present time are in favor of the +artificial nature of the stomata and pores in the walls of the +blood-vessels. An increased porosity of the vascular wall in +inflammation is necessary for the occurrence of the exudation, but +such porosity is regarded rather as a physical condition permitting an +observable filtration, and a filtration of solids as well as liquids. + +In this connection reference should be made to the observation of +Winiwarter, who has demonstrated that colloid material, a solution of +gelatin, passes through the vascular wall in inflammation more +readily--_i.e._ under less pressure--than through the normal wall of +the blood-vessel. + +The causes of inflammation are to be regarded as those which produce +an increased porosity of the vessel wall without causing its death, +for no exudation escapes from a dead vessel, its contents becoming +clotted. + +These causes may act from without or from within, primarily affecting +{44} the tissues outside the vessels, or exerting their action, at the +outset, upon the wall itself. The usual histological relation of +vessels and surrounding tissues is such that both are simultaneously +affected. The occurrence of an inflammation in non-vascular parts, +however, as the cornea, from irritation of its centre, the part +farthest removed from the surrounding blood-vessels, shows that the +affection of the vessels may be indirect as well as direct. This +indirect action is to be regarded as taking place through the agency +of nerves or through that of the nutritive currents. That nervous +influence alone does not suffice to transmit the effect of an applied +cause is apparent from the absence of inflammation of the cornea which +has become anaesthetized by section of the trigeminus nerve. With the +protection of the cornea from external irritation there is an absence +of inflammation. + +The consideration of the final symptom of inflammation, the +disturbance of function, which has been added in recent times, belongs +to special rather than general pathology. It varies according to the +seat of the inflammation, the disturbed function of the brain or heart +differing from that of the liver or kidney. The clinical importance of +this symptom of inflammation is greater than of all the rest, as it is +the one whose presence is constant and indispensable. + +An inflammation may exist, as already stated, without heat, redness, +or pain. The swelling may escape observation from the limited quantity +of the exudation and other causative agents, or from the +inaccessibility of the inflamed part to physical examination. The +disturbance of function, however, becomes early apparent, and is +present throughout the course of the inflammation. A knowledge of its +nature enables the seat of the latter to be recognized, and its +variations furnish a desired test of the efficiency of therapeutic +agents. + + * * * * * + +The causes of inflammation may be divided into the traumatic, toxic, +parasitic, infectious, dyscrasic or constitutional, and trophic. + +The traumatic causes are those which act mechanically, producing an +injury to tissues by pressure, crushing, tearing, stretching, and the +like. Others represent modifications in temperature, thermic agencies, +and include extremes of cold as well as of heat. The chemicals whose +action is direct, as caustic, include a third variety of the traumatic +causes. Such chemicals are applied to surfaces, cutaneous or mucous, +and comprise the active element producing the perforating ulcer of the +stomach and duodenum, as well as such substances as potash or +sulphuric acid which may have been swallowed intentionally or +accidentally. + +The toxic group of causes is closely allied to the chemical variety of +the traumatic agencies. It includes chemicals whose action is +indirect, through absorption in a diluted form rather than from direct +application in a concentrated condition. Such chemicals are derived +from without, as arsenic, phosphorus, and antimony; or may be formed +within the body, and the latter include the chemical products of +putrefactive changes--in the urine, for instance--and, with +considerable probability, certain of the active agents of +blood-poisoning in septic diseases. It is not unlikely that some of +the inflammatory affections met with among the so-called +constitutional diseases, as rheumatism and gout, may owe their origin +to the production of chemical substances within the body, excessive in +quantity if not changed in quality. + +{45} The parasitic causes of inflammation are both animal and +vegetable, and act upon the surfaces of the body or within its +deeply-seated parts. Some of the animal parasites act locally at their +place of entrance, while others produce but slight disturbances in +this region, their effects usually resulting from the transfer of +their offspring to remote parts of the body. The vegetable parasites +are for the most part the various fungi, which act locally upon the +skin or on those transitional surfaces lying between skin and mucous +membrane. The resulting parasitic inflammations are known as favus, +sycosis, ringworm, thrush, etc. The border-line between such parasitic +diseases and those included among the infective diseases is somewhat +arbitrarily drawn. Parasites in the limited sense act chiefly as +foreign bodies, while the effect of minute vegetable organisms is +rather that of ferments, in virtue of their products. Such a +distinction is of relative value merely, as the micrococci and +bacteria are capable of acting in other ways than by the production of +septic material. + +The infectious causes of inflammation are for the most part parasitic +in their nature, although the discovery and identification of the +parasite are in most of these inflammations assumed rather than +demonstrated. The relation of the anthrax bacillus to malignant +pustule no longer admits of a doubt, mainly in consequence of the +researches of Koch. This investigator has been enabled to establish a +definite etiological relation between the septicaemia of certain +animals and accompanying minute vegetable organisms. His recent +discovery of the bacillus of tuberculosis definitely removes the +tubercular process from the group of dyscrasic or constitutional +affections to that of the infective diseases. The constant presence of +minute organisms in relapsing fever, leprosy, malaria, typhoid fever, +diphtheria, erysipelas, and numerous other affections associated with, +if not characterized by, inflammatory conditions, renders extremely +probable the closest pathological relation between such diseases and a +microscopic organism. That an inflammatory process may be regarded of +infectious origin, it is necessary, according to Koch,[14] that a +characteristic organism should be found in all cases of the disease, +and in such numbers and distribution as to account for all the +phenomena of the disease in question. + +[Footnote 14: _Untersuchungen uber die Aetiologie der +Wundinfectionskrankheiten_, 1878, 27.] + +These organisms may act in virtue of their growth and the consequent +demand for oxygen, as seems probable in certain cases of malignant +pustule, where the affected individual dies with symptoms of asphyxia. +Their operation may also be like that of ferments, which produce +chemical material whose effect may be remote from the immediate +presence of the minute organism. They may likewise, in connection with +their colonization in various parts of the body, act more immediately +upon the walls of the blood-vessels, and produce that increased +porosity which is so essential a factor in inflammation. + +The discovery of the immediate cause of the various infective +diseases, as measles, scarlatina, variola, cholera, dysentery, mumps, +whooping cough, cerebro-spinal meningitis, and numerous other epidemic +and endemic affections, still remains a question for the future. The +constant association of microbia with any or all of such diseases is +but one fact in connection with them, and such a discovery is to be +regarded merely as a step forward, to be followed by others, each of +which represents not only an advance, but confirms the position +attained. + +{46} The dyscrasic or constitutional causes of inflammation are those +which, though long established, appear less demanded as our knowledge +advances. Regarded as the result of an alteration in the composition +of the blood, it is obvious that such changes may arise from the +introduction, from without, of wholly foreign material. The dyscrasia +may also represent modifications in the relative proportion of the +normal constituents of the blood. In the former series are included +what, for the most part, have already been referred to under the toxic +and infectious causes of inflammation. The dyscrasiae from lead, +alcohol, and the like belong to this series. Still more important are +the poisons, the virus of tuberculosis and scrofula, of leprosy and +syphilis. The dyscrasiae known as anaemia, leucaemia, uraemia, +icterus, and diabetes are to be regarded less as inflammatory causes +than as predisposing conditions which favor the action of other groups +of causes. + +The trophic causes of inflammation are those whose action is supposed +to take place through the influence of nerves. Although, as has +already been stated, a faulty innervation of tissues is an important +element in favoring the action of various inflammatory causes, there +remain certain forms of inflammation where the disturbance of nervous +action seems to be the essential feature. The occurrence of an acute +peripheral gangrene soon after certain traumatic or inflammatory +lesions of the brain or spinal cord, of articular inflammation +following chronic affections of the cerebro-spinal axis, are instances +in point. The origin and distribution of herpes zoster, the occurrence +of sympathetic ophthalmia and symmetrical gangrene, suggest a +predominant disturbance of innervation as the exciting cause. At the +same time, it is desirable to call attention to the recent +observations of MacGillavray, Leber, and others,[15] which suggest +that a sympathetic ophthalmia is due to the extension of a septic +choroiditis along the lymph-spaces of the optic nerve. It is further +apparent that in certain so-called trophic inflammations, as the +pneumonia after section of the pneumogastric, and the inflammation of +the eye following paralysis of the trigeminus, the paralysis of the +nerve is a remote, rather than an immediate cause, of the +inflammation. There still remain, however, a number of localized +inflammations whose origin is so intimately connected with nervous +disturbances as to demand, for the present at least, a corresponding +classification. + +[Footnote 15: Wadsworth's "Report of Recent Progress in +Ophthalmology," _Boston Medical and Surgical Journal_, 1882, cvi. +517.] + +The course of an inflammation is often indicated by the predominance +of certain symptoms, which, for the most part, indicate a condition of +the individual acted upon rather than a peculiarity of the cause. The +sthenic inflammations take place in robust individuals with powerful +hearts and an abundant supply of blood. In such persons a strong +pulse, high fever, and an injection of the superficial blood-vessels +suggested, in former times, the necessity of bloodletting as the +essential therapeutic agent. The sthenic form of inflammation was most +commonly associated with pneumonia, where the obstruction to the +passage of blood through the lungs was an important cause of the +superficial injection of the blood-vessels. + +The asthenic inflammations, on the contrary, are those occurring in +feeble individuals, debilitated in consequence of pre-existing +disease, exposure, or habits. A weak heart, low febrile temperature, +and {47} superficial pallor, characterize the asthenic inflammations, +which show a frequent tendency to become localized in the more +dependent parts of the body, the force of the circulation being too +feeble to overcome the effect of gravitation. + +In the typhoidal inflammations are associated those symptoms which are +so prominent in the severe varieties of typhoid fever. These are the +predominant symptoms: hebetude or low, muttering delirium, picking at +the bed-clothes, involuntary evacuations, stertor, and the like. The +nervous disturbances are associated with a feeble pulse and a dusky +hue of the skin. + +The constituents of an inflammatory exudation are frequently used as a +basis of classification, and characterize the inflammation from the +anatomical point of view. As the exudation is complex in its +composition, the predominant element is made use of to designate the +variety, and in doubtful cases a combined adjective indicates the +presence of the two most abundant constituents. As the exudation is +directly derived from the blood and contains serum in addition to +white and red corpuscles, the serous, purulent, and hemorrhagic +varieties of exudation naturally arise. The fibrinous and diphtheritic +inflammations relate to the presence of membranes or false membranes. +Finally, there are the productive inflammations, resulting in the new +formation of tissue, and the destructive inflammations, where losses +of substance occur. + +Serous inflammations are most frequent in those parts of the body +where the structure contains the largest lymph-spaces. The so-called +serous cavities of the body offer the most favorable opportunities for +the accumulation, as well as for the exudation, of the inflammatory +product; then follow the regions of the larger lymph-spaces, according +to the size and number of the latter. + +The serous inflammations may also arise from the epithelial coverings +of the body, as the cutaneous, alimentary, and respiratory surfaces. +The serous exudations of the skin are those present in vesicles, +blisters, or bullae, which owe their limitation to the resistance +offered to the spreading of the liquid inflammatory product by the +coherent epidermis. Serous inflammations of the alimentary canal may +assume a vesicular character, although, from the structure of its +mucous membrane and the macerating influence of its contents, the +vesicles are apt to be of an extremely transitory character. + +The more important serous inflammations of the intestines are those +manifested by profuse watery evacuations, the extreme form of which is +to be found in cholera. + +Serous inflammation of the lungs accompanies the more severe forms, +and usually represents but a limited and circumscribed affection, +associated with more abundant cellular and fibrinous products. + +Serous inflammations of the peritoneum, pleura, pericardium, tunica +vaginalis, and central ventricles often give rise to the presence of +enormous quantities of fluid, whose partial removal from many of the +cavities concerned by operative measures frequently represents a most +beneficial result of treatment. + +The smaller lymph-spaces of the connective tissue in various parts of +the body are the frequent seat of the inflammatory oedema, so called, +whose presence is an important indication of the direction assumed by +a {48} spreading inflammation, as well as a suggestion of the frequent +virulence of its cause. + +In general, the serous inflammations are to be regarded as less severe +than other varieties, or as representing an early stage of what later +may be otherwise characterized by a change in the nature of the +products. + +The purulent variety of inflammation is present when the exudation is +abundantly cellular. As has already been stated, such cells are, for +the most part, white blood-corpuscles. The purulent exudation, like +the serous variety, may appear either on surfaces, when the term +secretion is applied, or within the lymph-spaces of the connective +tissue over a considerable space, when the pus is said to be +infiltrated. When the infiltration is more circumscribed and the walls +of the affected lymph-spaces are destroyed, so that adjoining cavities +are thrown into larger holes, an abscess is present, from whose wall +pus is constantly derived, while the inflammation is progressive. + +The attention of the surgeon, in particular, has been directed to the +isolation of the immediate cause of suppurative inflammation, and the +modern, antiseptic, treatment of wounds is essentially based upon the +view of the infectious origin of pus. The frequent presence of +microbia in purulent exudation where no precautions are taken to +exclude their admission, and their frequent absence or presence in +minute quantities where such precautions are taken, have suggested +that through their influence an inflammatory exudation is likely, if +not actually compelled, to become purulent. + +Whether the microbia or their products are the cause of most +suppurative inflammations may be regarded as an open question. It is +generally admitted, however, that, as a rule, an inflammation becomes +purulent in consequence of the presence of an infective agent; in +other words, that most pus is of an infectious origin and possesses +infectious attributes. The labors of Lister in insisting upon the +exclusion of all possible putrefactive agencies in the treatment of +wounds have met with universal approval, and the basis of his +treatment remains fixed, although different methods have been devised +for its enforcement. His researches, and those stimulated by his work, +have resulted in the establishment of principles which affect the +whole field of theoretical as well as practical medicine. + +Although most pus may be considered as due to the action of a virus +introduced from without, and capable of indefinite progressive +increase within the body, all pus is not to be regarded as of +infectious origin. There are pyrogenetic agencies, like petroleum, +turpentine, and croton oil, which, introduced into the body, produce +suppurative inflammation without the association of microbia. + +A bland pus is usually in a state of beginning putrescence, so that it +is only relatively bland, and acquires extreme virulence when long +exposed to putrefactive agencies. It is possible that those agencies +producing an ichorous pus are the same or different from those present +in bland pus. The ichorous exudation contains less corpuscles than +bland pus, is more fluid, less opaque, strongly alkaline, of a +greenish color, and of offensive odor. + +In hemorrhagic inflammation the exudation contains large numbers of +red blood-corpuscles. The occurrence of this form is sometimes +associated {49} with peculiarities of the cause, as is obvious from +the epidemics of hemorrhagic small-pox, measles, scarlatina, and +cerebro-spinal meningitis. It is also associated with peculiarities of +the individual, as in such epidemics all cases are not equally +hemorrhagic, and in scurvy the hemorrhages are attributable to the +abnormal conditions to which the sufferers are exposed. Hemorrhagic +exudations are also met with in those inflammations of serous surfaces +accompanying the outcropping of tubercular and cancerous or +sarcomatous growths. In all cases a hemorrhagic exudation represents a +grave complication, and when found in serous cavities has a certain +diagnostic, as well as prognostic, importance. + +Fibrinous inflammations are characterized by the presence in the +exudation of considerable quantities of fibrin. As the prevailing +theory of the formation of fibrin demands fibrino-plastic as well as +fibrinogenous material, both are to be sought for in the exudation. +The latter is present in the liquid portion of the exudation; the +existence of the former, as well as that of the ferment, is dependent +upon the presence of the white blood-corpuscles. The more numerous +these, within certain limits, the more abundant the formation of +fibrin. As their death appears essential for the fibrinous +coagulation, the latter is most constantly met with in those parts of +the body where the white blood-corpuscles are quickest separated from +influences favoring their life. The farther removed they are from the +blood-vessels, the more likely is their early death. Fibrinous +exudations are therefore frequent and abundant in cellular and serous +(sero-cellular) inflammation of the great serous cavities of the body. +The clotted fibrin appears as false membrane lying upon the serous +surface, either smooth or rough, tripe-like, or as villosities +projecting above the surface, and again as bands, fibrinous adhesions, +stretching across the cavity and uniting opposed surfaces. + +The frequent occurrence of fibrinous exudations on the mucous +membranes of the larynx and trachea, accompanied by the suffocative +symptoms known as croup, has led to the use of the term croupous +inflammation as synonymous with fibrinous inflammation, and its +application to various parts of the body where croupous--_i.e._ +suffocative--symptoms are not in question. Croupous inflammation, when +used, is to be considered as an anatomical term, indicating merely the +production of fibrin, and, for the avoidance of confusion, it is +preferable to substitute fibrinous for croupous when such +inflammations are described. + +The disease, croup, it is well known, may exist without a +croupous--that is, fibrinous--inflammation, as is familiarly +recognized in the constant use of the terms spasmodic, membranous, and +diphtheritic croup. + +Fibrinous inflammation of the mucous membrane of the larger +air-passages is much more frequently met with than that of mucous +membranes elsewhere, as of the intestines, uterus, and bladder. The +pseudo-membranous inflammations of the latter tracts are more commonly +the result of the catarrhal and diphtheritic varieties than of the +fibrinous form. Fibrinous exudations on mucous surfaces, according to +Weigert, can only take place when the epithelium is destroyed. Hence +those causes which give rise to the destruction or detachment of the +epithelium are alone capable of producing a fibrinous inflammation of +mucous membranes, and a fibrinous laryngitis, trachitis, and +bronchitis may result from {50} the local application of such +irritants as steam or ammonia, as well as occur in the diseases croup +and diphtheria. + +Fibrinous exudations may also be present within tissues, especially in +those whose meshes are wide, provided the essential elements of +coagulation are present. The coagulative necrosis of various organs, +to be more fully mentioned hereafter, is closely allied to fibrinous +clotting, the fibrino-plastic element being derived from the death of +the parenchymatous cells of the part. + +In the existence of a fibrinous pneumonia the conditions are somewhat +analogous to those present in the fibrinous inflammation of serous +surfaces and of the areolar connective tissue. There is present an +abundantly cellular exudation, held in the place of its origin, the +cells undergoing rapid death and surrounded by a wall whose +superficial cells resemble in structure, if not in origin, the +endothelial cells lining the smaller lymph-spaces of connective +tissue, as well as the larger cavities within the same, known as +serous cavities. + +The diphtheritic inflammation is no more to be confounded with the +disease diphtheria than is the fibrinous inflammation with the disease +croup. Although diphtheria owes its name to the frequent presence of +an apparent membrane, it may be said that the latter is not essential +to the existence of the former. Diphtheria, like croup, is an +affection in which various exudations may be present, and the +anatomical product alone does not suffice in all instances for the +recognition of the disease. In croup there may be a swollen mucous +membrane, with a slight superficial mucous exudation, or a more +abundant exudation of desquamated epithelium and mucus, as well as a +fibrinous false membrane. In diphtheria the same varieties of +exudation may occur, and in addition the diphtheritic exudation may +also be present. The latter, however, is not limited to the disease +diphtheria, for its presence is apparent in other mucous membranes +than that of the air-passages, and in the pharyngeal mucous membrane +in other diseases than diphtheria. A diphtheritic conjunctivitis, +enteritis, cystitis, and endometritis are recognized. The cutaneous +surfaces of the body may also furnish a diphtheritic exudation. The +diphtheritic inflammations of wounds and of variolous eruptions are +instances in point. + +The characteristics of a diphtheritic inflammation are the presence +within the tissues of a clotted exudation, which is associated with a +defined swelling and death of the part. The exudation contains not +only dead leucocytes and interlacing fibres, but is also provided with +abundant granular material, much of which presents the well-known +peculiarities of microscopic organisms. The apparent false membrane is +thus dead, infiltrated tissue, which may be torn away from the +continuous unaffected tissue, leaving a raw, rough surface, but not +peeled from a comparatively smooth surface, as in other forms of +pseudo-membranous inflammation. + +The frequent association of a superficial false membrane, +corresponding in area with that of the deeper-seated changes, in which +cells and fibres may be present, is to be recognized. The diphtheritic +process, however, is localized within, and not upon, the tissues +affected. The diphtheritic exudation represents a local death, a +necrosis, of the part concerned, and the result has frequently been +compared with the death consequent upon the action of a caustic. + +{51} The immediate cause of a diphtheritic inflammation is now +generally attributed to the action of microbia which enter the tissue +from without, and in their growth beneath the surface produce not only +the local, but also the remote, constitutional disturbances which are +associated with a diphtheritic inflammation. The investigations of +Wood and Formad[16] point to ordinary putrefactive organisms as a +sufficient cause for the diphtheritic inflammation of diphtheria, +while other observers demand a specific organism as the exciting +cause. The occurrence of diphtheritic inflammations in various parts +of the body, in regions, as the intestine, where putrefactive +processes are constantly present, and in the bladder and uterus, where +the phenomena of putrefaction are often associated with diphtheritic +inflammation, suggest the efficacy of ordinary putrefactive agencies +in producing the latter. As all microbia found in putrefaction are not +alike, and as the properties of certain, differ from those of others, +and as our knowledge of the effects of all is but fragmentary, the +characteristics of specific germs for a diphtheritic inflammation of +one part of the body, or of all parts of the same, must still be +regarded as not proven. + +[Footnote 16: _Research on Diphtheria for the National Board of +Health_, 1880, Supplement No. 7.] + +Productive inflammations are those which result in the new formation +of tissues. One of the frequent products of inflammation is fibrous +tissue, which, at first abundantly cellular, later becomes more +vascular, and is finally transformed into a tissue whose fibres +predominate over its cells. This formation of a cicatricial tissue +demands further recognition when the termination of inflammation is +considered. + +In a more limited sense certain inflammations are called productive +when multiple circumscribed new formations, as cancer, sarcoma, +tubercle, and the like, arise in connection with the ordinary products +of inflammation. Such new formations are of frequent occurrence in +serous membranes, and a tuberculous pericarditis or a cancerous +peritonitis, indicates that a growth of tubercles or cancerous nodules +has taken place, in addition to a more or less abundant exudation with +various proportions of serum fibrin and cells. This association of +ordinary and transitory inflammatory products with the formation of +more permanent tissues may be found within organs as well as upon +surfaces. A tubercular arachnitis or lepto-meningitis presents the +various products of an inflammation of the pia mater with an abundant +formation of tubercles. In like manner, a tubercular pneumonia, or a +tubercular nephritis suggests an association of neoplastic growth and +inflammation, in the lung and kidney. Such a relation offers a basis +for the theory in favor of the inflammatory origin of tumors, and is, +in part at least, a cause for the frequent consideration of tubercles +as mere inflammatory products, wholly cellular or cellular and +fibrous, subject to the same modifications as take place during the +course of ordinary inflammations. + +Even if tuberculous and scrofulous inflammations are regarded as +inflammatory processes, modified by a specific cause and by +peculiarities of the individual, the cancerous and sarcomatous +inflammations are still to be considered as representing an +association of inflammatory disturbances and specific new formations, +the cause of the latter not being the cause of the former. As ordinary +inflammations of the regions concerned may take place in the absence +of the neoplasms, so may the {52} specific growth appear in the same +regions without anatomical or clinical evidence of inflammation. + +The classification of inflammation as to its products is supplemented +by distinctions drawn with reference to the seat. The exudations may +be superficial or deep-seated; they may lie within the cells, +parenchyma, of an organ, or within the interstitial tissue of the +same. + +The product of superficial inflammations may lie on the surface, as in +the case of inflamed mucous membranes, or immediately below the +surface, as in numerous cutaneous inflammations, of which erysipelas +may serve as the type. The term catarrhal, applied to superficial +inflammations, carries with it the idea of displacement, flowing, of +the exudation. The product of a catarrhal inflammation must be largely +liquid, that such a displacement may readily take place, and the +catarrhal exudation is chiefly composed of an excess of those elements +which are present in the normal, physiological secretion from the +membrane concerned. Mucus therefore represents a frequent constituent +of the catarrhal exudation, and mucous as well as muco-purulent +catarrhs of the gastro-intestinal, bronchial, genito-urinary, and +other mucous membranes are recognized. The catarrhal inflammation of +the respective membranes usually represents the mildest form, as it +demands an intact epithelium, and a ready removal of the inflammatory +product. + +As the cause of a catarrhal inflammation may occasion a destruction of +the epithelium or a necrosis of the mucous membrane, the frequent +association of catarrhal with fibrinous or diphtheritic inflammations +is obvious. In such cases the clinical importance of the latter +varieties gives them the precedence in the designation of the +inflammation. The retention of the catarrhal products is the frequent +cause of permanent disturbances of a more or less serious nature. +These result in part from the mechanical obstruction offered to the +function of parts beyond the seat of obstruction, as pulmonary +atelectasis; and in part from the changes taking place in the retained +product. Purulent otitis media with its dangerous or fatal results, +and gangrene of the lung terminating in septic pleurisy, are not +infrequent instances of severe disturbances from putrefaction of the +retained products of a primarily catarrhal inflammation. A cheesy +degeneration of the catarrhal cells leads to a surrounding fibrous, or +destructive, inflammation, with a corresponding diminution in the +function of the organ affected. + +Of the deep-seated varieties of inflammation, that requiring special +mention is the phlegmonous form. This runs its course within the less +dense fibrous tissue known as the areolar or cellular tissue. The term +cellulitis is usually employed by English writers to indicate the seat +and nature of the process, and although the use of the term cellular +tissue is rapidly becoming obsolete, the convenience of cellulitis +favors the retention of the latter name. + +The exudation lies within the larger lymph-spaces, and is therefore +sometimes designated as the result of a lymphangitis, the deep-seated, +wider lymph-spaces being concerned rather than those more superficial. +Certain forms of phlegmonous inflammation are of decidedly infectious +origin, and, when seated subcutaneously, are known as phlegmonous +erysipelas, being thus distinguished from the simple erysipelas, whose +seat is defined by the small superficial lymph-spaces of the skin. + +{53} Infective forms of cellulitis are also frequently met with in the +loose, sub-peritoneal tissue of the pelvis. The infectious element +usually proceeds from the uterus, and excites the malignant oedema of +the broad ligament, the septic parametritis, or the pelvic cellulitis, +according as the lymph-spaces inflamed lie nearer the fundus or +cervix, and as the direction of the current is upward toward the +spine, or outward toward the sub-peritoneal lymphatics of the pelvic +wall. + +Parenchymatous inflammation is present when the exudation is taken +into the cells of an organ, or when the changes dependent upon +inflammation of an organ take place within its functionally important +cells. Virchow originally used the term parenchymatous inflammation in +contradistinction to secretory inflammation, the changes in the former +occurring within the elements of the tissues, while in the latter the +exudation made its appearance on the surface of the organ. + +Parenchymatous inflammation is manifested by a degeneration of the +cells affected. This may terminate in their destruction through the +conversion of their protoplasm into fat-drops, fatty degeneration; +although more frequently a simple accumulation of albuminoid granules +(granular degeneration) occurs. The latter represents a transitory +condition, from which a return to the normal state readily takes +place. This form of inflammation is met with in those organs which +present a sharply-defined contrast between the functionally important +cells and the connective tissue which surrounds them. The liver, +kidneys, heart, spleen, pancreas, and glands in general, are +consequently the most frequent seat of parenchymatous inflammation. + +Opposed to this variety is the interstitial inflammation. The +exudation of the latter remains within the connective-tissue framework +of the organ. It is essentially cellular in character, and the number +of cells is comparatively small. With their presence and the +possibility of their nutrition a permanent increase in the quantity of +the fibrous tissue of the organ is permitted. This becomes relatively +greater in the course of time, and the parenchymatous cells become +degenerated and absorbed. Interstitial inflammations are likely to +become chronic in character, and, from the outset, are usually +associated with parenchymatous changes. + +An important clinical distinction is drawn with reference to the +duration of an inflammation. Acute inflammations are those whose +course is rapid, whose progress is associated with graver disturbances +of function, and with a greater prominence of the cardinal symptoms. +The chronic forms occupy more time in their progress, the functional +disturbances, though severe, are injurious more from their protracted +persistence, than their temporary violence, while redness, swelling, +heat, and pain are symptoms of trifling prominence. + +The exudation in acute inflammation, if recovery takes place, is +rapidly removed from the place of its origin, while in the chronic +variety it tends to become a part of the region in which it lies, or, +if removed, slowly disappears, and may be constantly replaced. Acute +inflammations may become chronic, and the chronic variety is liable to +acute exacerbations. + +The distinction between acute and chronic inflammations is essentially +one of convenience, and, when considered from the anatomical point of +view, relates rather to the persistence of the results. These may be +{54} present as a variously modified exudation or as a degenerated +condition of the parenchyma of the organ or tissue affected. + +Inflammation terminates in resolution, production, or destruction. + +For resolution to occur it is necessary that the causes of +inflammation cease to act, either by their removal or their isolation, +and that their results be removed. With the removal of the results +there is often associated the removal of the cause. That such may take +place it is necessary that the function of the vessel walls be so +restored that the exudation ceases to escape. Inflammatory products +already outside the vessels, if present on surfaces with external +outlets, are carried along in the course of the excretions. If they +lie within the cavities of the body not opening externally, their +removal is accomplished through the medium of the circulating lymph +and blood, by absorption. The liquid portion of the exudation becomes +a part of the circulating fluids of the body. The fibrin is converted +into a granular detritus, which eventually disappears from the place +of its formation. The leucocytes may return to the blood-vessels or +enter the lymphatics; the latter course probably being the one taken +by the larger number of the corpuscles. Many undergo a fatty +degeneration, and as they lie in lymph-spaces their conversion into an +emulsion permits a removal of the mechanical obstruction to the flow +of lymph through the spaces in which they were accumulated. The red +blood-corpuscles are destroyed, their pigment being dissolved by the +surrounding fluid and removed in the course of the circulation and +excretions, or it becomes transformed into granules or crystals, which +may remain in the place of their formation, or be transferred, within +amoeboid cells, to remote parts of the body. + +When the exudation is abundant, as in the great lymph-sacs of the +body--the several serous cavities--and especially when the openings in +the walls of these sacs are obstructed or the currents within them are +feeble, absorption takes place with great difficulty, and demands a +long interval of time. The fibrinous and cellular portion of such an +exudation frequently becomes converted into a caseous mass, from a +partial fatty degeneration and inspissation. This mass becomes +isolated from the cavity in which it lies, usually at the most +dependent portion, by the formation of a capsule of connective tissue. +It may subsequently become infiltrated with lime salts, calcified, and +thus remain comparatively inert throughout the life of the individual. + +The productive termination of inflammation is manifested by the new +formation of connective tissue. This tissue is variously designated, +as the inflammatory process is limited to the surfaces of the body +exposed to the air, or the surfaces of cavities and organs, or as it +lies within organs or the deep-seated parts of the body. In numerous +instances it becomes a permanent constituent of the body, and, as time +is usually essential for its formation, its occurrence is indicative +of a chronic, rather than an acute inflammation. Certain chronic +inflammations are progressive in character, the production of +connective tissue being continuous, with perhaps occasional +intermissions, as in the chronic interstitial inflammations of organs +and tissues. The new-formed tissue, which at the outset is rich in +cells, becomes in time more fibrous, and associated with this change +in structure is a physical modification, manifested by its shrinkage. +This new formation may fill a gap resulting from the destruction of +tissue in {55} the progress of an inflammation, when it is present as +cicatricial tissue--the scar which is usually met with upon the +surfaces of the body or of certain of its organs. When opposed +surfaces are united by the new-formed tissue, the term adhesion is +applied; the adhesions being present as fibrous bands, cords, or +membranes. The pericardial milk-spots and thickenings, the tendinous +or semi-cartilaginous, indurated patches of serous membranes and of +the intima of arteries, are all regarded as manifestations of a +chronic inflammation of these tissues. With the localization of the +inflammation in the outer walls of the bronchi and blood-vessels a +thickening of the external sheath results, called a peri-bronchitis, +arteritis, or phlebitis, as the case may be. + +The new formation of blood-vessels is essential for the production and +preservation of this connective tissue, and both arise from +pre-existing tissues. Pus-corpuscles represent the simple cellular +product of an inflammation, and their existence is but transitory. +With the new formation of blood-vessels imbedded in abundant cells +there exists a granulation-tissue, likewise transitory, but out of +which arises the permanent fibrous tissue. The question is still +mooted as to the part played by exuded white blood-corpuscles in the +production of the permanent results of inflammation. It is generally +conceded, especially since the observations of Ziegler, that they are +capable of transformation into lasting constituents of tissue, into +blood-vessels as well as into cells and fibres. Whether all the +resulting permanent products of inflammation are dependent upon their +activity, or whether the pre-existing fixed elements participate, is +still to be considered undecided. + +What, at present, appears most probable is, that from exuded +leucocytes there arise, in the course of several days, larger +cells--epithelioid or endothelioid--which are eventually associated +with still larger cells, more irregular in shape, and provided with +projecting filaments, giant-cells. Both varieties may result from the +enlargement of leucocytes by fusion or by the assimilation of +nutriment. The epithelioid cells eventually become fusiform or +stellate, and their projections, as well as those of many of the +giant-cells, become fibrillated. The fibrils of adjoining cells, +becoming united, are thus transformed into a meshwork of fibrous +bundles enclosing irregular spaces, while the nuclei of the cells, +with the immediately surrounding protoplasm, remain upon these bundles +as the permanent cells of the new-formed tissue. The blood-vessels +arise from pre-existing vessels, chiefly capillaries, and probably are +also formed from the cells present in the exudation. The former method +is indicated by the projection of solid sprouts from the wall of a +capillary, which may unite, forming arches, and communicate with +sprouts from neighboring capillaries, thus forming bridges. Both +arches and bridges then become hollowed and admit the circulating +blood. Ziegler maintains that the projections of the larger +epithelioid cells and giant-cells become elongated, and eventually +fused with capillaries, or the projections from capillaries. When this +fusion is accomplished the cells become hollowed, their cavities +communicating with those of the blood-vessels. These epithelioid +cells, whose formation and transformation are of such importance in +the history of productive inflammation, are designated by Ziegler as +formative cells, and are frequently derived from the exuded white +blood-corpuscles, though not identical with them. + +{56} The inflammations not terminating in resolution or production, +end in the destruction of the part. This result occurs when the +nutrition of the inflamed territory is so diminished, by the changes +in and around the vessels, as to become insufficient for its +preservation. As the nutriment is derived through the blood-vessels, +the more complete and the more permanent the stagnation in them the +more likely is death to result. This event also depends upon the +quantity and quality of the exudation. The more abundantly cellular +the latter, the more likely is an abscess or ulcer to result. + +As most abundantly cellular exudations are considered to be dependent +upon the presence of putrefactive agencies, those inflammations of a +predominant putrid character (gangrenous inflammations) are those +terminating in destruction. The dead product is present as a slough or +sequestrum, when dead soft or hard tissues are detached, entire or in +part, from the living; or as a granular detritus contained in a more +or less abundant liquid. The inflammatory process producing the slough +and sequestrum is characterized as a gangrenous inflammation of soft +parts or a caries of bone, while the process resulting in the +formation of the granular detritus, and which has no necessary +connection with putrefactive agencies, is called a softening, from the +physical condition of its result. + + +Thrombosis and Embolism. + +A blood-clot formed within a blood-vessel during life is called a +thrombus. The entire process of which the thrombus is the essential +element is designated thrombosis. + +These terms were introduced by Virchow[17] to avoid the confusion +which resulted from regarding the process and result as synonymous +with inflammation of the vessel. All writers, even at present, do not +adhere to this strictness of meaning. For a thrombus of the vulva +indicates a clot of extravasated blood within the connective tissue of +the labium; in like manner, a vaginal thrombus is the effused and +clotted blood in the loose connective tissue surrounding the vagina. +These exceptions are gradually disappearing, and the word haematoma, +tumor composed of clotted blood, is being substituted in both +instances. A cancerous thrombus represents a mass of cancerous tissue +whose growth is extended along the course of a vessel, its wall having +been penetrated. In general, however, the term thrombus, unless +otherwise qualified, is used as first stated. + +[Footnote 17: _Handbuch der Speciellen Pathologie und Therapie_, +Erlangen, 1854, i. 159.] + +Although thrombosis is commonly a morbid process, it is not uniformly +so. Its physiological significance is illustrated by the part it takes +in the closure of the umbilical and uterine vessels, after childbirth. +The surgeon makes use of it in his efforts to overcome certain of the +ill effects of amputation, and to accomplish a cure of such local +diseases as aneurism, where it is deemed important to diminish the +supply of blood. + +The thrombus being a blood-clot, it is composed, like the latter, of +fibrin and blood-corpuscles. It is presumable that the fibrinous part +of a thrombus owes its origin to the same conditions which determine +the presence of fibrin in blood removed from the vessels during life +or in that within the vessels after death. + +{57} According to A. Schmidt,[18] the blood and other fluids, in which +clotted fibrin makes its appearance, contain two generators, called +fibrino-plastic and fibrinogenous. The former is considered to be +paraglobulin, a substance contained mainly in the white +blood-corpuscles, while the fibrinogenous generator is held in +solution in the plasma of the blood. When these materials are acted +upon by a third, the fibrin ferment, clotting takes place and fibrin +is formed. It is thought that the ferment is intimately connected with +the white blood-corpuscles, for with the microscope coagulation is +seen to advance as these become destroyed, and where the leucocytes +are most abundant, there coagulation advances most rapidly. The +elements of clotted fibrin are always present in circulating blood, +but Brucke has shown that blood remains fluid, under ordinary +circumstances, because of its constant contact with the normal +vascular wall. + +[Footnote 18: Rollett, _Hermann's Handbuch der Physiologie_, Leipzig, +1880, iv. 1, 114.] + +The general causes of thrombosis are those which produce an abnormal +condition of the endothelium, a rapid destruction of the white +blood-corpuscles, or a stagnation of the blood. With the presence of +one of these causes there is often conjoined another, and the +conditions under which they are present are conveniently used in the +classification of thrombi. + +Although stagnation of the blood is often an important immediate cause +of its coagulation, it is apparent, from the investigations of +Durante[19] and others, that stagnant blood clots in the living +vessels only when their endothelium is in an abnormal condition. With +the co-existence of abnormal endothelium and stagnant blood, thrombi +form with greater frequency and become more voluminous in a given +interval of time. + +[Footnote 19: _Wiener Medizinische Jahrbucher_, 1871, 321.] + +The importance of the death of white blood-corpuscles in the formation +of thrombi is generally admitted, and is especially insisted upon by +Weigert. According to the observations of Zahn, the nucleus of certain +thrombi is the result of the death of these leucocytes and their +accumulation upon an altered intima. The experiments of Naunyn, +Kohler, and others show that a thrombus may be rapidly produced by the +injection into the blood of fibrino-plastic substances, and of those +through which free haemoglobin is admitted into the circulation. The +former may be expressed from a fresh blood-clot; the latter may be +obtained by thawing frozen blood, or by injecting such material +(bile-acids, for instance) into the circulating blood as rapidly +destroys the red blood-corpuscles. Although Weigert lays special +stress upon the destruction of white blood-corpuscles in the formation +of the thrombus, it appears, from the experiments above referred to, +that indirectly the destruction of the red corpuscles is also of +importance. + +Although largely made up of fibrin, a thrombus also contains +blood-corpuscles, both red and white, and the appearance of the mass +is modified according to the variations in the relative proportions of +these constituents. + +Zahn[20] divides thrombi, according to their color, into red, white or +colorless, and mixed varieties. The red owes its color to a large +number of red blood-corpuscles, while the white and mixed forms +contain various proportions of white blood-corpuscles and fibrin and a +diminished number {58} of red corpuscles. The cause of this difference +in the color of thrombi is to be sought for in their method of origin. +When blood clots slowly in a dish, the heavier red corpuscles settle +to the bottom, and the lighter white corpuscles form a superficial +layer. Stagnant blood clotting rapidly furnishes a uniformly red mass. +The red thrombus, like the red clot, is the result of the rapid +coagulation of stagnant blood. The white thrombus, on the contrary, +largely composed of white blood-corpuscles, represents a constantly +increasing deposition of these from flowing blood. The mixed thrombi +arise from a combination of both conditions, and are usually white at +the outset. Thrombi formed in the heart and larger arteries are +usually white, those in the auricular appendages and on venous valves +are mixed, while red thrombi are more common in arteries and veins, +since the conditions favoring their origin are more frequently met in +such vessels. + +[Footnote 20: _Virchow's Archiv_, 1875, lxxii. 85.] + +Thrombi are frequently stratified, in consequence of the successive +deposition of new layers of blood-corpuscles and fibrin upon a +pre-existing thrombus. Circulating blood is therefore necessary for +the stratification, and such thrombi are likely to be mixed in color. +Unstratified thrombi are usually white or red, the former largely +composed of agglomerated white blood-corpuscles so moulded and +situated as to prevent a stagnation of blood in their vicinity, while +the red thrombus is rarely stratified, since its formation demands a +stoppage of the blood-current. Stratification is intimately connected +with the enlargement or growth of the thrombus, which takes place from +the surface exposed to the flowing blood, and which is greater or less +according to the seat of the thrombus. + +Thrombi are usually divided into those from compression, dilatation, +traumatism, and marasmus; in all of which groups an abnormal condition +of the endothelium is to be met with. + +Thrombi from compression are frequently formed in veins, in the +vicinity of growing tumors. Their presence is most constant when the +vein is compressed between a resistant surface, especially bone, and +the tumor. A compression of the smaller blood-vessels within an organ, +as the liver or kidney, may take place in consequence of chronic +interstitial inflammation, or the growth of cancerous or other +malignant tumors in such organs. The production of this form of +thrombus is sought for in the treatment of certain aneurisms by direct +pressure, the resulting stagnation of blood being followed by a +coagulation within the aneurismal sac. + +Thrombi from dilatation are met with both in dilated arteries and +veins. In aneurism and varix a slowing of the blood-current is +present, and the intima of the diseased region is frequently in such +an abnormal condition that a clotting of the blood readily takes +place. The shape and situation of the dilatation are of importance in +promoting the formation of the thrombus; the more pedunculate and the +more voluminous the sac the more certain is the thrombosis. + +Traumatic thrombi result from a direct injury to the vessel. This may +be mechanical, as in the application of ligatures for the obliteration +of vessels, the tearing of the veins during childbirth, and the +infliction of wounds of every variety. The injury may likewise be +chemical, from the action of caustics; somewhat analogous to which, +are the effects of heat and cold. Allied to the traumatic thrombi are +those which arise {59} from acute inflammation of the intima extending +from wounds or inflammatory processes in the vicinity of +blood-vessels. + +Marantic thrombi are those whose origin is attributable to that +enfeebled condition of the body known as marasmus. This represents a +weakening of the several functions, especially the circulation, +respiration, and locomotion. Such may take place in disease or old +age; and it is important to bear in mind those diseases in which +marasmus is likely to arise, as thrombosis often proves a complication +of such affections. Protracted fevers, as typhus and typhoid, +puerperal diseases, the disturbances following surgical operations, +chronic wasting diseases, as the tuberculous and scrofulous +affections, are all likely to be accompanied by thrombosis. Stagnation +of the blood, as well as alterations of the intima, is an important +local condition in this variety of thrombosis, which is usually +valvular or parietal at the outset, and may be both arterial and +venous. Such thrombi are likely to become continued and to serve as a +frequent source of embolism. + +Thrombi are also divided into primitive, or autochthonous, and +secondary varieties. The primitive thrombus is one which owes its +local origin to conditions existing at the place of its formation and +attachment. The secondary variety demands for its existence a +primitive thrombus, whose place of development is remote in time and +seat, and from which a part has been transferred to serve as the +nucleus for the secondary formation. + +The continued thrombus is often confounded with the secondary variety. +Continuance is rather a quality of all thrombi, and is essentially +growth, whether by lamellation or agglomeration. Such continued +thrombi are extended in the course of the circulation, usually by a +conical end, which is pointed toward the heart in the case of venous +thrombi, but away from this organ when the thrombi are arterial. + +Parietal and obstructing thrombi form another subdivision. The former +arise from a limited part of the wall of the heart or blood-vessel, +and project into its cavity. They are always in contact with flowing +blood, and are white or mixed in color and primitive. They may attain +a considerable size, and may eventually become obstructing thrombi. +The latter are so called when they are of sufficient size to cause a +considerable or total obstruction to the current of blood. In the last +case the vascular canal is wholly filled by the thrombus. The shape of +the older parietal forms is usually globular or pedunculate, owing to +the growth in all directions except at the place of attachment; the +obstructing thrombi are elongated. + +Thrombi are also characterized by consistency and relative absence of +moisture. A thrombus is brittle and dry as compared with a clot. In +distinguishing between the two, difficulty arises only in the case of +a thrombus which may have formed within a few hours before death. +Post-mortem clots are moist, elastic, readily withdrawn from +blood-vessels, and have a smooth and lustrous surface. Their color is +either red, gray, grayish-yellow, or yellow, and is very often mixed. +The lighter colors are due to causes which favor the precipitation of +red blood-corpuscles before actual clotting takes place, or which +occasion an increase of the white blood-corpuscles in fibrin. The +thrombus becomes adherent to the vessel wall within a few hours, after +its formation, in the case of the red thrombus, and at once, in the +case of the white variety. A clot is never adherent, although it may +seem so from its entanglement between the trabeculae and {60} tendons +of the heart and the cavernous framework of venous sinuses. Such +apparent adhesions are easily recognized by the smooth, shining, +intact intima which is disclosed after the removal of a clot. + +The thrombus not only tends to become enlarged by further depositions +of material from the blood, but it also tends to become diminished in +size from the contractile properties of its fibrinous constituent. +Moisture is forced from the thrombus in consequence of this shrinkage, +and its dryness is increased by subsequent absorption through the wall +to which it adheres. + +The changes eventually taking place in the thrombus are known as +organization, calcification, and softening. + +Organization is the transformation of the thrombus into a mass of +fibrous tissue. This is accomplished, according to the researches of +Baumgarten,[21] by an outgrowth of endothelium from the intima of the +vessel, the thrombus being absorbed as the growth of tissue advances. +In the case of a thrombus due to the ligation of a vessel, a +granulation-tissue also makes its way into the thrombus between the +ruptured coats, and the new-formed fibrous tissue which replaces the +thrombus becomes vascularized through this granulation-tissue. The +vascularization of thrombi surrounded by unbroken walls is most likely +to result from the extension into the thickened intima of new-formed +branches of the vasa vasorum. Cohnheim claims that the organization of +the thrombus may take place solely through the entrance of migratory +cells, without any active participation of elements of the vascular +wall. The canal is thus obstructed or obliterated by a fibrous tissue, +which is pigmented or not, as the pre-existing thrombus contained red +blood-corpuscles or not. These, when present, become transformed into +granular or crystalline haematoidin, which may remain as a permanent +constituent of the new-formed tissue. + +[Footnote 21: _Die sogenannte Organisation der Thrombus_, Leipzig, +1877.] + +Even when the thrombus is completely obstructing at the outset, it is +not necessary that a total obliteration of the vessel should result +from its organization. It not rarely happens, either before or after +the thrombus has yielded to the fibrous growth, in consequence of the +shrinkage of the fibrin of the thrombus or of the contraction of the +fibrous tissue replacing it, that gaps arise which become +communicating canals. Through these the blood flows, and the vessel +thus becomes only obstructed, not obliterated. The sieve-like tissue +thus formed is spoken of as the result of a cavernous or sinus-like +transformation of the thrombus. The length of time necessary for the +removal of the thrombus and its replacement by fibrous tissue varies +considerably. A vascularized granulation-tissue may be present within +a week, and in the course of a month the thrombus may have been wholly +removed, or a period of months may elapse and the thrombus and +granulation-tissue still be present side by side. + +The calcification of a thrombus takes place when the latter becomes +impregnated with salts of calcium and magnesium. The condition may be +present in thrombi which are exposed to a rapidly-flowing arterial +stream, as well as in those which lie in venous pockets outside the +course of the direct current of blood. The well-known phlebolites are +examples of the latter variety. A calcified thrombus may be intimately +united to the vascular wall, the results of calcification and +organization being associated. Calcification and, in particular, +organization represent favorable {61} events in the history of +thrombosis, as through their occurrence the process comes to an end, +and disturbances, either local or remote, are prevented. + +The softening of the thrombus, on the contrary, is always a source of +danger. This is partly due to the nature of the products of the +softening, whether bland or septic, and partly to the mechanical +disturbances produced by the transfer of portions of the softened +thrombus to remote parts of the body. All thrombi may become softened. +When the process of organization advances normally, the softened parts +are absorbed as rapidly as the formation of vascularized fibrous +tissue progresses. If this formation is checked or stopped, the +process of disintegration still continues. White corpuscles undergo +fatty degeneration; red corpuscles give up their coloring matter and +become converted, like the fibrin, into granules, and there results a +granular detritus. This is present as a viscid, semi-fluid material, +either red, gray, or yellow, according to the color of the thrombus. +This simple softening is to be regarded as essentially chemical in +character, and begins at the oldest portion of the thrombus and +advances toward the periphery. Its products are capable of absorption +without the production of serious disturbances, and are usually +prevented from direct entrance into the blood-vessel containing the +thrombus by the continuation of the latter from new coagulation or +deposition upon its surface. The thrombus is thus extended as the +softening progresses. + +When the thrombus is comparatively free from red blood-corpuscles, the +softened product, in consequence of its yellowish color, opacity, and +viscidity, resembles pus. The so-called encysted abscesses projecting +into the cavity of the heart, from its wall, are parietal and globular +thrombi, in the interior of which softening has occurred. This form of +softening is called simple or bland, as it is free from any evidence +of local suppuration, inflammation, or general constitutional +disturbance attributable to an absorption of poisonous material. + +Septic softening is accompanied by general evidences of a +blood-poisoning, and by the local phenomena of purulent inflammation. +A suppurative thrombo-phlebitis or arteritis, occurs; that is, an +acute inflammation of the wall of the vessel, corresponding in its +origin to the seat of the thrombus, and characterized by the formation +of pus. In the earliest stage the softened thrombus need not present +products differing in appearance from those occurring in simple +softening, but their effect is manifested by a rapidly-advancing +inflammation of the vascular wall and by the evidence of septicaemia. +Inoculation with such material produces a group of symptoms classified +under the head of blood-poisoning. + +Cohnheim lays special stress upon the presence of micrococci in the +softened material, and it is generally agreed that the virulence of +septic softening is connected with, if not due to, the presence of +microbia. A septic softening may be induced by besmearing, with septic +material, the outside of a blood-vessel containing a thrombus, and +this form of softening is usually associated with those conditions +favoring this relation. Such are the gangrenous wounds following +surgical operations, the putrid inflammatory processes affecting the +uterine wall after childbirth, the offensive inflammations of the +middle ear, and the like. It is possible for a septic softening to +occur independently of such contiguous or continuous relations with +the surfaces of the body. It is considered, {62} however, that the +micrococci present in a softened thrombus must have obtained admission +from without through one of the surfaces of the body, mucous or +cutaneous, or through undiscovered abrasions of even intact surfaces +of peculiar structure, as the alveolar wall or the intestinal mucous +membrane. The thrombus is regarded as affording a favorable soil for +the growth and activity of the organism. + +The mechanical effect of a thrombus varies according to the venous or +arterial seat of the same. Venous thrombi, as they are continued +toward the heart, tend to become completely obstructing thrombi. In +most parts of the body the venous anastomoses are so numerous that the +obstruction of a vein is readily compensated for through the +collateral venous circulation. When such a compensation is prevented +by an extension of the thrombus from branch to branch, and finally to +the trunk, an accumulation of blood in the peripheral veins must +result. The remote parts become swollen, from the distension of the +vessels with blood and the transudation of liquid, and eventually +solid material from the blood. Venous thrombosis thus leads to oedema, +and even hemorrhage. The more rapidly the obstructing thrombus +extends, the earlier and more extreme is the oedema likely to become, +while the slower the advance of the thrombus, the more favorable is +the opportunity for an enlargement of the collateral vessels through +which a sufficient flow of blood is permitted to check oedema and +preserve nutrition. + +Local mechanical disturbances from arterial thrombi are scarcely +perceptible till obstruction is produced, and the results of arterial +obstruction will be mentioned in detail in connection with the +phenomena of embolism. Cardiac thrombi may occasion local disturbances +from interfering with the action of the valves of the heart. Those +thrombi which are attached to the valves, especially when calcified, +may produce inflammation and aneurism of the opposed wall of the +heart, by friction. The most frequent mechanical disturbance from the +non-obstructing parietal thrombi of the heart and arteries results +from the detachment of fragments and their transfer as emboli to +remote parts of the body. + +An embolus is a foreign body in a blood-vessel, usually too large to +pass through the smallest capillaries, and the disturbances resulting +from its presence are included under the term embolism. Although most +emboli are detached portions of thrombi, any foreign body of suitable +size may become an embolus. Such are tissues, as the pulmonary elastic +fibres, fragments of diseased valves of the heart and of the intima of +arteries, or portions of tumors growing into vascular canals. Others +are globules of oil entering the torn veins when fat-tissue becomes +crushed, or air-bubbles admitted through veins either wounded by +instruments or opened after parturition by the dislodgment of their +obstructing thrombi. Still others are granules of pigment derived from +the coloring-matter of the blood, as in melanaemia, or introduced from +without, as india-ink and cinnabar. The echinococcus has been found as +an embolus, and it is highly probable that the cysticercus, the +trichina, and other animal parasites may be disseminated as emboli +over the body. + +Vegetable parasites, like the bacterium and aspergillus, have also +been included in the list, although the disturbances resulting from +their presence are less due to mechanical obstruction than to +colonization and growth. The experimenter uses the most various +objects as emboli--bits {63} of wood, rubber, and glass, globules of +mercury, fragments of tissue, etc. Emboli are to be regarded as of +arterial or venous origin. The arterial emboli are carried toward the +capillaries, while venous emboli are carried toward the heart. The +effect of both is partly or wholly mechanical, and partly due to the +specific properties of the constituents. + +The mechanical effect of an embolus is manifested by the obstruction +it offers to the circulation, and the degree of the obstruction +depends upon the size, shape, and density of the embolus and the +nature and size of the vessel obstructed. An embolus may be so large +as to be unable to pass through the valvular orifices of the heart. A +long and narrow embolus might pass through a vessel which would not +admit one which was short and thick. A jagged and dense embolus, by +repeated blows or prolonged and forcible contact, might cause a +weakening or rupture of the wall of a vessel, and thus produce an +aneurism. Certain vessels (the terminal arteries of Cohnheim) furnish +the sole supply of arterial blood to a district, and when they are +obstructed, the results, to be mentioned later, differ widely from +those taking place where free vascular anastomoses exist. When a trunk +bifurcates, the larger branch usually receives the embolus. + +Venous emboli are those which approach the heart by the peripheral +veins of the body or the pulmonary veins, and the liver by the +radicles of the portal vein. Emboli from the veins of the body are +carried through the right side of the heart, if not so large as to be +stopped at the tricuspid or pulmonary opening. As they enter the +latter, they are carried along its course under the influence of +gravity and the direction and force of the current, which are +determined by the direction and relative size of the bifurcations of +the artery, the right primary branch being larger than the left. +Eventually, a point of the artery is reached whose diameter is less +than that of the embolus, and the latter is stopped. This point +usually corresponds with a place of bifurcation, and the embolus +frequently rides the wall separating the branches. + +Emboli from the radicles of the portal vein owe their most frequent +origin to thrombi associated with inflammatory processes in the +intestine, especially of the caecum and vermiform appendage, to +inflammatory processes in the spleen and obstruction to the flow of +blood through the splenic artery, or to inflammatory changes +proceeding from the kidneys. Such venous emboli are carried toward the +heart, but are stopped on the way by the intrahepatic branches of the +portal vein. + +Arterial emboli are those which enter the left side of the heart from +the lungs, which arise in the left ventricle or auricle, which may +pass through an open foramen ovale from the right auricle, or which +arise from the arterial wall. They are carried along the course of the +arterial circulation, and are distributed over the different regions +and organs of the body. Usually following the more direct course of +the circulation, they are more likely to enter the abdominal aorta +than to be carried toward the brain or upper extremities. Embolism of +the carotids, especially of the left carotid, is more likely to ensue +than embolism of the subclavians. Embolism of the coronary arteries is +rare, while embolism of the splenic artery, the left renal and left +iliac arteries, is comparatively common, and in the order mentioned. + +When an embolus is found, or embolism suspected, the source is always +{64} to be searched for in those regions from which the affected part +receives its blood. The source of arterial and portal emboli is +usually found with ease, while the pulmonary embolus may come from so +wide a region, the body-veins, that much time may be spent before its +place of origin is discovered. An appreciation of the laws of the +transfer of emboli renders such a discovery almost certain. + +When the embolus reaches a point beyond which it cannot pass, the +resulting disturbance depends essentially, as shown by Cohnheim, upon +the presence or absence of arterial anastomoses beyond the place of +obstruction. He gives the name terminal arteries to those which have +no anastomosing arterial branches. These are met with in the spleen, +kidneys, lungs, brain, and retina. If the obstructed artery is not +terminal, the embolus may produce no further disturbance, the +collateral supply of blood through the anastomoses sufficing for the +nutrition and function of the part. If, however, the vessel is a +terminal artery, and the embolus is completely obstructing, the supply +of arterial blood must be wholly cut off from the region beyond the +seat of obstruction. + +If the embolus does not completely obstruct at once, it soon becomes +sufficiently large for this result to ensue in consequence of a +secondary coagulation. The rider assumes legs extending into the +arterial branches beyond the place of obstruction, and a body which +extends backward in the course of the circulation to the nearest +branch. The result of the total obstruction of the vessel is to cut +off the admission of arterial blood, producing a local anaemia. The +contraction of the elastic tissues of the part propels toward the +capillaries a certain quantity of the blood in the vessels beyond the +point of obstruction, till this force becomes neutralized by the +blood-pressure in the vessels surrounding the obstructed region. The +anaemic part may subsequently become engorged with blood; it may die, +a region of anaemic necrosis resulting, or the dead portion may become +softened. + +The engorgement of the obstructed territory has received the name of +hemorrhagic infarction. A solid, wedge-shaped mass of a reddish-brown +color is present, whose shape is due to the arborescent branching of +the terminal arteries. According to Cohnheim, the engorgement of the +region with blood takes place from venous regurgitation into the +obstructed part, till the intravenous pressure is overcome by the +resistance of the tissues in the region affected. The capillaries and +larger vessels thus become distended, and an escape of liquid and +solid constituents of the blood takes place. If the veins are provided +with valves, or the venous regurgitant current is opposed by gravity, +the hemorrhagic infarction is prevented or greatly impeded. + +Litten,[22] on the contrary, who has furnished a recent contribution +to this subject, claims that the hemorrhagic results of embolism are +not accomplished through venous regurgitation, unless increased venous +tension is produced by coughing, vomiting, and like efforts. His +experiments lead him to maintain that arterial blood from surrounding +tissues is supplied to the obstructed region through the anastomosing +capillaries. The force is not sufficient to drive the blood through +the capillaries into the veins beyond, but an accumulation takes place +in the capillaries, which become dilated and distended. The escape of +blood-corpuscles and {65} serum then takes place, the more freely, as +Weigert[23] suggests, the larger and more numerous are the +pre-existing spaces in the organ. Hence the infarction becomes the +most characteristically developed in such organs as the lungs and +spleen. Causes which obstruct the venous flow, as well as those which +increase the arterial tension, promote the hemorrhagic infarction. + +[Footnote 22: _Untersuchungen uber den hemorrhagischen Infarct., +etc._, Berlin, 1879.] + +[Footnote 23: _Virchow's Archiv_, 1878, lxxii. 250.] + +A necrosis of the part whose direct arterial supply is cut off takes +place when the structure of the organ affected is such that the +admission of arterial blood is wholly interfered with. This is the +case in the heart and kidneys, and to a less extent in the spleen. The +opportunity is presented for the diffusion of a fibrinogenous fluid, +lymph or blood-serum, through the cells of the organ which contains +the other essentials for coagulation, and the dead part presents the +characteristics attributed by Weigert[24] to death from clotting of +the protoplasm, coagulative or ischaemic necrosis. + +[Footnote 24: _Ibid._, 1880, lxxix. 87.] + +Embolism of the cerebral arteries produces softening of the brain, not +a hemorrhagic infarction or a yellowish necrosis. Weigert attributes +this result, on the one hand, to the absence in the brain of abundant +cells from which are to be had the ferment and fibrino-plastic +material necessary for coagulation, and, on the other, to the closure +of the spaces into which blood might collect by the rapid swelling of +the tissues from the exuded lymph. + +The hemorrhagic results of embolism are also met with in obstruction +of branches of the mesenteric artery, which is considered by Litten, +at least from its function and in connection with its sluggish +current, to correspond with a terminal artery. + +If the patient outlives these more mechanical results of embolism, the +local changes taking place are those tending to remove the +extravasated blood or the dead tissues. The embolus has become an +obstructing thrombus, and its removal is accomplished in the manner +already stated in connection with the subject of thrombosis. The +wedge-shaped nodule of hemorrhagic infarction becomes decolorized +through the absorption, in part, of the blood-pigment. That portion +which is not absorbed remains at the site of the original lesion as +granular or crystalline blood-pigment. A granulation-tissue is formed +at the periphery, which extends into the infarcted region, very much +as the endothelial and vascularized growth extends into a thrombus. +Eventually, a patch of cicatricial tissue remains as the sole +indication of the previous disturbance. This termination is rather +suggested for the hemorrhagic infarctions of the lungs. The results +are more apparent and more easily demonstrated in the case of the +anaemic necroses, and the somewhat irregular depressions with +wedge-shaped scars, seen upon the surface of the spleen or kidneys, +call attention to the probable nature of the process giving rise to +these results. A source of embolism must also be associated, that +these scars may be regarded as of embolic origin. The embolic +softenings of the brain are likewise represented in after years by +losses of substance. The superficial, yellow patches or localized +oedematous blebs, with corresponding atrophy of the convolutions +beneath, call attention to a nutritive disturbance, as do cyst-like +cavities in the deeper parts of the brain. Here, too, a source of +embolism must be found, that {66} the local destruction of tissue may +be attributed to embolic obstruction of vascular territories. + +When the embolus arises from a septic thrombus, the results differ +from those above described. The embolus then carries not only +mechanical possibilities, but also a virulent action. The latter is +manifested by the rapid production of local inflammatory disturbances, +as circumscribed abscesses and gangrenous destruction of tissue. Since +emboli are frequently lodged near the surfaces of organs, a septic +pleurisy, pericarditis, or peritonitis is the usual result of the +dissemination of the virus contained in the embolus. This virus is +similar in character to that found in septic softening of the +thrombus, and, like it, is intimately connected with the presence of +microbia. Whether the latter are specific in character, as maintained +by Klebs and others, or whether they are to be included among those +associated with putrefactive processes, still remains an open +question. + +The symptoms of thrombosis obviously depend upon the resulting +obstruction to the circulation of blood, and in the case of primitive +thrombi are gradual in their occurrence. The degree of mechanical +obstruction is determined by the nature of the thrombus, whether +parietal or obstructing, and by that of the vessel, whether provided +with anastomoses sufficient to permit a compensatory collateral +circulation or not. In the former case, if the thrombus is small and +deep-seated, there may be no symptoms to indicate its presence. When +the collateral circulation is insufficient to remove the blood from a +region whose efferent venous trunk is completely filled with a +thrombus, the phenomena of stagnation are produced. The part becomes +oedematous, and red blood-corpuscles escape from the distended vessel. +If the obstructed vein is superficial, the seat of the thrombus is +indicated by the resistance and sensitiveness of the part. +Characteristic disturbances of function are associated with thrombosis +of the various organs of the body. If the cerebral sinuses are +affected, mental disturbances arise; if a cardiac thrombosis is +present, it is frequently accompanied by irregularity and feebleness +of the heart. When the portal and renal veins are obstructed, +functional disturbances arise in the parts from which they receive +their blood. + +The symptoms of embolism, like those of arterial thrombosis, are +primarily due to anaemia. Suddenness is their characteristic in +embolism, while they are gradual and progressive in the case of +thrombosis. An embolic anaemia is complete or incomplete according to +the terminal or anastomosing character of the obstructed vessel. The +effect of the anaemia is to stop or check the function of the part, +and varies according to the size and situation of the vessel. +Hemiplegia, or perhaps aphasia or other evidence of localized +disturbance, follows central embolism; angina pectoris, with a +disturbed cardiac action, results from embolism of the coronary +artery. Sudden suffocative symptoms, with open air-passages, suggest +embolism of the larger branches of the pulmonary artery. A +considerable haematuria often excites suspicion of an embolism of the +renal artery, the hemorrhage coming from the vessels in the +neighborhood of the obstructed region. Embolism of a large artery of +an extremity is often localized by the sensation of a blow at the +part, to be followed by absent pulsation, pallor, and coldness of the +region beyond the place of obstruction. + +{67} The symptoms of the subsequent effects of thrombosis and embolism +are to be inferred from what has already been stated with regard to +the nature of the possible lesions. To enter into their detailed +consideration would demand more space than is permitted, and would +modify an established sequence or necessitate a repetition, which is +undesirable in a systematic treatise. + + +Effusions. + +The various fluids of the body are derived from without, and admitted +into the blood-vessels. The physiological transudation through the +walls of these vessels, in the main modified serum, becomes lymph as +it appears in the several lymph-spaces. From the latter the transuded +fluid either returns through the lymph-vessels to the blood-current or +makes its appearance upon surfaces as secretions. These are variously +modified as they pass through the specific cells of glands or as they +are met with in the several closed cavities of the body. + +The transudations thus occurring may vary in quantity within certain +limits, the latter being somewhat indefinite, owing to the +difficulties in the way of exactly measuring the fluid transuded. The +greater part of this transudation is represented by the quantity of +lymph flowing through the main lymph-trunk, and of the secretion from +the glandular surfaces of a given region of the body; but that +transuded fluid is not included which may return to the blood-vessels +without being carried into the general lymph-current or secreted from +a gland. Such a direct return may be considered to take place whenever +the pressure upon the outside of the vessel wall is greater than that +within the latter, or when the chemical composition of the fluids on +the two sides of the filter permits endosmosis as well as exosmosis. +This varying relation in the direction of the current through the +vessel wall is likely to be of frequent, if not constant, occurrence +in connection with the physiological processes taking place throughout +the body. + +The undue accumulation of the transudation in the various closed +cavities of the body is known as dropsy, and the fluid present is +regarded as an effusion or an exudation. These terms are often applied +somewhat vaguely, now being used as synonymous, again as representing +different conditions of the transudation, which are attributed to the +varying conditions of its accumulation. + +Exudation is more generally used when an inflammatory process is the +cause of the increased transudation, while effusion is more strictly +associated with causes other than inflammatory. In the present +consideration this etiological distinction will be maintained. + +To appreciate the conditions under which pathological accumulations of +fluid, whether effusions or exudations, may arise, it is desirable to +bear in mind the essential conditions which prevail in the occurrence +of transudation, since the former are likewise chiefly derived from +the blood and are transuded through the walls of its vessels. These +conditions are largely dependent upon the laws governing the diffusion +of substances through an animal membrane, the vascular wall +representing the filter. As a living membrane its relation is +dependent upon vital as well as {68} physical conditions, and the +former produce certain important modifications in the physical process +of filtration. + +The transudation through the vessels takes place chiefly through those +with the thinnest walls, the capillaries, although it is probable that +a certain degree of transudation may also occur through the walls of +the smallest veins. The causes which are instrumental in promoting the +circulation of the blood--viz. the contraction and dilatation of the +heart, the contraction of the arteries, the inspiratory action of the +thorax, and muscular movements throughout the body--are also essential +in producing the flow of lymph; and the existence of pressure upon the +haemic side of the filter is the first feature of importance in +occasioning the transudation. The constant removal of the transudation +from the outer side results from the pressure being less in this +position. + +At the same time, an increase in the quantity of blood in the vessels +is not necessarily productive of any considerable increase in the +fluid transuded. Cohnheim calls attention to the experiments of Worm +Muller, which show that a plethoric condition may readily be produced +by the injection of quantities of blood into the circulation of +animals, the amount of which cannot exceed twice the volume of the +animal's blood without producing death. Although a temporary increase +of the blood-pressure results, a return to the normal quickly follows. +This is permitted by the propulsion of the excess of blood into the +capillaries and veins, which become consequently distended, especially +those of the abdominal organs. There is no increased transudation +corresponding with the quantity of fluid introduced, nor is there any +considerable distension of the blood-vessels of the skin, subcutaneous +or intermuscular connective tissue. Such experiments show no permanent +increase in the blood-pressure within the large veins if there is no +obstruction to the admission of venous blood into the heart, +presumably owing to their capacity for considerable distension. + +Although experiments show that a simple plethora with great distension +of the capillaries of the abdominal organs occasions no considerable +increase of transudation, a different result follows a hydraemic +plethora[25] induced by the injection of immense quantities of salt +water into the blood-current--often six times as much liquid as the +animal had blood. Here, too, the arterial blood-pressure shows no +permanent increase, nor does that within the large veins become +perceptibly increased till enormous quantities of fluid are injected. +The blood flows through the vessels with increased rapidity in +consequence of the diminished friction of the diluted blood, and an +increased transudation begins at once. The various glands, salivary +and gastro-intestinal, kidneys and liver, secrete more copiously, and +the flow of a dilute lymph from the thoracic duct becomes greatly +increased, while that from the cervical lymphatics becomes moderately +accelerated. The lymph from the extremities, however, is no greater in +quantity than that flowing from an animal in a perfectly normal +condition. The localization of the increased transudation from the +blood-vessels is further characterized by the abundant accumulation of +watery fluid in all the abdominal organs and abdominal cavity, in the +salivary glands and surrounding connective tissue, while elsewhere in +the body the organs and tissues are almost invariably in the same +condition with {69} regard to moisture as are those of a healthy +animal under normal circumstances. + +[Footnote 25: Cohnheim and Lichtheim, _Virchow's Archiv_, 1877, lxix. +106.] + +The importance of these experiments with reference to the causes of +the transudation of fluid from the blood is obvious. The pressure upon +the walls of the blood-vessels cannot become sufficiently increased to +be accompanied with augmented transudation until limits are reached +which are beyond the possibilities of occurrence in the human body. +When such limits are attained in animals, the increased pressure, +however great it may be, does not suffice to produce a general +transudation, but one limited to the vessels of those parts of the +body whose normal function is connected with too abundant transudation +of fluid. A simple hydraemic condition of brief duration has been +proven, by experiment, insufficient to give rise to increased +transudation, neither increased secretion nor increased flow of lymph +taking place. The inference from these experiments is that an +increased transudation is more dependent upon conditions of the filter +than upon those of blood-pressure. The absence of any observable +changes in the filter leads to the assumption of an increased +permeability, of physiological occurrence in certain parts of the +body, as the chief feature in the occurrence of increased +transudations. + +Dropsy arises when the transudation is accumulated. As dropsical +accumulations are transudations from the blood, essentially +blood-serum with a diminished percentage of albumen, and as such +blood-serum is practically lymph from its presence in the +lymph-vessels, dropsical effusions are to be regarded as stagnant +lymph. Such stagnations may be present in the small lymph-spaces +within the connective tissue, or in the larger lymph-sacs, as the +peritoneal, pleural, pericardial, and scrotal cavities. In like +manner, the stagnation may take place in the cavities of joints and in +those of the brain and cord, although the latter represent functional +rather than structural lymph-canals. + +The term oedema is applied to the accumulation in the +connective-tissue lymph-spaces in general, while the term anasarca is +confined to those cases where the subcutaneous lymph-spaces are +concerned. The accumulation in the great lymph-cavities is known as +ascites when peritoneal, hydrothorax when pleural, hydropericardium +when pericardial, hydrocele when in the cavity of the tunica +vaginalis, hydrocephalus if within the ventricles of the brain, and +hydromyelocele when within the central canal of the spinal cord. + +The accumulation of dropsical effusions may be considered as possibly +resulting from an obstruction to the channels through which the +transudation should flow, or from insufficient force to overcome +normal obstructions, or from an abnormally increased transudation. + +Lymph-channels are frequently obstructed, but no appreciable diffused +retention of lymph results unless the thoracic duct is obstructed. +This rare affection is followed by enormous distension of the thoracic +and abdominal portions of the parts beyond the stenosis. Ascites and +hydrothorax may follow, but not necessarily any considerable oedema of +the peripheral parts of the body. As a result of the distension of the +thoracic duct, rupture is not unlikely to take place, and the effused +fluid contains chyle.[26] + +[Footnote 26: Quincke, _Deutsches Archiv fur Klin. Med._, 1875, xvi. +121.] + +{70} That the obstruction is not followed by oedema is attributable to +the innumerable anastomoses between the lymph-spaces, and also to the +probability that a part of the transuded fluid returns to the +blood-vessels when the obstruction is impassable. + +The forces necessary to promote the flow of lymph have already been +mentioned, and their entire removal is inconsistent with life. A +diminution of their activity is more likely to result in a diminished +flow of lymph than its accumulation, although a slowing of the +lymph-current may represent a favoring element in the accumulation of +an increased transudation. + +The occurrence of dropsy with unobstructed lymph-channels, and in the +presence of efficient agencies in promoting the flow of lymph, +indicates the importance of an increased transudation as the chief +element in the occurrence of a dropsical accumulation. An increased +transudation, with resulting oedema, is readily produced by preventing +the flow of blood from a part, and may be directly observed with the +microscope. Cohnheim states that after a sudden venous obstruction, in +case an efficient collateral circulation does not interfere, the +capillaries and small veins become distended with stagnant blood and +appear as masses of red blood-corpuscles. This distension results from +the continuance of the arterial flow into the capillaries of the +obstructed region under a pressure which is only neutralized by the +resistance of the tissues and the transudation from the capillaries. +Sotnitschewsky[27] shows that a concurrent paralysis of the vaso-motor +nerves, as claimed by Ranvier, is unnecessary. The transudation +through the capillary wall is increased, the flow of lymph from the +part is accelerated, and oedema arises when the transudation is so +much augmented that the calibre of the lymph-vessels is insufficient +for its removal; and the greater this insufficiency the greater is the +oedema. With the continuance of the arterial flow and intravenous +resistance, red blood-corpuscles are forced through the filter, and +form an important constituent of the effusion from venous stagnation. + +[Footnote 27: _Virchow's Archiv_, 1879, lxxvii. 85.] + +Although the existence of an increased pressure upon the capillary +wall is obvious from the experiment referred to, there is no increased +arterial pressure--rather a diminution--and the important element in +occasioning the increased permeability of the capillary wall is the +obstruction to the outflow of venous blood from the oedematous region. +In consequence of the latter the arterial flow is followed by +increased transudation. + +Dropsies resulting from venous obstruction, as well as those following +an obstruction of the thoracic duct or its branches, or of the several +lymphatics of a part, are classified as mechanical dropsies. That from +venous obstruction is the most frequent, and its seat may lie in the +course of venous trunks or in the heart, lungs, or liver. The venous +obstruction must be so situated that the stagnant blood is unable to +find a ready escape through collateral branches. The more sudden and +complete it is, the more likely is the effusion to contain +considerable numbers of red blood-corpuscles. + +In addition to the element of venous stagnation in producing increased +transudation, the condition of the filter is of importance. The +occurrence of oedema in chronic diseases, especially of the kidneys, +and in those attended with protracted suppuration, continued +hemorrhage, and the {71} rapid growth of tumors, has usually been +attributed to the watery condition of the blood, with a diminution of +the albumen. Cohnheim, however, suggests that the condition of the +vessel wall is of more importance than the contents as the immediate +cause of the increased transudation. The more or less protracted +action of various agents--temperature, insufficient oxygen, and +diminished albumen--is likely to so modify the condition of the +endothelium as to favor an increased permeability of the wall. +Experiments show that a simple acute hydraemia produces no increased +transudation, and that a chronic hydraemia, if connected with dropsy, +is likely to be influential by increasing the permeability of the +wall. Even in those cases where a hydraemia and an oedema co-exist, +the localization of the latter is favored by obvious disturbances of +the function of the capillary walls, as in case of the cutaneous +oedema after scarlatina. In like manner, a feeble heart, favoring +venous stagnation, and gravitation are of importance, as general +causes, in promoting dropsy in hydraemic conditions. + +The possibility of the occurrence of oedema through nervous influence +is not to be denied. The localized and fleeting oedema of urticaria +and erythema, the swollen lip and tongue in connection with digestive +disturbances, are not to be explained by the two main factors of +oedema--viz. venous stagnation and increased permeability of the +vascular walls. Cohnheim refers to the rapid occurrence of oedema of +the tongue as a result of irritation of the lingual nerve, and oedema +is known to occur rapidly in cases of acute myelitis. A similar result +follows the experimental destruction of the spinal cord, although the +mechanism of its production is not apparent. + +Dropsies are subdivided, as regards their distribution, into general +and local forms. The causes producing the two varieties are +essentially those already described. The causes of all local dropsies +are not always to be regarded as the same. Regions which are the seat +of mechanical dropsies are often affected by inflammation, with +abundant serous exudation--the so-called inflammatory dropsy. The +properties of the effusion and exudation are quite different, the +former having a small percentage of albumen, but few leucocytes, with +a corresponding absence of fibrin, and few or many red +blood-corpuscles. The exudation, on the contrary, is highly +albuminous, though less so than the blood-plasma; it contains numerous +leucocytes and much fibrin; under ordinary circumstances there are but +few red blood-corpuscles. + +The local dropsies are often characterized by special terms. Hydrops +ex vacuo is applied to the collections of fluid found in closed +cavities with unyielding walls, as the cranium and thorax, or to the +recurrence of fluid in cavities from which the same has been rapidly +removed, in the absence of inflammatory disturbances. Collateral +oedema is usually applied to the association of oedema with +inflammatory disturbances, and represents an extension of the +inflammatory process to the region concerned. Oedema of the glottis +and circumscribed oedema of the lung are instances. The term +hypostatic oedema is often used to designate the association of oedema +and inflammation, the former caused by the latter, and to indicate the +effect of gravitation in the localization of oedema from the general +causes already mentioned. + +Another localized oedema of interest, from its frequent occurrence and +{72} importance, is oedema of the lungs, often taking place toward the +end of life, at times quite suddenly. This form has usually been +attributed to increased transudation from arterial congestion or +venous stagnation. The former view is directly refuted by the +experiments of Welch,[28] who offers the explanation now accepted. +With the obliteration of three-fourths of the arterial supply to the +lungs of the animals experimented upon, no oedema resulted from the +assumed collateral fluxion into the branches of the pulmonary artery +which were left open. The obliteration of the same area of venous +distribution was necessary before the occurrence of oedema. Oedema of +the lungs was further found to result from a ligature of the aorta +near the heart. The comparative frequency of oedema of the lungs in +man, and the rarity of such extreme mechanical disturbances as those +produced experimentally, led Welch to paralyze the left ventricle. The +conditions as regards the pulmonary circulation then corresponded with +those mentioned as causes for oedema from venous obstruction. The +continued action of the right ventricle forced blood into the +pulmonary capillaries, where it was compelled to accumulate in +consequence of the inability of the left ventricle to receive and +expel it. Welch consequently regards the immediate cause of this form +of pulmonary oedema as a predominant weakness of the left ventricle. A +weak heart does not suffice for the production of the oedema, since +this condition is not found when both ventricles are alike enfeebled. + +[Footnote 28: _Virchow's Archiv_, 1878, lxxii. 375.] + + +Degenerations. + +The degenerations represent disturbances in the nutrition of the +tissues of the body, in consequence of which their functions become +impaired, if not destroyed. The latter result obviously attends the +death of cells, which may occur in the course of the degeneration. The +processes concerned are called necrobiotic by Virchow, as they +represent vital processes leading to death. Although in many of them +the cell is decaying during their continuance, its recovery is +possible with the disappearance of the conditions which have +transformed physiological into pathological processes. The +degenerations affect intercellular substance as well as cells, and are +called metamorphoses, infiltrations, or degenerations, as a +transformation of normal into abnormal material, or the addition of +extraneous substances, or the functional impairment of the part +assumes the greatest prominence. + + +_Cloudy Swelling, Albuminoid Infiltration, Granular Degeneration, +Parenchymatous Degeneration._ + +Of the various modifications in the appearance of cells under +pathological conditions, there is none, perhaps, more commonly met +with than that known by the above terms. A granular appearance may be +regarded as an essential characteristic of protoplasm, and is an +attribute of cells of epithelial origin as well as of those which +belong to other groups of tissues. The abundance of granules present +in a normal cell depends largely upon its shape, size, and situation. +These granules present various {73} relations to chemical agents, some +being soluble in alcohol and ether, others in acids and alkalies, and +many of them, especially those met with in the form of degeneration +now being considered, show from the various reactions that they are of +the nature of albumen. Since their exact composition, in all +instances, is undetermined, they are called albuminoid, and when in +excess the cell is considered to be infiltrated with these granules, +and the organ presents the appearances regarded as characteristic of +an albuminoid infiltration. A granular cell becomes much more granular +when it is thus infiltrated, and it is therefore a matter of +difficulty to recognize from the appearance of certain single cells, +as those of the liver or kidney, whether or not the number of granules +present is abnormally increased. When, however, a large number of +cells of any given organ contain more than the normal quantity of +these albuminoid granules, the appearance of the organ becomes +modified. In extreme cases the latter is swollen, doughy in +consistency, with ill-defined structural details, and in all instances +presents an opaque appearance. The term cloudy swelling is thus purely +descriptive, and was applied by Virchow to designate the optical +appearances of the condition in question. The granules, which +disappear on the addition of acids and alkalies, are apparently either +added to the cell or result from a precipitation within the same. + +Frequently associated with these albuminoid granules are others, +distinctly recognizable as globules of fat. An apparent increase of +nuclei is often observed, and in certain organs, as the kidneys, the +cells seem less coherent than is normally the case. The study of this +condition in the kidneys is further of interest as indicating that the +border-line between a parenchymatous degeneration and a parenchymatous +inflammation is purely arbitrary. From similar exciting causes there +may be associated, with the described alterations of the epithelial +lining of the tubes, the exudation of albumen, the formation of casts, +the desquamation of epithelium, and the presence of leucocytes within +the tubules. + +When the macroscopic changes are of moderate degree, and the +disturbance of function relatively slight, while the concurrent +alterations elsewhere, from the simultaneous action of the same cause, +are predominant and characteristic of the disease, the condition is +conveniently regarded as a degeneration occurring in the course of the +latter, rather than an inflammation. The latter term, on the contrary, +is to be applied when the granular infiltration of the cells is +associated with other evidences of an inflammatory exudation, and when +the pathological disturbances are to be directly attributed to the +parenchymatous changes. + +It is customary to speak of cloudy swelling as a nutritive change, and +the condition may be induced by those causes which interfere with the +nutrition of parts or of the whole of an organ. Many authorities +regard this granular or parenchymatous degeneration as closely allied +to fatty degeneration, since many of the causes which produce the one +occasion the other. The former is often spoken of as an earlier stage +of the latter, from the frequent association of the albuminoid +granules with numerous globules of fat as a result of the more +prolonged or more intense action of a given cause. + +Organs which give evidence of a granular degeneration contain, as a +rule, a diminished quantity of blood. This feature is usually +attributed to the pressure of the swollen cells upon capillary +blood-vessels. The {74} anaemic organ obviously becomes still more +cloudy, gray, and opaque in appearance from the diminished quantity or +impoverished quality of the blood. + +The granular degenerations of the heart, liver, and kidneys, as a +whole, usually occur simultaneously, and afford a most important means +for the post-mortem recognition of the infective diseases. The +condition is therefore to be looked for in the exanthemata, especially +in small-pox and scarlet fever, also in erysipelas, septicaemia in its +manifold forms, diphtheria, typhoid and typhus fevers, cerebro-spinal +meningitis, etc. A common feature in all these cases is the occurrence +of fever, and it has been claimed that this element is the cause of +the degeneration. In opposition to this view is the well-known fact of +its presence in afebrile cases of poisoning from carbonic oxide, and +its absence in certain cases of pneumonia and exposure to high +temperatures. + +The universal occurrence of cloudy swelling in fatal cases of the +affections above mentioned leads to the inference of its presence in +those instances terminating in recovery without obvious permanent +impairment of the organs and tissues concerned. It is therefore agreed +that the process may terminate in resolution--_i.e._ in a +disappearance of the excess of granular material. On the other hand, +its association, under circumstances, with fatty degeneration suggests +as extremely probable that the latter condition may represent a result +of the albuminoid infiltration. Even if this more serious issue +exists, the possibilities are still at hand for an absorption of the +degenerated material and a restitution of the destroyed protoplasm. +The effect upon the individual is evidently determined by the +persistence and dissemination of the condition, which, in turn, are +controlled by the immediate cause and the peculiarities of the +individual acted upon. + + +_Fatty Metamorphosis, Fatty Degeneration, and Fatty Infiltration._ + +The fat which is present within the body under physiological +conditions owes its origin primarily to the food taken. A diet which +is abundantly fatty furnishes a direct source for much of the fat +which appears accumulated in the various organs and tissues. Although +it may now appear that such a statement needs but little confirmation, +it is not long since the opinion prevailed that nearly all the fat in +the body came from the hydrocarbons of the food. This seemed all the +more plausible as the herbivora readily accumulated fat, although +their diet might contain this element in very small quantities. +Hofmann[29] made a decisive experiment with reference to the origin of +fat from fatty food by feeding a dog, made lean by starvation, with +bacon in abundance, but with little meat. In the course of a few days +the greater part of the fat introduced was deposited within the +tissues of the animal. Other experimenters have arrived at a similar +result, and it can no longer be questioned that fat, accumulated +within the body, owes its origin chiefly to the absorption of fat from +the food taken. + +[Footnote 29: _Zeitschrift fur Biologie_, 1872, viii. 153.] + +Another source for the fat of the body has long been +suggested--namely, the albuminates of the food. In the admirable +article on the formation of fat by Voit,[30] from which most of the +information herein {75} presented is derived, it is claimed that he +and Pettenkofer were the first to prove the origin of fat in the body, +under normal conditions, from albumen. This proof was an inference, +however, although presenting a high degree of probability. Valuable +evidence in the same direction was furnished by Kemmerich, who found +that the milk of a cow during a certain period held more fat than was +contained in the food; Subbotin and Voit have shown that more milk is +secreted the richer the diet in albumen. Still other observers have +furnished more decisive proof that fat is formed from albuminates. + +[Footnote 30: _Hermann's Handbuch der Physiologie_, 1881, vi. 1, 235.] + +Two sources for fat in the body under physiological conditions are +thus recognized: 1, the free fat in the food; 2, the fat derived from +the decomposition of the albuminates of the food. + +Voit admits the possibility of the hydrocarbons serving as a third +source, although this possibility is unnecessary in most cases. Should +instances arise, however, where other sources for fat are found +insufficient, the hydrocarbons must be regarded as filling the gap. + +Fat which is taken into the body is considered to be either consumed +or stored. That which is stored is chiefly accumulated in the great +reservoirs--viz. the subcutaneous and perinephritic fat tissue, the +mesentery, omentum, and bone-marrow--although it may be found +elsewhere, in the fluids and tissues of the body. This accumulation +serves as a source to be drawn from in case of need, and is called +upon where the easily-decomposed soluble albumen is disposed of by the +functional activity of the cells. An acting muscle demands food for +its work, and consumes first the soluble albumen, then the fat. An +excessive waste of fat is delayed by the decomposition of +hydrocarbons, but the demands may become so great that albumen, fat, +and hydrocarbons are consumed more rapidly and constantly than they +can be supplied. It being, therefore, admitted that fat is formed from +the albuminates, as well as from the fat of the food, the question +readily presents itself whether fat may not be formed from the fixed +albuminates of the body, especially from those contained within its +cells. + +It is well known that in the secretion of sebum the superficial cells +of the sebaceous follicles contain fat in great quantity, while the +deeper layers are comparatively free from any appearances indicative +of the presence of fat. It is further admitted that when pus is +retained for a time the individual corpuscles contain fat-drops in +quantity and become transformed into fatty granular corpuscles. +Eventually, the pus is transformed into a detritus in which fat-drops +are found in great number. + +Similar appearances may be present in the protoplasm of muscular +tissue, the cells of the liver, kidneys, and gastric glands, when +poisonous doses of phosphorus or arsenic are given. The occurrence of +an acute fatty metamorphosis of the cells of various organs in +new-born children has repeatedly been observed. The presence of fat in +various organs of the body in pernicious anaemia, and in the heart in +connection with stenosis of the coronary artery, is universally +recognized. The abuse of alcohol, long-continued obstruction to the +flow of venous blood, exposure to high temperatures, are all known to +be conditions in connection with which fat-drops are found in the +various cells of the body. The effects of poisoning with phosphorus +and arsenic are of special importance, as showing that the abundance +of fat present in the cells represents a result of the degeneration of +these cells, {76} since it takes place when the animal is deprived of +food. Although there is an evident destruction of albumen, there is +also a diminished elimination of carbonic acid and admission of +oxygen. These facts are explicable on the ground that the fat present +is not consumed, and the accumulation in the cells is evidence of this +lack of consumption. The fat is not simply stored, as none is taken +in, nor is any food received from which fat might be formed. Its +presence, therefore, must be regarded as due to degeneration. + +Since fat may be formed in the body as a result of the metamorphosis +of cell-protoplasm, it is desirable to ascertain whether there are any +means by which stored fat may be distinguished from that present as +the result of a degeneration of the cell. The term fatty infiltration +has been used to indicate the presence of stored fat, the latter being +regarded as simply taken into the cell and retained for a longer or +shorter time, without any necessary interference with other functions +possessed by the cell. + +In fatty degeneration, on the contrary, it is considered that the +quantity of fat present indicates a corresponding diminution in the +albuminates of the cell, and is connected with a diminution in the +function of the latter, all the greater the more abundant the fat. + +It is found that in fatty infiltration, as a rule, the fat is present +in large drops, the size of the cell being increased in proportion to +the quantity of fat present. Although there may be several drops +present, they tend to run together, as is suggested by their different +size, varying proximity, and the constant presence of a considerable +quantity of protoplasm. In organs, on the contrary, whose function is +seriously, even fatally, impaired, the fat, as a rule, assumes rather +a granular form. Many minute fat-drops are present, and the cell is +not particularly, if at all, increased in size. The more abundant the +fat the less the protoplasm. Appearances are met with indicating a +transition between cells with few fat-granules and those with many. + +If the morphological appearances of fatty infiltration and of fatty +degeneration were constant, there would obviously be little or no +difficulty in determining the nature of the process manifested by the +presence of fat. The exceptions occur both in fatty infiltration and +fatty degeneration. In the cells of the liver of an animal poisoned +with phosphorus fat makes its appearance in large drops, while in the +heart and kidneys of the same animal the fat is present in a granular +form. + +During absorption from the intestine in the process of digestion fat +is present in the epithelium in a finely granular form. When digestion +is completed fat is no longer met with in these cells. The presence of +large or small drops, therefore, cannot be regarded as a sufficient +test of the origin of the fat. It is of equal, if not greater, +importance to bear in mind the organ concerned. + +In the heart, liver, kidneys, and gastric glands, as well as +elsewhere, with the exception, perhaps, of the mammary gland, the +presence of many small fat-drops in the cells indicates a degeneration +of its protoplasm. The presence of large fat-drops, on the contrary, +in the organs and tissues, with the exception of the liver, indicates +an infiltration. Large fat-drops, then, may be present in the cells of +the liver as the result of an infiltration or of a degeneration. In +order to form a satisfactory opinion of the {77} nature of the +appearances in the liver in doubtful cases, it is important to note +the condition of those organs which may be simultaneously in a state +of fatty degeneration. + +The accumulation of fat under physiological conditions is obviously +brought about, on the one hand, by those causes which permit a free +introduction, absorption, and deposition, and, on the other, by those +which check its oxidation or elimination with the secretions of the +body, as the bile, in which it may be present to a considerable +extent. A diet rich in fat, or in albuminates readily converted into +fat, offers a favorable element for the absorption of fat by the +healthy individual. If the organism demands but little of this fat for +oxidation, as in the case of the sedentary person, an accumulation is +likely to occur. This may become so considerable that obesity results. +Tissues in which normally but little fat is accumulated may become +infiltrated to a large extent. The intermuscular fibrous tissue thus +becomes loaded, and the activity, as well as the nutrition, of the +muscles is impaired. This accumulation may be manifested not only in +the voluntary muscles, but in the heart as well, which may present +abundant sub-pericardial and sub-endocardial fat, the myocardium also +being interlarded with streaks of fat, the so-called fatty +infiltration of the heart. The abdominal walls may become thickened to +the extent of a couple of inches, and the mesentery, omentum, +perinephritic tissue, and liver may become enormously increased in +weight from the mass of accumulated fat. + +This infiltration of fat may take place under pathological as well as +physiological conditions. It is apparent that those causes which check +oxidation are likely also to prevent the consumption of fat, and it is +well known that the destructive processes in the lung, grouped under +the term pulmonary consumption, accomplish this result. Something +more, however, is necessary than the obliteration of pulmonary +blood-vessels and the destruction of an aerating surface. There may +be, as in emphysema of the lung, a diminished respiratory and vascular +surface, yet evidences of fatty infiltration, particularly of the +liver, are wanting. It seems probable that the constant anaemia, with +the loss of the blood-corpuscles, of pulmonary phthisis is an +important additional factor in checking oxidation in this disease. +This factor, it is needless to say, is not a necessary occurrence in +pulmonary emphysema. + +Litten[31] has shown that when certain animals are exposed to high +temperatures the appearances of fatty infiltration and degeneration +are present in various organs of the body. He attributes the fatty +degeneration to a direct poisoning of the red blood-corpuscles and a +resulting diminution of the oxidizing processes. + +[Footnote 31: _Virchow's Archiv_, 1877, lxx. 10.] + +It is universally admitted that in chronic alcoholism a fatty liver is +frequently met with, even in the absence of those chronic interstitial +tissue-changes usually characterized under the name cirrhosis. Alcohol +is known to check the reception of oxygen and the elimination of +carbonic acid, and, whatever other disturbance of cell-activity it may +produce, its effect in favoring the accumulation of fat is directly +attributable, in part at least, to this disturbance of oxidation. + +In those conditions known as cachexiae, the constant accompaniment of +progressive and wasting diseases, as cancer, leucaemia, chronic +dysentery, {78} etc., a fatty infiltration, particularly of the liver, +is a frequent accompaniment. A cachexia is dependent upon a complex +series of processes, many of which tend to check oxidation, and in +this respect is to be grouped with the conditions previously +mentioned. That the associated fatty infiltration is intimately +connected with the deficient oxidation is not to be doubted, although +the agents producing this deficiency may vary in detail. + +The causes which favor fatty degeneration are numerous, and the result +represents one of the most serious conditions which can affect an +organ. As oxidation represents the chief means of normally disposing +of fat, so, pathologically, deficient oxidation favors the retention +of fat due to degeneration. Were a constant renewal of protoplasm to +take place, the degenerated fat might be displaced into the +circulation or retained within the cell. If the latter event should +occur, the result would be apparent as an infiltration, owing to the +increased size of the cell, although the condition giving rise to the +presence of the fat is a degenerative process. The importance of +impairment of nutrition as the chief cause for fatty degeneration is +thus obvious. It may readily be produced, experimentally, by measures +which check the flow of blood to a part. The same measures necessarily +prevent the presence of abundant oxygen, as fewer red blood-corpuscles +are presented. + +Fatty degeneration resulting from impaired nutrition is apparent in +the heart in consequence of stenosis of its coronary arteries, in the +kidneys as a result of interstitial processes obstructing the +capillary circulation, in the brain from obliterative processes in the +arteries at the base or within the organ, and in blood-vessels from +the effect of age. + +The cause of fatty degeneration may be general as well as local. In +poisoning from phosphorus and arsenic the appearances in most of the +organs indicate an actual destruction of protoplasm. Analysis of the +secretions confirms this inference, as the production of urea is +largely increased. Furthermore, there is less oxygen taken in and less +carbonic acid eliminated. As has been previously stated, these +conditions may be present in the starving animal. The fatty +degeneration is thus easily explained as a metamorphosis of +cell-protoplasm, and the deficient oxidation of the fat calls direct +attention to its accumulation rather than elimination. + +In acute yellow atrophy of the liver and in cases of severe jaundice +fatty degenerations are constantly met with. That the origin and +accumulation of fat in these affections is also due to rapid +tissue-metamorphosis and checked oxidation is highly probable. +Although the elimination of urea diminishes rather than increases, as +shown by Schultzen and Riess, there are other links in the chain of +retrograde changes, as the appearance of leucin and tyrosin, +indicative of the extensive destruction of albuminates. + +It is unnecessary in a work of the present character to call attention +to all the possible circumstances under which fat is present in the +body as the result of degeneration. Mention may be made of the acute +parenchymatous (fatty) degeneration of new-born children, of the +results of excessive bleeding, and of pernicious anaemia otherwise +occasioned. The fatty degeneration of the uterus after parturition, of +paralyzed muscles, and of tumors, the atrophic fatty degeneration of +the liver in chronic {79} passive congestion (nutmeg liver), are all +well-known examples. To these may be added the fatty degenerations +associated with amyloid and interstitial processes. It is apparent +that in most of these instances the common features of rapid +tissue-metamorphosis and deficient oxidation are present, and, being +present, offer a ready explanation for the appearance of the fat. + +The clinical importance of fatty metamorphosis requires consideration +in connection with the description of the diseases in which its +occurrence is a constant feature. As the presence of fat in cells is +not necessarily pathological, so an interference with the function of +the cell is not invariably implied by its presence. When its existence +is suggestive of a local destruction of albuminates, a diminution of +cell-activity is a necessary consequence. Such diminished activity +must produce different results as the cells are those of muscles, of +vessels, or of glandular organs. + +Even if fat is found in cells under conditions favoring such a +suggestion, it does not follow that the destruction of the cell must +result. Not only is it possible that the fat may be reserved for +eventual oxidation, and its place in the protoplasm be filled by +normal constituents, but it is also possible that the fat may be +eliminated, as such, from the body. The latter event is made apparent +by the experiments of numerous observers referred to by Cohnheim, who +have found free fat in the urine after its introduction into the +venous current. + + +_Cheesy Metamorphosis, Cheesy Degeneration, Caseation._ + +Virchow introduced the term cheesy metamorphosis, tyrosis, to +designate the process resulting in the incomplete absorption of pus +and the production of apparently similar changes in certain other +occasional constituents of the body. The characteristic cheesy +appearances were regarded as due to the inspissation of the material +concerned, in consequence of the absorption of its fluid. With this +inspissation there was frequently associated a partial fatty +degeneration, and the cheesy matter represented dead material, which +might undergo further changes, of which softening and calcification +were the more important. + +Inflammatory products, as pus and fibrin, were especially prone to +become thus transformed, as well as other relatively transitory +materials of new formation--viz. tubercle and parts of various tumors. +The type of the cheesy metamorphosis was found in the enlarged +lymphatic glands, commonly called scrofulous. + +The importance of a clear understanding of the cheesy metamorphosis is +now a matter of history. It is merely necessary to allude to the fact +that these cheesy products were formerly regarded as indicative of the +presence of tubercle, and were the tubercles. Tuberculization and the +cheesy condition were synonymous terms, and their indiscriminate use +led to much confusion with reference to the nature of tubercle. + +Quite recently Weigert[32] has called attention to the conditions +present in necrosis resulting from the intermediate stoppage of the +blood-current in a part. The effect is manifested, under favoring +circumstances, by a cheesy appearance of the affected region, to which +the terms decolorized hemorrhagic infarction, anaemic or ischaemic +necrosis, have been applied. {80} Weigert lays stress upon the +existence of a coagulation of the protoplasm of the cells, with an +early disappearance of the nuclei, as the essential feature of this +form of necrosis, the conditions present being regarded as analogous +to those met with in the coagulation of the blood. The term +coagulative necrosis has consequently been introduced by Cohnheim to +represent the process first fully described in detail by Weigert. The +optical and physical properties of the ischaemic or coagulative +necroses of tissue are often manifested as cheesy appearances, +although the term coagulative necrosis includes conditions which do +not present a suggestion of cheese. It is thus apparent that cheesy +appearances may result in two ways: 1, by the inspissation of material +in a state of partial fatty degeneration; 2, by a coagulation of the +constituents of cells whose blood-supply is suddenly and completely +cut off. In the more restricted sense these caseous appearances are +regarded as indicative of a cheesy metamorphosis which arises by the +former of these methods. Cheesy appearances, on the contrary, +dependent upon the sudden death of a part, indicate an ischaemic or +coagulative necrosis. + +[Footnote 32: _Virchow's Archiv_, 1880, lxxix. 87.] + +Whatever may be the origin of the cheesy condition, the material +presenting this appearance is liable to further changes, known as +softening and calcification. The former event results from the soaking +of the dead part with liquid, in consequence of which a detritus +results. The softening usually begins at the oldest part of the cheesy +mass, and advances toward the periphery. The sanatory evacuation of +the emulsive detritus is permitted when a surface continuous with that +of the external surface of the body is reached, as instanced by the +escape of softened cheesy material from the lungs through a bronchus. +The possibility of the complete removal of the dead mass is thus at +hand, and an eventual obliteration of the resulting cavity may take +place by an adhesive inflammation of its walls. + +The complete absorption of the cheesy material of an ischaemic +necrosis may occur by the extension into the latter of a +granulation-tissue from the periphery. Whenever cheesy appearances are +found on surfaces, as the degenerated tubercles of mucous membranes or +the circumscribed necroses in diphtheritic inflammation or in typhoid +fever, healing may be accomplished by their detachment as sloughs, a +clean ulcer being left. Cheesy material is frequently +encapsulated--_i.e._ imbedded in a layer of dense connective tissue, a +condition which indicates a local cessation of the process through +which the cheesy appearances arose. The same may be said of the +infiltration of the cheesy mass with earthy salts--calcification--an +event which will again be referred to in connection with the +consideration of the general subject. + + +_Hyaline Degeneration, Fibrinous Degeneration, Croupous +Metamorphosis._ + +Certain of the conditions now regarded as indicative of a coagulative +necrosis or a hyaline degeneration were previously described by Wagner +as the result of a croupous or fibrinous metamorphosis. According to +this observer, the cell-contents were transformed, under certain +circumstances, into a substance resembling externally clotted fibrin. +The formation of croupous and diphtheritic membranes, especially of +the larynx, pharynx, and trachea, was thus explained, also the hyaline +casts of the kidney. + +{81} The results of this metamorphosis presented a hyaline appearance +under the microscope, and the term hyaline degeneration is now applied +more especially to indicate the production of microscopic changes, +while the hyaline appearances visible to the eye are rather included +under mucous, colloid, or amyloid metamorphoses. + +The limitations in the use of the term hyaline degeneration are but +ill defined. On the one hand, there is included the transformation of +muscular tissue, first discovered by Zenker; on the other, the various +changes described by Recklinghausen and others, among which are +embraced the results of Wagner's croupous metamorphosis. As the +hyaline appearances are a frequent result of coagulative necrosis, +these terms are frequently used to indicate the same condition, +according as the optical or etiological features are uppermost in the +mind of the observer. + +The hyaline or waxy degeneration of muscular fibre described by Zenker +represents a metamorphosis of the protoplasm of striated muscle in +particular, although the fusiform cells of the muscular coat of the +stomach and intestine may present a similar transformation. + +The microscopic appearances are more characteristic than those visible +to the naked eye. To the latter the muscle appears paler, more +translucent, and homogeneous, and proves to be more brittle than +normal. The muscular fibres are found with the microscope to be +swollen, irregular in outline, the myosin transformed into flaky, +glistening masses, without evidence of the normal transverse +striation. These appearances have given rise to the term waxy +degeneration, which suggests a possibility of confusion with the +earlier recognized waxy degeneration of organs, due to the presence of +amyloid material. The waxy transformation of muscular fibre, however, +does not present the reaction with iodine characteristic of amyloid +substance. The degeneration of the muscle is usually regarded as the +result of a coagulation of the myosin, and it is claimed by Cohnheim +that the latter takes place only in dead muscle, either during the +life of the individual or as a post-mortem appearance. + +The hyaline degeneration of muscular fibre is found in certain febrile +diseases, as typhoid and typhus fevers, scarlatina, variola, and +cerebro-spinal meningitis. It may also be met with when a muscle has +been exposed to violence, as in the insane who have been placed under +mechanical restraint. It has further been found in the vicinity of +tumors, especially where muscles have been invaded by their growth. +Cohnheim and Weil describe a similar condition in the tongue of frogs +after ligature of the lingual artery. + +The pathological importance of the above-mentioned degeneration of +muscle is most prominent in cases of typhoid fever. The occurrence in +this disease of the haematoma or blood-tumor of the rectus abdominis +is thus explained, the degenerated muscle and its contained +blood-vessels being ruptured. The muscles of the thigh and the +diaphragm frequently undergo this degeneration; the change is more +rarely met with in other muscles of the body. + +Recklinghausen regards a hyaline substance, hyalin, as a normal +constituent of cell-protoplasm which escapes in drops when the cell +dies. Its presence indicates a diminution in the vitality of the cell +from various causes. Under the microscope it appears as a sharply +defined, highly refractive meshwork, enclosing spaces of irregular +shape and size, in {82} which are frequently found nuclei, more rarely +cells or granules. Langhans has described this appearance as +channelled fibrin. It has been met with in the placenta, diphtheritic +membranes, blood-vessels, tubercles, and gummata. + +The latest contribution to the history and nature of this form of +degeneration has been furnished by Vallat,[33] from whose article many +of the above data have been obtained. + +[Footnote 33: _Virchow's Archiv_, 1882, lxxxix. 193.] + + +_Mucous Degeneration, Mucous Metamorphosis, Mucous Softening._ + +Of the various degenerations presenting a colloid--_i.e._ +gelatinous--condition, the mucous variety is one of the most striking. +Its gross appearances may not differ materially from those to be +described under the head of colloid degeneration, but the diagnostic +characteristic of the change is to be found in the presence of mucin. +The presence of this substance is readily detected by the addition of +acetic acid to mucus, the effect being a fibrillated appearance of the +latter, the fibres presenting a more or less parallel distribution. +This fibrillation of mucus is regarded as the result of a coagulation +of its mucin, previously held in solution by an alkali. Mucin is thus +present in the body as a normal constituent, and, in the secretions +from mucous membranes, owes its origin to the existence of epithelial +cells, whether these represent gland-cells, as in the case of the +muciparous glands of the bronchial mucous membranes, or whether they +are superficial cells, as those of the gastric and intestinal mucous +membranes. + +In the origin of mucus as a secretion from glands Heidenhain[34] +claims that a destruction of gland-cells accompanies the continuance +of the secretion. At the outset, however, the mucin escapes from the +cells, the latter remaining relatively intact. With the persistence of +the secretion there results a destruction and a new formation of the +muciparous cells. In the pathological production of mucus from mucous +membranes, as in catarrh, there is no reason to doubt that the +persistence of an irritation is the cause of abundant mucus, and that +the latter is dependent upon the rapid formation and destruction of +epithelial cells. + +[Footnote 34: _Hermann's Handbuch der Physiologie_, 1880, v. 64.] + +The origin of mucus from epithelial cells under physiological and +pathological conditions being apparent, it readily follows that the +epithelioid cells of tumors might be supposed to be liable to a +similar metamorphosis. It is well known that cancerous tumors, +especially those of the stomach and large intestine, are frequently +met with, which present an abundant gelatinous material, more or less +completely filling the spongy, fibrous meshwork. These are the +alveolar, gelatinous, or colloid cancers. + +The gelatinous or colloid material often gives the reaction of mucin, +and the microscopic appearances of the tumor show that the jelly-like +substance lies in that part of the tumor which corresponds with the +position of the epithelioid cells. The latter are found in various +stages of degeneration, the appearances being similar to those +observed in the mucous degeneration of true epithelium. + +The prevailing theory of the origin of cancer from epithelial +structures {83} readily suggests an explanation for the frequency of +the mucous variety of cancer in connection with those parts from which +mucus normally arises from the degeneration of the epithelium. + +The mucous metamorphosis affects connective tissues as well as +epithelium. The Whartonian jelly of the umbilical cord and the +vitreous humor of the eye are known, through the investigations of +Virchow, to owe their gelatinous condition to the presence of mucin. +The latter lies in the intercellular substance; that is, between the +cells. The appearance of these indicates no degenerative process, but +the presence of mucin is obviously an essential constituent of the +tissue. Whether this mucin represents a transformation of the gelatin +of the intercellular substance, or a secretion from the fixed cells, +or a metamorphosis of the migratory cells of the tissue, is not known. +In mucous tissue, however, there is present mucin, wholly independent +of any epithelial degeneration. Mucous tissue is present in the eye as +a normal constituent of the adult, and in the umbilical cord as a +normal constituent of the infant at full term. It is also abundantly +met with in the subcutaneous and intermuscular tissues of the foetus. +Its pathological occurrence in the adult as a circumscribed tumor, the +myxoma, may also be mentioned. + +A gelatinous substance containing mucin is found in the adult +independent of the mucous tissue, but obviously arising from a +transformation of intercellular substance. The most striking example +of this occurrence is the cystoid softening of cartilage, especially +of the costal cartilages of old people, the basis substance being +transformed into a fluid containing mucin. A similar metamorphosis is +of frequent occurrence in the intervertebral disks and in the +destruction of cartilage in acute and chronic inflammations of the +joints. The intercellular substance of cartilaginous tumors also +becomes softened and converted into a liquid containing mucin. + +In osteomalacia and in the absorption of bone the mucous degeneration +of the bone-cartilage plays an important part. The lime salts are +first set free, and the cartilage then undergoes a mucous +degeneration; the product is either absorbed or remains as a liquid +within cavities of large or small size. The mucous metamorphoses of +fibrous and fat-tissues, likewise of bone-marrow, are well recognized +instances of the occurrence of a mucous transformation of the +intercellular substance of connective tissues. Finally, clotted +fibrin, so often met with as the product of the inflammation of serous +surfaces, may undergo a mucous metamorphosis, and, thus transformed, +offer a suitable material for absorption. + + +_Colloid Degeneration, Colloid Metamorphosis._ + +Laennec used the term colloid in a descriptive sense to indicate a +gelatinous appearance, and for a long time its use was thus +restricted. As the colloid appearances were found to differ in their +chemical reaction, their distribution, and their pathological +importance, and as the term was further extended to include +appearances seen with the microscope, it obviously became necessary to +subdivide the colloid series of changes according to the observed +differences. Its use is now limited to those gelatinous conditions or +appearances due to the presence of a fixed albuminate, homogeneous or +finely granular, translucent, colorless or pale {84} yellow, of +varying consistency, which does not become fibrillated on the addition +of acetic acid, and which does not change in color when acted upon by +iodine. This albuminate is considered in most instances to represent +the result of a transformation, a metamorphosis of cells, and is +associated with an impairment of their function--a degeneration which +is progressive, and leads, sometimes, to the destruction of the organ, +as occurs in certain instances of colloid degeneration of the thyroid +body. Usually, the process is limited, affecting particular parts +rather than the whole of an organ. The reaction presented by a +solution of sodium albuminate in the presence of neutral salts leads +to the view that colloid material may represent a coagulation of an +albuminous substance or substances under favoring conditions. The +presence of colloid masses in the kidney thus meets with a plausible +explanation. + +The place of its typical occurrence is the thyroid body in certain +cases of goitre, and it is early met with as a homogeneous substance +replacing the granular cell-protoplasm. With its increase the latter +disappears, and the entire cell is transformed into a homogeneous +sphere. At times the colloid substance may be seen to project from the +surface of the cell as a pale rounded clump. The aggregation of these +clumps results in the presence of masses of various size, in which may +be found granules of fat or pigment and crystals of cholesterin, which +are accidental, not essential. Colloid masses are sometimes met +with--in lymphatic glands, for instance--as concretions, mulberry-like +aggregations of stratified colloid bodies, which may be infiltrated +with earthy salts. Colloid material may eventually become liquefied, +transformed into a sodium albuminate; and the presence of cysts in +certain varieties of goitre is thus explained. The coexistence in the +kidney of colloid accumulations and watery cysts has led to the view +that the latter may, under certain circumstances, result from the +former through the liquefaction of the colloid material. The same view +is held with regard to the origin of cysts frequently met with in the +choroid plexuses. + +The colloid metamorphosis of cells is also to be found in the +epithelium of mucous membranes and their glands, in the prostate, +suprarenal capsule, sebaceous glands of the skin, and in the cells of +certain tumors. + + +_Amyloid Degeneration, Amyloid Infiltration, Waxy Degeneration, +Lardaceous Degeneration._ + +The colloid appearances due to the amyloid degeneration of cells are +of the greatest clinical importance from their frequent occurrence and +the gravity of the symptoms connected with their presence. In amyloid +degeneration there is the transformation of the cell-protoplasm into +an albuminous material different from other albuminates found in the +body. This transformation is at the expense of the functional activity +of the cell, and the latter becomes inert. Amyloid degeneration +represents no mere substitution, but an addition, since the affected +tissue is increased in volume. The albuminate was called amyloid by +Virchow in consequence of its color-reaction with iodine. Its method +of origin is wholly unknown, never being found in the circulating +fluids nor in articles of food. It is met with chiefly in the cell, +although its presence in the intercellular substance of old people is +recognized, and its occurrence in {85} the midst of the thrombotic +deposition on inflamed valves and in the results of inflammatory +processes is also recorded. + +At present the question is under discussion whether the amyloid +degeneration may affect cells of the most varied character, or whether +it is limited to those of connective tissues. Eberth[35] maintains +that in all cases the amyloid disturbance is seated in the connective +tissue. Kyber,[36] the latest investigator, in opposition to this view +maintains that this affection is not limited to the connective tissue, +but may also be seated in the parenchymatous cells of organs. Whether +the one of these views is to exclude the other, or whether both are +not correct, remains for future investigation to decide. + +[Footnote 35: _Virchow's Archiv_, 1880, lxxx. 138; 1881, lxxxiv.] + +[Footnote 36: _Ibid._, 1880, lxxxi. 7, 111.] + +Wherever the amyloid material may be situated, the result is a +transformation of the cells into a homogeneous, glistening, colorless +material, which occupies more space than the original cell, and, when +abundant, is accompanied with a loss of the primitive details of the +cell-structure. This material is recognized by the color it presents +when acted upon by iodine alone, by iodine and sulphuric acid, or by +methyl-aniline. The first produces a reddish-brown color, the second a +blue, and the last a violet or purple color. These reactions are all +characteristic, and the first is of special value in the macroscopic +recognition of the process, while the last two are of special +importance in the microscopic recognition of the earlier stages of the +affection. + +With the advance of the degeneration and its dissemination, the organ +affected presents, in the diseased portions, pale-gray, glistening, +translucent patches, and becomes increased in size and density in +proportion to the quantity of amyloid material present. The change +appears primarily in the vessel wall or outside the same, and there +results a diminution in the calibre of the vessels, with a lessened +quantity of blood in the organ. + +From the homogeneous and translucent appearance of the surface and the +increased density of the tissues the resemblance to bacon or wax is +suggested, and the terms lardaceous, bacony, or waxy degeneration have +been applied. Notable differences in degree and seat occur in +connection with the organs diseased. In the spleen, for example, the +change may be limited to the arteries of the Malpighian bodies and +their immediate surroundings. To this condition the term sago spleen +is applied, the enlarged, rounded, translucent, and projecting bodies +suggesting granules of boiled sago. The appearances of the diseased +part are further affected by the association of other conditions, as +the presence of fat or pigment. When fat is present, it is often to be +regarded as a result of the gradual and progressive increase in the +obstruction to the circulation of blood in the organ. + +Although so little is known of the immediate cause of amyloid +degeneration, its distribution in the various organs of the body is +fully ascertained, as well as certain of the conditions which are +likely to be followed by its presence. It is known to occur as a +localized process in cartilage, in the conjunctiva, in certain tumors, +cardiac thrombi, scars, retained inflammatory products, and renal +casts. The causes of this localized appearance are wholly obscure, and +little or no general inconvenience results. Its presence, however, on +a large scale and in various parts of {86} the body at the same time, +is met with under such circumstances as indicate a distinct +etiological relation. An appreciation of these circumstances is of +importance, since their existence demands an investigation as to the +probable presence of the degeneration. The organs thus affected are +the spleen, liver, kidneys, and intestine. It is to their disturbance +of function that the pathological importance of amyloid degeneration +is to be especially attributed. + +Other organs which may sometimes be affected are the lymphatic glands, +pancreas, suprarenal capsules, omentum, uterus, bladder, prostate +gland, heart, and thyroid body. In the case of a general diffused +infiltration these organs are variously degenerated, now some, and +again others, showing a more extensive alteration, while few or many +may be simultaneously diseased. The longer the process has continued, +the greater the degree of the disturbance and the larger the number of +the organs infiltrated. Although, in general, a period of months and +years may be demanded for these extensive changes, very serious +disturbances may arise within a short time, and Cohnheim[37] records +several cases which suggest that widely diffused amyloid degeneration +may occur within a few months--in one instance in less than four +months. + +[Footnote 37: _Virchow's Archiv_, 1872, liv. 271.] + +All that is at present known with regard to the etiology of this +process applies to certain general diseases with which in the course +of time it is likely to be associated. These have one element in +common, that of chronicity, and are likewise the occasion of a +progressive wasting of the body. Of these affections, that which holds +the first place is chronic pulmonary consumption, especially that form +in which extensive destruction of the lungs and ulcers of the +intestine are present. Another disease whose effects are in like +manner to be regarded as general is syphilis, and in the later stages +of this disease amyloid degeneration is likely to occur, and often to +represent by its resulting disturbances the immediate cause of death. +Again, chronic suppurative processes, especially those due to disease +of the bones and joints, are a frequent antecedent of amyloid +degeneration. Finally, the process has been found in connection with +leucaemia, chronic intermittent fever, rickets, gout, and certain +malignant tumors. This last group, however, is one in whose sequence +the degeneration is to be regarded as exceptional. + +The clinical importance of this process is due to the resulting +disturbances in the function of such important organs as the liver and +intestines, the spleen and lymphatic glands, and the kidneys. The +nature of these disturbances obviously demands detailed consideration +in connection with the description of the diseases of the respective +organs. It may be mentioned here that the infiltration of the walls +leads to a narrowing of the calibre of blood-vessels, and thus a +diminution in the supply of blood to the part or organ. The resulting +impairment of nutrition becomes enhanced from the condition of the +blood, which is impoverished from the simultaneous infiltration of the +blood-making organs. The nutrition of the individual thus suffers as +well as that of the immediately diseased organ. Fatty degeneration and +atrophy of the parenchymatous cells of organs like the liver and +kidneys is the constant result of long-continued and extensive +infiltration of these glands. + +Mention is intentionally omitted of the so-called amyloid bodies, {87} +corpora amylacea, considered in connection with amyloid degeneration +in most text-books on pathology and pathological anatomy. They usually +present a different reaction with iodine, their origin has but little +in common, their distribution is for the most part unlike, and little +or no clinical importance is to be attached to their presence. + + +_Calcification, Ossification, Petrifaction._ + +When salts previously held in solution are precipitated under abnormal +circumstances in the tissues of the body, the part is said to be +calcified, ossified, or petrified. Although these terms are often used +as equivalent, the last is to be regarded as more general than its +predecessors, since it includes the deposition of other than the +calcareous salts. + +In the pathological ossification, as well as its physiological +prototype, the carbonates and phosphates of calcium and magnesium are +present in a specially formed tissue of the nature of bone-cartilage, +whereas calcification occurs independently of such a new-formed +tissue. The deposition of the calcareous salts takes place either in +the cells or intercellular substance of living or dead tissues, when +the terms calcification or ossification are applied, or as +accumulations of various size in tissues or canals, which are known as +concretions and calculi. + +The immediate causes of the physiological deposition in the formation +of bone are so obscure that only more or less probable explanatory +theories are advanced, to all of which obvious objections arise. The +causes of a pathological precipitation may be regarded as equally +hidden. It is apparent, however, that old age usually furnishes the +necessary factors. This in part may be due to the feeble nutrition +associated with impairment of function in advancing years. In part it +may be the result of the numerous opportunities offered in a long life +for the occurrence of inflammation, the products of which are +frequently infiltrated with calcareous salts. The latter are +apparently kept in solution by the action of living cells, for, though +presented to all in the fluids of the body, they are precipitated most +constantly in dead parts or in the vicinity of those cells whose +function is presumably lessened from disease or age. The solvent +action of living cells is further demonstrated by the effect of the +giant-cells in removing calcium salts from living or dead bone. + +The causes of calcification are therefore to be regarded as local, +depending upon a destruction or weakening of the cells of a +part--conditions which are directly attributable to an interference +with nutrition. The deposition of calcium salts thus represents a +disorder of nutrition, and may be experimentally produced by agencies +which occasion a necrosis of tissues. + +Although the immediate causes of the precipitation of the calcium +salts must be expressed somewhat vaguely, the places and effects of +their accumulation are sufficiently well known, as are the resulting +appearances. The presence of these salts in sufficient quantity +produces a homogeneous, granular, strongly refractive appearance of +the cell or intercellular substance, in addition to a greatly +increased resistance to pressure. When muriatic acid is added to the +affected part, the salts are dissolved, with the escape of abundant +bubbles of gas when a carbonate is present, and with a rapid fading of +the glistening appearance, without effervescence, {88} when the salt +is a phosphate. After the removal, the cell or intercellular substance +is readily recognized, with such modifications in its appearance as +may be due to the action of the strong acid. The parts in which this +deposition or infiltration has taken place are either relatively +normal in appearance or variously altered from disease, and the +calcium salts are to be regarded as absorbed from the constituents of +the food and deposited, or as taken up and transferred from the bones +of the body. That both sources are drawn upon is obvious from the +abnormal presence of calcareous material in the soft parts, in +connection with increased density of the bones, as well as with a +diminution in the density of the latter. The term calcification is +more correctly applied to the presence of the salts in normal tissues +other than bone, or in the products of disease not simulating +bone-cartilage in structure. A pathological ossification is to be +considered present when an actual new formation of bone has taken +place so limited and so situated as not to suggest a tumor of bone, or +when the calcium salts are deposited in a new-formed tissue whose +structure stimulates that of bone-cartilage. + +Tissues which may become calcified are, in the first instance, the +connective tissues, and of these fibrous tissue and cartilage are +especially liable. Epithelial, muscle--in particular the unstriped +variety--and ganglion-cells may also become calcified. The frequency +with which blood-vessels, especially arteries, are affected is such +that it is regarded as almost normal in advancing years that +calcareous material should be deposited within the vascular walls. A +distinction is drawn between an ossification and a calcification of +the blood-vessels. The former term should be limited to the osteoid +plates so often found as circumscribed thickenings of the aortic +intima, and which are obviously new-formed patches of fibrous tissue +in which the calcium salts are accumulated. A calcified artery, on the +contrary, is one usually of a size varying between that of the common +iliac and the temporal arteries, whose wall has become rigid and +unyielding, suggestive of a pipe-stem, from the presence of calcareous +deposits in the muscular middle coat. + +From the frequency with which the osseous plates of the aorta are +associated with the fatty and fibrous changes in chronic inflammation +of the intima, the so-called atheromatous degeneration of the same, it +is customary to speak of the calcified artery at the wrist or temple +as an atheromatous artery or as evincing an atheromatous degeneration. +The common feature in the aortic changes and in the calcified muscular +coat is the element of age. They are frequently, though not +necessarily, associated. The one is the result of an inflammatory +process productive of a new, fibrous, tissue in which the calcium +salts are infiltrated; while the other is due to a deposition of the +latter in the normal, pre-existing, muscular elements of the vessel. + +Calcification and ossification of blood-vessels are frequent when the +latter become dilated, as in aneurisms, whether these occur as +circumscribed tumors or as a serpentine elongation and widening of the +affected vessel. + +Cartilage is also a tissue which presents a double relation to +calcareous deposition. On the one hand, there may exist an +ossification resulting from the extension of a growth of bone from the +perichondrium into the cartilage. The structure of this bone presents +all the details found in {89} normal bone--lacunae, lamellae, and +marrow-spaces. On the other hand, a section of the cartilage, +especially the costal cartilages, may contain opaque, gray, or +grayish-yellow patches, grating under the knife, which are wholly due +to the presence of calcium salts in the hyaline intercellular +substance of the cartilage. This calcification of the cartilage, which +may also involve the capsules of the cells, is frequently associated +with an ossification, although this relation is in no way essential. + +Calcification of the placenta, of the fibrous framework of the lungs, +of the mucous membrane of the stomach, or of the atrophied glomeruli +of the kidney, are well-recognized instances of the infiltration of +calcareous material in normal or atrophied tissues. On the contrary, +ossification of the fibrous inflammatory products of the pleura, +pericardium, and peritoneum are instances of a pathological +bone-formation, analogous in its nature to that met with in the intima +of the aorta. The fibrinous and fibrino-cellular products of the +inflammation of serous surfaces are favorable positions for the +deposition of calcium salts, as are thrombi arising from the walls of +blood-vessels. The latter are rather instances of the calcification of +dead parts, analogous to the members of the group which includes the +formation of calculi and concretions, the calcification of the dead +foetus in abdominal parturition, of cheesy lymphatic glands, and of +cheesy material in the lungs and elsewhere. Finally, there remains the +calcification of tumors of the most varied nature, the salts being +present either in living or dead parts of the tumor. + +Instances of the deposition in the tissues of other than calcareous +salts are abundantly met with in gout. In this disease cartilage, +ligaments, and tendons, bone-marrow, muscle, the endocardium and +aorta, the membranes of the brain and spinal cord, the skin and +kidneys, may contain deposits of acicular crystals and amorphous +granules. Although these deposits are largely composed of sodium +urate, calcium urate may be present with other salts, as sodium +chloride and calcareous compounds. According to Ebstein,[38] the +earthy salts in gout are deposited in necrotic patches of previously +diseased tissue. The local conditions are therefore analogous to those +concerned in the formation of chalky concretions. + +[Footnote 38: _Die Natur und Behandlung der Gicht_, Wiesbaden, 1882, +45.] + +Concretions and calculi are collections of earthy salts, the former +lying within tissues, the latter being present in canals opening +externally. Both represent the results of a deposition in and upon +organic material, which is often an inflammatory product, at times +surrounding a foreign body acting as the exciting cause of the +inflammation. + +The earthy matter of which the concretion is composed consists mainly +of carbonate and phosphate of calcium, while the chemical properties +of the calculi often vary in accordance with the nature of the +secretion which flows by them. The salivary, pancreatic, intestinal, +lachrymal, and prostatic calculi are chiefly formed of calcareous +salts. These salts also are an important, if not the chief, +constituent of biliary and urinary calculi. In the former pigment, +bile acids, and cholesterin may also be present. Urinary calculi are +of still more varied composition, containing not only the calcium +salts, as the oxalate, phosphate, and carbonate, but also uric acid +and the urates of sodium and ammonium, in addition to the +ammoniaco-magnesian phosphate. + +The infiltration with calcium salts may prove beneficial as well as +{90} injurious--beneficial under those circumstances where further +changes might prove harmful, as in the softening of cheesy material or +the maceration of a dead foetus in the abdominal cavity. The +calcification of certain tumors, as the fibro-myoma of the uterus, is +equally sanatory, the further growth of the calcified parts being thus +checked. The calcification of an aneurismal sac may prove beneficial +in strengthening a weakened blood-vessel. + +The injurious effects are seen more particularly in case of the +calcareous infiltration of the middle coat of arteries. Such vessels +become converted into rigid and unyielding tubes at various parts of +their course, and the nutrition of peripheral parts becomes +correspondingly lessened. Hence, in great measure, the liability of +old people to serious inflammatory processes from trivial irritation +of peripheral portions of the body, such inflammations often +terminating in gangrene. + +The calcification and ossification of the cardiac valves and the +calcification of attached thrombi, furnish frequent and constant +occasion for disturbances in the functions of the heart, resulting in +dilatation and hypertrophy, with the sequence of symptoms of chronic +valvular endocarditis. + +The great clinical importance of the presence of calcium salts in the +circulatory apparatus is such that further reference in this place to +its results is unnecessary, as its special relations are more +important than its general features. + +Calculi act as local causes of inflammation, and their presence is +likely to be followed by ulceration, abscess, and stenosis, perhaps +obliteration, of the smaller canals in which they may lie. + + +_Pigmentation._ + +The pathological pigmentation of the body results, presumably, from +the metamorphosis of the coloring matter of the blood or from the +introduction from without of pigments insoluble in the fluids of the +body. The former of these methods has recently been studied by +Langhans[39] and Cordua,[40] and the present views of this subject are +chiefly due to their observations, as well as to the earlier +investigations of Virchow and others. + +[Footnote 39: _Virchow's Archiv_, 1870, xlix. 66.] + +[Footnote 40: _Ueber Resorptionsmechanismus von Blutergussen_, Berlin, +1877.] + +The haemoglobin contained in red blood-corpuscles is considered to be +composed of a coloring matter, haematin, combined with an albuminate, +globulin. When blood is removed from the body the haemoglobin is +readily separated from the corpuscles by various agents, and is then +dissolved in the plasma, which becomes lac-colored. This solubility of +the haemoglobin is of importance in connection with the absorption of +extravasated blood. During the time necessary for this process to take +place, observable changes are apparent in the color of the affected +part when its seat is superficial, especially cutaneous. These changes +in color are largely dependent upon the modifications undergone by the +haemoglobin. + +It is well known that a yellowish discoloration of the general surface +frequently takes place when extensive internal hemorrhages have +occurred, constituting a form of jaundice (haematogenous) attributed +to the presence of the coloring matter of the blood. As yet there has +been no satisfactory chemical analysis of this diffused pigment, which +if not haematin must be regarded as its derivative, although a +coexistent increase of the urobilin in the urine has been observed. +The association of the stained skin and urine, {91} in the absence of +causes favoring an absorption of bile-pigment, leads to the inference +that the abnormal discoloration is due to the absorption into the +circulating fluids of the body of a pigment dissolved out of the +extravasated red blood-corpuscles. This view is confirmed by the +microscopic examination of the latter, which discloses the presence of +pale, shadowy, round outlines enclosing faintly granular material, +which are regarded as decolorized red corpuscles. In the course of a +few days glistening crystals and granules of a yellowish-red color +make their appearance in the midst of the unabsorbed blood. The +crystals are usually oblique rhombic prisms, varying in size from the +larger symmetrical shapes to the more minute, apparently granular, +forms. Acicular crystals are also to be met with, more yellow than red +in color, and are sometimes present in great abundance, although they +may be wholly absent. Virchow has applied the term haematoidin to +these crystals. Owing to the resemblance in the chemical reactions of +solutions of haematoidin and of the biliary coloring matter, +bilirubin, and to the similar crystalline forms of the latter, it has +been maintained that the two are identical. Late investigations +indicate that solutions of crystals with the appearances of +haematoidin are not invariably alike in their reaction. A solution of +these in chloroform may become decolorized when acted upon by a dilute +alkali, or it may not be thus altered. Bilirubin presents the former +relation, while chloroform solutions of the coloring matter of the +yelk of egg and of the corpus luteum, called lutein or haemolutein, +are not decolorized by an alkali. Although the crystalline forms of +haematoidin and bilirubin are not to be distinguished, it is not to be +conceded that the two substances are identical. As Maly,[41] the +latest writer on this subject, states, the term haematoidin is merely +indicative of a microscopical picture. Although the identity of the +coloring matter of the blood and of the bile is not admitted, the +intimate relation of the two is not only suggested by the similarity +of crystalline form, but by the relation determined between urobilin, +bilirubin, and haemoglobin. Urobilin is the coloring matter extracted +from the urine in fever by Jaffe, and it has since been obtained from +bilirubin by Maly,[42] who has given it the name of hydrobilirubin. +This hydrobilirubin has also been derived from haemoglobin. According +to Maly, this genetic relation between the coloring matter of the +blood and bile, shown in the production of hydrobilirubin, is the only +chemical evidence of the connection of the two pigments. + +[Footnote 41: _Hermann's Handbuch der Physiologie_, 1880, vii. 155.] + +[Footnote 42: _Op. cit._, 161.] + +Haematoidin is to be regarded not only as directly derived from +solutions of haemoglobin, but as originating through the medium of +indifferent cells. Langhans claims that this pigment is formed within +movable cells which accumulate in great numbers in the vicinity of the +blood-clot, and, in virtue of their amoeboid properties, take into +themselves the extravasated corpuscles, entire or in fragments. The +indifferent cell may become enlarged into a giant-cell, and then +contain numbers of whole or disintegrated red corpuscles. In time +these colored corpuscles and fragments become smaller, more +glistening, and darker-colored, and eventually are transformed into +granular or crystalline haematoidin. These granules may be set free by +the fatty degeneration of the cell, or may be transferred within the +cell to distant parts. + +{92} The diffusion and absorption of a solution of haemoglobin, and +the formation of crystals of haematoidin from the same or through the +medium of cells, are supplemented by an apparent inspissation and +condensation of the haemoglobin. The resulting dark-brown pigment may +remain at the seat of the hemorrhage indefinitely, and may be +accompanied with reddish-brown flakes, which, as shown by Kunkel,[43] +are composed of hydrated ferric oxide. + +[Footnote 43: _Virchow's Archiv_, 1880, lxxxi. 381.] + +Another feature in the absorption of extravasated blood is to be found +on examination of the nearest chain of lymphatic glands. These may be +seen swollen, of a dark-red color, and homogeneous surface. In density +and color, as well as shape, they suggest the small supplementary +spleens so frequently met with. These glands owe their change in +appearance to the presence of large numbers of unaltered red +blood-corpuscles which have entered the lymphatics traversing the +region of hemorrhage. Within the lymph-glands they undergo a +metamorphosis similar to that taking place at the part from which they +were transferred. In the course of weeks or months there remains in +the place of extravasation simply pigment, either as crystals or +granules. Such pigment may remain for years imbedded within the +tissues, or it may become absorbed, no trace of the original +disturbance remaining. Its removal may take place presumably through a +local solution of the pigment or the transfer of the granules or +crystals by means of wandering cells to the nearest lymphatic glands +or to the more remote parts of the body. An eventual elimination may +occur through the secretions, especially the urine or bile, or there +may result a deposition and permanent retention of the granules. + +The investigations of Langhans are especially interesting, as +suggesting efficient means for the production of pigment by cells +whose function is intimately connected with pigmentation, as the cells +of the rete Malpighii, of the choroid, and of certain tumors. The +observations of Gussenbauer,[44] however, lead to the conclusion +earlier advanced by Virchow, that pigment may be produced by the +diffusion into cells, outside the vessels, of a solution of the +pigment of the blood in the plasma of the latter. A precipitation of +this dissolved pigment into granules is considered as eventually +taking place. + +[Footnote 44: _Ibid._, 1875, lxiii. 322.] + +The method of origin of pigment thus described applies only to those +discolorations which are unquestionably due to the metamorphosis of +the coloring matter of the blood. Examples are furnished not only by +the extravasation of blood on a large scale, but also by the escape of +red blood-corpuscles in small numbers. Such an escape takes place from +the pulmonary vessels in chronic obstruction to the admission of blood +into the left side of the heart. The resulting brown induration of the +lungs owes its color to the metamorphosed blood-pigment which is +present as haematoidin in the interstitial tissue of the lungs, as +well as contained within amoeboid cells in the alveolar and bronchial +cavities. + +It is probable that a similar transformation of haemoglobin takes +place in the spleen and elsewhere in melanaemia. In this condition the +black granules of pigment, although differing in color and form from +haematoidin, contain iron, and have received the name melanin. These +granules are either free in the blood or are contained within the +white {93} blood-corpuscles. Their origin in the spleen is directly +suggested by their frequent presence, often in considerable numbers, +in the large, so-called splenic, corpuscles of the blood in the +hepatic capillaries. Eventually, the pigment is found at more remote +points in the circulation, and becomes fixed in the interstitial +tissue of the various organs of the body. + +The black pigment of the cells of melanotic tumors, also called +melanin, is not to be directly traced to the haemoglobin. Virchow[45] +early called attention to the absence of iron in such pigment. +Ferrated and non-ferrated varieties of melanin are thus to be +recognized, the term being used in the same way as haematoidin, +indicative of a microscopical appearance. A still further complication +in the composition of melanin is suggested by Kunkel,[46] who has +isolated a ferrated pigment from melanotic tumors. It shows, however, +with the spectroscope, no relation to haematin, bilirubin, or +hydrobilirubin. That its nature is similar to the normal pigment of +the skin and choroid is suggested by the customary origin of the +melanotic tumors in such pigmented tissues, and by the resemblance in +appearance and reactions. + +[Footnote 45: _Virchow's Archiv_, 1847, i. 378.] + +[Footnote 46: Ziegler, _op. cit._, 100.] + +That pigment of the most varied sort may be introduced into the body +from without, and may remain indefinitely in the organism, is +sufficiently well known from the results of tattooing. What is +essential in such cases is, that the pigment shall be finely divided +and insoluble in the fluids of the body. The most important of such +pigmentations are those taking place through inhalation into the +lungs. The reception by this channel of particles of soot is so common +that it is most exceptional for the lungs of an adult to be free from +the bluish-black discoloration due to this agent. Particles of +coal-dust presenting the details of vegetable structure are met with +in the lungs of individuals exposed to an atmosphere charged with this +material. The worker compelled to inhale the dust of iron eventually +accumulates a store of this substance, the quantity of which is +essentially dependent upon the length of exposure, the degree of +impregnation of the atmosphere, and the insufficient nature of the +protectives employed. + +Although a large part of the pigmentation under such circumstances is +due to the direct presence of the foreign body, the appearances are +also partly the result of consequent minute hemorrhages. The coal-dust +and the iron-filings are often sharp and jagged fragments, which +penetrate the delicate tissues, and the escaping red blood-corpuscles +are acted upon by the amoeboid cells in the air-passages, with the +consequent formation of haematin or haematoidin, as are the +blood-corpuscles in larger hemorrhages. The inhaled pigment finds its +way, either directly or by the agency of amoeboid cells, into the +lymphatics and fibrous tissue of the lungs, and remains indefinitely +either in the bronchial and pulmonary lymphatic glands or in the +interstitial tissue of the lungs. + +Attention may be here called to that pigmentation of the skin and +deeper-seated parts of the body, especially of the kidneys, known by +the term argyria. The long continued internal use of nitrate of +silver, in former years so extensively employed, especially in +diseases of the nervous system, results in the reduction of the silver +and its deposition as minute particles in the tissues. Whether the +silver is first reduced in the {94} intestine and then absorbed, or +whether it is absorbed as an albuminate and subsequently reduced, +still remains an open question. + +Although the pathological pigmentations form an extended series of +alterations, the clinical importance of the condition may be regarded +in many instances as trivial. The pigments resulting from +extravasation produce no disturbance of function. The presence of +bile-pigment does not account for the symptoms of jaundice. The +clinical importance of melanaemia has perhaps been overrated. The +earlier observations led directly to the inference that mechanical +obstruction to the circulation in various organs might take place. The +particles of pigment and the cells containing them were so numerous +that this inference seemed quite probable. The evidence is still +lacking, however, which proves the existence of definite symptoms and +characteristic lesions as the result of the melanaemic condition. + +The inhaled foreign bodies, as coal and iron, are productive of +greater disturbances, and are well known as efficient causes in the +production of chronic pulmonary consumption. The coal-miner's and +scissors-grinder's phthises usually have, as an anatomical basis, +catarrhal conditions of the aerating surfaces and interstitial +inflammations of the pulmonary connective tissue. Mechanical +obstruction to the aeration of the blood may also be present from the +extreme quantity of the foreign material in the lungs. + + +Tuberculosis. + +Until the investigations and discoveries of the past few years, the +presence of tubercles in the various organs and tissues of the body +had been regarded as the essential element of tuberculosis. The +evidence to be presented in the following pages will show that the +immediate cause of tubercles may produce other lesions as well, and +that the presence of a specific virus as the efficient cause of +whatever may be the lesion, rather than the existence of tubercles, is +to be regarded as the characteristic feature of the disease +tuberculosis. + +The tendency of the present is to regard the latter term as including +the various morbid processes connected with the origin, presence, and +growth of a specific, organized virus, their dissemination, +metamorphoses, and effects. Whether all those processes in connection +with which the virus is found are due to the latter, or whether some +may not arise and exist independently of the same, are among the +questions whose answer is remote rather than at hand. + +As the presence of the cause of tuberculosis is the test demanded by +some authorities for the existence of the process, so the anatomical +classification has depended upon the existence of the tubercle. The +substitution of tubercle for organized virus in the general definition +of tuberculosis represents the distinction between the anatomical and +the etiological classification of this affection. + +A tubercle was originally a small rounded body, a little tuberosity, +and at the close of the last century the specific tubercle was +distinguished from other rounded nodules. + +Till the discovery of Villemin, the recognition of the tubercle was +{95} essentially based upon its anatomical characteristics. Previous +to the studies of Reinhardt and Virchow these related to appearances, +which were attributed to a deposition of material, scrofulous or +tuberculous, from the blood or lymph. The idea was eventually +maintained that this material formed the basis of a growth or new +formation, and Virchow showed that the tubercle was composed of a +tissue, of cells and intercellular substance, growing within and from +pre-existing tissues. He classified the tubercles among the tumors as +circumscribed new formations whose structure resembled that of +granulation-tissue. The specific tubercle was, at the outset, minute, +smaller than a millet-seed, submiliary, although indefinite numbers of +these minute tubercles might be grouped together and form closely +massed aggregations. From this agglomeration of single tubercles, and +their frequent association with inflammatory products, both of which +were prone to early death and transformation into a cheese-like mass, +the extensive tubercular infiltrations of organs arose. The latter +were regarded as a frequent cause of the wasting disease phthisis, +which was either pulmonary, intestinal, or renal according as the +lungs, intestine and mesenteric glands, or kidneys were the +predominant seat of the tubercular growth. + +The histological features of the tubercle were further investigated by +Wagner,[47] who described the resemblances and differences of the +structure of the tubercle and the lymphatic gland. Schuppel[48] soon +after published his monograph, essentially confirming the statements +of Wagner. According to these observers, the typical tubercle, as +found in lymphatic glands, presents essentially the same peculiarities +of structure when seen elsewhere in the body. This structure consists +of a non-vascularized network of fibres, in the meshes of which cells +are imbedded. The fibrous network resembles the reticulum of a +lymphatic gland, and nuclei are often found at those points where the +fibres are united. This appearance has suggested that the network is +formed of branching and anastomosing cells. Within the meshes are +three sorts of cells--viz. giant-cells, epithelioid (endothelioid) +cells, and small, round, indifferent cells. One or several +giant-cells, each with its abundant nuclei, lie near the centre of the +tubercle or are diffused throughout the same. These are usually +immediately surrounded by the large epithelioid cells, with one or +more nuclei, which are often so numerous as to compose the greater +part of the tubercle. The indifferent cells, resembling +lymph-corpuscles, occur singly or in groups, distributed throughout +the tubercle more abundantly at the periphery, between the cells +previously described, and with them completely fill the spaces of the +fibrous network. + +[Footnote 47: "Das tuberkelahnliche Lymphadenom," _Archiv der +Heilkunde_, 1870, xi. 6; xii. 1.] + +[Footnote 48: _Untersuchungen uber Lymphdrusen-Tuberkulose_, 1871.] + +Although the typical tubercle is thus constituted, the structural +features depend somewhat upon its age. It is generally admitted that +the freshest tubercles, as found in the external coat of the smaller +arteries of the pia mater, are composed of little else than a +circumscribed accumulation of small, round cells, without a distinct +reticulum. The giant-cells, the epithelioid cells, and the +well-characterized reticulum appear as the tubercle increases in age. +It is thought probable that the giant-cells represent the +agglomeration of the small, round cells in pre-existing cavities, +lymphatics, blood-vessels, or secretory canals. The epithelioid cells +in like {96} manner are considered to result from the enlargement or +fusion of the smaller cells, while the reticulum represents either a +secretion from, or a transformation of, the cellular elements of which +the tubercle is composed. + +The subsequent history of the tubercle is dependent upon its +metamorphoses. These are known as cheesy degeneration, calcification, +and fibrous transformation. + +The absence of blood-vessels, already stated, and the abundantly +cellular nature of the growth, with the possible action of +micro-organisms, result in a tendency to the early death of the cells +and a necrosis of the tubercle. This is the cheesy degeneration, and +is regarded as a form of coagulative necrosis, which begins at the +centre, advances toward the periphery, and results in the +transformation of the gray into a yellow tubercle. This termination in +cheesy degeneration likewise affects inflammatory products surrounding +the tubercle, and even relatively normal tissues in which numerous +tubercles may lie. This cheesy material either softens or becomes +infiltrated with lime salts, calcified. The softening of the tubercle +results in the formation of a material capable of removal as a +discharge from the surfaces of the body or by absorption through the +lymphatics and blood-vessels. In the former event ulcers arise upon, +and cavities communicate with, the surfaces of the body opening +externally. + +The cheesy material frequently becomes calcified, thus remaining as a +comparatively inert mass. The earthy salts may be diffused throughout +a uniformly cheesy basis, or they may be deposited in a partially +softened, cheesy menstruum, when a mortar-like material results. + +The tubercle becomes fibrous with the diminution in the number of its +cells and the increase in the thickness of the reticulum, with the +transformation of the latter into a homogeneous hyaline substance. The +cornified, horn-like tubercle is one whose size is diminished from the +shrinkage of its cells into glistening flakes, without an evident +associated cheesy or fatty degeneration. + +The intimate relation of scrofula to tuberculosis has been variously +expressed from time to time in accordance with the amount and accuracy +of the existing knowledge. At the outset the enlargement of the +lymphatic glands, especially of the neck, characterized the scrofulous +affection. As the enlargements of the glands were found to present +intrinsic differences connected with differing clinical histories, +only those glands were regarded as scrofulous which presented the +cheesy appearances. With the recognition of the cheesy condition of +tubercles the latter were identified with the scrofulous gland, from +the cheesy condition common to both. + +This identification of scrofula and tubercle prevailed till Virchow +showed that cheesy material might have a different origin, and +maintained that there were cheesy lymphatic glands without tubercle, +as well as tuberculous lymphatic glands which might become cheesy. A +distinction was thus drawn between scrofula and tuberculosis. The +former term was applied to that condition of the individual which +favored the retention and cheesy degeneration of inflammatory +products, not only in the lymphatic glands, but elsewhere in the body. +Tuberculosis, on the contrary, was characterized by the production of +tubercles which were often accompanied by retained inflammatory +products, both of which were prone to undergo cheesy degeneration. + +{97} The frequent association of well-defined tubercles with what were +regarded as antecedent scrofulous disturbances also suggested an +intimacy of relation between scrofula and tuberculosis. Virchow[49] +had always maintained the possibility of regarding tuberculosis as a +heteroplastic or metastatic scrofula. The occurrence of cases of +tuberculosis without evidence of an antecedent scrofula prevented him +from making a more absolute statement of the above relation. + +[Footnote 49: _Die Krankhaften Geschwulste_, 1864-65, ii. 629.] + +The views with regard to the connection between scrofula and +tuberculosis have become essentially modified of late years as a +result of the investigations concerning the etiology of tuberculosis. + +In 1856, Buhl[50] first published his view, although he had for +several years been impressed with the idea, that miliary tuberculosis +was an infective disease resulting from the absorption of a specific +virus. He based his theory upon the almost constant coexistence of one +or several cheesy collections and miliary tubercles. The former were +recognized as the remains of previous inflammatory processes, and the +tubercles were looked upon as the immediate result of the absorption +of this cheesy material. The individual thus infected himself. +Buhl[51] claimed that the simultaneous occurrence of tubercles and +inflammatory products was the co-effect of the same cause, and that +the acute miliary tuberculosis, as a localized process, was merely an +inflammation with the development of tubercles. He restricted the term +tuberculous inflammation, however, to those forms which necessarily +and from the beginning, produced tubercles whose presence was limited +to the tissue inflamed. The tuberculous inflammation was regarded as a +primary condition, while the acute miliary tuberculosis was a +secondary process resulting from infection. + +[Footnote 50: _Lungenentzundung, Tuberkulose und Schwindsucht_, 1872, +iii.] + +[Footnote 51: _Op. cit._, 123.] + +The tuberculous inflammation of this author was largely characterized +by those features which, with the exception of the constant presence +of tubercles, were recognized by others as attributes of a scrofulous +inflammation. At the same time, he objected to the latter term as a +substitute, since its use would imply that no other cheesy product +than that from a tuberculous inflammation would serve as the origin of +tubercles. Buhl strictly maintained that the absorption of any cheesy +material, whatsoever its source, might give rise to a general growth +of tubercle in the body. + +The views of this author were popularized mainly through the teachings +of Niemeyer[52] concerning pulmonary consumption. The latter adhered +to Virchow's views relating to scrofulous inflammation, but maintained +that most consumptives were in imminent danger of becoming tuberculous +in accordance with the doctrines of Buhl. + +[Footnote 52: _Klinische Vortrage uber die Lungenschwindsucht_, 1867.] + +The theory of an infectious origin of tuberculosis, advanced from time +to time by others, but most forcibly presented and maintained by Buhl, +was first demonstrated by Villemin[53] in 1865. This observer showed +that certain animals, especially rabbits and guinea-pigs, might be +successfully inoculated, beneath the skin, with fragments of gray +tubercle, cheesy products, sputum, and blood from cases of phthisis. +The development of tubercles took place within three weeks after the +{98} inoculation, and became general within four weeks. He also +demonstrated that rabbits became tuberculous when inoculated with bits +of the tumors occurring in the pearly distemper of cattle. + +[Footnote 53: _Etudes sur la Tuberculose_, Paris, 1868, 528.] + +Villemin's observations have been repeatedly confirmed and extended; +although subjected to the severest criticism and control, their +results are so constant that the law of the inoculability of tubercle +is almost universally regarded as fixed. Its value as a test is +evident from the statement of Cohnheim,[54] who regards as tuberculous +only that which produces tuberculosis when transferred to suitable +animals. The transfer may be made in various ways. Chauveau and others +were successful in producing an intestinal tuberculosis by the +introduction of tuberculous material into the intestinal canal of +animals, especially the Herbivora. Tappeiner[55] succeeded in +producing pulmonary tuberculosis, with or without general +tuberculosis, in dogs, by compelling them to breathe air in which were +contained minute particles of sputa from tuberculous pulmonary +cavities. + +[Footnote 54: _Die Tuberkulose vom Standpunkte der Infections-Lehre_, +1880, 13.] + +[Footnote 55: _Virchow's Archiv_, 1878, lxxiv. 393.] + +The production of a tuberculosis of the iris, as well as of remote +organs, by the inoculation of tuberculous material into the anterior +chamber of the eye, was an ingenious method devised by Cohnheim and +Salomonsen.[56] It permitted the direct observation of the several +steps in the process of absorption of the inoculated material and +development of the tubercles. + +[Footnote 56: Cohnheim's _Vorlesungen uber Allgemeine Pathologie_, 2te +Auflage, 1882, i. 707.] + +The objections to the various experiments above alluded to are based +upon the assumption that the results of the inoculation are not +tubercles, but inflammatory products resembling tubercles. It is +further advocated that the inoculation of indifferent material, as +bits of glass or hairs, as well as other foreign substances, will +produce the so-called artificial tuberculosis, especially in rabbits +and guinea-pigs. It is admitted that these animals readily become +tuberculous when exposed to simple inflammatory irritants, the local +action of which frequently results in the production of cheesy +material. This termination is now regarded as due to faults in the +method of experimentation, the animals not being thoroughly protected +from the influence of the virus of tuberculosis. + +The objection on the ground of structure loses its force in connection +with the well known differences in the structure of miliary tubercles +in the human body, already mentioned. The tubercles resulting from +inoculation often resemble in structure the meningeal tubercles of the +brain rather than the type presented by tubercles in lymphatic glands. +The development of tubercles in the iris may take place without any +permanent inflammatory reaction. The association of evidences of +inflammation with the development of the tubercle is therefore +unnecessary. + +The experiments of Villemin have not only demonstrated the infectious +nature of tuberculosis, but have also led to a more accurate knowledge +of the relation between tuberculosis and its allied affections, +scrofula and pearly distemper. + +The anatomical characteristics of scrofula have obviously proved +insufficient in determining the relation presented by this affection +to tuberculosis. The tendency to cheesy degeneration of its +inflammatory {99} products was the feature of chief importance. +Villemin showed that portions of a scrofulous (cheesy) gland when +inoculated were followed by tuberculosis, and that the inoculation of +cheesy material from non-tuberculous or non-scrofulous sources was not +followed by this result. The assumption of Buhl, that the absorption +of cheesy material, as such, was the cause of tuberculosis, was thus +disproved. The frequency with which the inoculation of cheesy +material, from what were regarded as scrofulous sources, was followed +by tuberculosis, led to more exact studies concerning the anatomical +peculiarities of scrofulous inflammation. Koster[57] called attention +to the regularity of the occurrence of miliary tubercles in the +fungous granulations of the inflamed joints of scrofulous and +tuberculous individuals. Wagner[58] and Schuppel[59] discovered that +scrofulous glands, in most if not in all instances, were tuberculous +glands. The regularity of the presence of tubercles in scrofulous +abscesses and ulcers of the skin and in scrofulous caries was shown by +Friedlander.[60] This observer likewise called attention to the +presence of agglomerated tubercles as the chief constituent of the new +formation of lupus. These anatomical discoveries resulted in uniting +more closely the affections scrofula and tuberculosis from the +histological standpoint, and the union has become more firmly cemented +from the etiological investigations. + +[Footnote 57: _Virchow's Archiv_, 1869, xlviii. 95.] + +[Footnote 58: _Loc. cit._] + +[Footnote 59: _Op. cit._] + +[Footnote 60: _Volksmann's klinische Vortrage_, 1873, lxiv.] + +Schuller[61] has shown that the introduction of finely divided +material from a scrofulous joint--that is, from one containing +tubercles--into the lungs of rabbits was followed by a tuberculosis of +the tracheal wound, the lungs, and liver. Similar experiments with +reference to the introduction of lupus-tissue produced results +suggestive of tubercle, if not actually tuberculous. + +[Footnote 61: _Untersuchungen uber die Enstehung und Ursachen der +Skrophulosen und Tuberkulosen Gelenkleiden_, 1880.] + +The intimacy of relation between tuberculosis and pearly distemper is +a necessary result of Villemin's[62] experiment, in which the rabbit +became tuberculous after inoculation with fragments of the pearly +tumor. Gerlach,[63] and especially Schuppel,[64] showed that the +structure of the nodules of the pearly distemper is the same as that +of the tubercles of man, and that the two diseases are identical from +the histological point of view. + +[Footnote 62: _Op. cit._, 537.] + +[Footnote 63: _Virchow's Archiv_, 1870, li. 290.] + +[Footnote 64: _Ibid._, 1872, lvi. 38.] + +From the anatomical identification and the etiological connection, as +shown by Villemin, Gerlach, and Aufrecht, the pearly distemper became +designated as a bovine tuberculosis. + +The experiments of Villemin were further productive in leading to the +discovery by Koch of the bacillus tuberculosis. It was early obvious +that certain cheesy material and gray tubercles possessed the +infectious qualities, and Villemin[65] maintained that the immediate +cause of the latter was a germ introduced from without, which +propagated and perpetuated itself in man and certain animals. This +view acquired prominence through the investigations of Klebs, who in +1877 claimed to have isolated the micrococci which produced tubercles +when injected into animals. Three years later Schuller[66] confirmed +the statements of Klebs, and asserted that he had been enabled to +obtain infective micrococci by cultivation from {100} miliary +tubercles, scrofulous glands and joints, and from the tissue of lupus. +Aufrecht[67] found micrococci, single and in chains, and short +glistening rods, within tubercles resulting from inoculation with +material from pearly tumors. The same organisms were found in +tubercles produced by the inoculation of tubercles from man, and he +regarded these rod-shaped bodies as the specific element productive of +miliary tuberculosis. + +[Footnote 65: _Op. cit._, 620.] + +[Footnote 66: _Op. cit._, 55.] + +[Footnote 67: _Pathologische Mittheilungen_, 1881, p. 43.] + +The isolation of the virus of tubercle was thus regarded as an open +question till the announcement by Koch[68] of the constant presence of +a hitherto unknown, characteristic, well defined organism in all +tuberculous affections, which, when isolated and introduced into +animals, produced tuberculosis, the resulting tubercles likewise +containing the organism. + +[Footnote 68: _Berliner klinische Wochenschrift_, 1882, p. 15.] + +The latter, the bacillus tuberculosis, was to be seen in preparations +methodically treated and carefully stained with aniline colors, by all +of which, excepting the browns, the bacillus was tinged. It was found +in miliary tubercles of the lung, cerebral and intestinal tubercle, +cheesy bronchitis and pneumonia, phthisical sputa, scrofulous glands, +and fungous inflammation of the joints. It was also seen in the +nodules of pearly distemper and in the cheesy masses from the lungs of +cattle. It was furthermore met with in the cheesy lymphatic glands of +swine, in the tubercular nodules of a fowl, and in the tubercles of +guinea-pigs, rabbits, and monkeys. The bacilli were likewise found in +the tubercles resulting from the inoculation of animals with +tubercular virus from its various sources. + +The microphytes were described as very slender rods, varying in length +from one-fourth the diameter of a red blood-corpuscle to its entire +diameter, and spores were occasionally seen within the rods. In shape +and size they resembled the bacilli of leprosy, but the latter were +narrower and pointed at the ends. They were found in greatest +abundance when the tuberculous process was recent and rapidly +advancing, and were present within, as well as between, cells. The +younger giant-cells contained them in larger numbers than the older +forms. They were present at the periphery of cheesy nodules rather +than at the centre. + +The bacilli were cultivated through successive generations and +required a temperature of between 30 degrees C. and 41 degrees C. (86 +degrees F.-105.8 degrees F.) for their development, one of 37 degrees +C. or 38 degrees C. (98.6 degrees F. or 100.4 degrees F.) being the +most favorable. The crop first became apparent on the tenth day after +sowing, and the growth extended through a period of three to four +weeks, forming a compact scale. The cultivated bacilli, even +propagated through several generations, when inoculated, produced the +same positive results as follow the inoculation of fragments of +tuberculous material, although animals might be used which are not +easily infected with tuberculosis. + +Koch's publication was immediately followed by a statement from +Baumgarten[69] of his discovery of rod-like bacteria in the tubercles +of rabbits resulting from the inoculation with pearly masses, and in +the pleural and pericardial tubercles of man. They were made evident +by treating the sections for microscopic examination with very dilute +solutions of soda or potash. + +[Footnote 69: _Centralblatt fur die med. Wissenschaften_, 1882, xv. +257.] + +{101} The discoveries of Koch thus show that the production of +tuberculosis is dependent upon the presence of distinctive bacilli, +and that these bacilli are present not only in miliary tubercles, but +in scrofulous glands and joints, in cheesy inflammation of the lungs, +and in the pearly distemper of animals. The identification of +tuberculosis with the pearly distemper and certain scrofulous +affections is thus established from the etiological as well as the +histological point of view. + +As the bacilli are to be regarded as the virus of tuberculosis, so +their introduction into the human body is necessary for the production +of this disease in man. It is obvious, however, that other factors +than the virus are necessary, for not every one exposed to the +reception of tubercular bacilli becomes tuberculous. It may well be +that scrofula is still to be regarded as that condition of the solids +and liquids of the body which offers favorable opportunities for the +retention and growth of the bacilli, and thus for the production of +tuberculosis. Formad[70] claims that he has discovered structural +peculiarities of tissue as a cause for the scrofulous habit, which he +regards as synonymous with a predisposition to tuberculosis. These +peculiarities are manifested by a narrowness of the lymph-spaces and +their partial obliteration by cellular elements. He also maintains +that these features are not only of congenital origin, but may be +acquired through malnutrition and confinement. + +[Footnote 70: _Studies from the Pathological Lab. of the Univ. of +Penna._, reprint, 1882, xi. 3.] + +The occurrence of a local, circumscribed tuberculosis in extreme old +age, without antecedent or other concurrent evidence of scrofulous +disturbances, suggests that favorable opportunities for the +development of the tubercular bacillus may arise in advancing years. +In like manner, the frequent termination in phthisis of cases of +diabetes suggests the likelihood of tuberculous inflammation arising +in the absence of any evidence of previous scrofulous or tuberculous +disease. The scrofulous condition or constitution, as indicated by +vulnerable tissues, with a protracted course of inflammations, and a +persistence of their products, with a tendency to cheesy degeneration, +may still exist without a sign of tuberculosis. Those who claim that +scrofula and tuberculosis are identical must, in the light of Koch's +discovery, demonstrate the presence of the bacillus in all scrofulous +inflammations, and deny the existence of scrofula apart from +indisputable manifestations of the activity of the bacilli of +tuberculosis. It may be that such evidence will be presented; until it +is collected scrofula and tuberculosis are to be regarded as distinct +though often coexistent. The scrofulous person is frequently +tuberculous, the tuberculous person is usually scrofulous; the +non-scrofulous person, however, may die of tuberculosis, while the +individual may be scrofulous without containing tubercle. + +The actual inheritance of tuberculosis is very unlikely, although this +disease is frequently found in successive generations of a single +family. The various members of the family are rather to be regarded as +furnishing a suitable soil for the growth of the tubercular bacillus, +and their exposure to its seed is favored by the existence of +tuberculosis in one or more members of the household. The scrofulous +condition is still to be regarded as hereditary as well as acquired, +and the scrofulous remain as the class to be especially protected from +the reception and effects of the bacilli of tuberculosis. + +{102} It is obviously a matter of importance to determine in any given +case of phthisis whether bacilli are present or absent. A ready means +of ascertaining this fact is offered by the examination of the sputum +in cases of pulmonary phthisis, the feces in intestinal phthisis, the +urine in renal phthisis, and the aspirated pus in cases of supposed +tuberculosis of the joints. Koch has found in examining the sputa from +numerous cases of phthisis that the bacilli were present in one-half +the number, and that they were absent from the sputa of individuals +who were not phthisical. Balmer and Fraentzel[71] have found bacilli +in the sputum from one hundred and twenty cases of phthisis, and +concluded that the progress of a case of pulmonary tuberculosis might +be readily determined from the number and degree of development of the +typical bacilli present in the sputum. The more numerous and +well-developed bacilli, with distinct and constant spores, were found +in the graver cases, which advanced more rapidly. The sputum of the +protracted cases contained few, small, and thin bacilli with scanty +spores. The presence of fever was associated with numerous bacilli, +while its absence was noted in those cases where but few were present. + +[Footnote 71: _Berliner klinische Wochenschrift_, 1882, xlv. 679.] + +The bacilli are readily detected by means of the staining method +devised by Koch. Various modifications have been presented from time +to time, of which that of Ehrlich[72] has proved the most +satisfactory. The essential features are to obtain a dry, thin layer +of a selected portion of the suspected sputum, which is then to be +deeply stained with fuchsin or methyl-violet; the excess of color is +to be removed with nitric acid, and the preparation is then ready for +examination with the microscope. A power of four or five hundred +diameters is sufficient for the recognition, and the object should be +illuminated with a flood of light through a large diaphragm or an +achromatic condenser. The bacillus retains the color notwithstanding +its exposure to the acid, and the violet colors are more strongly +presented if the preparation is tinted yellow after the action of the +acid. If the bacilli are stained red with fuchsin, the background +should be made blue. It is important that the reagents should be +freshly prepared and filtered, that other bacteria may not obscure the +picture, and that all the apparatus employed should be thoroughly +clean. + +[Footnote 72: _Allg. med. Centr. Zeitung_, 1882, xxxvii. 458.] + +A fragment of thick, opaque sputum is to be taken in forceps, placed +on a cover-glass, and spread into a thin layer by means of a second +cover-glass. The prepared slide is then to be passed slowly through an +alcoholic flame, or that of a Bunsen burner, till the layer of sputum +is dried. A saturated alcoholic solution of methyl-violet or fuchsin +is made and filtered, and added, drop by drop, to a filtered, +saturated solution of aniline oil shaken in water. The color is to be +added with stirring till an opalescent film forms on the surface of +the mixture. The slide containing the dried sputum is to be placed in +or on this staining fluid, and allowed to remain for half an hour or +less, the application of warmth hastening the process, when it is +removed, and the specimen is decolorized in a solution of one part of +nitric acid and two parts of water. The preparation is then washed in +water, and may be examined directly in water, glycerin, or, after +dehydration in alcohol, in oil of cloves. The tinted bacilli are made +more prominent by a secondary staining, for a minute or two, of the +red (fuchsin) preparation {103} in a concentrated solution of +methyl-blue, the violet preparation being secondarily stained in a +like solution of aniline-brown. If the preparation is to be +permanently preserved, it should be dehydrated in strong alcohol after +washing with water, and it may then be treated with oil of cloves and +mounted in Canada balsam. + +After the observer has become thoroughly familiar with the tubercle +bacilli by means of the method of Ehrlich, much time may be saved by +following that of Baumgarten.[73] The cover-glass bearing the dried +sputum is placed in a very dilute solution of caustic potash (two +drops of a 33 per cent. solution in a watch-glass of distilled water) +till the layer of sputum becomes transparent. The cover is then placed +on a slide moistened with a drop of water, tapped slightly, and +examined with the microscope. The bacilli are readily seen, and may be +differentiated from other varieties of bacteria, if necessary, by +again drying the object and examining it in a drop of a dilute watery +solution of aniline-violet or of other preparations of aniline used +for staining nuclei. The tubercle bacilli remain unstained, while +putrefactive bacteria are tinted. + +[Footnote 73: _Centralblatt fur die med. Wissenschaften_, 1882, xxv. +433.] + +The tubercular products of the invasion of the body by the bacillus +tuberculosis are regarded as primary or secondary, according as they +are present at that part of the body which directly receives the +organisms or as they are dependent upon the transfer of the latter to +parts remote from the region of their admission and immediate effects. +This differing relation is also expressed by the terms local and +general tuberculosis. In the former the bacilli excite the growth of +tubercle only at a given part of the body. Their apparent effects may +be wholly limited to this region, and it not rarely happens that the +same is quite distant from the channels through which the bacilli are +admitted. A general tuberculosis occurs when the latter are +disseminated over the body, and their effects, especially the +production of numerous tubercles, are found at various parts. The +dissemination may take place at the time of entrance, or, as is more +commonly the case, apparently occurs at some subsequent period, the +immediate disturbances being localized at a given portion of the body. +The necessary conditions being here offered for the propagation of the +bacilli, their sudden distribution in great numbers is afterward +permitted when favorable opportunities arise for their absorption. +Such conditions are present when the local tubercular growths extend +into lymphatics or blood-vessels. The frequency with which scrofulous +glands are tuberculous--that is, contain miliary tubercles--is already +fully recognized, and a tuberculosis of the lymphatic glands is +essentially regional. These glands become affected in consequence of +disturbances, the local effects of which may have wholly disappeared, +in the region from which they receive their lymph. The cervical glands +become permanently enlarged, perhaps tuberculous, in connection with +persistent or recurrent inflammatory processes in the tonsils and +pharynx, the bronchial glands from similar bronchial or pulmonary +affections, and the mesenteric glands from like intestinal +disturbances. In such instances, the direct reception of the bacilli +into the lymph-current is assumed rather than demonstrated from a +knowledge of the possibilities of absorption and an appreciation of +the conditions in the glands. + +That an actual growth of tubercles from the wall of the intestinal +{104} lymphatics may take place has long been known, and Ponfick has +recently discovered that tubercles may be found growing from the wall +of the thoracic duct. The possibility of the direct admission into the +lymph-current of the infective element in tuberculosis is thus +apparent, and its indirect entrance into the blood-current is equally +obvious. That the bacillus of tubercle may be directly received into +the blood-current is likewise evident from the observations of +Weigert, who found tubercles growing from the walls of the pulmonary +blood-vessels, venous as well as arterial. This discovery of a +tuberculosis of the blood-vessels was confirmed by Klebs, who had +found a tuberculosis of the azygos veins. The occurrence of multiple +miliary tubercles of the pulmonary veins, especially near the place of +entrance of smaller branches, has been asserted by Mugge,[74] although +appearances similar to those described by him may be met with, due +simply to the agglomeration of white blood-corpuscles and their +necrosis. Such a condition simulates very closely the miliary +tubercle, but is usually analogous to the appearances figured by +Virchow,[75] and described by him as one of the phenomena of +coagulation. In his observation the white bodies were adherent to the +red clots, and were with them drawn from the pulmonary artery. + +[Footnote 74: _Virchow's Archiv_, 1879, lxxvi. 243.] + +[Footnote 75: _Die Cellular Pathologie_, 4te Auflage, 1871, 184.] + +With the admission into the body, and the colonization of the +tubercular bacilli, their effects may either be progressive until the +death of the individual is occasioned, or, with the cessation of the +growth of the bacilli or a possible modification of their noxious +properties, recovery may ensue. The history of scrofulous glands, as +well as that of circumscribed pulmonary inflammation in scrofulous +persons, both presumably of a tuberculous nature, show that the +effects of an invasion of the parasites may be overcome. + +The regions of the body which are usually the seat of a primary +tuberculosis are unquestionably the respiratory and intestinal tracts. +With regard to the first of these regions, the one most frequently +affected, there can be no doubt that in most instances the inhaled air +carries the bacilli or their spores, or both. Their constant presence +in the sputum of the frequent cases of tuberculous phthisis suggests a +ready means for their escape into the atmosphere. The well recognized +infective qualities of the sputum, as demonstrated by the various +experiments before the bacillus was discovered, demand the thorough +disinfection of phthisical sputa, since these are in all probability +the chief source of the dissemination of the disease. + +The tuberculosis of the intestine in like manner is to be regarded in +the main as the result of an absorption from its surface of the +specific agent. An obvious direct means of the approach of the bacilli +is offered in the sputum, which, when swallowed, is likely to retain +its virulent properties. The frequent coexistence of chronic pulmonary +and intestinal tuberculosis is thus most readily explained. To what +extent the presence of the bacilli in the pearly distemper of cattle +and in the tuberculosis of other edible domesticated animals, as fowls +and swine, may lead to an infection of the intestinal wall, still +remains an unsolved problem. It is not yet determined at what +temperatures the bacilli are destroyed, although their growth takes +place only between 30 degrees C. (86 degrees F.) and {105} 41 degrees +C. (105.8 degrees F.). The inoculation of pearly masses produces +tuberculosis in certain animals, yet the effect of cooking in +destroying the bacilli and their spores is likely to prove of great +importance. Aufrecht's[76] attempts at inoculating rabbits with cooked +pearly masses proved unsuccessful. Schottelius[77] publishes an +interesting series of observations relating to the prolonged use of +meat from cattle affected with the pearly distemper, and shows that +after a period of years no disease of the nature of tuberculosis +occurred among the one hundred and thirty individuals included in the +families concerned. Whatever may be the value of this negative +testimony, there is, as yet, no evidence on the other side which +satisfactorily determines the point in question--viz. that the flesh +of animals affected with pearly distemper produces tuberculosis in the +human consumer. + +[Footnote 76: _Op. cit._, 51.] + +[Footnote 77: _Virchow's Archiv_, 1883, xci. 129.] + +The milk from cows thus diseased has likewise been regarded with +suspicion, and the frequency of intestinal tuberculosis among children +has been attributed to this source. Although the theoretical +possibility of the escape of the bacilli into the milk of cows +affected with pearly distemper is obvious, their presence in such milk +is first to be demonstrated under conditions which necessitate their +origin from the animal. If boiling the infective material for three +minutes destroys its virulence, as claimed by Aufrecht, a ready means +is offered of destroying the tubercle bacilli which may be present, +not only in the milk from animals affected with pearly distemper, but +in all milk which has been exposed for a certain time to an atmosphere +which may contain the bacilli of tuberculosis. In the light of our +present knowledge extreme hygienic precautions are only demanded in +those cases where such a congenital or acquired basis (constitution) +is present as facilitates the development of tuberculosis. + + +Morbid Growths. + +In a system of practical medicine it is obviously important to include +under the head of Morbid Growths not only what is spoken of by the +surgeon as a tumor, but also those new formations of tissue which, in +virtue of their nature, seat, manner of growth, and retrograde +changes, produce an important series of disturbances in the +physiological processes of the individual. The surgeon deals +essentially with the swelling, which, producing irregularities in the +outline of the accessible surfaces of the body, is regarded as an +excrescence or outgrowth. It is important for him to realize the +nature of this swelling, that he may follow a different treatment for +the abscess, the wen, the watery accumulation, or the fleshy mass. The +last is the tumor in the limited sense; it is the growth which, though +called morbid, becomes so only in consequence of its presence being +associated with symptoms whose existence and persistence interfere +with the well-being of the possessor. + +The physician, on the contrary, is more concerned with the tumor as a +growth than as a swelling. The latter element in deeply-seated +portions of the body may not be brought to his attention. The growth +takes place in such a manner as to be productive of certain symptoms +more or less serious, among which swelling is least obvious. The +morbid {106} growth to him becomes prominent as it displaces or +replaces normal tissues by those newly formed, which may or may not be +normal to the part in which the growth is situated. His tumor is +therefore a morbid growth, a new formation, a neoplasm or pseudoplasm, +rather than a swelling, a bunch, or an excrescence. + +In a consideration of the general pathology of morbid growths the +first question which suggests itself relates to the method of origin +of the tumor. The tendency of the present seeks for a local cause, and +the most recent theory, that of Cohnheim, demands an accumulation of +dormant embryonal cells as such a cause. Cohnheim supports this view +by the experiments of Zahn and Leopold, which show that foetal +cartilage transplanted into the tissues of a mature animal may grow so +rapidly as to present the characteristics of a cartilaginous tumor, +while tissues transferred from the animal after birth do not increase +in size, but are usually absorbed. + +As the active elements of the growth are cells, and all cells +admissibly arise from pre-existing cells, it follows that the +primitive cells of a tumor are derived from those resulting from the +segmentation of the ovum or are introduced from without. Numerous +experiments have been made with a view to the inoculation of tumors, +the transplantation of living fragments of the latter to the living +tissues of a healthy individual, for the sake of producing a tumor, +but hitherto almost invariably without success. The alternative +remains that the embryonal cells are those whose derivatives are +present in, and form the essential element of, the morbid growth. All +tumors may thus be said to have an embryonal origin. As the +segmentation of the ovum eventually results in the production of +normal tissues and groups of tissues whose structure and function are +wholly different, so the possibility of the production of abnormal +groupings of tissue with corresponding irregular manifestations of +function is obvious. + +The cells of the part from which a tumor arises may be regarded as +indifferent, those whose limitations of growth, like the early +embryonal cells, are only determined by the changes they undergo, or +their limits of growth may be already defined in kind, and their like +be produced in the formation of the tumor. The origin of a tumor thus +presupposes the existence of such indifferent cells, or the presence +of those whose limit of transformation has already been reached. The +leucocytes of the body, whether found as white blood-corpuscles or +lymph-corpuscles, or as the wandering cells of connective tissue, are, +as Virchow has indicated, such indifferent cells. Always present and +apparently transitory, what they are to become can only be determined +from their condition and surroundings at the time of observation. +Although their actual transformation into the various cells of a more +permanent type is merely a matter of inference in the growth of +tumors, the evidence presented by Ziegler[78] leads directly to the +conclusion that their presence is necessary to the new formation of +tissues whose growth is the result of an inflammatory process. These +tissues may occur under such restrictions as permit them to be +classified as tumors, and the granulomata, or tumors whose tissue +resembles that of the granulations upon the surface of a wound, +represent a well defined group in structure as well as method of +origin. + +[Footnote 78: _Op. cit._, 150.] + +{107} The production of the cells of a tumor from indifferent cells is +at present an assumption, based upon the frequent presence of the +latter within tumors and in their vicinity; and the obvious objection +arises that even if the presence of these cells is admitted as +indispensable, it by no means follows that they are directly +transformed into the more characteristic cells of the tumor. That they +may serve for the nourishment of the amoeboid cells of certain tumors +is suggested by the existence of both in morbid growths, and the +well-known property of amoeboid corpuscles to take in formed material, +even cells, from without. + +The origin of tumors from cells whose limits of growth are already +defined is rendered probable from the absence, entire or in great +part, of indifferent cells from certain tumors, and the direct +continuity of the latter with a similar normal tissue of the body. +Various tumors show such an intimate relation, and there is no sharply +defined border-line between the normal tissue and that which +represents the tumor. The occasional presence of islets of well +characterized tissue at points more or less remote from the normal +position of such tissue at the time of their discovery suggests a +feasible source for an eventual tumor. Virchow long ago called +attention to isolated nodules of cartilage within bones in the +vicinity of epiphyseal cartilages, probably detached from the latter, +which might serve as the origin of a cartilaginous tumor in this +region. This inclusion of tissue is also suggested by the frequency of +certain tumors in certain regions where the developmental conditions +are favorable. Lucke[79] mentions the frequency of dermoid cysts near +the median line of the head, the vicinity of the eye, and the side of +the neck. Such regions are those where fissures exist during foetal +life, with normal involutions of the outer germinal layer; which +involutions may become irregular, and eventually included or shut in, +as the fissures become closed. A similar explanation is offered for +the frequent occurrence of cartilaginous tumors at the angle of the +jaw, it being thought probable that bits of embryonal cartilage, +during the formation of the ear, become included in the salivary +glands. + +[Footnote 79: _Volkmann's Sammlung klinischer Vortrage_, xcvii. 819.] + +In like manner, Cohnheim explains the frequent occurrence of certain +epithelial tumors at the orifices of the body--the cervix uteri and +the vicinity of the tracheal bifurcation--not through the exposure of +these parts to injury, but because they are regions in which embryonal +irregularities of development are likely to arise. + +That congenital, local peculiarities are an important element in the +origin of tumors has already been strongly advocated by Virchow. Not +only are children born with tumors, but instances of growths +eventually arising from birth-marks, and the occurrence of certain +tumors in the same locality in successive generations of the same +family, are sufficiently familiar. + +Although certain tumors are admitted to be due to congenital +peculiarities of tissue, and even to represent atypical growths from +embryonal tissue, the theory of such an embryonal origin for all +tumors seems unnecessary. The resemblance in symptoms as well as in +appearance, and even in structure, of certain tumors to inflammatory +products, and their frequent association with these, has led to the +suggestion of an irritant as an exciting cause for the tumor, even in +the absence of local peculiarities of tissue. {108} It is obvious that +were the embryonal theory of origin, as extended by Cohnheim, +universally applicable, the growth demands something more than a focus +of embryonal cells. An immediate cause for their growth after a +dormant period, extending even into old age, is required. Cohnheim +finds such in a sufficient supply of blood. He attributes the +development or rapid growth of the tumor to this feature, and supports +his view by the usual appearance of exostoses when the skeleton is at +its period of most vigorous growth, and of dermoid cysts at a time +when the formation of the beard indicates active developmental +conditions in the outer germinal layer. + +The growth of ovarian cystomata at and after puberty, and of these and +mammary tumors during pregnancy, are also explained on the ground of a +more abundant supply of blood at such periods. He and others find in +physiological conditions a source for the abundant blood-supply--that +is, the efficient nutrition for the growth of a tumor. The necessity +of sufficient nutrition in the development of tumors is universally +admitted, and its source may be looked for in pathological as well as +physiological conditions. + +The existence of an irritant of some sort often seems probable, and, +although its absence is more frequently determined than its presence, +it is obvious that when present it may be overlooked. Although +traumatic irritants of considerable mechanical severity exist in but a +small percentage of tumors, their occasional influence in the +production of morbid growths is not to be denied. Their action may be +explained as producing a congestion or as enfeebling the opposition of +physiological tissues to pathological growths. The importance of an +irritant as the exciting cause, however its action may take place, is +supported not only by the sequence of injuries and tumors, but also by +the frequent occurrence of tumors in parts exposed to injury and +irritation. Such exposure may result from position, structure, or +function. The orifices and prominences of the body, the retained +testis in the inguinal canal, are notoriously liable seats of tumors. +Soft, friable, and slightly resistant structures, like mucous +membranes, are not only the frequent place of origin of tumors, but +the most exposed parts of such structures are oftenest affected. The +exposure resulting from function is manifest by the relation presented +by the periods of greatest functional activity of the growth of tumors +in such organs as the mammary gland, uterus, and ovaries. + +The importance of an irritant is still further suggested by the +association of tumors with inflammation. The growth of tubercles and +cancer from serous membranes is frequently accompanied by an acute +inflammation of the latter; fibrous tumors and chronic interstitial +inflammations often coexist, while elephantiasis is usually preceded +by recurrent, erysipelatous inflammation of the skin. + +The recent discovery of infective organisms as an exciting cause for +many of the members of an entire group of tumors, the granulomata, has +resulted in making prominent the etiological rather than the +structural features of the tumors concerned. + +Local peculiarities of tissue, whether congenital or acquired, are +thus regarded as representing the beginnings of the growth. With the +multiplication of the cells their transformation may take place or a +change in their grouping may arise. The essential condition in the +production {109} of the morbid growth is that the formation of the +cells should take place at an abnormal time or place and should +progress in a normal or abnormal manner. + +The growth takes place with greater or less rapidity in one or another +direction according to the nature of the tumor and its seat. The more +closely the tumor resembles the normal structures of the body, the +slower is its growth; the more it differs in composition, the more +rapid is its progress. This difference may arise from a predominance +of cells over intercellular substance, as in the case of the sarcoma, +or it may result from an atypical combination of tissues, as seen in +the development of epithelium and connective tissue in cancer. + +The seat of the tumor is of importance mainly on account of the +vascular supply of a part and the more spongy or yielding nature of +certain regions. That the more abundant the nutrition of certain +regions of the body, the more favorable the opportunities for growth, +may be admitted without question. The spongy nature of tissues implies +a predominance of cavities over solid constituents. These cavities are +lined by surfaces which represent, on the one hand, the walls of +lymph-spaces, on the other the free surfaces of the body exposed to +the air, as the mucous or cutaneous surfaces and the pulmonary +surface. The rapidity of growth in the direction of the least +resistance is amply shown in the projection of tumors above the +surface of serous membranes and the frequent presence of fungoid +excrescences in various parts of the body. + +The growth of tumors extends in all directions, but a distinction has +long been drawn between the concentric or interstitial manner of +growth and the excentric or infiltrating form. This distinction is +based upon the presence of a sharply defined limitation of +pathological and normal tissues or upon the absence of such a +limitation. Such a distinction is merely of relative importance, as +certain tumors may grow in both ways. This is best observed in those +bulging superficial tumors whose base is irregularly extended into the +continuous healthy tissues. + +The concentric variety of growth includes those tumors which have +commonly been described as encapsulated, and which are capable of +ready enucleation from their surroundings in virtue of a thin layer of +loose connective tissue lying between the tumor and the contiguous +tissue. Such a capsule represents the matrix, the pia mater, in which +lie the blood-vessels going to and coming from the tumor, and is often +nothing else than the distended and hyperplastic fibrous tissue +remaining after the absorption of the muscular fibres or gland-cells +from the tissues surrounding the morbid growth. + +The excentric, peripheral, or infiltrating extension of the tumor +takes place when the surrounding parts are invaded by the active +elements of which the tumor is composed. The amoeboid property of the +cells of certain tumors is well known, and the possibility is +admissible that the indifferent cells of the body, so often +accumulated at the periphery of the growth, become impregnated with a +formative function by the constituents of the tumor. Such amoeboid and +wandering cells represent a means through which the growth of the +tumor may become extended in its vicinity as well as in more remote +parts of the body. + +The extension in the vicinity may be continuous or the reverse, the +latter through the formation of secondary nodules, which may {110} +eventually become fused with the primary mass. The continuous growth +takes place, as has been more particularly shown by Koster, along the +lymph-channels surrounding the tumor, which may become filled, +distended, and eventually obliterated by projections from the +neoplasm. Both methods of peripheral growth, by secondary nodules and +continuous extension, represent an infection of the surrounding +tissues, especially if it be admitted that the cells through which the +increase is accomplished are direct descendants of the pre-existing +cells of the part. Not only does the extension take place through the +lymphatic vessels about the tumor, but blood-spaces as well as +lymph-spaces may be invaded. Thrombi are then found whose structure is +frequently that of the tumor, and whose connection with the same is +direct through the perforated wall of the vessel. These features in +the growth of tumors lead directly to the consideration of the means +by which multiple tumors appear in remote parts of the body after a +single tumor has appeared in a given locality, and after the removal +of such a primitive growth. + +The distinction between primary and secondary tumors is now so obvious +that one is inclined to forget that the presence of numerous tumors at +various parts of the body was at one time regarded as evidence of the +constitutional or dyscrasic nature of the morbid growth. Such a +multiplicity seemed to indicate that the blood was charged with the +constituents of the tumor, which were deposited at various parts of +the body. + +Although certain multiple tumors may be present in different +localities without an apparent relation between an antecedent and a +subsequent growth, such tumors are usually limited to certain systems +of the body. Multiple bony tumors are found growing from bones, +fibrous and warty tumors from the skin, and fibro-myomata from the +uterus. Cohnheim's theory of the embryonal origin of tumors may seem +applicable in such cases, but the frequent association of the +osteomata with chronic inflammatory conditions, of cutaneous warts and +fibrous tumors with local irritative processes, makes such a +hypothesis unnecessary. + +Those tumors whose multiplicity is of the greatest clinical importance +are the rapidly growing forms terminating fatally. Such are those +which reappear in the scar after the removal of a cancer, or in the +adjoining chain of lymphatic glands or at remote parts of the body. +The most satisfactory explanation of their presence, and of the +generalization, recurrence, or metastasis of tumors, is derived from +what has already been stated with reference to the manner of the +growth of the latter. + +It is well known from experiments on animals that various living, +normal tissues when transplanted to remote parts of the same +individual or to other individuals may continue to grow. Cohnheim +claims, as has been previously stated, that a distinction is to be +drawn in this respect between the tissues of the adult and the foetus, +where the genesis of tumors is concerned. This observer, in connection +with Maas,[80] has found that the transplanted material (periosteum), +although growing for a while, disappears at the end of five weeks, and +it is asserted that fragments of tumors, when transferred, suffer a +similar fate. Wile,[81] on the contrary, {111} who has experimented +with reference to the fate of transplanted tissues and portions of +tumors, reports that one hundred days after the transfer of periosteum +the lung was found to contain several centres of ossification. He +regards the latter as proceeding from the fragments of periosteum +introduced into the jugular vein, and his results thus widely differ +from those of Cohnheim. + +[Footnote 80: _Virchow's Archiv_, 1877, lxx. 161.] + +[Footnote 81: _The Pathogenesis of Secondary Tumors_, reprint from +_Philadelphia Med. Times_, July, Aug., and Sept., 1882.] + +Notwithstanding the numerous experiments which have been made in +various parts of the world to excite the growth of transplanted bits +from tumors, most of them have terminated unsuccessfully. Although a +temporary growth of fragments of tumors has taken place after +transplantation, their eventual disappearance has usually occurred. +Cohnheim lays stress upon this fact in connection with his theory of +the origin of tumors. He considers that the fragments of tissue and +tumors disappear in consequence of the inability of the foreign +particles to withstand the metamorphosis of physiological tissues. If +this opposition is neutralized, the existing germs of tumors become +capable of development. Wile, however, found that eight weeks after +the introduction of a bit of cancer into the lung of an animal the +fragment had increased nearly twice in size. He also refers to the +positive experiments of Newinsky,[82] who transplanted a bit of cancer +from a dog to the subcutaneous tissue of another, young dog, and +found, after five months, not only an ulcerating cutaneous cancer at +the place of inoculation, but also a metastatic nodule of the size of +a hazel-nut in an axillary lymphatic gland. + +[Footnote 82: _Allgem. medicinische Central-Zeitung_, 1876, lxxi. +875.] + +For the present consideration it may be borne in mind that fragments +of normal (foetal) tissues, as shown by the experiments of Zahn and +Leopold, when introduced into the organs of animals, may become +enlarged. It is also certain that bits of tumors, after their +introduction into the tissues and organs of animals, have become +increased in size. What their eventual fate might have been does not +appear; and herein lies the weak point of the experiments with +reference to the production of secondary tumors. For such experiments +to be regarded as crucial it is necessary that a large number of +previously healthy animals, after inoculation with fragments of morbid +growths, should present in various parts of the body well +characterized tumors whose structure should be like that of the +particles introduced. + +The experiments above referred to are of value in confirming the views +concerning the generalization of tumors which have been generally +admitted since Virchow's discoveries with regard to the phenomena of +embolism. + +Tumors are said to become generalized when they appear not only in +various systems of the body, but in various organs and tissues. They +are found usually in considerable numbers, and with such differences +in size, shape, and appearance as to indicate different ages. Such +tumors are regarded as arising directly or indirectly from a common +source. This source is called the primitive or primary tumor, and its +derivatives the secondary tumors. The latter are usually considered as +the direct descendants of the former, although their relation may be +that of several successive generations. + +The primitive tumor in its growth may extend into lymphatics and +blood-vessels, as has already been suggested. Such an extension may be +{112} so little obvious when the tumor is removed by the surgeon that +all diseased tissues are apparently separated from the body. A +recurrence of the tumor is said to take place when the growth returns +in the cicatrix, frequently in a multiple form. The explanation of +such a recurrence is based upon the probable presence, at the time of +the operation, of fragments of the tumor within the tissues forming +the base and edges of the wound. During and after the healing of the +wound their growth is supposed to continue till they become apparent +as small tumors. The progress of these recurrent tumors is at times +extremely rapid, and they may attain a considerable size in the course +of a few weeks. Such nodules are secondary in point of time, although +they were actually a part of the primary growth. + +Secondary nodules in descent as well as time are those which appear at +distant parts, often after the discovery of the primary tumor. Such +nodules are regarded as resulting from the transfer of particles of +various size from the primitive growth, either through the +lymph-vessels or blood-vessels. If the invasion of the body takes +place through the former, the fragments may be floated along to the +nearest lymphatic gland, where it remains when too large to pass +through. If it retains the capacity of growth or of stimulating a like +growth, there results a more or less complete transformation of the +gland into a morbid tissue like that from which the fragments came. +Adjoining lymph-glands may become infected from the first, until +eventually an entire series becomes more or less completely +transformed into morbid growths. A like invasion of the lymphatic +glands may take place through a continuous extension along the +lymph-vessels; and it is not rare to find the sub-pleural or +sub-peritoneal lymphatics as an elevated meshwork in consequence of +the neoplastic growth within them. Such a method of extension may take +place when a cancer of the stomach or liver is associated with a +cancer of the pleura, the intervening lymphatics of the diaphragm +offering a direct and continuous communication. + +With the outcropping of a tumor upon a serous surface the possibility +of the detachment of particles is at hand. These may become +transplanted to the opposed serous surface or may be transferred to +the most dependent parts, and there serve as seed for subsequent +growth. + +The probability of the embolic nature of many secondary tumors was +early suggested in the history of embolism. Rapidly growing tumors +were known to be capable of perforating the walls of adjacent +blood-vessels, especially veins, and to continue growing along the +course of such vessels. The possibility of the detachment of portions +of these tumors and their transfer along the course of the circulation +was an inevitable inference from the results of experimentation with +foreign bodies. Cancerous emboli were thus recognized as a possible +variety, and their distribution was subject to the same laws as those +governing emboli otherwise constituted. Multiple nodules were +frequently found in the lungs in connection with tumors growing into +the inferior vena cava, while multiple nodules in the liver were +usually associated with tumors of the gastro-intestinal canal or other +regions whose vessels formed a part of the portal circulation. The +readiness with which portions may be detached after death from the +soft masses projecting into the interior of veins suggests the ease +with which particles may be {113} separated during life. The +experiments already referred to show that isolated fragments of tissue +serving as emboli may grow in the place of their reception, and it is +presumable that the resulting growth takes place under the same +conditions as those prevailing at the place from which the embolus +started. The question whether the secondary tumor arises from the +reproduction of elements transferred from the primitive disease, or +whether these excite a characteristic, specific growth of the cells in +the place of their retention, may still be regarded as open. The +experiments favor the former view, and they alone are capable of +satisfactorily determining the point in question. + +The secondary nodules, whatever may be their method of origin, present +the peculiarities of the primitive growth. If the cells of the latter +are pigmented, those of the former show the same peculiarity. If the +structure of the primitive tumor contains bone, cartilage, or squamous +epithelium, the secondary growths show like characters, though they +may be present in the heart or other organs where such tissues are not +present as normal constituents. So constant and characteristic is this +feature that the structure of the tumor is usually as well displayed +in the examination of the secondary as of the primitive nodule. +Indeed, the structural peculiarities of the growth may be more +characteristically shown in the former in those instances where the +primitive tumor has undergone degenerative changes obscuring its +histological features. + +The tissues of the tumor are subject to the various changes which take +place in the normal tissues of the body. Their growth is attended with +a multiplication of cells and a formation of intercellular substance. +Tumors whose growth is the most rapid are those whose blood-vessels +are the most numerous and whose relation to the cells is most +intimate. The slower the advance of the tumor, the more permanent is +it likely to become, while the more rapid the progress, the more +transitory are its elements. The growth may continue, and yet the +actual size of the tumor may diminish through the absorption of its +degenerated parts. The cells of the neoplasm may undergo fatty +degeneration, or they may become cornified. They may undergo the +mucous metamorphosis or the amyloid and colloid degenerations. They +may take up pigment or they may produce the same. The intercellular +substance varies in its character as does that of normal tissues. It +may be slimy, homogeneous, or fibrillated. It may contain mucin, +chondrin, or gelatin, and may be infiltrated with calcareous salts. +Limited necroses with characteristic cheesy appearances are of +frequent occurrence. + +Tumors may become the seat of inflammatory processes, indicated by +suppuration and fever, which may result in abscess or gangrene, or +their progress may terminate in the production of scars. Ulceration +may occur in consequence of the extension of an inflammatory process +to the surface, or it may result in the course of the degenerative +softening of a tumor. In both cases the cutaneous or mucous surface is +involved and destroyed, and the interior of the tumor being exposed +putrefactive processes, with fistulae and sinuses, arise, the latter +favoring the retention of the product and the persistence of the +inflammatory process. + +Tumors are always pathological, but the resulting disturbances vary +within wide limits and are often of a complex character. The familiar +distinction between benignant and malignant tumors is based chiefly +{114} upon this variance in the nature of the disturbances. Those are +benignant which closely resemble the normal structures of the body, +increase but slowly, and, if they attain a large size, produce mainly +mechanical disturbances. They may prove serious, even fatal, if so +seated as to interfere with the function of important parts of the +body. Very large and heavy tumors may prove burdensome solely on +account of their weight, while others of similar character, elsewhere +seated, may interfere with respiration or circulation, and eventually +with nutrition. Tumors in exposed situations may become important only +in virtue of their liability to injury, while others impede the +function of a part or an organ by pressure upon its nerves and vessels +or by obstructing its ducts. + +The malignant tumors, on the contrary, differ in their structure from +the normal tissues of the body. Their growth is rapid and infiltrating +rather than slow and concentric. Such tumors usually have a +predominance of cells and thin walled blood-vessels. The former may be +little else than nuclei enveloped in an easily destructible +protoplasm, or they may be composed of multi-nucleated masses of +protoplasm, and are then known as giant-cells. The most malignant +tumors are those which tend to become generalized as well as to spread +locally. They recur locally, and appear in the nearest lymph-glands +and at remote parts of the body. The disturbances produced by the +malignant tumors depend less upon their mechanical relations than upon +their tendency to destroy tissues and disturb functions. With their +presence and progress in vital organs there is associated, from their +manner of growth, a destruction of the cells of such organs, as the +kidneys and liver, the lungs and heart. When they are seated in the +spleen and lymphatic glands, a disturbance in the blood-making process +must be associated. Their occurrence in the alimentary canal opposes +the admission, digestion, and expulsion of its contents, and produces +disturbances varying as to the seat and peculiarities of the tumor. +The progress of the malignant tumor is often associated with +ulceration, watery discharges, and hemorrhage. The frequent +coexistence of emaciation, weakness, anaemia, and a yellowish +discoloration of the skin forms a group of disturbances which, +included under the name "cachexia," have long been prominent as +significant of malignant tumors. At the present day this cachexia is +regarded rather as the result than the cause of the tumor, whereas +formerly the reverse was the case. + +The modern classification of tumors is based chiefly on their +structure, in part upon their method of origin, and in part upon their +cause. + +With the observation of the similarity of appearances in the flesh of +which the external and internal neoplasms are composed, the suggestion +readily presented itself to regard the external tumors and the +internal growths as similar in character. External forms, physical +characteristics, clinical peculiarities, all proved insufficient as a +means of identifying the two, and the step was a short one which led +to the minute study of the flesh of the tumor and a comparison of its +resemblances and differences. This comparison obviously included a +knowledge of the structure and peculiarities of normal tissues. As +histological studies advanced, so did the pursuit of pathological +histology, and the tumors which were once designated as encephaloid, +mastoid, pancreatoid, or nephroid, from real {115} or fancied +resemblances to certain organs of the body, became analyzed into their +microscopic rather than macroscopic characteristics. + +It is unnecessary to say that the modern classification of morbid +growths owes its foundation and a large part of its superstructure to +Virchow, whose classic work, _Die Krankhaften Geschwulste_, showed the +direction which future investigators were to pursue and the nature of +the discoveries likely to result. + +The tumor represents the result of the growth of a tissue or tissues +which are like or resemble those which form the normal constituents of +the body. Although a new formation is present, it is composed of +tissues lying within the possibilities of the individual. A new +formation of feathers, as Virchow suggests, is beyond the productive +powers of human tissues, though within those of feathered animals. A +goose can produce a tumor containing feathers, not one in which hairs +are found; in the human species tumors containing hairs may occur, not +those, however, in which feathers are present. Although the cells of +the tumors of man may deviate in their appearances from the cells of +normal tissues, this deviation is never so extreme that their analogue +cannot be met with in some part of the body. + +As the normal tissues originate from pre-existing tissues, so the +pathological tissues of the tumor grow only from the antecedent +tissues. The matrix from which the tumor arises is a normal tissue. +There is produced from it, as a neoplasm, either a tissue which +follows the type of the maternal tissue, a homologous tumor, or one +which deviates in type from that of the matrix, a heterologous growth. +Although the latter differs in its composition from that of the +matrix, it does not vary essentially from a like tissue to be found +elsewhere in the body. It occurs where it does not belong either in +place, time, or quantity. The homologous tumor appears rather as a +hypertrophy of the tissue from which it arises, and the line between +this variety of growth and a simple hypertrophy is often purely +arbitrary. + +Although tumors, in the more limited sense, are solid, fleshy masses, +the new formation of tissues may result in the presence of a tumor +within which is a cavity with various contents. Such a cavity is not a +mere hole, but has a distinct wall of connective tissue lined with +epithelium or endothelium. A distinction is thus drawn between cysts +and growths--one which is of daily importance in the practice of +medicine--and Virchow's oncology includes the consideration of the two +varieties of tumors. + +Cystic tumors are subdivided according to the nature of their contents +and the method of their origin. One group is composed of clotted blood +within cavities resulting from the laceration of tissues or in +preformed spaces. If the cyst primarily is merely a rent, the wall +becomes thickened in time from a growth of the limiting tissues, and +the blood-clot, of which the tumor was chiefly composed, may remain or +become absorbed. If the latter event occurs, its place of deposit may +become obliterated by a fusion of the walls of the cyst, or may +persist from the subsequent addition of serum. + +The cystic tumor whose contents are extravasated blood is the +haematoma, familiar instances of which are met with in the haematoma +of the dura mater, of muscle, of the vulva, and the polypoid haematoma +of {116} the uterus. The latter is the long retained and constantly +enlarging blood-clot, due to the adherence of portions of the placenta +after childbirth. + +The second group of cystic tumors has for its contents a more watery +fluid, and to this the term hygroma is applied. This watery fluid +lies, for the most part, within preformed cavities, and its +accumulation is connected with a dilatation of these cavities. +Instances are met with in the tumors resulting from the accumulation +of fluid in the membranes of the brain or spinal cord, and in the +ventricles of the former or in the central canal of the latter. These +lead to the congenital cystic tumors of the cranium or spine, with +watery contents. The ganglion, the house-maid's knee, as also the +hydrocele of the tunica vaginalis, are regarded as hygromata. The +hydrocele of the neck and elsewhere in the subcutaneous or +intermuscular connective tissue is now removed from the hygromata to +the tumors which arise from lymph-vessels. A like transfer of other +hygromata might be made in accordance with the prevailing views +concerning the cavities in which the watery fluid is accumulated. + +A third group of cysts contains material which represents essentially +a production from the wall, with a difference of composition dependent +upon the nature of the wall. Such cysts give rise to tumors through +the retention of their contents, and they are called retention-cysts +or retention-tumors. In the wall of the cysts is a gland-tissue, which +may line the surface or lie beneath. The glandular structures may be +cutaneous, mucous, or represent a part of the great glands of the +body, as the liver and kidneys. The atheromatous cyst of the skin, the +mucous cysts of the gastro-intestinal mucous membrane, and the ovula +Nabothi of the uterus are examples of the retention of secretion +within glands. The dropsical dilatations of the antrum, the vermiform +appendage, the uterus, the biliary and renal canals furnish instances +of tumors resulting from the retention of secretion on a large scale. +In the subsequent history of these retention-cysts the secretion may +be modified chemically and physically; the cells upon the walls may be +transformed from columnar forms into flattened and scale-like +varieties. In time, the original secretion frequently becomes a watery +fluid, resembling the contents of the hygroma previously mentioned. + +This grouping of cysts in contradistinction to fleshy tumors omits the +consideration of a series of cystic tumors of enormous size, the +multilocular tumors of the ovary. This class represents a more complex +form of cystic growth--one whose tendency is toward the reproduction +of cysts, to which the term cystoma is applied. The cystoma is the +result of an active new formation of epithelium and connective tissue, +and is classified as a variety of the epithelial group of tumors. + +Morbid growths, as distinguished from cysts, are divided by Virchow +into the simple and complex forms. The former consist of a single +tissue, the histoid tumors; the latter of several tissues suggesting +an organ, the organoid tumors; while still others, in which the number +and grouping of tissues is so complex as to simulate systems of the +body, even monstrosities, have received the term systematoid or +teratoid tumors. + +Virchow claimed that the growth of most tumors took place from the +connective tissues, and that most of the organoid tumors, especially +cancer, arose from the formative action of the connective tissue in +the part where {117} it first made its appearance. The structure of +cancer suggested an organ, as it consisted of collections of cells +resembling epithelium, within spaces or alveoli whose walls were +formed of connective tissue. The epithelioid cells of the cancer, as +well as the connective-tissue corpuscles, were considered to arise +from pre-existing cells of connective tissue. + +The first, most important, modification of Virchow's views, which has +led to a more rational appreciation of the relation of the various +tumors, especially of the epithelial group, to each other, arose in +consequence of the investigations of Thiersch and others with regard +to the origin of certain cancers. This observer[83] claimed that the +epithelioid element of cutaneous cancers arose in all instances from +pre-existing epithelium, either of the rete mucosum or cutaneous +glands. Similar views were suggested, with various degrees of +precision, by other authors concerning certain cancerous tumors +elsewhere, but were first applied to all cancers with a more exact +formulation by Waldeyer,[84] to whom the prevailing views with regard +to the histogenesis of morbid growths are due. According to him, the +essential (epithelioid) element of all primitive cancers arises from +pre-existing epithelium; consequently, no cancer-cell can arise except +in organs where epithelium is normally present. + +[Footnote 83: _Der Epithelial Krebs, namentlich der Haut, etc._, +1865.] + +[Footnote 84: _Virchow's Archiv_, 1867, xli. 470; 1872, lv. 67; +_Volkmann's Sammlung klinischer Vortrage_, 1871, xxxiii.] + +This comprehensive statement was rendered possible by the +embryological researches of Remak at the outset, and afterward by +those of His and Waldeyer. Remak showed that after differentiation of +the cells of the ovum into the several germinal layers, those from one +layer could not serve to originate the cells belonging to another +layer. The development of normal tissues takes place within the limits +defined by this differentiation. Epithelium thus is not derived from +connective tissue, nerves, or muscles, nor was the reverse known to +occur. To His is due the exact appreciation of the superficial cells +of serous membranes, which had been previously called epithelium, and +had thus been confounded with the epithelial cells of mucous or +cutaneous membranes and of secretory glands. He showed that these +cells had a wholly different origin from epithelium, and were simply +scale-like cells of fibrous tissue, to which he applied the name +endothelium. The latter is now used as the term for the thin, squamous +cells of fibrous tissue, whether they are found lining the walls of +the great serous cavities or the smaller lymph-spaces, the +endocardium, or the inner coat of blood-vessels and lymphatics. + +The importance of this distinction is obvious when the occurrence of +tumors, called cancers, is observed in parts which contain no +epithelium. Aside from the vagueness of the term cancer, as applied +clinically, tumors are sometimes met with, even in parts where +epithelium normally does not exist, whose structure resembles more or +less closely that of cancer as usually recognized. Such tumors are to +be regarded as of an endothelial rather than epithelial character, and +as such their histogenesis falls under the general laws of the +development of tissues. + +Waldeyer[85] has suggested that the primitive basis for the +development of the genito-urinary tract contains cells which are +equivalent in their possibilities of ultimate development to the +epithelium of the limiting germinal layers--a suggestion which is of +importance in permitting the {118} epithelial tumors of the ovary to +be brought under the general embryological laws of development. + +[Footnote 85: _Eierstock und Ei_, 1870.] + +As the growth of embryonal tissues is so defined that descendants are +like their ancestors in all respects, so the development of tissues in +the adult is regarded as defined with equal precision. Eberth and +Wadsworth[86] have shown that the regeneration of corneal epithelium +takes place from pre-existing epithelium. E. Neumann and others claim +in like manner the development of muscular tissue from antecedent +muscular cells. + +[Footnote 86: _Virchow's Archiv_, 1870, li. 361.] + +The relation of cancer to epithelial tumors is regarded as similar to +that borne by sarcoma to tumors composed of connective tissues. The +growth of the epithelial elements into the neighboring parts is +through paths determined by pre-existing or new-formed connective +tissue. The active element of the cancer lies more especially in its +epithelioid cells, and its growth takes place in an atypical rather +than a typical manner. Of the various epithelial tumors, there are +those like the cutaneous horn or corn, the adenoma or cystoma, whose +epithelial growth takes place in accordance with normal methods of +production. The epithelioid constituent of the cancer, on the +contrary, grows often with great luxuriance and with but little +tendency to carry out the normal mutual relations of the epithelium +and connective tissue of the part from which it proceeds. The +epithelioid masses or sprouts are composed of cells whose relation to +each other resembles that of normal epithelium in the absence of an +intercellular substance, while the shapes of the cells correspond more +or less closely with that of the epithelium in the region from which +the tumor arises. The epithelioid cells of cutaneous cancers resemble +those of the surface, the rete, or the glands of the skin. Cancers of +the stomach or uterus contain epithelioid cells whose shape simulates +the varieties in the stomach and uterus. Such resemblances are carried +out in the degenerations which the cells of cancer undergo. The +horn-like, keratoid, transformation of epidermoid cells in cutaneous +cancers, the mucous degeneration of the epithelioid cells of cancers +of mucous membranes, are sufficiently familiar. Notwithstanding these +resemblances, which are also present in secondary tumors at remote +parts of the body, the epithelioid growth advances without limit and +without reproducing the normal type. Cancer is therefore defined as an +atypical, epithelial new formation. + +Sarcoma, on the other hand, whose clinical features correspond so +closely with those of cancer, simulates, as shown by Virchow, the +connective tissues. It is composed of cells and intercellular +substance, both of which may be as varied as are those of the +connective tissues. The shape of the cells is as diverse and their +contents as various, while their possibilities of degeneration are +alike. The cells of the sarcoma are not simply cemented together, as +are epithelial cells, but they are separated from each other by an +intercellular substance, which corresponds in its appearance and +chemical properties with that of mucous, fibrous, cartilaginous, or +osseous tissue. The structure of the sarcoma differs from that of +these tissues in presenting a predominance of cells over intercellular +substance, while the reverse is the characteristic of most varieties +of connective tissue. In this predominant cell-formation lies its +absence of type, {119} whereas the atypical character of the cancerous +growth is manifested rather by the irregular grouping of the cellular +masses than by an abundance of cells. + +As the original cancer is considered as possible only in parts where +epithelium is a normal constituent, so the primitive sarcoma is +possible only in parts where connective tissue is present. The +apparent great frequency of sarcoma in recent times is thus obviously +explained. With an agreement as to its histological characteristics, +its possible place of origin is any of the connective tissues of the +body, and their presence is universal. In the manner of its growth, +its recurrence, and generalization it is subject to the same laws +which determine similar events in the history of cancer. Its +degenerations are often the same, and its symptoms are due to the +action of like causes. + +The importance of distinguishing between these atypical tumors is +real, in that it is only through the association of causes, symptoms, +and results with defined and constant characteristics that a practical +knowledge of tumors is to arise. The time-honored distinction between +malignant or semi-malignant and benignant growths is always to be +sought for, and can only be fully possessed when the natural history +of the new formations is known. With an exact appreciation of the +structure of a tumor it becomes possible to study its special +pathology. From a knowledge of the latter are to be derived those +features of importance in determining the relation of morbid growths +to other deviations from normal and physiological processes. An +immediately practical benefit arises from the Thiersch-Waldeyer +modification of Virchow's theory of the origin of tumors, in that it +permits with greater ease a more accurate clinical diagnosis. +Lucke[87] has been prominent in calling attention to the suggestions +thus presented. + +[Footnote 87: _Volkmann's Sammlung klinischer Vortrage_, 1876, xcvii.] + +The diagnostic value of the theory above-mentioned is rather negative +than positive. With rare exceptions, a tumor cannot be epithelial in +character if its origin is from an organ or a part in which epithelium +is absent. The possible exceptions admit theoretical explanations +which present considerable degrees of probability, and are also based +upon the existing views of the development of tissues. + +A tumor whose origin from the connective tissues is determined +partakes of the characteristics of its matrix, and is a +connective-tissue tumor. Its development from fibrous tissue is more +likely to result in a fibroma; from fat tissue, a lipoma, or a myxoma; +from cartilage or bone, a chondroma or osteoma. + +Tumors developing at certain periods of life in certain parts of the +body are more likely to belong to one than another of the histogenetic +groups. Tumors of the connective-tissue series are stated by Lucke as +more prevalent before the age of thirty-five years, while those of the +epithelial group are more likely to occur after this age, and cancer +of the lip is of special frequency in old age. The fibro-myoma is of +most frequent occurrence in the uterus, and rarely attains a large +size till the approach of the climacteric. + +The rapidity of growth of tumors is also associated with their +genesis. It has previously been stated that the more rapidly growing +tumors are those whose cells are most abundant and in the closest and +most {120} intimate relation to blood-vessels. The type of such tumors +is the sarcoma with its scanty intercellular substance, while the +other (histoid) tumors in the same series, as the fibroma, lipoma, +chondroma, etc., are of relatively slow growth. Tumors of the +epithelial series are of slow growth, from the constantly increasing +distance of the new-formed cells from the vascular connective tissue +which provides their nourishment. When, however, the growth of the +epithelium advances into the connective tissue, pushing out in all +directions and coming in contact with new series of vessels, the +opportunities for nutrition are favorable. In like manner, when the +new formation concerns the connective-tissue stroma, as well as the +epithelial sprouts, vascularization proceeds with the development of +the tumor, and favorable conditions for rapid growth are presented. +Large epithelial tumors may thus arise within organs, but, as the +surfaces are reached, the sources of nourishment become farther +removed and the degeneration of the epithelium favors its detachment +and the formation of ulcers. Hence the tumors whose advance is +associated with ulceration belong rather to the epithelial than the +connective-tissue group. + +The tendency of the cancerous tumors to become generalized through the +lymphatics, and that of sarcomatous growths through the blood-vessels, +is admitted as an important feature in the differential diagnosis. +Although there are numerous exceptions, the rule is available. Its +explanation is based upon the assumed inability of the larger +epithelial cells of the cancer to pass through the lymph-glands; being +detained, they serve as new centres of growth. The smaller cells of +the sarcoma, on the contrary, are permitted a passage through the +gland. The numerous and thin walled blood-vessels present in the +rapidly growing sarcoma permit an extension of the latter into their +interior, and thus a ready opportunity is offered for the formation of +emboli. + +Another important modification in the classification of tumors has +resulted from the recent discoveries regarding the nature and effects +of infective agencies. Virchow grouped together under the term +granulomata certain growths composed of granulation-tissue occurring +in syphilis, lupus, leprosy, and glanders. Their relation to +inflammatory processes was very intimate, yet they were recognizable +as tumors from their possession of many of the characteristics +generally admitted as belonging to such morbid growths. Although at +times their presence might be regarded as evidence of an inflammatory +disturbance, their frequent appearance independently of general +symptoms of the latter was apparent. These tumors, furthermore, were +so frequently accompanied by inflammatory products as to suggest a +like cause for both. Virchow stated that the recognition of the +etiology of these tumors was indispensable to their separate +consideration, and laid stress upon the presence of a specific virus, +contagious and infectious, in the case of syphilis. His views +concerning the etiology of leprosy, though more guarded, yet carried +the suggestion of the importance of exact investigation concerning the +assumed contagious character of this disease. The contagiousness of +glanders was not only admitted, but the similarity of its manner of +origin and propagation to the invasion of syphilis was also stated. +Not only were the resemblances between glanders and syphilis +recognized, but lupus, leprosy, tubercle, and scrofula were also +admitted as presenting a similar relation. + +{121} The importance of recognizing the etiology of these tumors +rather than their anatomy as a basis of classification was strongly +urged by Klebs,[88] who proposed the term infective tumors for the +group of granulomata, including syphilis, lupus, leprosy, and +glanders; and for tubercle, scrofula and the pearly distemper of +animals, which Virchow had classified as lymphomata. This group has +been still further extended by the addition of the lymphomata +occurring in typhoid fever, scarlet fever, and diphtheria. Ponfick[89] +has recently added the disease actinomycosis to the series, and +Cohnheim suggests that certain of the lympho-sarcomata may be +similarly classified. + +[Footnote 88: _Prager Vierteljahrschrift_, 1875, cxxvi. 116.] + +[Footnote 89: _Die Actinomykose des Menschen_, 1882.] + +The growths thus included have a common element of structure--the +granulation-tissue, with its possible disappearance through absorption +or its transformation into an abscess or dense fibrous tissue. Such +features are those common to the granulation-tissue resulting from +ordinary inflammation. Their essential characteristic, however, lies +in the etiology of this granulation-tissue, and for many members of +the group the cause has been discovered to be microscopic organisms. +The constant presence of these is determined in sufficient numbers, in +such distribution, and in such relation, as to explain the nature and +occurrence of the tumors. + +The evidence recorded is not equally full and exact for all members of +this group. Neisser[90] has discovered the bacillus of leprosy, and +the discovery by Koch[91] of the bacillus of tuberculosis, scrofula, +and pearly distemper has already been referred to. Schutz and +Loffler[92] have lately announced their isolation of the +micro-organism causing glanders, and Bollinger[93] discovered the +fungus whose presence is necessary for the existence of actinomycosis. + +[Footnote 90: _Virchow's Archiv_, 1881, lxxxiv. 514.] + +[Footnote 91: See page 99.] + +[Footnote 92: _Deutsche medicinische Wochenschrift_, 1882, lii. 707.] + +[Footnote 93: _Centralblatt fur die med. Wissenschaften_, 1877, +xxvii.] + +In the above affections the organisms are to be regarded as the +characteristic active agent in producing the phenomena of the disease +in which they occur. The presence of micro-organisms in syphilis, +typhoid fever, scarlet fever, and diphtheria is admitted, yet their +absolute identification and constant presence as a cause of the +various manifestations of the respective diseases still remains to be +proved. + +The classification of tumors herewith presented is essentially that of +Virchow, with such extensions and modifications as have arisen in +consequence of the investigations and discoveries during the twenty +years which have elapsed since the delivery of his memorable series of +lectures. Cysts are mentioned, as well as growths, from the importance +of the former in practical medicine. The frequent simultaneous +occurrence of cysts and growths in the same tumor should be mentioned, +and the cystic feature is usually indicated as a qualification. + + +CYSTS. + +Cavities, either new formed or pre-existing, with various contents. +The latter are blood, liquid other than blood, and gland-secretion or +retained secretion. The wall varies in structure in accordance with +the method of origin of the cavity. + +{122} _Haematoma._ + +A collection of extravasated blood, usually within the tissues. +Examples, haematoma of the pericranium (periosteum), of the external +ear, muscle, dura mater, ovary, broad ligament, vulva, anus, uterus +(from retained placenta), haematocele, dissecting aneurism. + +_Hygroma._ + +A collection of transuded or exuded fluid in pre-existing or +new-formed spaces. Examples, hydrocele, hydromeningocele, +hydromyelocele, hydrencephalocele, ganglion, inflamed bursa. + +_Retention-Cyst._ + +An accumulation of retained secretion in follicles or canals from +obstruction to its escape. Examples, atheroma and comedo of the skin, +mucous cysts of the gastro-intestinal mucous membrane, ovula Nabothi, +and cystic polypus of the uterus; retention-cyst of the antrum, +vermiform appendage, gall-bladder, and bile-ducts; dropsical +dilatation of the ovarian follicles, Fallopian tube, uterus +(hydrometra), parovarium (cyst of the broad ligament); hydronephrosis +and multilocular cystic kidney, spermatocele, ranula, galactocele. + + * * * * * + +The growths are classified according to the tissues of which they are +chiefly composed and from which they originate, and according to their +etiology. There are consequently the connective-tissue group; that of +tissues of higher function, as muscle, nerve, and vessels; and the +epithelial group, in which the new formation of epithelium is the +essential feature. The teratoid group comprises a more complex massing +of tissues, representing a combination of those derived from all the +germinal layers of the embryo. The infective group includes those +tumors whose structure is closely allied to that of the products of +inflammation, but whose origin is the direct result of the +introduction from without of a microphyte. + + +CONNECTIVE-TISSUE GROUP. + +Each member mainly composed of a more or less typical growth of a +connective tissue: + + Myxoma, + Lipoma, + Glioma, + Chondroma, + Fibroma (including papilloma and melanoma), + Osteoma. + +To these are added tumors composed of an atypical growth of a +connective tissue, chiefly manifested by a predominance of cells: + + Endothelioma, + Sarcoma. + +The sarcoma includes as many varieties as there are tissues in this +group, hence, + + Myxosarcoma, + Liposarcoma, + Gliosarcoma, + Chondrosarcoma, + Fibrosarcoma, melanosarcoma, + Osteosarcoma. + + +{123} GROUP OF TISSUES OF HIGHER FUNCTION. + + Myoma, of striped (rhabdomyoma) and smooth (leiomyoma) muscular + tissue, + Neuroma, of nerve tissue, + Angioma, of blood-vessels, + Lymphangioma, of lymphatics, + Lymphoma (?), of lymph-gland tissue. + + +EPITHELIAL GROUP. + +Epidermis: + + Callus, + Corn, + Keratosis, + Horn, + Onychoma. + +Epithelium of mucous membranes or glands: + + Struma (?), + Adenoma, + Cystoma. + +In the above varieties the growth of epithelium is more or less +typical, a simple hyperplasia, either alone or combined with the new +formation of fibrous tissue. Only the last three members of the series +are tumors in the limited sense. + + +CANCER. + +Cancer remains as an epithelial tumor, representing the atypical +growth of cells resembling epidermis or the epithelium of glands and +mucous membranes, extending into parts where epithelium is not found +as a normal constituent. A new formation of connective tissue is +usually associated with that of the epithelial cells. + +Numerous varieties of cancer are described, according to the physical +and structural peculiarities of the tumor. The scirrhus and +encephaloid of the earlier writers are now transformed into fibrous +and medullary cancer. This change in name is due to the stress laid +upon the predominance of the fibrous stroma as the usual cause for the +hard, dense, scirrhous cancer, while an abundance of epithelioid cells +in relatively large alveoli is present in the encephaloid, +marrow-like, medullary variety. + +When the growth takes place from the skin or mucous membranes, the +surface frequently presents numerous and usually arborescent papillae +or villi. The papillary cancers of the skin and the villous cancers of +mucous membranes are thus distinguished. + +Cancerous growths of the skin and transitional membranes, often called +epithelioma or cancroid, usually contain epithelioid cells resembling +epidermis, and are therefore designated as epidermoid or +pavement-celled cancer. The alveolar contents of certain cutaneous +cancers are cells resembling those of the deeper layers of the rete +mucosum, while those of other cancers of the skin resemble rather the +epithelium of sweat-glands. Growths of the former character extend +laterally, ulcerate early, and are known as superficial cutaneous +cancer. They form one of the varieties of the so-called rodent ulcer. +Cutaneous cancers, simulating in their structure a reproduction of the +epithelium of sweat-glands, represent a variety of glandular cancer. +The latter term is applied to cancerous growths which arise in +glandular organs, with suggested resemblances of their cells to the +gland-cells of the respective organ. {124} Cylindrical-celled cancer +is frequently met with in those parts of which a cylindrical +epithelium is a normal constituent. + +The degenerations of the epithelioid cells and stroma suggest +qualifying terms. The mucous and colloid cancers are those whose +alveolar contents or stroma have undergone a mucous or colloid +degeneration. The keratoid cancer is one which presents the horn-like +transformation of its epidermoid cells. The melanotic cancer contains +abundant pigment, melanin, within its cells. + +These differences in the structure and appearance of the tumor are +frequently associated with certain modifications of growth and +clinical properties. The epidermoid cancers are less likely to recur +after early removal; the medullary cancers are of rapid growth and +prone to ulceration; while the fibrous or scirrhous forms are of +extreme slowness of growth. In general, however, the pathological +importance of cancerous tumors is essentially the same wherever the +seat and whatever the peculiarities of structure. + + +TERATOID GROUP. + +Includes those tumors, usually of congenital origin and apparent at +birth, composed of connective tissue, epithelium, nerves, muscle, and +vessels. These tissues are often so grouped together as to suggest +systems of the body and parts of an individual. Cysts are often +present which simulate cavities found in the body, whether of normal +or pathological origin. + +In this group are the dermoid cysts with their various contents, +epidermis, sebum, hair, teeth, and bone. The solid teratomata, with +all varieties of connective tissue, as fibrous tissue, fat tissue, +cartilage, bone, neuroglia, in addition to nerves, muscle, and +vessels. Squamous, cylindrical, and ciliated epithelium may be present +and line cavities, at times tubular, whose walls are formed of skin or +mucous membrane. Other tumors of this group are commonly included +under monstrosities, and comprise the varieties of duplication of +parts of the body, of which the extreme instances are such double +monstrosities as the Siamese Twins, Ritta and Christina, the Spanish +Cavalier, and the like. + + +INFECTIVE GROUP. + +The chief characteristic is the cause, micro-organisms, which, +introduced into the body, produce, through their dissemination and +development, multiple growths of tissue like those resulting from +persistent inflammation. As their structure corresponds with the +productive results of inflammation, and their cause is analogous to +the infective causes of inflammation, these morbid growths are closely +allied to inflammatory disturbances. Their classification among tumors +is desirable, as they represent circumscribed growths whose +appearance, persistence, and effects closely resemble those +characteristics of the morbid growths, in the limited sense, in which +the new formation of tissue occupies a wider range: + + _Granuloma_ of tuberculosis, scrofula, leprosy, glanders, + actinomycosis, syphilis, lupus. + _Lymphoma_ of diphtheria, scarlet fever, typhoid fever. + + + + +{125} + +GENERAL ETIOLOGY, MEDICAL DIAGNOSIS, AND PROGNOSIS. + +BY HENRY HARTSHORNE, M.D. + + +ETIOLOGY. + +Recognizing pathology as simply morbid physiology--that is, the study +of the body and its functions in states of disorder from morbid +conditions--how these morbid conditions are produced is the complex +question to be answered by Etiology. + +Nor is this question (or series of questions) by any means only of +speculative or theoretical importance. It is, indeed, eminently +practical. What a difference, for example, there must be in the +diagnosis, prognosis, and treatment of an attack of inflammation of +the eye, in accordance with its causation by ordinary conditional +influences (taking cold), by a particle of steel imbedded in the +cornea, or by syphilis! How great the difference between the wound +made by the teeth of an animal, in one case with, and in another +without, the presence of rabies in its system! Take the instance of +what we call fever: at a certain stage it is almost the same in half a +dozen diseases. By the causation, when known, of this common congeries +of symptoms we judge of the essential nature of the malady, and so of +its proper treatment. + +It is a maxim in philosophy that every event or effect must have at +least two causes. In medical etiology we often find many causes +conspiring to produce one effect. These may be, and commonly have +been, grouped together under two heads; as, 1, predisposing, and 2, +exciting, causes. But under each of these may come a number of +agencies contributing toward the production or modification of +disease. Thus, of predisposing causes we may enumerate inherited +constitution, habits of life, previous attacks of disease, atmosphere, +and other immediate surroundings. Exciting causes--say, of an attack +of apoplexy--may be, in the same case, mental shock, a stooping +posture, an over-heated room, etc. One disease is very often the next +preceding cause of another. So we speak of the great class of sequelae +of acute or subacute disorders; as, ophthalmia after measles, deafness +following scarlet fever, or blindness small-pox, abscesses following +typhoid fever, paralysis diphtheria, etc. But this kind of causation +is extremely common also in chronic affections. What a train of +organic troubles, of kidneys, heart, arteries, brain, and other parts, +attend the affection to which we give the name of Bright's disease! +How complex the sequence often of valvular disease of the heart, +itself in many instances the effect of rheumatic fever, with {126} +endocarditis as a local manifestation of that disorder! Hardly any +discovery in pathology (or pathogeny, the generation of diseases) of +the last half century has been more remarkable and fruitful than that +of thrombosis and embolism, with their serious and not rarely fatal +consequences, through obstruction of the blood-supply to different +organs. + +Previous diseases constitute an often overlooked class of factors in +predisposing to new attacks, and also in determining their course and +results. Of some affections one attack prepares the way for another, +as is the case with intermittent fever, convulsions, delirium tremens, +and insanity. Just the reverse is true of yellow fever and of all the +exanthemata, as scarlet fever, measles, small-pox; likewise of the +analogous disorders, mumps and whooping cough. The moot question in +this regard concerning syphilis may be left for discussion elsewhere. + +Our classification of the causes of disease may be set forth in simple +form, thus: + +1. Pre-natal causation--viz. hereditary transmission of a proclivity +to certain disorders, and also the influence of circumstances acting +on either parent at the time of conception or on the mother during +gestation. + +2. Conditional causation--_i.e._ that belonging to variations of +temperature, humidity, etc., affecting individuals. + +3. Functional causation--that which is connected with excessive, +deficient, or abnormal exercise of any of the functions of the +economy. + +4. Ingestive causation--_e.g._ bad diet, intemperance, poisoning. + +5. Enthetic causation--viz. that of all contagious, endemic, and +epidemic diseases. Closely allied to this is epithelic morbid +influence--namely, that of the parasites producing certain affections +of the skin, as itch, favus, etc. + +6. Mechanical causation. The effects of this belong chiefly, though +not exclusively, to the domain of surgery. + +Pre-natal causation is of immense consequence, and its study takes in +the whole scope of the influences of species, race, family, and +individual parentage. Darwin's observations and speculations, and +those of other evolutionists, have not ignored the field of human life +in considering the struggle for existence and the survival of the +fittest. If we are obliged to admit that such a struggle and survival +do exist for men as well as for animals and for plants, it is +nevertheless obvious that either man's reason and will introduce +exceptions to the ordinary laws of development and selection in +nature, or else a very peculiar standard of fitness must be recognized +in the survivals of humanity. Many feeble, inert, deformed, and +diseased forms survive and perpetuate offspring through a long series +of generations, while strong and admirable ones perish, often even +destroying each other. + +Leaving this theme, upon which biological science has not yet +pronounced its last word, we may inquire, What diseases are reasonably +ascribed to hereditary transmission? First, it must be remarked that +seldom is a disease actually received directly from a parent. Putting +aside a few asserted instances of variola and allied or analogous +affections in utero, congenital constitutional syphilis and (more +rarely) scrofulosis seem to afford almost the only examples of this. +Nearly always it is a predisposition merely that is inherited. This, +however, may be very strongly marked. Its seat is evidently in that +(as yet) occult law or {127} process of individual organic development +to whose manifestation we give the name of the constitution. In some +families all the men grow bald before forty; in others, scarcely so at +eighty. Some may expect deafness in middle life, others blindness in +old age, and others, again, have a probability of death from disease +of the heart at about fifty or apoplexy at about sixty years of age. +Such considerations enter into every examination for life insurance, +and they are no less important in our prognostications of the results +of diseases in practice. + +Speaking more definitely, gout is undoubtedly often hereditary. That +is, a healthy childhood may be followed by liability to gout in adult +or middle age, even in the absence of direct provocatives to that +disorder, but much more frequently when they are present. Gout affords +an example of the general fact that inherited proclivity to special +diseases shows itself at nearly the same time of life in each +generation--scrofula in childhood, phthisis in adolescence or early +maturity, gout from thirty to forty, apoplexy after sixty, etc. But +exceptions to such rules are not at all rare. Gout also exemplifies +another important fact--viz. the occasional modification of the +transmitted morbid tendency or "diathesis." Parents who have regular +gout--_i.e._ painful attacks of acute inflammation of the smaller +joints, followed by deposits of urates, carbonates, etc.--not +unfrequently have children who are subject to neuralgia or dyspepsia +or modified rheumatic attacks (not sufficiently recognized in +practical treatises), to which the name "gouty rheumatism" is most +applicable. Again, in one generation there may be a marked tendency to +insanity; in the next, to paralysis; in a third, to tubercular +meningitis during infancy.[1] Or some of these successions may occur +in a reverse order. + +[Footnote 1: For example, in one family known to me the grandmother +had paralysis, the mother died insane, and her three children all died +of tubercular meningitis.] + +Constitutional syphilis is undoubtedly often conveyed by inheritance +from either parent. Sometimes the impression of this diathesis is so +intense as to devitalize the foetus in utero, causing still-birth. Or +the manifestations of the disease occur early in infancy, with +symptoms like those of the secondary or tertiary affection in the +original subject of it. Not often, indeed, is the exhibition, in some +manner, of inherited constitutional syphilis delayed beyond the time +of childhood. + +Scrofulosis is well known to follow in the same family through +successive generations, in a manner apparently demonstrative of +hereditary derivation. It is true that here we have a problem not +without complication. Certain circumstances, as poverty of living, +dampness of locality, want of fresh air in houses, etc., promote +scrofula in children. Now, are we sure that it is from its parents +that each child, exposed to these morbific surroundings, has obtained +its disposition to strumous disorders? or may it not be that every +time the diathesis is thus originated de novo? It is to be answered +that decisive evidence in favor of inheritance is present in a number +of cases where the affection occurs so early in infancy as to be +almost or quite congenital in its beginnings; and in other instances +where removal of the parents into improved localities, and with better +living altogether, has not prevented the manifestation of the same +tendency in their offspring for two or three generations. The inquiry +does not differ very greatly in its nature from that concerning cases +of enthetic diseases--_e.g._ cholera, yellow fever, typhoid fever; as +to which the {128} succession of cases may be such as to allow +hypothetical explanation, either by transmission from one individual +to another or by the subjection of all to a common local infection or +epidemic influence. But in both sorts of cases crucial instances may, +with care, be found which determine at least the general etiological +law for each malady. + +Pulmonary phthisis has been always considered to be, in a marked +degree, a hereditary disease, until, latterly, the hypothesis of a +tubercular virus has threatened to displace old views about it. If, +however, we accept the classification of cases of pulmonary +consumption approved by several leading pathologists, in which a +position is provided for non-tubercular phthisis, we may at least +place hereditary vulnerability, or proclivity to consumption, in this +category, while awaiting the final decision of science upon the real +nature and origin of tubercle. My own conviction continues to be +positive, that tubercular phthisis is often transmitted by +inheritance, in the same sense as other diseases are generally +so--namely, by the bestowal upon offspring of a constitution +especially liable to the occurrence of the disorder at the time of +life when it is generally most apt to appear. The investigations of +Villemin, Cohnheim, Schuller, Koch, Baumgarten, and others have given +(1882) much prominence to the idea of the possibility of the +transplantation of tubercle from one human or animal body to another. +Koch's elaborate experiments especially are asserted to have shown the +existence of a bacillus tuberculosis, a true, minute vegetative +organism, which can be cultivated outside of the body, in a suitable +material, at a temperature like that of living blood, and which, when +inoculated, produces tubercular disease. The discussion of this +subject will occur on a later page as a part of the general topic of +the causation of enthetic diseases. + +Rickets occupies a much less prominent place in the experience of +American practitioners than in that of some countries abroad, and it +is therefore less easy here to obtain materials for the study of its +etiology. Among those who have had large opportunities for its +observation, opinion is divided very much in the manner above referred +to. Thus, Wiltshire and Herring assert it to be certainly hereditary; +Jenner denies this altogether, while Aitken adopts the ground that +predisposing causes are derived from the parents or the nurse, which +are so capable of influencing the health of the child as to lead in +course of time to the establishment of the disease. + +Goitre is manifestly a family disorder to a large extent in certain +regions, most familiarly in Alpine valleys in Switzerland. But this +local feature takes us back to the same kind of question: Is it the +transmission of a specially modified constitution from parents, or the +direct action of morbid local influences on the children themselves, +that produces bronchocele and its frequent attendant, cretinism? +Undoubtedly, goitre often occurs in children of healthy parents +brought from another locality into one where the disease is common; +and, per contra, goitrous subjects not infrequently recover from the +affection when removed for a length of time from the place where it +was developed in them. We are, apparently, at least safe in taking +here a position like that of Aitken concerning rickets: viz. that +predisposing causes are derived from parentage, whereby, more easily +than in those of different descent, certain influences will develop +goitre or cretinism, or both together. + +{129} As to leprosy, there seems no more room for doubt that it is +often--nay, generally--hereditary. The obscurity attending its +history, however (more than one cutaneous affection having been from +time to time classed under the same name), will justify our referring +the reader for the particular discussion of its etiology to another +part of this work. (See DISEASES OF THE CUTANEOUS SYSTEM.) + +Haemophilia is clearly hereditary in certain families. Immermann +asserts it to be even a race-liability in the Jews. "Bleeders" upon +occasion of very small wounds of the skin, gums, etc. have been known +in several successive generations, including (Borner; Kehrer) women at +the time of parturition, who then are apt to have dangerous +hemorrhages. + +Cancer presents as unmistakable examples of inheritance as any other +disease. Paget asserts this to be traceable in one case out of three; +Sibley, in one of nine; and Bryant, one of ten cases. De Morgan and +others have shown the same thing to be true of non-malignant morbid +growths. But, as Paget has remarked, when other local disease or +deformity is inherited, it usually involves in the offspring the same +tissue, often the same part of the body, as in the parent, but the +transmitted cancerous tendency may show itself anywhere: "Cancer of +the breast in the parent is marked as cancer of the lip in the +offspring. The cancer of the cheek in the parent becomes cancer of the +bone in the child. There is in these cases absolutely no relation at +all of place or texture." + +Cataract is believed by good authorities to be promoted by hereditary +tendency. It is of the nature of a degeneration. Possibly, in a +greatly-prolonged decay of all the organs with age, all eyes tend to +become cataractous from structural alteration of the crystalline lens. +Under observation a quite different rate of degenerative change takes +place among the organs of the body in different individuals and +families. Thus, the lens becomes opaque in some at an age when the +hearing continues good and the muscles retain considerable vigor, +while in members of other families the eyes remain in a sound +condition at a time when other organs and powers have failed. +Congenital cataract appears to be altogether independent of any +proclivity transmitted from parents in the nature of an inheritance. + +Affections of the nervous system very often show hereditary descent. +Neuralgia prevails strongly in certain families. Particularly, that +form of cephalalgia called sick headache is apt to appear, in the +periodical form, through several generations. Apoplexy and paralysis +are prone to occur at nearly the same time of life under the +transmission of like constitutions by parentage. Still more often this +has been observed of epilepsy and hysteria, and, most of all the +neuroses, in insanity. Monomania and melancholia have been in a great +number of instances traced to generative succession--sometimes, +especially suicidal monomania, through four or five generations. +Predisposition to intemperance, methomania, is also a terrible +inheritance in some families. Although the production of this malady +requires the provocative of indulgence in the use of alcohol for its +development, yet the facility with which this result occurs under the +same circumstances in different families is too marked to leave room +for doubt of its hereditary nature. + +Less certainly, but with much probability, we may assign parental +endowment as one of the factors in the causation of organic disease of +{130} the heart, arteries, liver, and kidneys, as well as of angina +pectoris, asthma, croup, dyspepsia, and hemorrhoids. + +Is a special proclivity to any of the group of enthetic febrile +diseases ever inherited? Dr. George B. Wood believed this to be the +case with enteric or typhoid fever. Few others have shared this +opinion, but it is not impossible that it has a basis of truth. + +Reference has been made already to the difference between periodical +malarial fevers (intermittent, etc.) and yellow fever, in that an +attack of the latter does, and one of the former does not, protect the +individual, usually, from liability to the disease on exposure to its +cause. Does this protection extend to offspring of parents who have +been "acclimatized" to yellow fever? Facts on this point are not easy +to obtain. While, however, there appears to be no proof that a single +generation can ever suffice to outgrow (so to speak) liability to this +disease, it is well known that creoles in Louisiana and the West +Indies are less susceptible to it than recent white residents, and +that the negroes are much less so, as a race, than the whites. +Furthermore, negroes whose ancestors have long been domesticated in +our Southern States appear to re-acquire susceptibility to yellow +fever in a degree more nearly like that of white people than is +observed in natives of Western Africa imported within one or two +generations. + +As to autumnal malarial fevers (remittent, intermittent), the black +race exhibits a sort of race-acclimatization, giving negroes, both in +Africa and in America, a much less degree of liability than is common +to all races of European descent. + +How far any similar modification may occur in the course of +generations in regard to susceptibility to small-pox and allied +diseases remains at present a matter of speculation. Some authors +insist that there must be at least a kind of natural selection, +according to which a great epidemic of variola, destroying the lives +of many of those most predisposed to suffer from it, will leave the +remaining population less likely to be attacked by it. The endeavor +has even been made to explain away in this manner much of the +diminution of mortality from small-pox commonly credited to +vaccination. But the statistics of the ravages of variola in different +countries before and after the introduction of vaccination show that, +while we cannot deny that some alternation (of generations +respectively more and less susceptible) may occur, no such law can +compare in influence with that of vaccination in the protection of +individuals subjected to it. Indeed, the argument may be inverted; +thus: if in the days before Jenner small-pox itself weeded out the +persons most liable to it, or in some way prepared a partial family- +or race-protection, such a protection ought to be gradually conferred +upon a whole population through universal and persistent vaccination +carried on for several generations. + +Is it possible for one hereditary constitution or diathesis to become, +in transmission, not only modified, but transmuted, into another? Some +of the older pathologists imagined this to be the case with syphilis, +to whose past influence upon parents and ancestors they traced the +origin of scrofula. But no sufficient ground for such a pathogeny can +be ascertained. All that appears to be left after scrutiny of the +facts is, that syphilis is a depressing and perverting agency, and so +may join with {131} other depressing causes in preparing the way for +the engendering of scrofulosis. + +A few points still remain to be briefly mentioned in connection with +the hereditary conveyance of proclivity to disease. One or several +members of a family will often pass through life without any +manifestation of such transmission, while others, their brothers or +sisters, give marked evidence of it. Sometimes a whole generation may +be passed over, and yet the predisposition may be abundantly shown in +that next following. This is closely similar to atavism, as it is +called in zoology and general biology, according to which traits +occurring under admixture or variation of animal or vegetable stocks +may be absent in the immediate offspring of a couple, but reappear in +their next succeeding descendants, or even a still later reversion may +take place. Such instances are not rare, and they need to be +considered in the proper study of the influence of parentage, +intermarriage, etc. upon health and disease. + +A practical question of much importance (belonging, however, rather to +sanitary than to medical science) is, how far confirmation or +modification of hereditary proclivities may occur through the effect +of the conditions of marriage upon offspring. Consanguineous marriages +have been, time out of mind, held to be very objectionable. The +question has been much discussed whether the ground of sanitary +objection is properly against such marriages as per se injurious to +offspring, or whether the bad effect consists merely in reduplicating +and intensifying family constitutional taints. It would not be in +place here to go into this controversy. My own conclusion is, that a +natural law of sexual polarity or affinity exists, according to which, +in all the higher organisms, reproduction is most normal and gives the +best results when a considerable genetic difference (within the limits +of species) exists between parents. While, however, this is probable, +but difficult to demonstrate, it appears to be certain that when a +father and mother both possess morbid constitutional predispositions +(say, to phthisis, insanity, or gout), their children will be at least +twice as likely to suffer from the same as if only one parent were so +endowed. Whether or not, then, the marriage of two perfectly healthy +first-cousins may be expected (as several statisticians aver to have +been shown) to be attended by defects of health in their progeny, the +union of such relations when their common progenitors were in marked +degree consumptive, or scrofulous, or liable to insanity, epilepsy, +etc., has attached to it so unfavorable a prognosis for offspring as +to be rightly forbidden. Moreover, so few families possess an +absolutely faultless health-record that the chances of increasing +existing morbid traits by intermarriages are quite sufficient to +justify the commonly held objection against them. + +We must allude very briefly to the influence of conditions affecting +conception and gestation upon the health of offspring. Intemperance in +parents has, in many instances, been known to promote convulsions, +infantile or epileptic, and other cerebral or nervous disorders in +children, besides a general feebleness of constitution. Even +intoxication at the time of procreation has been asserted to mark a +similar difference between one child and another of the same parents. + +All are familiar with the (no doubt often quite imaginary) accounts of +the effect on infants in utero of powerful sensory or mental +impressions upon the mother during gestation. Abortion has, +unquestionably, been {132} often produced by violent nervous shocks. +Without deciding the question whether "monsters" are ever developed in +correspondence with particular experiences of the mother, we may hold +it to be clear that all depressing and disturbing agencies may +interfere with the process of nutrition of the foetus, and thus +develop mental anomalies, and that constitutional impairments may thus +be greatly promoted. + +All inherited predispositions, it is important to remember, are +aggravated, and each proclivity changed to actuality, by those +influences which in individuals tend to like effects upon health. Such +become exciting causes of various diseases. If these be constantly +avoided, and all the surroundings and the mode of life of the +individual be maintained in a manner most favorable to health, the +hereditary tendency may remain inert through a long lifetime. Every +physician must have seen this in scores of instances. The application +of the principle through special precepts belongs to personal hygiene. +But no physician can rightly ignore the study of this subject, or omit +the utilization of his acquaintance with it by preventive advice to +members of the families under his professional care. + +Our last remark in connection with pre-natal causation must be upon +the effects of circumstances and modes of living on masses of men, +especially in large cities and populous countries. Something has been +said already of race-acclimatization by which there may be acquired a +lessened susceptibility to certain endemic fevers.[2] Almost a reverse +action is exhibited in the gradual lowering of vital energy under what +has been called the "great-town system." While those having all the +comforts of life and avoiding excesses may manifest but little of this +deterioration, it is very observable in that mass of men, women, and +children who become the subjects of medical charities. Closeness and +uncleanliness of living, with more or less exposure to dampness and +extremes either of heat or cold, with intemperance and syphilis, are +the main causes of this general constitutional impairment. So +important is it that it should never be forgotten, not only in our +estimate of the causation of diseases, but in our anticipation of +their results, and also in our adaptation of measures of treatment, +medical and surgical, to different classes of patients. All that it is +allowable here to suggest in this regard may be summed up (although +very imperfectly) in the word hospitalism. + +[Footnote 2: It is important (but not before remarked in this article) +that cholera does not appear to allow of any such diminution of +liability to it among the natives of the country in which it is +endemic.] + +Conditional causation has been, to a certain extent, included under +what has been above said, as it is the action, in part at least, of +surrounding conditions, that establishes a family- or race-proclivity +and inheritance. But we must say something more about the direct +action of conditions upon individuals. + +Man, although organized with great delicacy of structure, is capable, +by the use of his intelligence, of adapting himself to a wider variety +of external conditions than any other animal. He is the only truly +cosmopolitan being on the earth. From the remote Arctic regions to the +hottest tropical climates there are tribes whose ancestors have dwelt +for centuries in the same localities. Not that no unfavorable +influence attends these extremes. The Esquimaux are stunted, the +Southern Hindoo and {133} Central African are enfeebled and +degenerate, partly from climate. But with man's numerous protective +devices, great cold and great heat only exceptionally affect +individual health. Freezing to death follows unusual exposures; the +loss of an extremity by sphacelus from congelation is more often met +with; heat-stroke also is tolerably frequent; and the influence of +heat in producing cholera infantum in some large cities is very +important; but much the most common kind of conditional morbid +causation is produced either by sudden changes of temperature or by +diversity of exposure of different parts of the body. These are the +two usual modes of "taking cold." When dampness accompanies a +relatively low temperature, such an effect is much more apt to follow +than in a cold dry atmosphere. + +Actual cold-stroke, the analogue of heat-stroke, may sometimes happen. +I once saw such a case in a previously healthy boy twelve years of +age, who, after standing for an hour in his night-shirt on a cold +winter night, became almost immediately ill, fell into a comatose +state, and died in about thirty-six hours. + +A simple rationale may be discerned for the phenomena of catching +cold. When, for example, a draught of air blows for a time upon the +back of a person at rest (especially one who has just before used +active exertion), the local refrigerant impression induces +constriction of the superficial blood-vessels. Hence follow two +effects: one, the repulsion of blood in undue amount toward interior +organs; the other, diminution, perhaps arrest, of excretion from the +skin of the exposed portion of the body, and consequent retention of +some effete material, promoting esotoxaemia.[3] If, then, there be in +the body any weak organ--that is, one whose circulation is partially +impeded or whose nutritive and functional activity is low--it suffers +first and most from the impulsion of blood from the surface. +Congestion, irritation, and inflammation may follow, and we have an +attack of pneumonia, pleurisy, bronchitis, or some phlegmasia. + +[Footnote 3: That is, blood-poisoning, originating within the body +itself; exotoxaemia being that which is enthetic--_i.e._ resulting +from a poison derived from without.] + +Excessive heat with dryness, as under the blasts of the Simoon or the +Harmattan of Arabia or Northern Africa (apart from insolation, +sunstroke, or heat-stroke), may sometimes parch the body even to a +fatal degree. Much more common is the combination of high temperature +with humidity. This has a relaxing effect, promoting indolence of +temperament and predisposing to disorders of a catarrhal nature, +especially of the digestive organs, such as were called fluxes by the +older writers. + +Cold climates are well known to present the greatest number of cases +of acute and chronic affections of organs of the respiratory system; +warm and hot climates, those of the stomach, liver, spleen, and +bowels. But we must recollect what various complications belong to +climate. Two important factors, especially, must be kept in view in +comparing the causation of diseases in colder and warmer +countries--namely, the difference in the articles of food partaken of +in each, and the external sources of enthetic disorders; _e.g._ +endemic and epidemic fevers, etc. + +With humidity must be considered variations in atmospheric pressure. +Physicists have long known that while watery vapor, by itself, is +heavier than air which is perfectly dry, moist air is lighter than air +containing {134} little or no moisture. Hence the barometer falls as +the quantity of atmospheric moisture approaches saturation. Other +causes, however, also affect barometric pressure. With the same degree +of humidity, cold air is denser and heavier than warm air, and by its +contraction lowering the "column" of atmosphere--the temperature of +which is reduced--a flow toward the upper part of the column increases +the actual mass of air pressing upon a particular place. Elevation of +a locality above the general level of the earth reduces atmospheric +pressure, sensibly as well as measurably. So "the difficult air of the +iced mountain-top" has become proverbial. + +These variations are familiar, though all their effects upon human +health have been by no means, as yet, fully studied. Most difficult to +determine and analyze are the influences of changes of pressure, +chiefly hygrometric, upon the course of diseases and upon the result +of severe surgical operations. Among the few important series of +observations bearing on this topic have been those of Dr. S. Weir +Mitchell on neuralgia,[4] and Dr. Addinell Hewson on the prognosis of +major operations,[5] in connection with the state of the weather. The +former ascertained a marked relation between the approach of a wave of +low barometric pressure and attacks of irregularly periodic neuralgia; +the latter proved, by the statistics of the Pennsylvania Hospital for +a number of years, that the most favorable time for amputations or +other capital operations is when the barometer is high, or at least on +the ascent. + +[Footnote 4: _American Journal of Medical Sciences_, April, 1877, p. +305.] + +[Footnote 5: _Pennsylvania Hospital Reports_, 1868.] + +Electrical atmospheric states and vicissitudes have, quite probably, a +practical consequence beyond what is usually ascribed to them in +connection with health and disease. But their effects are so difficult +to disentangle from those of other meteorological causes that we must +be content at present without attempting their exact specification. +The same observation may be made with reference to ozone. + +Elevation of site has importance, not only in regard to climatic +hygiene, but also to its therapeutic use, particularly in the +treatment of phthisis, goitre, and some affections of the nervous +system. But in our brief and general survey of Etiology this topic +must be left without discussion, since no disorder appears to be +traceable to elevation alone, beyond the temporary prostration on +exertion, with hemorrhages from the nose, lungs, etc., often produced +in those who climb to great mountain-heights or ascend rapidly in +balloons. It has been shown by ample experience that considerable +populations may live in ordinary health through long periods at +altitudes more than 10,000 feet above the level of the ocean. + +Depression below the surface of the earth has never become a part of +human experience beyond the limit of a few hundred feet. Miners living +underground in a few places in Europe have been found to exhibit +comparatively feeble health, but the privation of sunlight, the +confined atmosphere, and the dampness of such unnatural abodes will +suffice to account for these effects. + +Under functional causation of disease we may include all excessive, +deficient, or abnormal exercise of any of the organs of the body. To +simple excess may be ascribed the scrivener's or bank-officer's +paralysis of the muscles of the hand used in continuous writing; brain +{135} exhaustion from mental labor or anxiety, unrelieved by +sufficient sleep; and sexual impotence, temporary or lasting (or +sometimes even general paralysis), from inordinate sexual or sensual +indulgence. + +Deficiency of functional exercise is observed to produce disability, +as when the muscles of a limb, for instance, are for a long time +restrained from use. Surgeons meet with this inconvenience (unless +assiduously guarded against) when a fractured limb is kept long at +rest in a fixed position. Atrophy of the mammae in single women of +retired lives is common; atrophy of the testicles in unmarried men +much less so. These changes, however, are physiological, not +pathological; upon alteration of conditions--_e.g._ marriage--the +atrophy will disappear altogether. + +Abnormal functional action as a cause of morbid results is seen when +the eyes are injured by reading, writing, or doing any delicate work +in a bad light; for instance, late twilight. Also, in a secondary or +accessory manner, when a near-sighted person, having the action of the +muscles of convergence in excess of his accommodation, or a +long-sighted (hyperopic) person, whose accommodation is in excess of +convergence, suffers from asthenopia, perhaps with headache, distress, +nausea, etc. Another example of abnormal functional exercise and its +effects is that of self-abuse, where the unnatural mechanical +imitation of the physiological act of sexual coition induces +disturbances of the nervous and circulatory systems, besides debility +from excess. + +Ingestive causation is a sufficiently fit designation for all errors +of diet, as well as misuse of medicines, and poisoning. Starvation or +inanition belongs to the same category by negation. Gluttony and +intemperance are major members in the ingestive series, while haste in +taking food, without mastication, and the use of heavy bread, unripe +fruit, and other indigestible articles, account for many cases of +dyspepsia and some of colic, cholera morbus, diarrhoea, etc. With +young children, especially, no more frequently acting cause of +disorder exists than dietetic mismanagement, most of all during the +period of dentition, and earlier, when, from absence or insufficiency +of mother's milk, they have to be artificially fed. Then the supply of +good fresh cow's, goat's, or ass's milk may carry them well through +infancy, while a regimen of arrowroot or gum-arabic and water, or +stale, half sour milk, may either starve or sicken them to death. On +the subject of poisons and of misuse of medicines we have no occasion +here to make special remark. Only it may be mentioned that the +possibility of either is always to be remembered by the physician in +making up his mind in regard to the origin of symptoms observed. + +Enthetic causation is a large subject, including all origination of +disease by the introduction of morbid materials from without the +body.[6] Medical opinion has generally accepted, and facts fully +sustain, the recognition of three groups of enthetic disorders, viz.: +those which are personally contagious; such as are locally epidemic; +and epidemic diseases. Of the first group it will suffice to mention, +as an example, syphilis; of the second, intermittent fever; of the +third, influenza. + +[Footnote 6: Simon has proposed the term exopathic to indicate the +origin of such maladies; autopathic disorders being those which +originate within the body itself.] + +Were all maladies whose causation is evidently of external origin +capable of the same clear discrimination as these, we should have no +difficulty with the present topic. But, in fact, no subject connected +with {136} the history of disease has become surrounded by more +intricate controversy. Many times the same facts are, or appear to be, +explicable in two or three different ways. What some hold to be proofs +of contagion from person to person, others are ready to account for by +the subjection of a number of persons or of a whole community to +either a common local or a widespread migrating (epidemic) influence. +It is sometimes impossible, in the nature of things, to obtain an +absolute demonstration of the truth of one or another of these +theories without such experiments upon human beings as are +impracticable. + +While endeavoring to ascertain the limits of our present knowledge +upon these questions, let us first notice what are the most positive +facts concerning them, some of which are common to the whole group or +class of what have been, since Liebig, often called zymotic,[7] but +latterly more often enthetic, diseases. + +[Footnote 7: The term zymotic has, with many authors, fallen into +disrepute, chiefly because Liebig's hypothesis concerning the +chemico-physical action of ferments, as well as of contagia, has lost +ground in comparison with the vital or disease-germ theory. Yet the +analogy between fermentation, putrefaction, and the action of a virus +on an animal organism persists; whatever may be the theory of their +explanation, something appears to be common or similar in all these +processes.] + +These diseases may be enumerated as follows: + +1. _Only produced by contact or inoculation_. + + Primary Syphilis, + Gonorrhoea, + Vaccinia, + Hydrophobia. + +2. _Contagious also by atmospheric transmission through short +distances_. + + Variola, + Varioloid, + Varicella, + Measles, + Diphtheria, + Scarlatina, + Rotheln, + Mumps, + Whooping Cough, + Typhus, + Relapsing Fever. + +3. _Endemic, occasionally epidemic_. + + Malarial Fevers (Intermittent, Remittent, and Pernicious Fever), + Dengue, + Yellow Fever. + +4. _Other zymotic or enthetic diseases_. + + Influenza, + Cerebro-spinal Fever, + Erysipelas, + Puerperal Fever, + Tropical Dysentery, + Typhoid Fever, + Cholera, + Plague. + +As all observers are agreed in regard to the personal transmission of +the first named of these series (variola, etc.), we need to give +attention here only to the other groups; except merely to say that the +easily demonstrable existence of a morbid material (virus) in the +instances of primary syphilis, gonorrhoea, variola, and vaccinia +presents a very cogent analogical argument for the presumption that +all clearly contagious (even {137} though non-eruptive) maladies, such +as mumps and whooping cough, must also have a morbid material as their +essential cause; and also in favor of the supposition that a morbid +material may probably be the "causa sine qua non" of each of the other +maladies which are known to be endemic or epidemic. A few theorists +only have argued in favor of any other view than this. Sir James +Murray and Dr. Craig of Scotland, and Dr. S. Littell of Philadelphia, +have sustained an electrical hypothesis, and Oldham and others have +advocated one connected with changes of bodily temperature, or ozone, +etc., for the origination of certain endemic and epidemic diseases. +But all the facts point toward the existence of material causes, +specific for each of these disorders, and many observations and much +ingenuity of reasoning have been brought to bear upon the question as +to their intimate nature. + +Are these materiae morborum merely inorganic elements or compounds +entering human bodies and acting there as chemical poisons? Against +such a supposition we have, as almost decisive objections, not only +the absence, under the most searching analysis, of any chemical +peculiarity in the air of malarious or otherwise infected regions, but +also the clinging of many endemic and epidemic causes (as known by +their effects) to particular localities, notwithstanding the +recognized law of the diffusion of gases which must antagonize such +concentration. Therefore, we may rule out, as highly improbable at +least, the hypothesis of the inorganic gaseous nature of malaria, as +well as of the essential causes of yellow fever, cholera, plague, and +the other analogous diseases. + +By the once general use of the term zymotic, there is suggested a line +of thought which has been quite prevalent since the prominence of +Liebig's teachings in chemical physiology, until recently. That great +chemist did not imagine that a true zymosis or fermentation occurs +under the action of a virus upon the human economy. His thought was +more clearly expressed, in the phraseology of the late Dr. Snow of +London, as the theory of continuous molecular change. Its most +striking physical instance or analogue is the extension of flame from +a burning body to combustible matter within its reach. Sugar formation +from starch by diastase, and the change of albumen into peptone by +pepsin, are familiar examples, in organic materials, of the +propagation of molecular movement in special directions and with +characteristic results.[8] It does not seem to be more than a short +step from these to the processes which we study in fermentation, +putrefaction, septicaemia, and the multiplication of small-pox +contagion, from the smallest inoculation, in the human body.[9] + +[Footnote 8: In anticipation of the argument concerning the necessity +of the action of minute living organisms to produce fermentation, +putrefaction, and specific diseases, emphasis may be here laid upon +the fact that the above named changes, and many others like them, are +produced, in the absence of such organisms, by chemical agents formed +in the body, or even (as when sulphuric acid changes starch to sugar) +by inorganic substances. Pasteur considers that the yeast-cell +secretes a sort of diastase which changes starch or cane-sugar into +glucose, on which the cell then lives, decomposing the glucose into +alcohol, carbonic acid, etc. Koch and others now assert that a +bacillus produces the souring of milk, and another the butyric acid +fermentation.] + +[Footnote 9: The assertion of some advocates of the "germ theory of +disease," that only living organisms reproduce their kind, loses +weight as an argument in view of the natural history of small-pox and +analogous diseases; unless it be proved that every particle of +contagious matter is (at one time at least) a living organism.] + +But here comes in a new hypothetical factor, introduced by the aid of +{138} the microscope, although anticipated conjecturally before actual +discoveries in this field were made certain. So prominent is this +subject in the discussions of the present time, under the expression +"the germ theory of disease," that we are justified in giving +attention to it here somewhat at length. + +Stahl proposed a purely chemical theory of fermentation early in the +seventeenth century. Not much later Hauptmann suggested the probable +causation of epidemic diseases by minute living organisms. +Linnaeus[10] revived this hypothesis in the eighteenth century. These +two topics of inquiry, with the intermediate one of putrefaction, then +received much attention, at first apart, but afterward with +recognition of their analogies. When Fabroni, Cagniard de la Tour, +Schwann, and Kutzing had, with the aid of the microscope, made +familiar the life-history of the yeast-fungus[11] (Saccharomyces +cerevisiae), more close consideration still was given to these +remarkable changes in organic materials and forms, dead and living. + +[Footnote 10: Linnaeus accepted the asserted observation by Rolander +of acari in the stools in dysentery. The great naturalist deviated +somewhat here from his usual carefulness and accuracy, as that +observation was not afterward verified.] + +[Footnote 11: Leuwenhoek, however, had observed and described it in +1680.] + +Starting from the physical basis of inorganic chemistry, Liebig +followed the series up from the so-called catalytic[12] action by +which the presence of a substance, itself apparently unchanged, +induces reaction between two or more other bodies, to those which +occur within plants and animals, as examples of vital chemistry. Such +is the influence of diastase or invertin, which in the seeds of plants +brings on the conversion of starch into sugar and of cane-sugar into +glucose and levulose. Such is the agency of ptyalin in the saliva, of +pepsin in the gastric juice, and of pancreatin or trypsin in the +secretion of the pancreas, in the processes of digestion. From these +it appears to be an easy transition to those changes which occur in +organic matter no longer living, as in the fermentation of vegetable +juices and the putrefaction of animal tissues.[13] Liebig endeavored +to explain these also in the same manner as the chemico-vital +processes; and he then went farther to apply the same generalization +to the propagation of disease, by what is called virus, in the +instances of contagious, endemic, and epidemic maladies. + +[Footnote 12: The idea expressed by this term was especially favored +by Berzelius and Mitscherlich.] + +[Footnote 13: It is noticeable, however, although generally forgotten, +that the one set of changes and assimilations (namely, those of +digestion) are formative actions of life, and the others destructive, +in the direction of, or subsequent to, death.] + +But, meanwhile, observation and speculation gave almost equal +prominence to the importance of minute living organisms in the +apparent instigation of all these evidently analogous changes of +fermentation, putrefaction, suppuration, septicaemia (Piorry, 1835), +infection, and contagion. + +Upon this side the leading investigator for many years has been +Pasteur. As long ago, however, as 1813 Astier, and in 1840 Henle of +Berlin, and near the same time Sir Henry Holland of London and Dr. J. +K. Mitchell of Philadelphia, gave expression to opinions of a similar +kind, based upon many important facts before very much overlooked. By +exact experimentation, moreover, Schwann, Helmholtz, Schroeder, and +Dusch ascertained that the agent or agents causative of fermentation +and putrefaction can be detained by heated tubes, by animal membranes, +{139} and by cotton wool, anticipating the later observations of +Pasteur,[14] Tyndall, Chauveau, and others to the same or similar +effect. These results of experiments are commonly understood to prove +the particulate character of the agents so studied. What may be called +an era in the practical application of etiological inquiry dates from +the introduction by Lister (about 1860) of the principles of +antiseptic surgery, based upon the theory that disease-germs, derived +from the atmosphere or other external sources, are the essential +causes of suppuration, septicaemia, pyaemia, gangrene, etc. following +injuries or operations. + +[Footnote 14: Pasteur's experiments with long-drawn bent tubes had +especial significance.] + +So far from this inquiry being yet terminated, while experiments and +observations have become more and more numerous and elaborate, +opinions continue to differ; and we must yet await the time when, by +successively excluding, one after another, all the sources of error, a +truly scientific conclusion may be obtained. + +Roughly speaking, it may be said that parties in the debate are +chiefly ranged upon two sides--those who favor the probability that +only chemical, not vital, action is to be traced in fermentation, +putrefaction, suppuration, infection, and contagion; and those who +regard minute organisms, discovered or undiscovered, as causative of, +and indispensable to, all these processes. + +Without intention of injustice to other able investigators, the +principal names so far associated with the former of these views may +be thus mentioned: Panum (1856), Robin, Bergmann, Liebig, Colin, +Lebert, Vulpian, Onimus, B. W. Richardson,[15] Beale,[16] Senator, +Rosenberger, Hiller, Naegeli, Schottelius, Harley, Jacobi, Curtis, and +Satterthwaite. Of those maintaining, in some form and with more or +less positiveness, the disease-germ theory, the most conspicuous, +especially as observers, have been Tuchs (1848), Royer (1850), +Davaine, Branell, Pollender, Pasteur, Tyndall, Lister, Mayrhofer, +Ortel, Letzerich, Nassiloff, Hueter, Toussaint, Hansen, Salisbury, +Klob, Hallier, Basch, Virchow, Neisser, Eberth, Tommasi Crudeli, +Klebs, Talamon, Schuller, Tappeiner, Cohnheim, Koch, Baumgarten, +Buchner, Aufrecht, Birch-Hirschfeld, Greenfield, and Ogston. Besides +these the elaborate studies of microphytes by Cohn, and those of Coze +and Feltz, Waldeyer, Recklinghausen, and others upon septic poisoning, +have been of acknowledged importance; and the experimental labors of +Burdon Sanderson in England, and Sternberg,[17] H. C. Wood, and Formad +in the United States (under the auspices of the National Board of +Health), possess great value. But the scientific caution of these last +inquirers, like that of Magnin, has prevented them from formulating, +as yet, positive and final opinions upon the subject. It is not saying +too much to assert nearly the same of {140} several of those mentioned +above, as inclining to one or the other side of the controversy.[18] + +[Footnote 15: Dr. Richardson has long contended for the doctrine first +proposed by Panum, that a peculiar chemical agent, (called by Bergmann +_sepsin_) is the cause of blood-poisoning from virulent absorption or +inoculation. Latterly, attention has been called by Selmi and other +observers to the existence of complex compounds called _ptomaines_ in +decomposing animal substances--_e.g._ the human body after +death--these having considerable resemblance in their toxic action to +the poisonous vegetable alkaloids.] + +[Footnote 16: Opposed at least to the ordinary form of the germ theory +of disease.] + +[Footnote 17: Sternberg's observations and experiments (following +those of Pasteur) with the inoculation of animals with saliva, proving +that even when taken from perfectly healthy men this may be fatally +poisonous to animals, possess remarkable interest. They do not seem, +however, to be decisive either way in regard to the germ theory of +infection.] + +[Footnote 18: Billroth and Cohnheim are among those who have changed +their opinions on this subject after prolonged investigation.] + +It would appear, then, that the data for a final conclusion have not +yet been made certain. Several hypotheses are conceivable, and +capable, each, of plausible support: + +1. The purely chemical theory of Liebig, Gerhardt, Bergmann, Snow of +London, and B. W. Richardson. + +2. The bioplastic hypothesis of Beale, according to which germinal +matter may be detached from a living body and planted, while yet +retaining vitality, upon another, and there may undergo changes more +or less morbid, and destructive of the body by which it has been +received. This theory of migrating or transplanted bioplasts has +received very little support besides that of its distinguished author. + +3. That the minute organisms discovered so constantly upon diseased +parts of plants and animals (_e.g._ ergot of rye, _Peronospora +infestans_ of potato-rot, _Botrytis Bassiana_ of silk-worm muscardine, +_Panhistophyton_ of silk-worm pebrine, _Empusa muscae_ of the fly, +_Achorion_, _Tricophyton_, _Oidium_, and _Leptothrix_ of human +affections of the skin and mucous membranes) are incidental or +accidental only[19]--acting, as R. Owen observes, {141} most commonly +as natural scavengers in the consumption of effete organic material; +but that they may become noxious under two sorts of +circumstances--viz. when their numbers are enormously increased, as is +known to be the case with trichinae in the human body, and also when +they are brought in considerable number into contact with bodies +already diseased, or at least suffering under depression of vital +energy. + +[Footnote 19: This possibility has not been as yet altogether ruled +out in regard to Koch's _Bacillus tuberculosis_; concerning which +active discussion has been going on during the past year or two +(1882-83). A very large number of observers confirm the statement that +the bacilli are found in most specimens of tubercle. Several, also, +have repeated with success Koch's inoculation experiments, in which +tubercle appeared to be propagated by carefully isolated bacilli. But +many facts still stand in the way of the conclusion that the bacillus +is the causa sine qua non of tuberculosis. First, examples of the +production of phthisis by apparent contagion or infection are few. +Although Dr. C. T. Williams found bacilli in the air of the wards of +the Hospital for Consumptives at Brompton, yet of the experience of +that hospital Dr. Vincent Edwards, for seventeen years its resident +medical officer, reports as follows: "Of fifty-nine resident medical +assistants who lived in the hospital an average of six months each, +only two are dead, and these not from phthisis. Three of the living +are said to have phthisis. The chaplain and the matron had each lived +there for over sixteen years. Very many nurses had been in residence +for periods varying from months to several years. The head-nurses," +says the writer, "sleep each in a room containing fifty patients. Two +head-nurses only are known to have died--one from apoplexy; the other +head-nurse was here seven months, was unhappily married, and some time +afterward died of phthisis. Of the nurses now in residence, one has +been here twenty-four years, two twelve years, one eight years, one +seven years, one six and a half years, and one five years. No +under-nurse, as far as I am aware, has died of phthisis. All the +physicians who have attended the in-and-out patients during the past +seventeen years are living, except two, who did not die from +phthisis." + +Against the inoculation and inhalation experiments of Villemin, +Tappeiner, Koch, Wilson Fox, and others, by which the specific +character of tubercle has been said to be proved, must be placed those +of Sanderson, Foulis, Papillon, Lebert, Waldenburg, Schottelius, Wood +and Formad, Robinson, and others, by which tubercles have been induced +by the injection, inoculation, or inhalation of various non-tubercular +materials. In answer to the argument from these, it is asserted by +Koch and his supporters that "there is no anatomical or morphological +characteristic of tubercle," its only sufficient test being its +inoculability. This is almost begging the question; at all events, it +leaves it, for the present, unsettled. Moreover, tubercular deposits +do not always contain bacilli, as has been shown by Spina, Sternberg, +Formad, Prudden (_N.Y. Medical Record_, April 14 and June 16, 1883). +The last named made, in one well marked case, six hundred and +ninety-five sections from ninety-nine tubercles in different portions +of a tuberculous pleura, all of Koch's precautions being observed in +the examination. Belfield (_Lectures on Micro-Organisms and Disease_) +admits the possibility that tuberculosis may be produced by either of +several causes. It has, at least, not yet been demonstrated that the +tubercular tissue is more than a nidus or favorable "culture-ground" +for the bacilli, or that, in the presence of a constitutional +predisposition, they may not merely promote a more rapid destruction +of the invaded organs or tissues.] + +4. That such organisms are the essential and direct causes of enthetic +maladies by invading the human and other living bodies as parasites, +consuming and disorganizing their tissues, blood corpuscles,[20] etc. +Pasteur considers the abstraction of oxygen an important part of their +action. + +[Footnote 20: Against this view stands especially the objection that, +as Cohn, Burdon Sanderson, and others have fully shown, bacteria and +other Schizomycetae obtain their nitrogen, not from organized tissues, +but from ammonia, and their carbon and hydrogen from the results of +decomposition in organic tissues. (See B. Sanderson, in _Brit. Med. +Journal_, Jan. 16, 1875.) Pasteur has regarded the relation of these +organisms to oxygen as important; some of them requiring it for their +existence (aerobic), and others not (anaerobic). He has defined +fermentation as "life without free oxygen."] + +5. That these microbes, microphytes, or mycrozymes act not as +parasites, but as poison-producers, secreting a sort of ferment which +is the specific morbid material (Virchow); or, when multiplying in +excess of their food-material, they may die, and their dead bodies, +like other decaying organic matter, may become poisonous. This +possibility, although not distinctly suggested (so far as I know) +hitherto, appears to me to be not unworthy of consideration. That the +numbers of micro-organisms present have some important relation to +morbid conditions has long since been inferred from familiar facts. + +6. That they are not generators, but carriers, of disease-producing +poisons; their vitality giving to the latter a continuance of +existence and capacity of accumulation and transportation not +otherwise possible. + +Briefly, the following is a summary of the most generally accepted +classification of those microscopic organisms[21] whose role in the +causation of diseases is now under discussion; chiefly following Cohn +and Klebs: + +_Orders_: Hyphomycetae, Algae, Schizomycetae. + +Hyphomycetae, _genera_: Achorion, Tricophyton, Oidium. + +Algae, _genera_: Sarcina, Leptothrix. + +Schizomycetae, or Bacteria, _genera_: Micrococcus, Rod-bacterium, +Bacillus, Spirillum.[22] + +[Footnote 21: For further details concerning these the reader is +referred to the works of Magnin, Belfield, and Gradle on _The +Bacteria_, and on the _Germ Theory of Disease_.] + +[Footnote 22: Cohn also separates vibrio and spirochaete as genera +distinct from spirillum. They may, however, be regarded rather as +species of that genus. Some recent authors included bacterium and +bacillus under one genus, bacillus; against which simplification there +seems to be no valid objection.] + +Micrococci (Sphaerobacteria of Cohn) are asserted (under certain +conditions) by Letzerich, Wood, and Formad[23] to be causative of +diphtheria; Ogston has found them in ordinary pus; Rindfleisch, +Recklinghausen, Waldeyer, Birch-Hirschfeld, and others report them to +be always present in the abscesses of pyaemia; Buhl, Waldeyer, and +Wagner state their occurrence in intestinal mycosis; Eberth, Koster, +Maier, Burkhardt, and Osler, in ulcerative endocarditis; Orth, +Lukomsky, Fehleisen, and Loeffler, in erysipelas; Coats and Stephen in +pyelo-nephritis; Friedlander, in pneumonia; Eklund (_Plax scindens_) +in scarlet fever; Keating[24] and {142} Le Bel, in measles; Leyden and +Gaudier, in cerebro-spinal meningitis; Carmona del Valle, in yellow +fever; Prior, in dysentery; Gaffky, Leistikow, Bokai, and Bockhardt, +in gonorrhoea;[25] besides other similar observations by numerous +writers. + +[Footnote 23: _Bulletin of National Board of Health_, Supplement No. +17, Jan. 21, 1882.] + +[Footnote 24: _The Medical News_, Philadelphia, July 29, 1882.] + +[Footnote 25: Sternberg's careful experimentation seems to show the +identity of Neisser's gonococcus with the Micrococcus ureae, commonly +found in decomposing urine.] + +Bacterium termo is regarded by leading authorities as the special +ferment or causative agent of putrefaction[26] (Billroth, Cohn). + +[Footnote 26: Others have referred putrefaction to vibriones, less +precisely described.] + +Bacillus includes, hypothetically at least, several species; as +Bacillus subtilis, the innocent hay-fungus; Bacillus anthracis, the +microbe of malignant pustule (anthrax, milzbrand, charbon) and the +splenic fever of sheep; Bacillus typhosus (Klebs, Eberth, Meyer) of +typhoid fever; Bacillus leprae (Hansen, Neisser, Cornil, Koebner) of +leprosy;[27] Bacillus malariae, reported as having been +demonstrated[28] by Klebs and Tommasi Crudeli, Marchand, Ceri, and +Ziehl; Bacillus tuberculosis (Koch, Baumgarten, 1882); the bacillus of +malignant oedema (Gaffky, Brieger, Ehrlich); that of syphilis +(Aufrecht, Birch-Hirschfeld,[29] Morrison); of glanders (Loeffler, +Schuetz, Israel, Bouchard); of pertussis (Burger); besides the +Actinomycosis of Israel, Ponfick,[30] Bollinger, and others. Koch has +very recently (1883) been reported to have discovered in Egypt the +bacillus of cholera. + +[Footnote 27: Dr. H. D. Schmidt of New Orleans, an experienced +pathologist, reported (_Chicago Medical Journal and Examiner_, April, +1882) that critical examination of numerous specimens of tissues from +three cases of leprosy under his care failed to verify the existence +of bacilli as characteristic of that disease.] + +[Footnote 28: Not certainly, however, as shown by Sternberg (_Bulletin +of Nat. Board of Health_, Supplement No. 14, July 23, 1881). Dr. +Salisbury of Ohio in 1866 made a series of observations, on the basis +of which he asserted the discovery of a genus of malarial microphytes, +which he referred to the family of _Palmellae_. + +The oval and spherical organisms described by Richard and Laveran as +found in the blood of malarial patients resembled micrococci rather +than bacilli.] + +[Footnote 29: More recently described by him as micrococci.] + +[Footnote 30: _Die Actinomykose_, 1881.] + +[Illustration: FIG. 1. Micrococci: _a_, zoogloea form; _b_, +micrococcus from urine, in rosary chain; _c_, rosary chain from +spoiled solution of sugar of milk (Cohn).] + +[Illustration: FIG. 2. Bacteria: _a_, zoogloea of _Bacterium termo_; +_b_, pellicle of bacteria from surface of beer; _c_, _Bacterium +lineola_, free; _d_, zoogloea form of _B. lineola_.] + +[Illustration: FIG. 3. _Bacillus malariae_ of Klebs and Tommasi +Crudeli.] + +[Illustration: FIG. 4. Bacteria from gelatin solution, inoculated from +swamp-mud, X 1500 (Sternberg).] + +[Illustration: FIG. 5. Vibrios in gelatin culture-fluid, X 1000 +(Sternberg).] + +[Illustration: FIG. 6. Protococcus from slides exposed over swamp-mud, +X 400 (Sternberg).] + +[Illustration: FIG. 7. Bacilli from swamp-mud, X 1000 (Sternberg).] + +[Illustration: FIG. 8. Bacilli from septicaemic rabbit, X 1000 +(Sternberg).] + +[Illustration: FIG. 9. Bacilli from human saliva, X 1000 (Sternberg).] + +[Illustration: FIG. 10. _Bacillus anthracis_ (Sternberg).] + +[Illustration: FIG. 11. _Bacillus tuberculosis_, within and outside of +pus-corpuscles (Sternberg).] + +Spirillum (Spirochaeta of Ehrenberg) has its best ascertained example +in the minute forms first observed by Obermeier, and afterward by many +other observers, in the blood of patients suffering with relapsing +fever. They have been found present in the blood only during the +febrile paroxysm, disappearing in the intermission and through +convalescence. + +Hastening to close our consideration of this subject, we may note, +without much argument, a few of the points of difficulty needing yet +to be more fully illuminated by {143} careful observation before any +form of the germ theory can take its place as an established doctrine +in etiology: + +1. The absence of the characters belonging to definite organisms[31] +in the easily-studied virus of small-pox and vaccinia stands, a +priori, against the probability of such organisms being essential to +the causation of other enthetic diseases. + +[Footnote 31: The particulate character of variolous and vaccine virus +has been already alluded to, as asserted to have been shown by +Chauveau and others. Yet it is not absolutely demonstrated that +filtration may not produce an important chemical alteration in some +kinds of highly unstable organic material subjected to it. Cohn +figures a Micrococcus vacciniae in his article on Bacteria +(_Microscopical Journal_, vol. xiii., N. S., pl. v., Fig. 2). Beale +denies (_Microscope in Medicine_, 4th ed.) the existence of any +organisms in vaccine virus. Lugginbuhl, Weigert, Klebs, Pohl-Pincus, +and others have asserted their existence, but, especially in the +absence of any successful culture experiments, it does not seem to be +proved.] + +2. Analogy in nature, showing the commonly beneficial action of +nutritive processes in re-appropriating the products of organic decay +on a large or on a small scale, makes the scavenger theory of the +general function of minute cryptogamic organisms more probable, per +se, than that which holds many of them to be destructive parasites or +poison-producers in the bodies which they may inhabit. Few well known +parasites are capable of causing death in higher animals or in man. + +3. These microbes are among the minutest objects which can be studied +under the microscope. Bacteria average about 1/9000 of an inch in +their longest diameter; micrococci and spores (Dauersporen, Billroth) +are yet smaller. Much care, therefore, as well as skill, must be +exercised in making observations upon them.[32] Huxley asserted a few +{144} years ago that a distinguished English pathologist had mistaken +for movements of minute living organisms the "Brownian movements" seen +in the particles of many not living substances under a high magnifying +power. One observer, at least,[33] considers that the forms designated +as bacteria and micrococci, etc. are either forms of coagulated fibrin +or granules from morbidly-altered blood-corpuscles (zoogloea of +Billroth, Wood, Formad, and others). Koch denies the validity of the +observation of organisms in tubercle by Klebs and Schuller, while +insisting upon his own demonstration of a bacillus tuberculosis. +Authorities must, by mutual confirmation or correction, remove these +obscurities. + +[Footnote 32: A very interesting discovery was made by Tyndall, to the +effect that while one boiling of a liquid would sterilize it for the +time by destroying all the bacteria present, their spores might still +retain vitality and be afterward developed. By repeated exposure to a +boiling temperature, taking these spores in their developing stage, +they were destroyed, and complete sterilization was effected.] + +[Footnote 33: R. Gregg, _N.Y. Med. Record_, Feb. 11, 1882. Sternberg, +however, has replied to him (_N.Y. Med. Record_, April 8, 1882, p. +368). The latter admits a doubt as to whether the granules seen within +the leucocytes by Wood and Formad in diphtheritic material, and +believed by them to be micrococci, are such, or are merely granules +formed or set free by disorganization of protoplasm within the +leucocytes. This uncertainty well illustrates the difficulty of these +investigations. + +A chemical test much relied upon is, that bacteria resist the action +of acids and alkalies, which destroy granular material of animal +origin; also, that all these organisms are deeply stained by aniline +dyes and by haematoxylin. The most decisive test, however, is +cultivation in a liquid sterilized by heat. Koch prefers a process of +dry culture for the bacillus of tubercle. + +Gradle (_Lectures on the Germ Theory of Disease_, Chicago, 1883, p. +28) says that the absolute criterion of the life of bacteria is their +power of multiplication.] + +4. Bacteria and micrococci have been abundantly discovered (Kolaczck; +J. G. Richardson) in healthy bodies upon the various mucous membranes +and in the blood. The correctness of such observations has been +denied, but, so far at least as the mucous membranes are concerned, it +has been well established by Nothnagel, Sternberg, and others. +Bacteria have sometimes been found in countless numbers in fecal +discharges. + +5. Bacteria become most numerous in materials of a septic or +infectious character after their period of toxic intensity has passed +by. + +6. Suppuration can be produced (Uskoff, Orthmann) without the presence +of minute organisms of any kind. Bacteria have been found {145} under +Lister's antiseptic dressings without suppuration following. Paul Bert +destroyed all the microbes in a septic liquid, and yet found it to +retain its poisonous quality. Rosenberger (1881) has made similar +observations. + +Panum, Coze, and Seltz, Bergmann and Schmiedeberg, Hiller, Vulpian, +Rosenberger, Clementi, Thin, and Dreyer have, by various elaborate +investigations, proved that fatal septic poisoning can be produced in +animals by the products of organic decomposition, without the presence +of living organisms. Zweifel's experiments seem to have shown that +normal blood, when deprived of oxygen, in the absence of +micro-organisms, may acquire septic properties. + +As stated by Belfield,[34] many experiments by Schmidt, Edelberg, +Kohler, Nencki, and others, have shown that septicaemia may be induced +by the injection into the blood of free fibrin ferment and other +substances, in the absence of minute organisms. To such an affection +some authors now give the name sapraemia, to distinguish it from +bacterial infective disorders. + +[Footnote 34: _Lectures on the Relation of Micro-organisms to +Disease_, 1883.] + +Griffini ascertained that mixed saliva, filtered through porous +plates, and thus containing no microbes, will still produce +septicaemia in animals, when subcutaneously injected. Colin (1876) has +denied the conclusiveness of the experiments of Chauveau, which have +been held to prove the particulate nature of variolous and vaccine +virus. Moreover, it is well known that eggs with shells unbroken are +tainted when placed near others which are unsound. + +7. While Klebs and Koch maintain the definite specificity of each +minute microphytic organism, Naegeli and Billroth assert their mutual +convertibility. Burdon Sanderson avers[35] that "the influence of +environment on organisms such as bacteria is so great that it seems as +if it were paramount." Buchner, Grawitz, Greenfield, Pasteur, Wernich, +Thorne, Willems, Law, Wood, and Formad report experiments making it +appear that modification by culture is possible with bacilli and +micrococci, converting an innocent into a malignant parasitic +organism, or a death-producing microbe into one capable only of +causing {146} a transitory and not dangerous local affection; which +nevertheless secures to the animal thus treated immunity when +subsequently exposed to the deadly infection. Most interesting have +been the successes with such culture-inoculations obtained by Buchner, +Greenfield, and Pasteur with anthrax in sheep; by Pasteur also in +chicken cholera; and by Willems and Law[36] with the lung-plague of +cattle. + +[Footnote 35: _Brit. Med. Journal_, Jan. 16, 1875.] + +[Footnote 36: _N.Y. Med. Record_, June 18, 1881, p. 679. Exposure to +the air for a considerable period seems to be the agency chiefly +relied upon for what may be called the dynamic modification of these +microphytes. When cultivated in the depth of a liquid, so that air is +excluded, they are supposed to acquire a habit of obtaining oxygen by +decomposing organic substances, and thus act destructively upon the +cell-elements of living bodies. Analogous differences have long since +been observed in the study of fermentation between surface and +sedimentary yeast.] + +In none of these cases is there reported any morphological change +whatever in the bacillus (Grawitz) or micrococcus (Wood and Formad); +the change in the effects noted, and, in the case of the micrococci of +malignant diphtheria, the acquired capacity of reproduction through +several generations, are all. + +8. The immunity against subsequent attacks on exposure (similar to the +protection given by vaccination) continues to be without full +explanation upon any theory. But it is especially difficult to +reconcile it with the hypothesis of the infection being caused by, and +dependent upon, the presence of peculiar microphytes. Why should not +these, whether as parasites or as poisons, always produce the same +effects? + +9. The view entertained by Thorne, Wood, and Formad, that a common +benignant affection, such as ordinary sore throat, may be converted +into a violent infectious disease--_e.g._ malignant diphtheria--by +modification of innocent micrococci into those with lethal characters, +through local or bodily conditions, is sufficiently contravened by the +great frequency of such conditions compared with the decided relative +rarity of such malignant epidemics or endemics. + +10. Throughout all the investigations which have been, and are likely +to be, conducted, there remains the extreme difficulty, if not +impossibility, of total separation between the microbes themselves and +the matter of the vehicle in which they exist--the membrane, urine, +blood, virus, artificial culture-material, or whatever it may be. All +the effects ascribable to the disease germs may be, with no more +difficulty, attributed to the toxic action {147} of a portion, however +minute, of the soil in which they have lived, whose modifications must +be concomitant with those which they undergo. It appears necessary, +therefore, at the present time, to regard this whole question as still +undecided, with a predominance of probability, however, in favor of +the view that these minute organisms, or some of them, have a direct +and important relation of some kind to the causation of specific +endemic, epidemic, and contagious diseases. Altogether, the strongest +arguments are on the side of the view that the micrococci, bacilli, +etc. cause diseases, not as parasites, living upon their victims, but +as poison-producers infecting them.[37] The germ theory continues to +be in the position of a probable hypothesis, not in that of an +established doctrine of etiological science. + +[Footnote 37: This comports much the best with the general natural +history of parasites on the one hand, and of venoms, ptomaines, etc. +on the other. Gautier, Ogston, and others have expressed the opinion +that microphytes may produce ptomaines.] + +Practically, the result is nearly the same as if it were altogether +settled, since it is admitted on all sides that the presence of +microphytes (bacteria, micrococci, spirilla) coincides with those +conditions under which originate several of the most malignant +diseases. Measures which prevent the appearance or promote the +destruction of these minute organisms are at least often, and to a +great degree, preventive, if not curative, of such disorders; and the +glory of Jenner's discovery, by which the ravages of small-pox have +been made (potentially at least) controllable, seems not unlikely to +be paralleled by the achievements of Pasteur and others in a similar +preventive mastery over other maladies of men and animals. There is, +therefore, no branch of inquiry in connection with medical science +more worthy of being assiduously encouraged and extended. The present +may almost be said to be, in the history of medicine, an era of +myco-pathology. + +For an exhaustive study of Etiology attention would now have to be +given to the modifying influences affecting the occurrence and +character of diseases in connection with age, sex, and temperament. +But, as neither of these is ever, per se, causative of any malady, and +they merely determine some modification of the action of morbid causes +when these occur, want of space must be our justification for leaving +them to be considered, in this work, in connection with the special +causation of the different {148} diseases which will be hereafter +described. A larger treatment of our present subject belongs rather to +hygiene than to practical medicine. + + +MEDICAL DIAGNOSIS. + +For the purposes of the medical practitioner all professional studies +unite to the end of furnishing preparation for the diagnosis and +treatment of diseases. At the bedside the cardinal questions are, How +does the present condition of our patient differ from health? and, +What ought we to do to bring about his recovery? + +Diagnosis involves three main directions of inquiry: 1, as to the +general bodily state of the patient; 2, morbid changes in particular +organs, tissues, or functions; 3, as to what name properly designates +the disorder, according to accepted nomenclature. + +Pathology can never be out of view in connection with either the +theoretical or the practical study of diagnosis. But it is most +closely regarded when the last of these questions is before us, since +the names of diseases generally have a more or less distinct reference +to their pathological nature. Yet clinical observation always suggests +the early use of provisional terms for recognized groupings of morbid +phenomena; and sometimes these clinical designations remain for a long +time in use because of the imperfection of pathology. + +We ascertain, in practice, the nature of a given case, first, by +considering its symptoms. These are those obvious evidences of +deviation from health which the patient himself is aware of, or which +the physician readily discerns or elicits by simple inquiry or +examination. + +Secondly, taking the clue furnished by symptoms, a closer inspection +is made, with the intent of finding what is the actual state of +important organs, as the heart, lungs, liver, spleen, kidneys, and +alimentary canal. + +Lastly, when these means fail to remove all obscurity, or when special +scientific investigation is practicable, instruments of precision are +employed, as the thermometer, sphygmograph, ophthalmoscope, +aesthesiometer, or aspirator; or by the microscope and chemical +analyses still more minute examination is made into the particulars of +the morbid processes present and their results. + +We may subdivide diagnosis, then, into: 1, symptomatology; 2, +organoscopy or physical diagnosis; 3, instrumental diagnosis. + + +Symptomatology. + +Semeiology (from [Greek: semeion], a sign) is a term much in use, with +essentially the same meaning as symptomatology, but less conveniently +distinctive, since it does not so well indicate the contrast between +obvious signs, or symptoms, and those more recondite, obtained by the +methods of physical diagnosis. + +Signs of disease cannot be recognized as such except by one who is +{149} familiar with the appearances, actions, and manifestations which +belong to health. Nor can they be understood, so as to infer what they +mean, without knowledge of normal physiology on the one hand, and, on +the other, of the natural history of diseases. Physiology constitutes +the etymological grammar, symptomatology the vocabulary, and diagnosis +the syntax of practical medicine. Just as grammatical knowledge will +not enable any one to read or speak a language without acquaintance +with its words, so clinical observation is necessary to the physician +over and above all the knowledge he may have of physiology and +pathology. He must learn to know diseases by sight, or at least by +personal contact and observation. + +Every one has, of course, a general familiarity with the state and +actions of his own and other bodies in health, yet a more exact +knowledge of the movements of respiration, circulation, secretion, +etc., as well as the form, size, and relative location of all the +organs of the body, is needed. Physiology and medical anatomy furnish +such information. The more thorough this knowledge is appropriated, +the better fitted the student is for practical diagnosis. For its +application, however, cultivation of all the perceptive powers is very +important. Some men have a genius for quick and clear discernment of +symptoms and for their interpretation, as well as for that of physical +signs. But all can much improve their senses, and their sagacity in +using them, by experience. For this, if for no other reason, +scientific training, in field or laboratory studies, affords the best +introduction to the work of the medical student and physician. The +traits most needed for success in diagnosis are exactness and +comprehensiveness. First, to be sure precisely what each sign is that +comes under observation; next, to overlook no existing symptoms or +physical signs; and, last, so to combine them into a mental map, +diagram, or picture, as to make a coherent and rational whole. This +nosogram may then be compared with the descriptions of standard +authorities, to find its place (if it has one) in technical +classification. First, however, ascertain the thing, the morbid state +or combination of states; afterward the name, or morbid species, when +practicable. It is always to be remembered that complication of +diseases, or at least the existence of some irregular manifestations +along with those which are characteristic, is more common than the +occurrence of purely typical cases. The portraits of most diseases in +the books are averages, like the composite class-photographs of +Douglas Galton. Not nearly every case will correspond with such an +average in all respects. Moreover, so great is the possible variety of +alterations among the different organs of the body that the chances of +two instances of disease being precisely alike in every particular are +hardly greater than those in favor of every move being the same in two +games of chess with the same opening. + +In an essay like the present it is not easy to decide upon the best +manner of treating the subject before us. Too much or too little may +be said. With advanced readers the whole history of symptoms and +physical signs might be left to the special discussions occurring in +articles upon different diseases. But it may be taken for granted that +those who consult the present work will do so either at a +comparatively early stage of their studies or when time has made +desirable a renewal of what may have been once known and then +forgotten. Since, then, it is impossible {150} to anticipate what may +be the exact needs of either class, a somewhat elementary statement of +main facts appears justifiable here. + +Following the natural method, we may suppose a call to visit a +patient. Arriving in his presence, the first question (mostly left out +of view and rarely expressed) may be, Is it a case of real or only +imaginary indisposition? Army medical officers, more than most others, +can appreciate the possibility of this inquiry sometimes disposing of +the whole case. + +Supposing it to be real, is it an illness or an accident or other +injury? Is it severe or of trifling account? Acute or chronic? We +observe the position of the patient, lying quietly in bed, sitting up, +or walking restlessly about the room. Then the countenance is +observed--pale or flushed, tranquil or excited in expression. We feel +the forehead, touch the cheek and hand. Is the skin hot or cold, dry +or moist? The pulse is felt; the breathing also is counted. + +Of the patient himself or of another (in serious acute cases better of +his care-taker, in another apartment) we ask questions whose answers +give us the general history of the case. When not before known these +should include his antecedent personal history, even extending to that +of the family, as far as can be learned. What tendencies have they, or +has he or she, shown by previous attacks and their results? + +So we come to the present attack: When did it begin, and how? What +have been its prominent symptoms since? Questions are then to be put +concerning the heat of the body, appetite, complaint of pain, sleep, +movement of the bowels, discharge of urine: in the female, +menstruation; if married, pregnancy or parturition, how often and when +occurring last. Thus the practitioner is enabled to get a clue to the +diagnosis, to be followed out through his own observation and closer +examination. If the patient be a child and the attack be acute and +febrile, an early question must be as to its having passed or not +through the different diseases of childhood--viz. the exanthemata, +mumps, and whooping cough, and also what exposure to any of these it +may have been recently subjected to. + +Going farther into particulars, let us review some of the possible +developments obtained in the above questioning of symptoms. + +When lying in bed the decubitus may be significant, as, upon the back +with the knees drawn up in peritonitis; with the hands pressing the +abdomen in colic; tossing to and fro in the delirium of fever or of +early cerebral inflammation; on one side constantly in acute +inflammation of the liver or in pleurisy. Or the patient may be +obliged to be propped in a sitting posture (orthopnoea) from +heart-disease, asthma, or ascites, or leaning forward upon the back of +a chair or a pillow with aneurism of the aorta. More remarkable still +may be the subsultus tendinum of low fever, the opisthotonos of +tetanus, the respiratory spasms of hydrophobia, or the clonic +movements of epileptic, hysterical, or occasional convulsions. + +In the face we see pallor in syncope and in anaemia in any of its +varieties and with varied associations; a general redness in some +cases of apoplexy and in remittent fever; flushing of the forehead and +eyes especially in yellow fever; dusky redness in typhus, and a more +purple hue in typhoid fever; yellowness in jaundice, in some cases of +remittent and in most of yellow fever; sallowness in cancer; a bright +central glow upon each cheek in early pneumonia or the hectic of +phthisis; a blue or ashen appearance in the collapse of cholera, and +blackish-blue in {151} cyanosis or carbonic acid poisoning; bronzed in +Addison's disease; puffy about the eyelids in Bright's disease; the +surface swollen, yet resistant to the touch, in myxoedema. The eyes +(one or both) glare prominently in exophthalmic goitre; squint in +advanced cerebro-meningitis; roll to and fro often in the prostration +of cholera infantum and in convulsions; are clear and bright in +phthisis; yellowish in hepatic disorder; dull and clouded in low +fevers; without expression in imbecility and general paralysis. + +Contraction of the pupil is observed in inflammation of the retina or +of the brain, narcotism from opium (until near death) or eserine, or +apoplectic effusion near the pons varolii. Dilatation of the pupil is +seen in most cases of hydrocephalus and of apoplexy; in +nerve-blindness (amaurosis), glaucoma, cataract, and narcotism from +atropia, duboisia, or hydrocyanic acid. Inactivity of the pupil +(Argyll Robertson) under changes of light and darkness is common in +locomotor ataxia. Different states of the two pupils under the same +light show disorder, either ophthalmic or cerebral in site, or may +indicate pressure on the cervical sympathetic ganglia, as from aortic +aneurism. + +In elderly persons we ought always to look for the arcus senilis, +which is a sign of a tendency to fatty degeneration. It is a ring, or +part of a ring, with ill-defined edges, best seen by lifting or +depressing an eyelid, at the junction of the cornea and sclerotic coat +of the eye. In some quite healthy old persons there may be seen at the +same junction a clearly-defined circular line of calcareous nature. +This must be distinguished from the true fatty arcus senilis. + +Of the face we may also notice the pinched nose, hollow eyes, and +falling jaw of the facies Hippocratica, presaging death; the square +forehead of the rickety child (not common in this country); ulcers on +the forehead, scars at the mouth-corners, or copper-colored eruptions +in syphilis; the full, flabby lips of scrofula. In peritonitis or +gastritis the mouth is apt to be drawn up with a peculiar expression +of suffering and nausea. Very striking is the characteristic one-sided +appearance in facial palsy, from lesion of the seventh nerve. There +may be a smile, a frown, or other expression on the sound side of the +face, while the paralyzed side is quite immovable. As the seventh +nerve (portio dura) supplies the orbicularis muscles, its paralysis +(so often temporary) may cause inability to close the eye upon the +affected side. Ptosis, or inability to open the eye, involving the +levator palpebrae, which is innervated by the third nerve (motor +oculi) is more significant of cerebral lesion. + +Even the ears may have language, as when their lobes are full and +glistening red in the gouty diathesis, or wrinkled in prolonged +cachexiae, or when they are running with discharges in the struma +(scrofula) of childhood. The hair becomes dry and lustreless in +phthisis, and falls out during convalescence from many acute diseases. + +If we look at the gums in a case of lead-poisoning, we may expect to +find a blue line along their edges. Scurvy is betokened by a swollen, +spongy, and easily-bleeding state of the gums. Many scorbutic cases, +however, lack this so-called pathognomonic feature. It may be +remarked, by the way, that absolutely pathognomonic signs of +particular diseases, never absent and exclusively seen in them, are +very few. Albuminuria, for example, is not always present in Bright's +disease, and is {152} also met with in a number of other affections. +Sugar in the urine may follow inhalation of chloroform or an attack of +cholera, as well as diabetes mellitus. Rice-water discharges may be +absent in the collapse of cholera, and patients may die with yellow +fever without black vomit. Still, these symptoms have great diagnostic +value, and, taken with others associated with them, may often enable +us to attain to a diagnosis of much importance. + +Perfect teeth in an adult in this country are rather the exception +than the rule. In the notched incisors of inherited syphilis, however, +there is something quite distinctive. The notches in Hutchinson's +teeth are vertical, not horizontal. + +Old as medicine is the examination of the tongue in disease. It may be +protruded with difficulty, as in low fevers, in apoplexy, and in +cerebral paralysis (bulbar sclerosis, glosso-labio-pharyngeal +paralysis) or thrust to one (the paralyzed) side in hemiplegia. It is +pallid in anaemia; yellow in bilious disorder; red in glossitis (then +swollen also), in scarlet fever, and in gastritis; furred in +indigestion, gastro-hepatic catarrh, and the early stage of various +febrile attacks; dry, brown, cracked, or fissured in typhus or typhoid +fevers and in the typhoid state of malarial remittent fever; bare of +epithelium in advancing phthisis and in imperfect convalescence from +severe acute diseases. Coldness of the tongue is one of the worst +signs in the collapse of cholera. + +As we examine the throat internally we look for signs of faucial +inflammation in redness and swelling, with or without enlargement of +the tonsils, or relaxation and elongation of the uvula, or ulceration, +or the gray or brown membranous deposit of diphtheria. In the mouth of +a child we may find the little white vesicular patches called aphthae, +the curd-like exudations of thrush, or possibly the much worse grayish +ulcerations of cancrum oris, or the rarer ashen sloughs of gangrene of +the mouth. + +Outside of the throat we must remember the significance of glandular +swellings or scars of suppurated glands in children; nor overlook, if +present, stiffness of the muscles, or torticollis, or goitrous +enlargement of the thyroid gland. Observation should be made also of +the site of the carotid artery on each side, and of the jugular veins, +since aortic regurgitation may be indicated by violent action of those +arteries or tricuspid regurgitation by pulsation of the veins in the +neck. + +Long before vaso-motor physiology had any place in science the pulse +was known to afford valuable indications in disease. Either of the +accessible arteries will answer instead of the radial; its convenience +merely makes the wrist the common place of comparison. By careful +examination of the pulse something may be learned of several of the +factors concerned in its production. These factors are--1, the +muscular force of the walls of the heart; 2, the state of the cardiac +valves; 3, the muscularity of the arteries; 4, the elasticity of the +arterial coats; 5, the state of the capillary circulation; 6, the +qualities of the blood; 7, the condition of the nervous system as to +excitability or apathy. + +A feeble heart must induce a feeble pulse. Moderate debility may be +attended by slowness of the pulse, but usually a weak circulation is +marked by frequent, small beats, like the vibrations of a short +pendulum. A strong heart-beat (other things being equal) is relatively +slow, with a proportionate pause after the second sound. + +{153} Valvular lesions produce various effects upon the pulse. Most +notable are the irregularity connected often with mitral insufficiency +and the jerking pulse (Corrigan) of aortic regurgitation. + +Believing, as the present writer does, in the existence of a true +arterial systole following and supplementing the ventricular +contraction,[38] it must be urged that a vigorous muscularity in the +arteries promotes strength in the pulse--not by resistance, but by +auxiliary propulsion of the blood. Another condition altogether is +tonic, spasmodic contraction of the arteries. This is not often met +with pure and simple, but a measure of it is seen in the corded or +wiry pulse of acute enteritis or peritonitis. + +[Footnote 38: This view, although advocated by Sir Charles Bell, +Legros and Onimus, Hermann of Zurich, and others, is opposed to the +most prevailing vaso-motor physiology. Several complications and some +contradictions in pathological discussion at the present time would be +cleared up by the abandonment of the now commonly-held stopcock theory +of arterial function, which has really nothing whatever to support it +except the misinterpretation of some experiments upon arteries made +many years since.] + +Deficient elasticity of the arteries is not easily separated in +observation from muscular relaxation. When arteries undergo +degeneration (atheromatous, fatty, or calcareous), their middle coat +suffers the deterioration of both elastic and muscular tissues, these +being substituted by materials either more or less yielding, and +always less resilient, than the natural fabric of the vessels. + +The influence of the condition of the capillary circulation upon that +of the arterial system and the heart is manifest in inflammations. By +reflex excitation the arteries are made to contract actively and impel +the blood more forcibly than in the normal state toward the centre of +impeded nutrition (stasis). This has been abundantly proved by the +comparison of the amount of blood flowing through the arteries of a +sound limb and those of its fellow, when the latter is the seat of a +violent acute inflammation. + +Blood-states also affect the pulse by the differences in direct +stimulation to which the heart and arteries are subjected according to +the qualities and composition of the blood. It is probable that the +fever-pulse of typhus, typhoid, the exanthemata, septicaemia, and +pyaemia has its origin in morbid conditions of the blood, acting in a +twofold manner--directly upon the heart and arteries themselves, and +mediately through the vaso-motor ganglia. + +Lastly, the nervous system stands in an important relation to the +action of the heart and arteries, and thus to the pulse. In a nervous, +excitable person, changes in the rate of the pulse may take place, +with slight significance, which in a different constitution might be +of serious import. + +To understand the language of the pulse care must be taken in several +respects: + +1. Both wrists should be felt. Sometimes there is an abnormal +variation in the course of the main radial trunk which may pass over +the thumb. Again, an aneurism may cause a great difference between the +two radial pulses, or, possibly, an embolus may occlude one of the +radial vessels, annulling its pulsation. + +2. Other arteries also, especially the carotids, should be +examined--in all obscure cases at least. Visibly beating, distended, +and tortuous temporal arteries are occasionally met with. They are not +pathognomonic of any one malady, although often referred to the gouty +diathesis. They {154} may attend irregular malarial attacks, or may be +connected simply with a hyperaemic state of the brain. + +3. The heart's impulse should always be compared with the arterial +pulsation. The former may be strong and regular, while the latter is +small, feeble, or intermittent. Something must then be wrong, either +in the aortic valves or in the arterial system. + +5. On account of possible nervous agitation, the pulse should usually +be examined more than once, during each visit to the patient. + +6. Sex, age, position of the body, and time of day must all be taken +account of. In men the average rate of the pulse is between 65 and 75 +per minute; in women, between 70 and 80. The pulse-rate of early +infancy varies from 100 to 120, and is very easily hurried. That of +old persons is commonly between 60 and 70, until, at a very advanced +age, with debility, its frequency may be increased, especially upon +exertion. Lying down, we find the slowest pulse; sitting, somewhat +more rapid; and most so in the standing position. In health the time +of day makes no constant difference apart from the effects of food and +exercise. In disorders attended by fever there are important changes +to be regularly observed. Excepting the variable paroxysms of +remittent and intermittent, which are a law unto themselves, in +febrile affections the pulse may be expected to be slowest in the +morning and most excited in the early part of the night. A diminution +of this difference is a favorable sign. Sleep generally slows the +pulse decidedly. The ordinary statement is, that the pulse is always +slower during sleep, but I have several times found that in states of +exhaustion without fever it may be considerably more rapid while the +patient is asleep. Nothing is more sure to increase the strength and +rapidity of the pulse than high temperature. + +7. Very important is the relation between the pulse and respiration. +Normally, four pulsations occur to each respiratory act. In pulmonary +affections, while the circulation is often disturbed pari passu with +the breathing, it may be quite otherwise. Great acceleration of the +rate of breathing, with little increase in the rapidity of the pulse, +should lead us to suspect disease involving the respiratory organs. +Conversely, a much hurried or otherwise perturbed pulse, with little +or no change in the breathing, points toward the heart as either +functionally or organically the seat of disorder. + +Let us further consider, briefly, the kinds of pulse to be met with +and interpreted in practice. + +A natural pulse is always, per se, a good sign. Yet in the history of +a disease usually so well marked as yellow fever some fatal cases have +been recorded (walking cases) in which the pulse, almost to the last, +was natural. + +Strength of the pulse, to a certain degree, belongs to it normally. +But this is often exaggerated, and we may have the strong, hard, full, +perhaps bounding, pulse of an inflammatory affection (of the brain, +for example, or of the joints in acute rheumatism) in a person of +vigor. A bounding pulse often accompanies mere palpitation of the +heart, whose source may be the sympathetic influence of indigestion or +nervousness. A similar pulse is apt to be constantly present in +hypertrophy of the heart. In this case it is made more forcible as +well as more rapid by {155} active exertion; while palpitation, +without organic trouble, is usually diminished by moderately active +exercise. + +A full pulse is not always strong, nor is a small pulse necessarily +weak. Mention has been made already of the tense, corded pulse met +with in acute peritonitis, and sometimes in enteritis. Gastric +inflammation, with nausea, may exhibit a depressed pulse, weak and but +little accelerated. Under still other circumstances we may find a full +pulse which is soft, easily compressible, even gaseous. Most +frequently a feeble pulse is rapid, and a very rapid pulse is weak. +Slowness, in marked degree, attends apoplexy, opium narcotism, and +fracture of the skull compressing the brain. Functional disturbance of +the heart may occasionally exceed in effect these causes of +retardation. I have met, under such circumstances, with a pulse of 20 +in the minute; one of 18 has been recorded. A few apparently healthy +persons have habitually a pulse with but 40 or 50 beats in the minute. + +Quickness in each beat may occur, while a long interval makes the rate +per minute slow. The jerking pulse of aortic regurgitation is the most +remarkable example of this. Galabin asserts that without imperfection +of the valves of the aorta a decidedly abrupt pulse may attend great +lowering of arterial tension. Something of the same kind may be +noticed in the temporarily excited pulse of very nervous subjects +under agitation. + +Dicrotism, or reduplication of the pulse-beat, is not uncommon in +typhus and typhoid fever. Here relaxation of the heart as well as of +the blood-vessels appears to allow a momentary interruption in the +succession of the arterial upon the cardiac systole.[39] + +[Footnote 39: An exceptional phenomenon, noticed by a few observers, +is the recurrent pulse; _i.e._ a pulsation felt below the finger, +whose pressure interrupts the flow of blood through an artery. It may +be explained by supposing unusual fulness of the vessels (local, if +not general) with, at the same time, relaxation of their walls; +bearing in mind, also, the manner of anastomosis of the radial and +ulnar branches which favors recurrence.] + +Intermittence and irregularity of the pulse are not exactly the same +thing. Occasional intermittence may be merely a nervous symptom or a +muscular twitch of the heart, like the twitches now and then occurring +without significance in voluntary muscles. Persistent intermittence, +with feebleness of the pulsations (these being generally somewhat +rapid), is among the signs of dilatation of the heart. + +It is possible for intermittence of the radial pulse to accompany +regularity in the heart-beat. This usually results from narrowing +(stenosis) of the aortic valvular outlet from the left ventricle. Only +a certain number of impulses fairly reach the more distant arteries. +This symptom may result also from fatty degeneration of the heart. + +Absence of pulse in one radial vessel, while it is present in the +other, shows the presence of an obstacle to the circulation on one +side, which may be an aneurism, or an embolus plugging the artery. + +Irregularity of the pulse, a total derangement of its rhythm, while +not often important in young children, is a serious symptom at other +times of life. In one disease most common in childhood, acute +hydrocephalus, the pulse in the first stage is apt to be hard and +rapid, in the middle stage slow and tolerably full, in the third +rapid, feeble, and often irregular. Mitral disease frequently presents +considerable irregularity of the pulse; and so does dilatation, even +without mitral lesion. Brain trouble, especially late in life, whether +structural or functional, may produce the {156} same symptom. B. W. +Richardson has pointed this out as one of the effects of the excessive +use of tobacco, even in young persons. + +The pulse of continued, relapsing, and remittent fevers is, during the +febrile exacerbation, rapid (100 to 120); in the earlier part of the +attack full, but only moderately hard, or even soft and yielding. As +the attack passes its height and critical defervescence occurs, the +pulse grows slower, unless great prostration has supervened; in which +case it increases in rapidity, while it fails more and more in fulness +and resistance. + +The pulse of the moribund state is nearly always small, very rapid +(130-150), and thready, without force or fulness. It may become +imperceptible before death. A pulse of 140 beats in the minute is +always alarming; if much beyond that rate the case is desperate. A +pulse of more than 150 beats in the minute is very difficult to count +accurately. + +Exophthalmic goitre is attended characteristically by a full, somewhat +rapid, and bounding pulse, the cardiac impulse being also +proportionately violent and extended. Exercise much increases this +hyper-pulsation. + +Pulsation of the jugular veins is ordinarily explained by tricuspid +regurgitation, a portion of the blood being sent back to the vena cava +with an impulse reaching to the jugulars. In some instances, however, +as the writer has repeatedly observed, jugular pulsation takes place +without any abnormality in the action or condition of the heart, from +a local inflammation (as tonsillitis) causing a marked exaggeration of +the muscular contractility resident in the larger veins. + +Retardation of the flow of blood through the veins is manifest during +the collapse of epidemic cholera. On pressing the blood back in a vein +upon the hand, for example, and then lifting the finger, instead of +the movement being, as in health, too swift to be seen, it is so slow +as to be easily followed. + +Capillary movement may be estimated in a similar manner. If it be very +sluggish, pressure upon the cheek, forehead, or hand will cause a +pallor which remains for some seconds, instead of disappearing at once +when the pressure is withdrawn. This is, it may be noticed, entirely +different from the pitting upon pressure, without much if any change +of color, in local oedema or general anasarcous effusion. The tache +meningitique of Trousseau is a pink or rose-red line left for a time +after drawing the finger across the forehead or abdomen in cases of +acute hydrocephalus (tubercular meningitis). + +Respiration must be watched carefully in all cases of disease. +Normally, in the adult, while at rest, from 16 to 18 respiratory +movements occur in each minute. The number is somewhat greater in +women, and is considerably increased in children, at birth being about +40 in the minute. Men breathe most by the diaphragm; in women there is +a greater lifting of the ribs. In either sex a disorder attended by +pain in breathing may modify this proportion. If pleurisy, for +example, be present, the ribs will be but slightly lifted, abdominal +breathing taking predominance. When peritonitis makes every movement +of the abdomen painful, costal respiration is maintained almost alone. +Likewise, a unilateral pleurisy or pneumonia will check the +respiration on the affected side, with an increased movement on the +sound side. This difference is less manifest to the eye than to the +ear in auscultation. In all febrile {157} affections respiration is +hurried proportionately with the pulse, unless some complicating local +disorder disturbs the relation. + +Dyspnoea may be produced by many different causes, whose possibility +must be remembered in its interpretation as a means of diagnosis. In +asthma violent efforts are made to compel the entrance of air into the +lungs by the intercostal muscles and diaphragm, aided by all the +accessory muscles of respiration, including the sterno-cleido-mastoid +and others of the neck. Expansion of the nostrils may occur in +sympathy with these efforts. Yet the amount of resistance may be shown +by a partial sinking-in of the lower ribs, as well as by the patient's +distress. These last signs are sometimes very marked in the collapse +of one or both lungs now and then occurring in whooping cough. + +Croup induces a similar struggle for breath, although the obstruction +is differently located. Early in the croupal attack a hoarse sound may +accompany each inspiration and expiration. Later, when the danger to +life from apnoea becomes more imminent, a hissing or whistling sound +succeeds. This last-mentioned kind of sound results temporarily, also, +from the spasmodic obstruction to breathing in laryngismus stridulus. + +Besides the affections of the lungs which impede respiration (as +pneumonia, hydrothorax, etc.), we may have dyspnoea induced by +extra-pulmonary causes, such as dilatation of the heart, aneurism of +the aorta, mediastinal cancer, pleuritic effusion; also by abdominal +dropsy, extreme elephantiasis, etc. Mention need hardly be made here +of respiratory obstruction from defective or injurious qualities of +the air, threatening or producing asphyxia. + +Sighing respiration takes place in heart disease not infrequently. A +peculiar modification of the breathing movements has been associated +especially with fatty degeneration of the heart. From the +distinguished authors who first described it this is called the +Cheyne-Stokes respiration. Intervals of suspension of breathing occur, +after which short, shallow inspirations begin, and gradually increase +for a time in depth; then they grow shorter and shallower again, until +apnoea is reached. Such a cycle may occupy from half a minute to a +minute and a half, with from fifteen to thirty increasing and +decreasing respirations in all. It has been shown by several observers +that this type of respiration is not peculiar to fatty degeneration of +the heart. It has been met with in cases of cardiac dilatation, aortic +atheroma, cerebral hemorrhage, tubercular meningitis, and uraemia. + +Sometimes a kind of dyspnoea common in advanced disease of the heart, +especially in mitral lesion with dilatation, has been confounded with +this. Here the breathing is constantly labored (orthopnoea); but the +patient from time to time dozes off into an imperfect sleep, in which +the breathing almost entirely ceases. Then he is awakened with a start +of distress, perhaps out of a painful dream. This succession of dozing +apnoea and waking dyspnoea belongs to a late stage of heart disease, +and usually ends in death. + +Stertorous respiration is familiar in apoplectic coma, as well as in +that of brain compression from injury or from opium or alcoholic +narcotism. In uraemic coma true stertor is less apt to be observed; +sometimes the respiration in this condition has a hissing sound. + +Along with the movements of respiration we may notice that the breath +{158} is hot and has a heavy odor in the early stages of all febrile +disorders. Disagreeable breath is common, however, in persons not ill, +from bad teeth or from indigestion. It is worst of all, putrid, in +gangrene of the lung. Certain cases of chronic or subacute bronchitis +(as well as of ozaena) also have very offensive breath. Coldness of +the breath is a very bad sign; it is observed sometimes before death +in the collapse of cholera. + +Hiccough (singultus) is a spasmodic affection of the diaphragm. It is +innocent, though annoying, in most cases, resulting from indigestion +or from nervous disorder; in children, occasionally, from long crying. +When it takes place in cases of general prostration it betokens +threatening depression or exhaustion of vital energy. + +The voice is mostly altered by serious disease. It may be feeble and +whispering, from debility; hoarse, from laryngeal inflammation and +tumefaction; thick, from cerebral oppression; lost (aphonia), in some +cases of chronic laryngitis and in paralysis of the vocal muscles. The +manner of articulating words is often changed in disorders of the +nervous system. A marked example of this is the monotonous scanning +speech of cerebro-spinal sclerosis. + +Cough is an extremely variable symptom, always to be understood in +connection with the attendant circumstances. Usually, however, the +character of the cough itself is more or less distinctive. A dry, hard +cough may be merely sympathetic or nervous, or it may belong to the +first stage of acute bronchitis. A hacking cough, with little +expectoration, is not infrequently observed for a time in incipient +phthisis. Pneumonia has, if any, a short and rather sharp cough. +Progressing bronchitis is recognized by the deepening and greater or +less loosening of the cough. In advanced phthisis there are +distressing spells of deep, laborious coughing, especially in the +night or in the morning after sleep. Croup is known (whether sporadic +or in the form of laryngeal diphtheria) by the barking cough of the +early stage and its whistling character toward the fatal end. Nearly +the same sort of hissing or whistling sound in breathing has been +mentioned already as occurring in laryngismus stridulus. Paroxysms of +coughing, with or without whooping, are pathognomonic of pertussis. + +Expectoration often affords important signs. Briefly, it may suffice +to say here that it is mucous, whitish, or colorless in early +bronchitis; more or less yellowish and muco-purulent in severe and +protracted bronchitis; rusty, from admingling of the coloring matter +of blood, in pneumonia, early and middle stages; bloody and +muco-purulent in early and of heavy roundish (nummular) masses in late +pulmonary phthisis; putrid, rotten, in gangrene of the lung. + +Continuing our survey of obvious symptoms, we must now take account of +the conditions of the general surface of the body. Temperature is of +great consequence. Most precisely determinable by the thermometer, the +touch, when educated, will give very useful indications of its +changes. It is difficult, and not commonly desirable, to separate +variations of moisture from those of temperature. Reserving for +another place the special consideration of medical thermometry, it may +be here said that the skin is hot and dry in the typical condition of +fever, whatever its special associations. Heat and moisture of the +skin are more often met with together in the fever of acute articular +rheumatism than in any other {159} affection. As a rule, perspiration +lessens febrile heat. Copious (colliquative) sweating is habitual in +many wasting diseases, notable in pulmonary phthisis. It is then a +sign of great general relaxation of the system. + +Coldness of the surface attends prostration, either from temporary +collapse or from positive exhaustion. The skin is perceptibly cold in +the algid stage of cholera. It may be so in very severe cases of +sporadic cholera morbus. In the chill of intermittent, while the +patient has the subjective sensation of coldness, his temperature is +seldom reduced, and is often higher than natural, although lower than +during the febrile exacerbation. + +The color of the skin is pallid in anaemia, phthisis, dropsy, etc., +and in syncope; ashen or livid in cholera collapse and in the cold +stage of pernicious malarial fever; yellow in jaundice, remittent, and +yellow fever; sallow in chlorosis, cancer, and chronic dyspepsia; +purple, almost black (especially the lips and ends of the fingers), in +asphyxia; dark, as if stained with ink, after long use of nitrate of +silver; bronzed in Addison's disease; bright red in scarlet fever, +etc. The eruptions of this and other exanthemata, and of the different +cutaneous diseases, will be best considered in the special articles +treating them of in this work. + +Odor is perceptible and peculiar (though not easily described) in some +bad cases of typhus fever and of small-pox; less often in aggravated +chlorosis. Lunatics and paralytics (especially when assembled together +in institutions) often give off a noticeable smell. Most distinct, +however, is the cadaverous odor, sometimes perceptible for hours +before death. Corroborative of this, in summer, is the flocking of +flies around the bed of a dying patient. In a hospital ward this +selection amongst a number of patients may be quite observable. + +Emphysema, from the presence of air in the connective tissue under the +skin, is rarely met with except as the consequence of an injury or of +local gangrene. + +Oedema is local watery effusion, which may have various causes and +significance. Anasarca must have a general causation, either connected +with the state of the blood or with disorder of the heart, kidneys, or +liver, or of more than one of those organs at once. Pitting on +pressure is the sign of watery effusion. Soft crackling under the +touch distinguishes emphysema. A firm enlargement of the surface of +the face and upper part of the body occurs in myxoedema. + +Swellings of all kind must be carefully observed, and their nature +inquired into--whether they be inflammatory or other chronic +enlargements of joints, tumors, fibrous, fatty, or cancerous, +aneurisms, hernial protrusions, or of any other character. In +protracted disease of the liver (cirrhosis) it is not uncommon to find +the superficial abdominal veins dilated and tortuous. + +Abdominal enlargement may result from adipose accumulation (obesity), +distension of the bowels with wind (meteorism), ascites, ovarian +cysts, cancerous or other tumors, aneurism of the aorta, abscess, +retention of urine, or pregnancy. By the methods of physical +diagnosis, along with careful inquiry into the history of each case, +we are to make out the distinctions amongst these different +conditions. + +Emaciation always marks either defect of nutrition or morbid excess of +tissue-waste. It is counterfeited in the sudden collapse of malignant +{160} cholera, and exaggerated in appearance during the analogous +condition of cholera infantum. On recovery from these states, +especially the latter, roundness and fulness of the face and limbs may +return much too soon for the actual restoration of fat and flesh. A +young child may be plump and chubby to-day, seemingly wasted with +acute illness to-morrow, and, if soon relieved, the next day almost as +rotund as ever. + +Continued diarrhoea, phthisis pulmonalis, mesenteric disease, cancer, +and aneurism of the aorta are among the most frequent causes of great +emaciation. Sometimes, as in progressive pernicious anaemia, we are +struck with the comparatively slight degree of wasting of the body +while the disease is advancing toward death. + +In myxoedema there is a swelling or general enlargement, especially of +the upper portions of the trunk. This is not anasarcous, but depends +upon a morbid change in the connective tissue throughout the body. + +Articular enlargements may be (particularly in the knee in children) +scrofulous, or gouty (in the smaller joints), rheumatic, with +evidences of inflammation, acute or chronic; or, what is not well +named, rheumatoid arthritis. In this last affection there is a gradual +swelling and stiffening, with but little inflammation, of several, +sometimes all, the joints of the extremities. Locomotor ataxia is in +some cases attended by a degenerative alteration in one or more of the +larger joints. + +The limbs may furnish to the eye many expressive signs of disease or +disability. In the listlessness of one arm and hand, while the other +can perform various movements, we see reason to suspect hemiplegia. If +the fingers are rigidly contracted, as well as powerless, we have this +diagnosis confirmed, whether the rigidity be early or late in its +stage. We must then look for a similar condition of the lower +extremity on the same side. Paraplegia and general paralysis have +their more extended (bilateral) indications in like manner. +Characteristic also are the wrist-drop, from paralysis of the +extensors of the hand, in lead-palsy; weakness or incapacity of the +flexors and extensors in writer's cramp; the hand fixed helplessly in +the position for writing in paralysis agitans (advanced stage); the +main en griffe, with shrunken muscles and drawn tendons, of +progressive muscular atrophy (wasting palsy). In the legs at first and +chiefly, but in time also in the arms, increase of bulk with loss of +power in the muscles shows the existence of pseudo-hypertrophic +muscular paralysis. + +Gouty fingers have their joints not only swollen, but distorted by +deposits of urates and carbonates. Clubbed finger-ends, in the adult, +are seen mostly, with incurvation of the nails, in advancing +consumption. The nails are sometimes striated after attacks of gout, +the lines disappearing gradually during the interval. In many acute +diseases, transverse ridges are noticeable on the nails, marking the +date when their growth was arrested and subsequently resumed. These +are specially remarkable after attacks of relapsing fever. + +A tendency to dropsical effusion is generally first shown, besides a +puffiness of the face, in the feet and ankles, the shoe or slipper +marking off the enlargement above its margin. Often this has no other +cause than debility, with a watery condition of the blood. Varicose +veins, with old and resultant ulcers, are also among the possible +things to be found in examination of the legs and feet. + +{161} Movements of the hands are incessant and jerking in chorea; +perpetually trembling in delirium tremens, and often in one arm and +hand only, in paralysis agitans; with tremor, seen in voluntary +motions alone, in multiple cerebro-spinal sclerosis. More unusual is +the rhythmical closing and opening of the hand, successively, of +athetosis. + +In the walk of patients able to be upon their feet there may be much +significance. A hemiplegic subject will circumduct the feeble limb +after the other; one suffering with paraplegia will shuffle the feet +slowly along the floor; the hysterical paralytic drags the lame limb +behind the other; the patient with spastic spinal paralysis rises on +his toes in walking, with his legs held close together; the shaking +paralytic rather trots forward, with the body bent; and the subject of +locomotor ataxia lifts his feet and kicks out forward or sideways, +then bringing down the heels with a stamp at each step. In progressive +muscular atrophy and advanced pseudo-hypertrophic muscular paralysis a +waddling or rolling gait is seen. Choreic patients are very irregular +in their walk, as in all other movements. Hip disease (coxalgia) shows +itself in a child by its lifting the pelvis and limb of the affected +side and bending the knee, so as to touch only the toes to the ground. +Club-foot and other deformities require no description in this place. + +Sensibility of the extremities and of other parts of the surface of +the body needs to be examined into, with all its possible variations +(hyperaesthesia, anaesthesia, analgesiae, etc.), especially when the +nervous apparatus is for any reason supposed to be involved. Motions +of an unusual character must likewise be carefully noticed. +"Westphal's symptom" is regarded as having considerable diagnostic +value. It is otherwise called the tendon-reflex, with its +modifications. When a person in health is seated with one leg crossed +over the other or with the legs dangling over the edge of a high bench +or table, and a sudden blow is struck upon the tendon of the patella, +the leg and foot will be spontaneously jerked forward. In locomotor +ataxia, even from an early period, this tendon-reflex is abolished. In +spastic spinal paralysis (lateral spinal sclerosis) it is exaggerated. +Quite analogous to this is the ankle-clonus. This is obtained by +firmly flexing the foot and then tapping sharply upon the tendo +Achillis. The foot is then involuntarily extended and flexed several +times in succession. There is more doubt in regard to the associations +of this symptom than as to the knee movement, but it has been +clinically shown to be exaggerated in spastic spinal paralysis. + +At our first acquaintance with a case of disease, while making inquiry +into its nature, the genital organs must not be forgotten. Not that we +need always make examination of them, but any pointing in symptoms +toward them must be borne in mind, so as to guide us in or toward +further procedures in diagnosis. In making, in obscure cases, a +diagnosis by exclusion, we are sometimes driven to a scrutiny of the +genital system. + +We have now, however incompletely, touched upon the greater number of +obvious signs or symptoms which a view of a patient would furnish +without making minute inquiry of himself or others concerning his or +their knowledge of the illness. Such are the objective signs of +disease, which must be still more exactly and extensively discerned +and understood by means of the processes of physical and instrumental +diagnosis. {162} But the subjective symptoms also, and all those +observed and described by the patient and his or her friends, must +receive very careful attention. Much practical skill may be shown by +the kind of questions asked and the use made of the answers given. + +First, as to the alimentary apparatus: + +Taste is very commonly altered in disease, being sour in indigestion, +bitter in disorders of the liver, saltish in haemoptysis, rotten in +gangrene of the lungs. + +Dryness of the mouth is the rule in fevers. Sometimes the saliva is +viscid and adherent. Increased flow or salivation was formerly +frequent in practice under large doses of mercurials. Jaborandi or its +alkaloid pilocarpin will generally produce it. Iodide of potassium +occasionally has the same effect in less degree. + +Loss of appetite nearly always attends serious diseases of any kind. +Excessive craving for food (bulimia) is rare. Tapeworm accounts for it +in some instances. Desire for strange articles of food, as +slate-pencils, ashes, etc., is met with in some instances of chlorosis +and of hysteria. A return of natural appetite is one of the best signs +toward the close of any acute attack of illness. + +Thirst is seldom absent in fever. It is also usually present in the +state of collapse, as from cholera, pernicious intermittent, or the +shock of severe (especially railroad) injuries. + +Dysphagia or difficulty of swallowing may result from simple debility, +as in the moribund state; inflammation of the fauces, tonsils, or +pharynx; stricture of the oesophagus; obstruction by a foreign body or +by a cancerous or aneurismal tumor; retro-pharyngeal abscess; +paralysis of the muscles of the throat, such as sometimes follows +diphtheria. Soreness of the throat is present in some, but not in all +of these examples of dysphagia, being most marked in the inflammatory +condition of pharyngitis, tonsillitis, scarlet fever, and diphtheria. +Ulceration of the throat should always be carefully looked for, and if +present investigated to ascertain whether it is simple, diphtheritic, +or syphilitic. We must be careful not to mistake a mere local +accumulation of mucus, or aphthous vesicle, or the curd-like formation +of thrush or muguet, either for ulceration or pseudo-membranous +deposit. Aphthae and thrush are most frequently met with in children, +though small aphthous ulcers frequently appear toward the close of +wasting, and especially cancerous, affections. If there be a doubt, +pass a moistened hair pencil lightly over the apparent deposit, or +allow the patient to gargle the throat with water, and then re-inspect +it. + +Many causes may produce nausea and vomiting, which almost always occur +together; that is, vomiting rarely takes place without previous +nausea, although the latter may exist without the former. In the +manner of vomiting there are some differences more or less +characteristic, as the distressing retching of sea-sickness and of +tartar emetic or other irritant poisoning, and the spasmodic +out-spurting of rice-water fluid in malignant cholera. The matter +vomited is often very important in diagnosis. In mere indigestion the +food taken is apt to come up, and the same may happen in flatulent +colic. When the liver is involved, as in bilious colic, bile also is +ejected. Nothing peculiar exists in the ejecta of morning sickness in +pregnancy. The ejecta contain mucus in gastritis, blood in ulcer and +in cancer of the stomach, stercoraceous {163} material in obstruction +of the bowels, black vomit in bad cases of yellow fever. Hysterical +vomiting sometimes closely imitates the latter in appearance. Other +affections attended by vomiting are cholera morbus, remittent fever, +brain disease, Bright's disease of the kidney, etc. + +Spitting blood may be either haematemesis or haemoptysis proper. If +the former, nausea generally precedes the ejection of the blood by +vomiting, and it is apt to be mingled with food partly digested. It is +coughed up, bright red and frothy usually, when coming from the lungs +or bronchial tubes. But blood may proceed from the gums or throat, or +may run back through the posterior nares from the nose, and then it +gives alarm by seeming to proceed from the chest. It is necessary to +inquire very particularly into all such possibilities in every case of +hemorrhage. + +Between vomiting of blood from ulcer and from cancer of the stomach we +have mostly these distinctions: in ulcer it follows soon after taking +food, in cancer (this being generally at the pylorus), an hour or more +after eating; ulcer is attended also by tenderness on pressure at a +certain spot over the stomach, without tumor; cancer presents a tumor, +with much less marked tenderness on pressure. By aid of the microscope +in examination of the matter vomited this diagnosis may be completed. + +Constipation is an exceedingly frequent symptom under many and diverse +circumstances. Pathologically, we account for it in several ways: 1, +torpor of the muscular coat of the intestinal canal; 2, deficiency of +secretion in the glands of the bowels and in the liver; 3, imperfect +innervation of the abdominal organs; 4, mechanical obstruction, as by +a foreign body, intussusception, strangulated hernia, cancerous or +other tumor, stricture of the rectum, etc. Dyspeptic persons are +ordinarily constipated. So are almost all patients at the beginning of +attacks of measles, scarlet fever, small-pox, and other acute febrile +maladies. Typhoid fever is scarcely an exception to this; although the +bowels in that affection become loose after a few days, they seldom +are so at the very beginning of the attack. Sea-sickness is commonly +accompanied by total or nearly total inaction of the bowels, the +secretion of the intestinal glands being almost null, often for many +days together. Torpor of the brain is sometimes attended by marked +constipation. The latter may be a contributing cause of the former, as +in certain severe cases of scarlet fever, in which threatening coma +may be relieved by active purgation. We must not, however, occupy +space here by attempting to enumerate the many conditions under which +constipation may present itself as a symptom. + +Almost as various are the associations of the opposite state of the +bowels, diarrhoea. Excessive or abnormally frequent discharges from +the bowels may be either fecal, bilious, mucous, membranous, purulent, +bloody, fatty, or watery, and they may occur with or without pain and +straining (tenesmus). + +If, with frequent disposition to pass something, only small quantities +of bloody mucus escape, with pain and bearing down, we recognize +dysentery. When, instead, a large quantity of colorless fluid, with or +without floating flakes (rice-water), comes from the bowels at short +intervals, with vomiting of the same sort of material, we suspect +epidemic cholera, and must inquire for corroborative or corrective +indications in {164} reference to that suspicion. Very bad cases of +cholera morbus also may, at a late stage, present this symptom. So may +exceptional cases of pernicious malarial fever. The diarrhoea of +typhoid fever exhibits usually liquid stools of a brownish color +(gutter-water passages). Occasionally, hemorrhage from the bowels adds +to the danger of this fever, as well as to that of malarial remittent +fever. In phthisis pulmonalis, at a late stage, colliquative +diarrhoea, like colliquative perspirations, shows the breaking up of +the system by excessive waste. Very foul, offensive discharges from +the bowels may always be understood as showing that in the alimentary +canal, whether originating there or in the blood, morbid changes have +been going on. The indication is to promote the elimination of such +material as soon and as thoroughly as possible. + +Clayey stools show absence or deficiency of bile in the intestines, +whether from its non-secretion by the liver or from obstruction to its +entrance by a gall-stone in the common gall-duct. Green stools are not +uncommon in sick children. The cause of the color has been much +disputed. Probably it depends chiefly on a modification of the +bile-pigment, with some admixture of altered blood. When mercurials +have been taken sulphide of mercury may give a green color to the +discharges. + +Blood, nearly or quite unmixed, coming from the bowels, may have its +origin in internal hemorrhoids, intestinal ulceration, cancer of the +rectum, intussusception, rupture of an aneurism, typhoid or yellow +fever, or vicarious menstruation. + +Pus is discharged per anum in cases of dysenteric or other ulceration +of the bowel; also when an abscess occurring in any part of the +abdomen (most frequently hepatic) opens into the intestine. +Pseudo-membranous discharges, shreds or other fragments of fibrinous +material, appear sometimes in what may be called diphtheritic +dysentery. Tubular casts are occasionally seen (diarrhoea tubularis), +which, however, are most likely to consist of thickened and +accumulated mucus. Fatty discharges from the bowels are rare. Authors +report observation of them in cases of disease of the liver or +pancreas, as well as in phthisis, typhoid fever, diabetes mellitus, +cholera, and tubercular enteritis of children. + +Lientery is the term applied when imperfectly changed food appears in +the stools. It shows, of course, great deficiency in the process of +digestion. + +Urination affords symptoms often of extreme consequence in disease. +Suppression of urine is one of the most alarming of signs; an +approximation to it only is likely to be met with in cholera, a late +stage of scarlet fever, typhus or typhoid fever, in acute yellow +atrophy of the liver, and in advanced kidney disease. Careful +examination of the abdomen, by inspection, palpation, and percussion, +as well as by inquiry of attendants, is needful in all cases of fever +or other disorders with delirium or stupor, to ascertain the presence +or absence of retention of urine. Dysuria--_i.e._ difficult urination, +strangury--may have several causes. Cantharides, absorbed from a +blister, may produce it temporarily. The more continuous states which +cause it are--stricture of the urethra, enlargement of the prostate +gland, and calculus in the bladder. In stricture, when the patient can +pass water, it is apt to be in a twisted stream. Dribbling often +occurs when the prostate is enlarged. When a stone is present the +{165} stream may flow naturally for a time and then suddenly cease +from obstruction at the outlet of the bladder. Enuresis, incontinence +of urine, is often very troublesome in children; its diagnosis +presents no difficulty. + +Diabetes properly means simply excessive flow of urine. It may be +attended by no change in the secretion except dilution of its solids +(diabetes insipidus), as in certain nervous cases or after very large +imbibition of fluids. More serious is diabetes mellitus, in which +large amounts of sugar are found in the urine. + +Variations in the quantity and in the composition and solid +ingredients of the urine, as ascertained by aid of chemical analysis +and the microscope, will be fully considered in other portions in this +work. + +Menstruation in the female requires scrutiny in every case of +deviation from health. Its abnormities will be elsewhere treated of. +The subject of the signs of pregnancy belongs of course to treatises +on Obstetrics. + +Pain is one of the most important of the signs of disease. We must +always examine its character, location, and associations. As to +character, that of pleurisy is sharp and cutting, increased by deep +breathing or coughing. In pneumonia and in myalgia it is dull or +aching. Rheumatic joints or muscles suffer a gnawing, tearing pain. In +neuralgia it is darting, shooting, lancinating; and the last of these +expressions is often applied to the pains of cancer. Griping pains +occur in colic, and bearing-down pains in dysentery, as well as in the +second stage of labor. Besides these varieties we have the pulsating +pain of an acute external inflammation, as of the hand, especially +before suppuration has occurred; the burning and smarting of +erysipelas; and the stinging, nettling sensations (formication) of +urticaria. + +Tenderness on pressure is significant either of local inflammation, +whose other signs are then to be discerned, or of non-inflammatory +hyperaesthesia. The origin of the latter may require careful +examination of various organs for its discovery. If pain is relieved +by pressure, we may be sure of the absence of severe acute local +inflammation. + +Not infrequently the seat of disease may be at some distance from that +of pain, as in the familiar instances of pain at the top of the head +in uterine derangement; in the glans penis from calculus in the +bladder; in the knee from hip-joint disease; under the shoulder-blade +in liver disorder; about the heart or between the shoulders from +dyspepsia. + +Anaesthesia, loss of sensibility, has much value as a symptom in +neurotic affections, as paralysis, etc. Its discussion will find place +in connection with diseases of the Nervous System in other portions of +this work. + +As an example of the diversified associations of pain, cephalalgia +(headache) may be mentioned as having at least the following possible +causes: congestion of the brain, neuralgia, rheumatism of the scalp, +uterine irritation, disease of the kidneys, early stage of remittent, +typhoid, or yellow fever, alcoholic intoxication, chronic disease of +the brain. + +Abdominal pain may, in like manner, be traced, in different cases, to +many morbid conditions, such as flatulent colic, lead colic, neuralgia +or rheumatism of the bowels, intestinal obstruction, dysentery, +passage of a gall-stone or of a nephritic calculus through one or the +other duct {166} respectively; cancer, aneurism of the aorta, caries +of the spine; in the female, dysmenorrhoea, metralgia or +ovaralgia--_i.e._ neuralgia of the uterus or ovaries. + +Similar diversity in the origins of pain might, but for want of space, +be pointed out in morbid states of the contents of the chest and of +other parts of the body. + +Subjective symptoms often affect the special senses. + +Taste and touch have been already referred to. Of sight we may have +photophobia, connected with exaggerated sensibility of the retina or +of the brain; muscae volitantes, specks, rings, or chains of spots +from floating semi-opaque particles in the vitreous humor; diplopia, +double vision; hemiopia, seeing only half of an object at a time; +amblyopia, indistinctness of vision of all objects. + +Hearing is affected, besides all possible degrees of deafness, with +the subjective sensations of ringing, whistling, or roaring +sounds--tinnitus aurium. One form of this (as I conclude from +observation in my own ears) depends upon spasmodic vibration of the +tensor tympani or stapedius muscle. Sometimes the seat of the +sensation is in the auditory nervous apparatus proper. It has, not +seldom, a marked connection with brain-exhaustion. An attack of +Meniere's disease (labyrinthine vertigo) is often preceded by it. No +constant signification, however, can be attached to aural tinnitus. +Large doses of quinine or of salicylic acid will occasion it in many +patients. + +Very briefly, deafness may be here disposed of by mentioning that, in +greater or less degree, it may be produced by accumulated wax in the +ear; obstruction of the Eustachian tube; thickness of the membrana +tympani; perforation of that membrane; mucus or pus in the middle ear; +disease of the ossicles of the ear; paralysis of the auditory nerve; +typhus or typhoid fever; excessive doses of quinine or salicylic acid. + +Vertigo is chiefly of two kinds, dizziness or giddiness (swimming in +the head), and reeling vertigo, or a disposition to fall or turn to +one side or the other. Giddiness is produced by running or whirling +many times in a circle, or, in some persons, by swinging rapidly or +sailing. Reeling vertigo is mostly observed in connection with +disorder of the brain or of the labyrinth of the ear (Meniere's +disease). Dizziness, with nausea, is common as a symptom of cholaemia +(cholesteraemia of Flint) in what is popularly called a bilious +attack. + +Delirium is present in many acute disorders, and not infrequently at a +late stage in pulmonary phthisis. Its special study will be taken up +in connection with the special articles upon these affections. + +Coma, or stupor, is met with chiefly in the following morbid states: +severe typhus or typhoid fevers; malignant scarlet fever; small-pox; +rarely in measles; pernicious malarial fever; uraemia; apoplexy; +opiate narcotism, or that from chloral or alcoholic intoxication; +asphyxia from inhaling carbonic acid gas, ether, chloroform, etc.; +fracture of the skull with compression of the brain. + +For an account of aphasia and other morbid psychological +manifestations the reader is referred to the articles on Aphasia, +Insanity, Hysteria, etc. in this work. + +Physical and Instrumental Diagnosis will be treated in connection with +those diseases in which they have special importance. + + +{167} PROGNOSIS. + +The elements of medical prognosis are essentially involved in +diagnosis. Our ability to anticipate the mode of progress, duration, +termination, and results of any case of illness depends upon our +knowledge--1, of the nature of the malady, with its tendencies toward +death, self-limitation, or indefinite continuance; 2, the soundness or +imperfection of the patient's constitution, with or without special +predispositions or the consequences of previous ailments; 3, the +present state of his system as to the performance of the general +functions, his strength, and vital resistance or persistence; 4, the +probable modifying influences of medical treatment, and also those of +situation, surroundings, and nursing--_i.e._ the care of those +attending to the patient during the absence of the physician and +having the duty of carrying out his directions. + +1. As to the nature of the malady. While every sickness must be +supposed to encroach somewhat upon the vital energy of its subject, +very few diseases (leaving aside deadly poisons and surgical injuries) +are, ab initio, certainly fatal. Hydrophobia (rabies canina) has been, +until latterly, regarded as incurable, and always mortal within a few +days or a week or two. A few cases have, during the last few years, +been reported as cured, but the diagnosis of these continues to be +somewhat doubtful. + +Cancer exhibits a tendency to extend its destructive malnutrition so +as to render death inevitable unless it can be removed early and +completely, or unless the morbid process can be arrested in some +manner not yet known. Remedies, such as condurango and Chian +turpentine, which furnished hope of such an effect, have, after +prolonged trial, been abandoned as not justifying the confidence of +the profession. + +Tubercular phthisis was once considered to be almost necessarily a +fatal disease, although with a very indefinite period of duration. +Under improved hygienic management, with mild palliatives and +recuperative medication, a not inconsiderable minority of cases now +end in recovery. This term may be properly applied when, with +cicatrization of a cavity or cavities in the lungs, no more tubercle +is deposited and lung-substance enough is left for good respiration, +even although the structurally changed portions of pulmonary tissue do +not undergo entire repair. + +Tubercular meningitis is a nearly always incurable affection. Yet a +few instances of lasting recovery have been reported where the +diagnosis was as certain as it can be in that disease in the absence +of post-mortem examination. A child attended by myself, in whom the +symptoms had been of the most unfavorable kind, became apparently +quite well, and continued so for a month. Then it was attacked +suddenly with convulsions, which were almost unremitting until it died +within a day or two. + +Gangrene of the lung is very seldom recovered from, but, unless the +diagnosis from examination of putrescent sputa has been at fault, +there have been cases in which, with the limited destruction of the +affected lung, it was not fatal. + +Pseudo-membranous croup destroys life in the majority, but not in +nearly all the cases of its occurrence. It is most likely to end in +death when distinctly a part of an attack of epidemic or endemic +diphtheria. + +{168} Valvular heart lesions were formerly regarded as incurable, in +the sense of restoration of the normal condition and action of the +valves impaired, yet not incompatible with years of life. This +restoration certainly very seldom takes place. But the experience of +many close observers leads to caution in anticipation of necessary and +permanent disability of the heart because of murmurs, or even +functional disturbances, seeming to prove either aortic or mitral +insufficiency or stenosis. + +Aneurism of the aorta is very seldom recovered from, but, besides a +variable duration, whose period can almost never be anticipated with +exactness, there appear to have been some cases of disappearance, or +at least prolonged quiescence, of the tumor and of its morbid effects. + +Yellow atrophy of the liver is one of the disorders most rarely ending +otherwise than in death. + +With a course altogether indefinite in time, there appears to be a +tendency to exhaust vital energy, without self-limitation, in the +different forms of organic degeneration, such as fatty heart, +Addison's disease, chronic Bright's disease, diabetes mellitus, +cirrhosis, and amyloid degeneration of the liver, etc. The same may be +said also of the different forms of cerebral and spinal sclerosis, of +pernicious anaemia, and of myxoedema. + +Lastly, it is an exception to a very general rule of fatality when a +case of trichinosis, with well-marked abdominal, muscular, and general +symptoms, ends otherwise than in death within a few weeks. + +Self-limitation is familiar in the natural history of typhus and +typhoid fever, relapsing fever, yellow fever, cholera, diphtheria, +whooping cough, mumps, small-pox, varicella, scarlet fever, and +measles. In the sense of a definite duration of each paroxysm +intermittent and remittent fevers are self-limited. Are they so also +in tending toward recovery, without curative treatment within a +certain time? This has been asserted, and in the case of remittent +there is evidence that spontaneous cures do sometimes happen. Some +observers aver that ague tends toward cessation of the chills after +six, eight, or ten weeks. The obstinacy of the attacks in many +instances under anti-periodic medication seems to make it probable +that spontaneous recovery from intermittent hardly belongs to the +typical natural history of the disease. + +Whether the term self-limited can or cannot with propriety be applied +to pneumonia and other acute inflammations, as pericarditis, etc., has +been a mooted question. If it be so, it appears to the writer to be +true in a different meaning of the word self-limitation from that in +which it is applied to variola or typhoid fever. Yet some nosologists +deny this distinction, and regard pneumonia as strictly a lung fever. +Some of the facts supporting this view belong to the history of +pneumonia as complicating malarial fever; _e.g._ in the winter fever +of some parts of our Southern States. It must be admitted, however, +that the inflammatory process, though morbid, is generally eliminative +or corrective of a disturbing cause which produced it, and, unless +that cause is continued or repeated in action, a limitation belongs to +the succession of stages, ending either in resolution or in adhesions, +serous accumulation, suppuration, or gangrene. + +2. It is not necessary to dwell here upon the significance in +prognosis of the patient's original constitution and hereditary or +acquired {169} predispositions, or on that of results left by previous +attacks of illness. These are all obviously of importance. In a member +of a family predisposed to consumption a bronchial attack following +exposure may be much more dangerous than in others. So also a cause of +mental agitation may produce insanity in a person who inherits a +tendency thereto or who has before had an attack of mental +derangement, while it would be innocuous to another who has no such +proclivity. A second or third attack of delirium tremens is much more +dangerous to life than a first attack. On the other hand, if yellow +fever occurs at all in a patient who has before had it, the course of +the disease is apt to be milder than usual. The most striking example +of the influence of previous disease is seen in the comparative +mildness of varioloid--_i.e._ small-pox modified by the system having +been placed under the action of the vaccine virus. + +3. Most important of all data in prognosis are, in most cases, the +indications of the present state of the patient's system as to the +performance of the organic functions, his sum of energy, and vital +resistance and persistence. Especially must these indications be +regarded comparatively; that is, ascertaining whether, in a period of +weeks, days, or, sometimes hours (in malignant cholera even of +minutes), the patient's general condition has been and is gaining or +losing in the evidences of strength and healthy function of the great +organs. + +Every student of clinical medicine must become acquainted, as soon as +possible, at the bedside, with these tokens and evidences, which make +almost the alphabet of practice: What is a good, a doubtful, and a bad +pulse? How does a patient breathe when moribund from simple +exhaustion, and how does such respiration differ from the toil and +struggle of asthma or the stertor of narcotism? Why does a glance +suffice to make known to a surgeon the state of collapse after a +railroad accident, or to a physician that of cholera or pernicious +intermittent? What is the impression given to the finger upon the skin +by intense fever, and what by the relaxation which precedes death? +These and many other such questions are to be answered fully to each +student only by the use of his own senses, with such interpretation as +is to be obtained by the careful comparison of cases, with the aid of +books and didactic instruction. + +To a well-trained eye and hand a look and a touch will often suffice +to make known the commencement of convalescence or of the precipitous +decline toward death. Yet a wise physician will be very cautious in +acting upon even seemingly obvious prognostications. Changes may be +going on in important organs whose effects have hardly yet begun to +show themselves, and which may after a while materially alter the +aspect of the case. Particularly near the beginning of an attack of +enthetic disease, such as scarlet fever, small-pox, typhus or typhoid +fever, the physician should beware of too confidently forecasting the +progress of the case for better or for worse. In nothing, probably, is +the prudence of a practitioner more often or more severely tested than +in his answers to inquiries made concerning prognosis. + +4. Anticipation of the modifying action of remedies is undoubtedly a +proper factor in our estimate of the probable result of any case of +illness. Few diseases, however, are as yet so subject to control by +specific medication as to allow certainty in such expectations. In a +first attack of ague we may look with much confidence toward the +speedy cure of our {170} patient under quinia. In one who has had +chills all winter even this confidence may need qualification. A +sufferer with syphilitic rheumatism may generally be promised relief +under the use of iodide of potassium, or one afflicted with scabies +under the application of sulphur ointment. We seldom have misgivings +about our ability to give relief in colic, constipation, or diarrhoea. +Yet the first two of these may prove to be symptoms of intestinal +obstruction resisting treatment, and the last may depend upon chronic +ulceration of the bowel, giving it unexpected continuance. In all such +instances careful and (when practicable) accurate diagnosis must +precede prognosis; our estimate of the action of remedies becomes then +a secondary, although often a valuable, part of the calculation of the +probabilities of the case. + +Prognosis in particular diseases involves the consideration not only +of those signs of the general vital condition to which we have just +been giving attention, but also of such as are more or less peculiar +to each disorder. To a certain extent these signs may be grouped. We +may refer to good and bad signs in pulmonary, cardiac, intestinal, +renal, cerebral, and febrile affections respectively. Still, there +will be for each malady, if it really has a distinctive character, +some tokens which experience shows to be specially indicative of +favorable or unfavorable progress and results. + +Let us notice some of these as examples. + +In pneumonia the best signs are the lowering of a high temperature, +reduction of the number of respirations to 20 or 25 in the minute, +expectoration of sputa less and less tinged with red or brown, and +gradual reduction of the region of dulness on percussion. Worst, in +the same disease, are an axillary temperature over 106 degrees, +respirations 40 or more per minute, with delirium, and expectoration +becoming more abundant, grayish, and purulent; also with continued +dulness on percussion and abundant mucous rales on auscultation. + +In croup the best sign is, after a hoarse, dry, barking cough and +dyspnoea, a soft, liquid rale, heard in the larynx and trachea during +respiration or coughing. Worst, in croup, is a steadily or +paroxysmally increasing difficulty of breathing, with a dry hissing or +whistling sound of respiration and cough succeeding the barking sounds +of the earlier stage. + +In phthisis pulmonalis among the best signs are the patient's +increasing in weight, coughing and expectorating less, ceasing to have +hectic and night sweats. These may give renewed hope, even before much +change is discernible in the physical signs. Of bad omen are intense +hectic fever, incessant cough with abundant nummular sputa, copious +perspirations, diarrhoea, breathing growing shorter and shorter, and +extreme emaciation and debility. + +In all organic affections of the heart an extremely rapid and +irregular pulse, with orthopnoea and increasing anasarca, and +especially the Cheyne-Stokes respiration (described under DIAGNOSIS), +must cause unfavorable expectations. + +In obstruction of the bowels the best of all symptoms is, usually, of +course, a copious fecal evacuation. Yet a few cases have occurred in +which a very large evacuation, delayed by obstruction for a week or +two, has been almost immediately followed by collapse and death. The +worst signs in cases of obstruction are (besides long-unyielding +constipation) {171} stercoraceous vomiting, a small, rapid pulse, and +increasing coldness and clamminess of the surface of the body. + +In cholera infantum the best signs are cessation of vomiting and +purging, the discharges growing more nearly natural, the face becoming +less shrunken in aspect, sleep taking the place of coma vigil or +waking apathy, and water or milk, when taken, remaining on the +stomach. Worst, in the same disease, are incessant rejection of +everything swallowed, watery passages from the bowels every half hour +or hour, shrinking of the face and body to skin and bone, with an +apathetic expression of the open or half-open eyes, the latter rolling +often from side to side. + +In epidemic cholera good signs are the arrest of vomiting and of +rice-water discharges from the bowels, rapid movement of the blood in +the veins after removal of momentary pressure, return of natural color +and warmth to the skin, with filling up of the pulse at the wrist. Bad +signs in cholera are shrinking of the cheeks and of the flesh upon the +hands, deepening ashiness or blueness of the skin, coldness and +clamminess to the touch, dyspnoea, loss of pulse, incessant vomiting +and purging of rice-water stools, constant cramps of the limbs, and +suppression of urine. + +In acute cerebral meningitis good signs are lessened temperature of +the head, quiet sleep without stertor, disappearance of delirium, more +natural pulse, and attention to surrounding objects, without +disquietude. Bad signs in the same disease are deep stupor, +strabismus, convulsions, paralysis, involuntary defecation and +urination. + +In typhus fever good signs are the pulse becoming slower and fuller, +the skin less hot, more soft and moist, the tongue moist and clean, +the face losing its dusky flush, and consciousness returning instead +of muttering delirium.[40] Bad, in the same fever, are deepening of +the flush of the countenance, profound stupor, rapid and feeble pulse, +lying on the back and sinking down toward the foot of the bed, with +suppression of urine. + +[Footnote 40: Incidentally, it may be mentioned that the return of the +pulse to its normal rate is often considerably delayed in +convalescence from typhus and typhoid fevers and other protracted +diseases. If, then, the temperature is not above 99 degrees F., and is +stable from morning to night, the tongue is clean and moist, and +appetite begins to appear, we need not be alarmed, although the pulse +continues as high as 90 or 100 per minute, in a case attended by +positive debility.] + +In typhoid fever many of the good and bad signs are the same as in +typhus, belonging to closely similar general conditions. But in +typhoid fever we observe also as favorable signs the lessening of +tympanites, more nearly natural fecal stools, and the absence of +tenderness in any part of the abdomen. As unfavorable, increase of +tympanites and diarrhoea, sometimes large hemorrhages from the bowels; +worst of all, at a late stage, sudden increase of abdominal +distension, with dulness on percussion, coldness of the skin, great +rapidity and feebleness of the pulse following perforation of the +bowel, resulting usually in fatal peritonitis. + +In scarlet fever, measles, and small-pox it is a favorable sign for +the eruption to come out well at the usual time; its sudden recession +threatens malignancy. In small-pox a confluent eruption marks a +dangerous case, and so does the occurrence of distinct pustules in the +throat. Early in scarlet fever stupor is very threatening, though not +necessarily mortal. Late in the same disease bloody urine, or, worse +yet, suppression of urine, may well cause alarm. + +In all children's diseases the early occurrence of convulsions shows a +{172} severe but not always a dangerous attack. The late occurrence of +convulsions is commonly much more serious in its significance.[41] +Convulsions are always of vastly less importance, prognostically, in +children than in adolescents or adults. Yet they are always serious +signs. While recovered from in the large majority of cases, they may +at any time be fatal. + +[Footnote 41: Yet I saw a case of acute cerebro-meningitis, in a girl +ten years of age, in which a violent convulsion occurred on about the +sixth day of the disease, and was followed by convalescence.] + +These enumerations, selected as examples merely, might be much farther +extended but that the special prognosis of each disease will be fully +set forth in the several articles upon them in the body of this work. +Those now given may suffice for the illustration of the method and +general principles by which the physician must be guided in his +anticipation of the progress and result of cases of disease. The +caution may be repeated, to observe great care in forming a conclusion +in regard to prognosis in every instance, and still more in expressing +it, unless in the presence of very clear and positive evidence. + + + + +{173} + +HYGIENE. + +BY JOHN S. BILLINGS, M.D. + + +The purpose of this paper is to indicate some of the ways in which +hygiene, both private and public, is connected with the duties of the +general practitioner, and to give some information as to modern +methods of investigation and work in preventive medicine. + +While the business of the physician is more especially the care of the +sick with reference to the cure of disease, or, where that is beyond +his power, as is too frequently the case, to relieve suffering and +secure temporary ease for his patient, he is nevertheless often called +upon to answer questions as to the causes of disease, and the best +means of avoiding or destroying these causes. Not only does diagnosis +often turn upon considerations of etiology, but a very considerable +part of the treatment of actual disease must be hygienic in the +broader sense of the word. The prescription or the surgical operation +must not only be supplemented by advice as to residence, clothing, +food, exercise, etc., but must, in many cases, be merely supplementary +to such advice, which indicates the really essential method of +treatment; and the giving this advice then becomes the most important +part of the physician's work, although not usually recognized as such +by his patients. The chief value of the prescription is, in fact, +often to methodize the mode of life of the patient and to remind him +at frequently recurring intervals of the regimen which has been +ordered with it. + +The physician has also certain duties in relation to the public at +large, as well as to his individual patients, and these duties become +more numerous and important as the density of population increases, so +that in the large cities of most civilized countries he finds himself, +nolens volens, in almost daily contact with legally constituted +authorities in the shape of registrars, health officers, coroners, +etc., and is not infrequently summoned before the courts as a supposed +expert in matters connected with the public health. + +Moreover, the physician who has become eminent in his profession is, +in many cases the adviser, and, so far as professional subjects are +concerned, to a great extent the guide, of those who legislate for, or +execute the laws of, not only his own city or county, but his state +and the nation; and he must to a corresponding degree be held +responsible for the position which he takes and the advice which he +gives in regard to public health matters. This is true whether his +attitude on these subjects {174} be active or passive, for his silence +will be taken to mean that there is no necessity for action or change. + +The limits of this paper do not permit the presentation of proofs and +illustrations of these somewhat dogmatic assertions, but it is +believed that they will meet with general assent from medical men +without formal and detailed argument, and that it is unnecessary here +to urge the interest or importance of practical hygiene upon the +medical profession, or to enlarge upon the desirability that the +practitioner, as well as the professional sanitarian, should be +familiar with the conclusions of modern science and technology with +regard to it. + +In the minds of many intelligent and thoughtful physicians there is, +no doubt, a feeling of unformulated distrust as to the real +possibilities or probabilities of improving the health and diminishing +the mortality of the community at large; and this feeling is in part +due to the exaggerated claims and emotional exhortations of some +advocates of hygiene. A careful and unprejudiced survey of what has +been accomplished by sanitary measures will, however, largely +dissipate this distrust. + +The natural term of the life of man is fixed by the physiologist at +about one hundred years, which is nearly in accordance with the law +indicated by Flourens, that the period of life of an animal is about +five times that required to perfect the development of its skeleton +and unite the epiphyses with the shafts of the long bones. The actual +average duration of human life is less than half this, but there is +satisfactory evidence that it has increased in civilized countries. +The ancient estimate is expressed in David's declaration, that "the +days of a man are threescore years and ten, and if by reason of +strength they be fourscore years, yet is their strength labor and +sorrow." Kolb, a cautious and learned statistician, concluded, from +his studies, that while the maximum age reached by man has not +materially changed for many centuries, the number of persons who now +survive infancy and of those who reach a ripe old age has decidedly +increased; and this opinion is sustained by Mr. Lewis, the secretary +of the Chamber of Life Insurance of New York, who points out that +while civilization largely interferes with the laws of evolution by +survivorship, it aids by economizing the waste which occurs in its +absence. "Under natural selection, when variations in capacity arise, +thousands of them are wasted where one is secured, fixed, and +transmitted. But human society economizes much of this waste, fastens +upon and improves an immensely larger proportion of the capacities +lavishly produced by Nature, and thus concentrates forces which would +otherwise spread their operation over countless ages."[1] + +[Footnote 1: "Influence of Civilization on the Duration of Life," +_Reports Am. Pub. Health Ass'n_, N.Y., 1877, vol. iii. p. 173.] + +We have, however, no record of the duration of life in ancient Greece +and Rome, and it is quite possible that it was greater than in Western +Europe during the Middle Ages, which formed a period of retrogression +in a sanitary point of view. The Jew, the Greek, and the Roman, prior +to the Christian era, were probably cleaner in person and in dwellings +than the people of the time when dirt became the odor of sanctity. + +In the absence of reliable data for this country, it is impossible to +speak with certainty of the results of attempts made here to prevent +disease and death. Each sex, race, and age has its own rate of +mortality, {175} and until this rate is determined we can only guess +as to whether good work is being done or not. + +We can never hope to diminish the total number of deaths which will +occur in long periods, say two hundred years, but we may rationally +try to prolong the average duration of life, to diminish infant +mortality, and to secure greater comfort and better health for +individuals and for the community at large. + +The reader must remember that only a mere outline of the subject can +be presented here; the details would require several volumes, and the +tendency to specialization in this, as in other branches, is so great +that it is hardly to be expected that any one man shall have either +the theoretical or the practical knowledge necessary for covering the +entire field. There are certain things in relation to hygiene which +every physician should know; there are many other things with regard +to which it is sufficient if he knows where to find full and reliable +information when he needs it. With this preface we will pass at once +to our subject, which may be conveniently divided as follows: + + I. Causes of disease, means of discovery, and prevention. + II. Personal hygiene in its relations to the practice of medicine. + III. Public hygiene in its relations to physicians. + + +I. Causes of Disease, Means of Discovery, and Prevention. + +Although the origin of disease has from the earliest times been the +subject of study by medical men, the physician has not heretofore, +usually, been called upon to investigate the causes of disease in +particular localities, until the occurrence of sickness in that +locality has called attention to the matter. The education of the +public as to the importance of sanitary work has, however, recently +made great progress, and it is now not unusual to ask the opinion of +the family physician as to the healthfulness of a given locality or +house. The question may be presented in three different ways: First. +In a given case of disease, what is the probable cause? Second. Given +the presence of a known or suspected cause of disease, what are the +best means of avoiding or destroying it? Third. In the absence of +cases of disease, to determine whether causes of disease are probably +present, and if so, what causes. + +The word "cause" is here used in its widest sense, including not only +what are commonly called predisposing and exciting causes, but also +those conditions which aggravate or continue the disease. These causes +may be roughly classed as follows: Heredity; impure air; impure water; +climate; habitations; occupation; food; intemperance of various kinds; +clothing; errors in exercise; sexual errors; parasites; contagia; +expectant attention and other mental causes, including worry, etc. In +most cases two or more of these classes of causes are combined in +action for the production of a given case or outbreak of disease, and +when we refer any disease to a single factor, what is meant usually +is, not that this is the sole and exclusive cause, but that it is the +most prominent one. + +Bearing this in mind, let us consider briefly some of the causes above +mentioned. + +I. HEREDITY.--That the child inherits from its parents its physical +{176} type, including color, stature, physiognomy, temperament, and +certain peculiarities of structure or arrangement of internal organs, +is well known. This hereditary influence is stronger from the +immediate than from the remote ancestry, although the curious +phenomena of atavism sometimes form exceptions to this rule. The +hereditary causes of disease can be guarded against when known. +Theoretically, by preventing generation on the part of persons who are +unfit to produce offspring; practically, to a certain extent, by +taking special precautions against these causes and their effects in +the individual, particularly at those ages in which these influences +seem to have their greatest force. The most important of these +hereditary diseases are syphilis, consumption, scrofula, cancer, gout, +certain skin diseases, insanity, and criminal tendencies of various +kinds. + +The physician's advice is rarely asked with regard to the propriety, +from a sanitary point of view, of a proposed marriage, nor is it often +taken when given, unless, indeed, it happens to correspond with the +wishes of the recipient; nevertheless, he is occasionally in a +position to exert influence in such a matter, and when this is the +case the following general rules may be borne in mind: 1. No marriage +should occur between persons having the same hereditary tendency to +disease; and this is especially important in marriages between +relatives. 2. A girl should not marry under the age of twenty. 3. A +person affected with hereditary or well-marked constitutional +syphilis, or having a strong consumptive taint, or tendency to mental +unsoundness, should not marry at all. + +The precautions to be taken in individual cases in which there is a +known hereditary predisposition to certain diseases will probably be +indicated in the articles upon those special diseases. The most +important of these, from the sanitary point of view, are consumption +and gout, partly because of their frequency, partly because of the +undoubted power which a proper regimen, applied in time, has in +controlling them. The pain in gout has often an excellent sanitary +effect; it is an inducement to temperance much stronger than any +amount of good advice. + +The influence of heredity in producing abnormities of refraction and +accommodation of the eye, and the importance of detecting these early +and giving them proper treatment, have not hitherto received, from the +general practitioner, the attention which they deserve. Children of +parents affected with astigmatism, ametropia, etc. should be carefully +examined before being placed at school, and if necessary fitted with +proper glasses. + +The heredity of idiosyncrasies as to certain articles of food or +certain drugs must also be borne in mind by the physician, for, +although implicit confidence is not always to be placed in the +statement of a patient that he cannot take a certain medicine, yet a +knowledge of the facts will occasionally save the prescriber from some +awkward mistakes. + +The importance of bearing in mind the family peculiarities is best +appreciated by the old family doctor who has had two or three +generations pass under his hands: he knows, for example, that in one +family he may expect brain complications, in another lung troubles, +and that what would be grave symptoms in one house are of +comparatively small import in another. Unfortunately, the greater part +of this kind of knowledge has not yet been formulated, and each +physician has to acquire it for himself; but he will find the process +of acquisition greatly facilitated if in all cases in a new family he +makes it a rule to learn something of the medical {177} history of the +parents, and he will find intelligent laymen quick to appreciate his +inquiries in this direction. + +The importance of taking into account hereditary influences is well +illustrated by the care which is taken to obtain information with +regard to them in well-conducted life insurance companies. The medical +examiners of such companies have their attention specially called to +this matter, and the following extract from a manual of instructions +shows how it is regarded from a business point of view: "If +consumption is found to have occurred in the family of the applicant, +he is to be regarded not insurable under the following circumstances, +viz.: + + YEARS OF AGE. + If in both parents, not insurable until . . . . . . . . . 40 + If in one parent, not insurable until . . . . . . . . . . 30 + (Except for ten-year endowments, then 20 years.) + If in two members (not parents) . . . . . . . . . . . . . 35 + If in one member (brother or sister) . . . . . . . . . . 20 + (Except for ten-year endowments, when peculiarly favorable.)" + +If apoplexy, paralysis, or heart disease is found to have occurred in +any two members of the applicant's family, he is to be regarded as +insurable only upon the endowment plan, the term of insurance to +expire prior to his reaching the age of fifty years. If insanity shall +have so occurred (in two members), a provisionary clause is essential, +and is attached to the policy by the company. + +II. IMPURE AIR.--The dangers of impure air, water, and food depend +largely upon the fact that through these media may be introduced into +the body particles of organic matter, living or dead, which tend to +produce disease in the recipient. The parasites are types of this mode +of disease-production, and these blend with the contagia of the +specific diseases in such a way that it is not easy to draw the +distinction in all cases. There are also certain poisonous gases and +inorganic compounds which may occasionally be present in air or water +to such an extent as to produce disease; but as a rule the gaseous +impurities of the air are offensive to the smell rather than +dangerous, as will be seen when we come to consider the effluvium +nuisances. + +The subject of ventilation, for the purpose of procuring an adequate +supply of pure air, is one of so much importance, and one upon which +the physician is so liable to be called for practical advice, that it +seems proper to state briefly the general principles which should +govern investigations into, or recommendations upon, this subject. + +The impurities of air which are to be disposed of by ventilation are +for the most part derived from the human body, chiefly from +respiration, and these only will be considered here. In some cases it +is necessary to make special provision for the products of combustion +from gas, etc., but as a rule this is rather for the purpose of +regulation of temperature than anything else. The impurities of air +due to the presence of human beings consist mainly of carbonic acid, +ammonia, sulphuretted hydrogen, and sulphide of ammonium, and of +various organic compounds, mostly in the form of minute particles of +organic matter of uncertain structure, but extremely prone to +decomposition. It is usual to estimate the degree of impurity by the +amount of carbonic acid present, and this leads many persons to +suppose that the carbonic acid is in itself the chief and most +dangerous impurity. This gas is, however, not perceptible to the +senses, {178} nor is it injurious to health, unless present in much +greater proportion than that in which it will be found in the most +crowded habitations or assembly-rooms. Its importance in questions of +ventilation depends upon the fact that its increase in a room beyond +the amount present in the outer air may usually be taken to be in +direct proportion to the amount of the really dangerous and offensive +impurities present, and that the amount of carbonic acid can be +ascertained by chemical tests with comparative ease and rapidity; +which is not the case with regard to the organic matter. The carbonic +acid is therefore taken as the measure of the impurity, although it is +not itself the impurity of which we are most anxious to be free. + +To decide as to whether a room is well ventilated or not, some +standard of permissible impurity must be fixed, and this standard is +now usually taken to be, in a room occupied by human beings, that +condition of air which produces in a person having a normal sense of +smell, and who enters from the fresh air, a faint sensation of an odor +very slightly musty and unpleasant. Upon testing the air of such a +room, it will be found that the amount of carbonic acid impurity +present--that is, the excess of this acid over the amount in the +external air--will be between 2 and 3 parts in 10,000. + +As the amount of carbonic acid in normal air varies from 2 to 5 parts +in 10,000 in different places, and in the same place at different +times, it is better to look to the carbonic acid impurity as above +defined rather than to the total amount of the acid found present, if +strict accuracy is desired; but usually the statement of Dr. Parkes is +correct, that the organic impurity of the air is not perceptible to +the senses until the total carbonic acid rises to the proportion of 6 +parts in 10,000 volumes. When the carbonic acid reaches 9 parts in +10,000 the air is close, and when it exceeds 1 part in 1000 the air is +usually decidedly unpleasant. If we take 2 parts in 10,000 as the +permissible maximum of carbonic acid impurity, it follows that the +amount of fresh air which must be supplied and thoroughly distributed +for each person per hour is 3000 cubic feet. If 3 parts per 10,000 be +taken as the permissible maximum (which is the standard of +Pettenkofer), the amount of air per head per hour must be 2000 cubic +feet. While it is impossible, as Dr. Parkes remarks, to show by direct +evidence that the impurity indicated by 7, 8, or even 10, parts of +carbonic acid per 10,000 is injurious to health, it is advisable to +accept his standard, because it is a simple one, and can be +practically applied without special apparatus or technical skill, and +because there is evidence of the injury to health which continued +exposure to air impure, by this standard, ultimately produces. + +Keeping this standard in view, the physician may be called on for an +opinion as to whether the ventilation of a given building is +satisfactory or as to the merits of a proposed plan for ventilation. +The first is a question of fact: What are the effects produced upon +the inmates? Are there unpleasant odors in the building or not? What +percentage of carbonic impurity is present? What is the number of +cubic feet of air per head that is introduced and removed per hour? +And what is the character of the fresh-air supply as to purity? Does +it come from the cellar, or from other rooms, or from a foul area? +Air-currents can usually be best investigated by the fumes of nascent +muriate of ammonia produced by {179} exposing a cylinder of common +blotting-paper, moistened with dilute hydrochloric acid, to the vapors +coming from a crumpled fragment of the same paper moistened with +common aqua ammonia and placed within the cylinder. The process for +carbonic acid determination is simple, and can be learned in three +hours in a laboratory under a skilful teacher. It does not seem worth +while to describe it here. The determination of the amount of air +passing through a given register, flue, or chimney in a given time is +to be made by the use of an anemometer, an instrument which registers +the velocity of the current of air passing through it. + +In judging of the merits of a plan of ventilation the following points +should be remembered: The defect in most plans for ventilation is in +the air-supply. Many people suppose that they have made all necessary +provision for ventilation if they have put in tubes or openings for +the escape of foul air, forgetting that these outlets will have no +effect if corresponding inlets are not provided. Examine, first of +all, therefore, the ducts, flues, and openings proposed for the +fresh-air supply, with reference to their size and position and the +amount of air to be furnished by them. These will almost invariably be +found to be too small. The proper size of flues and registers for a +given room is ascertained by dividing the number of cubic feet of air +to be supplied per second by the velocity in feet per second which the +air is to have in the flue or opening, bearing in mind that it is much +better that these flues and registers shall be too large than too +small, since it is easy to reduce their capacity, but, in most cases, +impossible to increase it. When the fresh-air register is so situated +that the current of air from it is liable to strike upon the person of +an occupant of the room, the velocity of this current should not +exceed 1-1/2 feet per second if unpleasant draughts are to be avoided; +and it will usually be found best that the velocity of the air in the +flue shall not exceed 6 feet per second, except in the case of very +large flues, where the element of friction becomes of comparatively +small importance. In the great majority of cases the amount of air to +be supplied depends upon the number of persons, and not on the cubic +space; but in exceptional instances, where the amount of cubic space +is very large in proportion to the number of persons, and the heating +is effected by warm air, it may require more air to keep the room at a +comfortable temperature than is necessary for the supply of the +occupants. The cubic space is also relatively much more important in +rooms which are to be occupied but a short time continuously, and can +then be thoroughly aired, than it is in rooms constantly occupied. + +The methods of calculation can be best illustrated by one or two +examples. What should be the number and size of flues and registers +for fresh-air supply for a hospital ward to contain 24 beds, the ward +being a rectangular pavilion with windows on opposite sides? In this +case the room is constantly occupied, and the supply of air should be +1 cubic foot per head per second, or, in all, 24 cubic feet per +second. The velocity of current at the registers should not exceed 3 +feet per second--better only 2. This will require from 8 to 12 square +feet of clear opening in the registers. If we allow four on each side +of the room, each register must have at least 1 square foot of clear +opening. The velocity of the air in the flues supplying these +registers should not exceed 4 feet per second, and therefore the area +of each flue should be about 9 by 12 {180} inches. Suppose the same +question be asked with regard to a school-room to contain 48 pupils. +In this case the room will not be occupied more than two hours at a +time. The air-supply desirable may be put down at 35 cubic feet per +head per minute, or 28 cubic feet per second for the whole. The +velocity in the flues may be put, as before, at 4 feet per second; +hence we need 7 square feet area of flue, or seven flues, each having +1 square foot of area. It is safe to say that there are not twenty +school-houses in the United States which have fresh-air flues of +sufficient area; the deficiency is made up, for the most part, by +leakage of the outer air through cracks around windows and directly +through the wall, and also by the passage of air from the central hall +into the room, this last air coming from the cellar or basement. + +The velocity of the air at the foul-air registers and in the foul-air +ducts may be greater than in the fresh-air flues, since there is no +danger of its causing draughts, and hence there is no truth in the +common notion that the outlets should be larger than the inlets to +allow for the expansion of heated air. It is important that the +velocity of the current in the outlet shaft or chimney should be at +least 8 feet per second at the point where it escapes into the outer +air; and if the outlets be too large for the inlets, the result may be +that some of the foul-air flues will work backward and become inlets. +The plan of making everything a little larger than is necessary is not +a safe one as regards chimney-flues and outlet shafts. + +The merits of a plan of ventilation depend not only on the amount of +air introduced, but on its distribution. The test for distribution is +chemical analysis of samples taken in different parts of the room and +at different levels. A very good idea of the direction taken by the +incoming air can also be obtained by the use of fumes of nascent +muriate of ammonia, as above described. In considering the +distribution which will probably take place in a given plan, care +should be taken not to fall into the common error of supposing that +because pure carbonic acid gas is heavier than air, therefore the +carbonic acid derived from respiration sinks to the floor, and that +special provision should be made to remove it at that point. The law +of the diffusion of gases effectually prevents this separation and +sinking of the carbonic acid from the mixture of gases expired, and it +will be found to be present in about equal proportions in all parts of +an inhabited room. + +The methods of introducing and distributing fresh air depend to a +great extent upon the methods of heating employed; and it is necessary +to remember that while good ventilation is a very desirable thing, +satisfactory heating is, in cold weather, still more desirable, and +must be attained even if the ventilation is interfered with for that +purpose. The principal difficulty in the way of securing good +ventilation is its cost. In a cold climate satisfactory heating, good +ventilation, and cheapness are not compatible; it is comparatively +easy to obtain any two of them, but impossible to have the three +together. This fact should be fully understood and realized by the +physician, for its comprehension will save much time in considering +the merits of various patent ventilators and ventilating appliances, +which, according to their inventors, produce good ventilation at no +expense beyond that of the original cost of the apparatus; which is +practically about the same as a claim to have discovered perpetual +motion. Patent ventilators are usually cowls to be placed upon the top +of outlet {181} flues. I know of none which are superior to the common +Emerson Ventilator, on which there is now no patent. In cold weather +the air must be warmed to secure comfort; it must be changed to secure +ventilation. The changing of the air carries off heat, the loss of +which must be supplied by fuel, which fuel costs money. The greater +the ventilation, the more rapid the change and the more heat required. +It is therefore quite possible to judge somewhat of the merits of a +heating and ventilating apparatus--for example, of a +school-house--from the amount of fuel consumed; but the conclusion +will be precisely the reverse of that drawn by the average trustee, +since it will be, that within certain limits the less fuel required +the less satisfactory the apparatus. + +The evil effects of insufficient ventilation, although very certain +and very serious, are not immediate, or such as to attract attention +at first, except in very aggravated cases with excessive +over-crowding. The power of the organism to adjust itself to +surrounding circumstances is very great, and perhaps as great in +regard to the endurance of foul air as anything else. Yet this power +is greater in seeming than in reality, for at last such air produces +disease and shortens life. Its effects are manifested in diseases of +the respiratory organs, acute and chronic, and it is now generally +admitted that the undue prevalence of phthisis in troops is due to the +foul air of the barrack-rooms. + +Some persons are much more susceptible than others to the effects of +impure air, and will suffer from headache, languor, loss of appetite, +etc. where others would experience little inconvenience. Children thus +susceptible dread the school-room as ordinarily constructed and +ventilated, and their discomfort should be taken into account and +guarded against. + +Thus far, reference has been made only to those impurities of air due +to respiration and lights; in other words, the necessary impurities +found in human habitations. The impurities due to sewer gases will be +referred to hereafter; they should be prevented absolutely, and not +provided for by ventilation. One of the most difficult problems +presented to the physician is to determine whether the effluvia from a +given locality are injurious to health, and if so, to what extent. +These effluvia may be due to certain occupations or manufactures, or +they may result from the disposal of excreta, from obstructed drainage +giving rise to swamps and the collection of decaying organic matter, +and in other ways. The best definition of the term "injurious to +health" in this connection is perhaps that suggested by Dr. +Ballard--_i.e._ that exposure to the offensive effluvia causes bodily +discomfort or other functional disturbance, continuing or recurring as +the exposure continues or recurs, and tending by continuance or +repetition to create an appreciable impairment of general health and +strength, to render those exposed more liable than others to attacks +of disease, and more apt to suffer severely when attacked, and, in the +more serious forms, to the direct production of the disease and the +shortening of life. + +The group of symptoms due to offensive effluvia is, as Dr. Ballard +remarks, a tolerably constant one, and consists of loss of appetite, +nausea, headache, giddiness, faintness, and a general sense of +depression, with, in some cases, vomiting and diarrhoea. But it is +usually impossible to prove by statistics that these phenomena are due +to a given effluvium complained of, for those who suffer from it are +usually exposed to other causes of ill-health, such as poverty, +overcrowding, collection of filth, etc.; and, on the {182} other hand, +many of those exposed to the effluvium seem to suffer very little, if +at all, from their surroundings. And so true is this, that in the +carefully prepared report upon effluvium nuisances recently issued by +Dr. Ballard,[2] it will be found that as a rule no attempt is made to +prove that the effluvia from any particular branch of industry are +injurious to health; the test practically applied is that they produce +offensive odors. + +[Footnote 2: _Report in respect of the Inquiry as to Effluvium +Nuisances arising in connection with various Manufacturing and other +branches of Industry_. By Dr. Ballard, London. Her Majesty's +Stationery Office, 1882, 8vo.] + +The legal view of this subject is given in the various decisions as to +what should be considered a nuisance, the essence of which is the use +of one's own property in such a way as to inflict damage upon, and +injure the rights of, another. If a man collects on his own premises, +for his own use, any material, such as water or filth, he is bound to +retain it within his own premises or to let none of it escape in such +a way as to damage others; and this holds good as regards gases, +vapors, and odors. The decision of Mansfield, in the case of Rex _vs._ +White, is often quoted approvingly by jurists, viz.: "It is not +necessary that the smell be unwholesome; it is enough if it renders +the enjoyment of life uncomfortable." But, practically, the question +as to whether the discomfort produced is sufficient to produce +ill-health will be the one upon which the physician is called to give +evidence, and the one also upon which he will find it most difficult +to obtain data sufficient to enable him to form a positive opinion. + +III. IMPURE WATER.--Of all the various preventable or removable causes +of disease to which the attention of the physician engaged in practice +in the small towns and rural districts is directed, it will usually be +found that the water-supply is the most important, because it is in +these localities that it is most liable to become contaminated in such +a way as to produce sickness. + +All water used for drinking purposes is impure in the chemical sense, +since it contains some inorganic matters or salts, and in most cases +organic matter also. It is difficult to define precisely what should +be considered an impure water in a sanitary sense, and the best we can +do is to indicate probabilities in the absence of positive evidence of +the production of disease by the suspected water. So far as inorganic +impurities are concerned, the most important, from the sanitary point +of view, are the salts of lead, magnesia, and lime, but in this +country these are so rarely the cause of disease that they hardly +require special notice. The physician should, however, bear in mind +possibilities of lead-poisoning in some obscure cases which he will +meet. + +The diseases due to impure water are certain specific fevers, +diarrhoeal diseases, and some affections due to parasites which find +entrance to the body through this medium. The water-supply is to be +suspected in case of prevalence of diarrhoeal disease in a community, +and especially if the outbreak be sudden and affect a number of +persons and families. Sudden outbreaks of cholera, typhoid fever, or +malarial fever, confined to a limited locality, should lead to careful +examination of the water-supply. The impurity in water which causes +these diseases is supposed to be either organic or the product of +organic life, and at present the prevailing opinion is that the really +dangerous impurities consist of minute living organisms or {183} +germs. It is usual to estimate the impurity of water by the amount of +organic matter present, but it is evident that this alone can give no +positive information, since by this standard milk and soup would be +very dangerous. Much depends upon the character of the organic matter, +whether it is derived from the animal or vegetable kingdom--whether it +is in a state of fermentation or putrefaction, etc. etc.; but the +presence of specific germs in it is the most important part of all, +and at the same time the most difficult to ascertain. Nitrogenous +organic matter in a state of decomposition is dangerous, yet it does +not always produce disease, even when ingested in comparatively large +quantity, as in case of "high" game or tainted meat; and it is easy to +find instances where water strongly polluted with sewage has been used +for a considerable period without producing marked ill effects. It is, +however, so extremely probable as to be for practical purposes +certain, that water contaminated with the discharges from persons +suffering from certain diseases will produce similar diseases in those +who drink it, and there is also enough evidence that water containing +filth of various kinds either produces or promotes disease to warrant +much more attention to this subject than has heretofore been bestowed +upon it. + +The chemical examination of a suspected water is by no means a simple +process, and in most cases had better be referred to an expert in such +matters. It is highly desirable, however, that the physician should +have sufficient technical knowledge to be able to make a rough +analysis at least, if for no other reason than that he may be able to +appreciate the results reported by the chemist. As a rule, when a +water is so polluted with decomposing organic matter as to be +positively dangerous it will have an unpleasant odor, which is best +developed by half filling a quart bottle with the water to be examined +and shaking it thoroughly. The so-called simple and ready methods +which are from time to time advocated in the newspapers, such as the +addition of sugar to the suspected water and allowing fermentation to +take place, the use of tannin as a precipitant, or the decolorization +of a solution of potassium permanganate, are really of very little +value and should not be relied upon. In the hands of an expert the +best simple method of determining the quality of a water is by +evaporation of a known quantity and the ignition of the solid residue. +From the amount of the total residue, the quantity left after +ignition, the amount of blackening produced, and the odor, a very fair +opinion can be formed as to the amount of organic matter present, and +whether it is of animal or vegetable origin. + +It is not within the province of this paper to describe the methods +used by chemists in water analysis, of which the principal are known +as the Franklin and Armstrong, the Wanklyn, and the permanganate +methods. A careful examination of these methods has recently been made +under the direction of the National Board of Health, and a preliminary +note of the results, prepared by Professor Mallet, has been published +in the _Bulletin_. From this it appears that the chief value of +chemical analysis is, first, the verification of gross pollution, +which will usually be detected by the appearance and smell of the +water; and, second, in periodical examination of a water-supply to +detect changes from the normal or usual character of the water, which +may be taken to have a certain local standard of purity. Special +importance is attached to the careful determination of {184} nitrates +and nitrites in water to be used for drinking, these being the results +of oxidation of organic matters, and therefore giving evidence of +previous contamination. + +Prof. Mallet concludes that "there are no sound grounds on which to +establish such general standards of purity as have been proposed, +looking to exact amounts of organic carbon or nitrogen, albuminoid +ammonia, oxygen of permanganate consumed, etc., as permissible or not. +Distinctions drawn by the application of such standards are arbitrary +and may be misleading." While this is perfectly true, considered from +the standpoint of scientific precision, it does not sufficiently take +into account the value of probabilities in these matters, considered +as motives to action. It is perfectly true that there can be no fixed +standard--that a water which the chemist would report as relatively +pure might be much more apt to produce disease than one which he would +pronounce impure--but it is nevertheless true that from the results of +chemical analysis, taken in connection with evidence as to the source +and history of the water, an opinion can be formed as to the danger +from its use which is sufficiently reliable to be acted upon in the +absence of positive evidence, such as the production of disease. + +In many cases the matter must be doubtful, and Prof. Mallet truly says +that it will not do in all such cases to forbid the use of the water, +for it often happens that this should not be done unless it is +absolutely necessary; but there are many other cases in which there is +very little doubt, and where action should be governed by the +probabilities. + +The microscopical examination of suspected waters sometimes gives +decided indication as to the nature of the impurities; and it may be +that hereafter, in connection with physiological tests, it will become +of even more importance than the chemical. To determine the presence +of organisms in a sample of water the best method known at present is +to kill and coagulate them by means of osmic acid or chloride of +platinum, and allow them to subside. This method is of course +inapplicable if it be desired to use them for either culture- or +inoculation-tests. + +Chemists have no uniform system of reporting the results of their +analyses, some using grains per gallon, U.S. or Imperial as may be, +and others parts per hundred thousand or per million of the water. It +is therefore difficult to appreciate the value of the figures as given +by them. The following, in parts per 100,000, will enable the +practitioner to form a general estimate of the character of analytical +reports; but the opinion in individual cases is so modified by the +coincident amounts of chlorine, ammonia, nitrous and nitric acids, +that the experienced sanitarian only is qualified to put on the +results an estimate which shall be in accordance with our present +knowledge of such matter: + + _Upland Surface-Waters_. + Allowable. Doubtful. Impure. + Total organic elements to .4 .4 to .6 Over .6 + Oxygen required to .3 .3 to .4 " .4 + Albuminoid ammonia to .015 .015 to .025 " .025 + + _All Other Waters_. + Total organic elements to .2 .2 to .4 Over .4 + Oxygen required to .15 .15 to .2 " .2 + Albuminoid ammonia to .010 .010 to .015 " .015 + +{185} In connection with impure water should be mentioned impure ice. +Ice is purer than the water from which it forms, but if cut on a foul +pond it will itself be foul, and the vitality of some microscopic +organisms is not destroyed by their being frozen, as is shown by the +fact that samples from the centre of blocks of ice will inoculate +sterilized infusions with the germs of putrefaction, precisely as the +water of which the ice is composed would have done before it was +frozen. Disease has been traced to impure ice, and it may be that it +is more frequently due to this cause than has heretofore been +supposed; at all events, it is well to bear the possibility in mind. + +The subject of impure water will be further considered in speaking of +habitations. + +IV. CLIMATE.--The literature of the effects of different climates upon +the human body is very extensive, following the general rule that the +less positive or precise knowledge there is upon a given subject the +more will be written about it. Of all animals, man seems to adapt +himself most readily to the extremes of climate; and, although it is +commonly supposed that a tropical climate is injurious to those coming +from cooler regions, yet it has been found that where he takes the +same precautions to ensure cleanliness, pure water and air, and proper +food, the European does not have a higher rate of mortality in Algeria +or in the East or West Indies than he does at home, if the effects of +cholera and yellow fever be excepted. + +Dr. Parkes defines the effect of climate upon the human body to be +"the sum of the influences which are connected with the solar +agencies, the soil, the air, or the water of a place;" in other words, +he makes it nearly equivalent to the locality or the environment. By +"climate" we understand, commonly, the sum of meteorological +influences, the most important of which, as regards health, are +temperature, humidity, and wind. The effects of temperature in +producing disease are often confounded with the effects of change of +temperature, which last is perhaps the more important of the two, and +should be specially borne in mind in advising climato-therapy for +chronic or wasting diseases. + +The influence of climate in causing disease, although well known for +over two thousand years, has not led to much effort to avoid or +prevent effects which are accepted as inevitable by the great +majority. It is true that in the effort to secure physical comfort by +houses, clothing, artificial heat, and the like, much hygienic work +has been done, and the steadily increasing tendency on the part of all +who can afford it to seek rest and comfort at the seaside or in the +mountains during hot weather is no doubt due, in part, to the fact +that experience has shown that the money expended in thus securing +health and strength is a good investment. It is unfortunate that +"health resorts," so called, do not always prove to be such: they +become fashionable, overcrowded; the arrangements for the disposal of +excreta are cheap makeshifts, leading to soil- and water-pollution, +until finally an epidemic of diarrhoea or typhoid fever occurs, with +the usual results. + +The consideration of climate as a therapeutic agent belongs with the +articles relating to the several diseases to which it is applicable. +The great desideratum wherewith to place this subject upon a +scientific and practical basis is a system of reliable returns of the +deaths, and if possible of {186} certain diseases, throughout the +country, and especially at those points most in vogue as health +resorts. + +V. HABITATIONS.--That a man's health depends very much on the +character, condition, and location of his dwelling-place is now so +generally admitted that in many cases where a physician is called in +he will be asked whether he thinks the disease has been caused by any +peculiarity about the house or the bedroom of the patient. And a +careful examination will usually discover in one of them several evils +to be remedied, although their connection with the case in hand may be +very doubtful. There are very few homes properly constructed from a +sanitary point of view; and, although we may not agree with Dr. +Wilson, that "the modern prison is in all sanitary essentials the best +existing type of what a healthy dwelling ought to be," it is +nevertheless certain that the health of the inmates is much more +carefully consulted in planning a penitentiary than it usually is in +planning a college, a hotel, or a dwelling-house. Matters are +gradually improving in this respect: the worst of the tenement-house +rookeries and fever-nests in most of our large cities have been +improved or abolished, and our wealthier citizens are beginning to pay +some attention to their house-drainage as well as to the pattern of +their mantelpieces. But the great majority of men are still careless +and negligent as to the sanitary condition of their homes, and +probably two physicians out of three live in houses in which numerous +defects would be pointed out by a sanitary engineer--defects of which +they are themselves more or less aware. The majority of people in our +large cities under existing conditions cannot afford to have healthy +houses, and the great causes of the excessive mortality, and brevity +of life, in all such cities, are poverty and overcrowding, the latter +resulting from the former. The problem as to the best mode of +improving the sanitary condition of the tenement-house population does +not, however, come before the practising physician for special +consideration, and need not be considered here. Nor is the physician +liable to be consulted with regard to the sufficiency, from a sanitary +point of view, of the plan of a house yet to be built, although he +will occasionally be asked as to the healthfulness of a proposed site. +The questions which he will be asked are such as the following: "Is +the cause of this particular case of disease in the house, or +connected with it? and if so, what is it?"--"Do you think this is a +healthy house?"--"Is the location a healthy one?"--"Is it necessary +that I should give up this house to preserve the lives and health of +my children?" While it is, of course, often impossible to answer with +precision such questions as these, an answer of some kind must be +given; and this should not be a mere random guess, but based on a +deliberate estimate of the probabilities in the case. The +healthfulness of a house is to be judged of, in part, from its +history, if it be possible to obtain any; in part, from such facts as +can be discovered by a careful examination of the premises and +vicinity. The sanitary history of a house is the history of the +diseases and deaths which have occurred in it, together with a set of +plans showing the precise location and character of the house-drainage +and of its fresh-air supply. Such a record is in most cases, +unfortunately, not attainable, although to a person proposing to buy +or rent a house it would often be quite as important as a record of +title. In a well-organized health-office it should be possible to +ascertain the number and causes of the deaths which have {187} +occurred in any given house or square in the city, and also the +character and location of its drainage and sewer connections. Such +records are especially valuable in an investigation of an outbreak of +disease in a community. + +The sanitary inspection of a house includes the site and the building +itself. The character of the site is mainly determined by its dryness, +by the presence or absence of organic matter in the soil, and by its +porosity taken in connection with the character of the vicinity. +One-third of the volume of some soils consists of air, and all dry +soils and rocks contain a much larger quantity of air than is commonly +supposed. The influence of soil upon health is exerted mainly through +the media of water and air, but it also affects temperature and +vegetation, being an important factor in climate. Residence on a damp +soil has a tendency to produce diseases of the lungs, and especially +phthisis; but how it does this is unknown, though it would be easy to +construct a plausible theory in connection with the supposed causation +of phthisis by a bacillus. The practical point for the physician is, +that the prevalence of phthisis in a locality, even if it be so +limited as to comprise but a single house, should cause suspicion and +investigation as to the character of the soil-drainage. Soil-moisture +is also an important factor in the development of periodical fevers, +and the effect of thorough drainage in diminishing malaria is now +generally understood. + +It sometimes becomes an important question as to the influence which a +collection of water, such as a mill-pond or a reservoir, has upon the +health of a community, and the physician may be called on for an +opinion in such cases where large property interests are involved. The +essential points to be borne in mind are--first, that stagnant water +and damp soil do not in themselves produce malaria; there is something +else necessary, which is commonly designated by the word "germ." +Second, that they are in most cases essential conditions for the +production of the disease, so that if removed the disease will +disappear. Third, that the development of malaria may follow either +the rise or fall of the ground water. Fourth, that the condition of +the border of the collection of water as to presence of organic matter +and moisture is of more importance than the pool itself. And, finally, +that each case is a problem by itself, to be determined by the history +of the sickness of the vicinity, and that only probabilities can be +stated in any case, although these probabilities may be so great as to +amount, practically, to certainty. Of the four factors which appear to +be essential to the production of the malarial poison--viz. moisture, +high temperature, organic matter of vegetable origin, and certain +micro-organisms--the first is the one which in any given locality is +most under human control; it is the link in the chain of causation +which is most easily broken. + +The influence of the rise and fall of the soil water in typhoid fever, +upon which so much stress is laid by Pettenkofer and others, no doubt +exists, acting in some cases through pollution of the drinking water +by the subsoil water leaking through a polluted soil; in other cases, +perhaps, by air from the soil bearing the unknown germ. The filtering +power of soil as regards air is, however, very great, a few inches of +sand being sufficient to remove the ordinary germs of putrefaction +from air drawn through it, and this for a long period; while, on the +{188} contrary, many feet of the same sand will not remove the germs +from water passed through it. Usually, as Dr. Parkes remarks, in an +examination of soil the immediate local conditions are of more +importance than the general geological formation, yet this last, as +influencing conformation and the movement of water and air over and +through a country, is also important. The practical questions on this +point are, what higher ground than the site in question exists in the +vicinity? what are the character and direction of the strata between +such elevation and the site? and, what sources of soil-pollution exist +on the higher level? As to the site itself, is it on made ground? what +is the height of the foundation above the subsoil water? and, what +precautions have been taken to secure drainage and to cut off +communication between the interior of the house and the ground air? +Probably a trial excavation or boring may be necessary to determine +some of these points. + +The level of the subsoil water should be at least five feet below the +foundations, although it is often impossible to obtain this. At all +times when the temperature of the house is higher than that of the +external air--_i.e._ during a large part of the year and nearly every +night--there is a strong and constant aspirating force at work to draw +into the house, through the cellar floor and walls, all gases and +vapors contained in the adjoining soil. If this soil contains a large +proportion of organic matter, as is often the case in filled-in ground +in cities, or if there be a leaky cesspool or sewer or gas-pipe under +or near the house, the ground air passing into the house may be of +such a character as to be positively dangerous to its occupants. For +this reason it is very undesirable to have a sewer or soil-pipe +crossing beneath the site of a house, and when such location is a +necessity, as it often is in cities, the soil-pipe should be laid in a +cement-lined trench covered with a movable flap, so that it can always +be easily inspected and any leaks detected and remedied. Dampness in +the cellar or basement of a house is always a sign of danger. The +exhalation of gases and vapors from the ground into the house can be +to a great extent cut off by a layer of impervious material, such as +concrete covered with asphalt, but this layer must cover the sides of +the cellar as well as the floor to be thoroughly efficient. If a house +have no cellar, the space between the floor and the ground should be +thoroughly ventilated; and for this purpose, as well as to secure +cleanliness, the floor should be sufficiently elevated to permit of +easy access beneath it. + +Next to its dryness, the nature and condition of the arrangements for +removing excreta and soiled water from a house are of the greatest +importance in determining its healthfulness; and in cities it is with +regard to the sufficiency of these, including the whole system of +house-plumbing and pipe-fitting, that the inquiries of one wishing to +determine as to the presence or absence of causes of disease will most +frequently be directed. The soil-pipes, etc. of a house are commonly +referred to as constituting the system of house-drainage, but it is +desirable to use another term, for we need the word "drainage" to +describe the removal of surface and subsoil water, and it should be +distinguished from "sewerage," which has a different purpose and +requirements. + +In a properly-arranged system of house sewerage all the pipes, traps, +etc. are easily accessible for purposes of inspection, and an +examination of them is a comparatively simple matter. This examination +is to be {189} made with reference to the following points: 1. Are all +the pipes, joints, and connections air-tight? 2. Is the soil-pipe well +ventilated, or has it dead ends? 3. Is the communication between the +soil-pipe and the street sewer uninterrupted? 4. Are the pipes +properly trapped, and is there liability to the removal of water from +any of the traps, either by siphonage or evaporation, to such an +extent as to break the seal? 5. Is the water-supply of each closet +entirely cut off from the main supply to the house by means of a tank +or cistern? + +In houses as heretofore constructed it is often very difficult to +obtain satisfactory information upon these points, because a large +part of the soil-pipe and its connections is buried beneath the house +or concealed in the walls or floors; in which case the services of a +skilled mechanic will usually be necessary to obtain access to the +various parts of the system. In a paper of this kind it is of course +impossible to go into details as to methods of inspection, or as to +what is and what is not satisfactory; but the following are the +general principles upon which a judgment as to the merits of a system +should be formed, and these should be so clearly understood by every +physician that he can be neither persuaded nor frightened into +thinking them incorrect by the eloquence of the man with a patent +remedy to dispose of. The principal dangers to health from house +sewerage are due, first, to the passage of air from the general system +of sewers or from a cesspool into the house through the soil-pipe and +its connections; second, to the generation of offensive and dangerous +gases and organisms in the soil-pipe itself, and the passage of these +into the house; third, to leakage of soil-pipe causing contamination +of the water-supply either by improper connections of water-pipes with +water-closets or slop-hoppers, or by contamination of wells, cisterns, +or tanks with sewage or sewer gases. + +There is, of course, no such thing as a sewer gas having a definite +and distinctive composition, and the nature of the mixture of gases in +sewers is constantly varying according to season, temperature, etc. +The tendency which sewer air has to cause disease depends in part upon +certain gases, in part on minute particles of solid or semi-solid +matter which are suspended in the air. In rare instances the sewers +also contain illuminating gas, derived from leakage of gas-pipes in +the vicinity. These gases produce debility, headache, loss of +appetite, etc. As found in sewers and soil-pipes, they are so diluted +that they are not absorbed by the water of a trap and given off on the +other side to a sufficient extent to produce an evil effect. The air +in a soil-pipe which is not ventilated is much more impure than that +of the ordinary sewer, since the process of decomposition is +constantly going on in the slimy coat which lines the interior of the +pipes; and it is for this reason that it is so important to secure +thorough ventilation of all the soil-pipes in a building. When this +ventilation is secured, the proportion of dangerous gas in the pipes +becomes very small, and the amount absorbed by the water in traps is +almost inappreciable. The chief danger to life from sewer and +soil-pipe air arises from the presence of minute particles of organic +matter, dead and living, the so-called germs. Danger to life from +these germs cannot be entirely removed by dilution, as can be done +with gases. It has been found by the experiments of Dr. Carmichael and +Dr. Wernick that an ordinary water-trap entirely prevents the passage +of these germs, and that organic putrescible fluid will remain +unchanged when exposed only to the air immediately {190} above such a +trap. A pin-hole or minute sand-crack in the soil-pipe, or a very +slight defect in a joint, is far more dangerous than a trap. + +The forms of disease produced by sewer air and its contents are more +especially diphtheria, typhoid fever, and ill-defined disorders of the +throat and digestive organs. It is possible that the germs of other +specific diseases, such as scarlet fever, may be at times transmitted +through sewer air, but such transmission must be very rare. While it +is true that the germs of the specific diseases are very rarely +present in sewer air, the house system of sewerage must be arranged as +if they were always present, in order to obtain security. It must also +be remembered that a system originally well planned and properly +constructed will not always remain so; the pipes will corrode, the +joints will become loosened, the valves will become clogged, and +whenever alterations or repairs are made there is always danger of +injury. Bearing these points in mind, the method of investigating a +system can be readily understood. + +The first step is to ascertain whether there is a trap outside the +house disconnecting the sewer from the house system and permitting +inspection. If there is not, the first thing to be done is to make an +excavation and open the drain at the proper point for placing such a +trap. The next step is to set the water flowing in the various closets +and watch the flow at the external trap, or opening, which has been +made to ascertain whether there is any obstruction in the pipe within +the house. If the sewer is properly arranged for inspection, as has +been above suggested, to determine whether there is any leakage from +the sewer under the house will be an easy matter; if, however, it is +buried beneath the cellar floor, as is usually the case, an excavation +should be made along the floor in the line of the pipe, with a view to +having it properly arranged, as well as for the purpose of examining +the soil. It may also be tested by opening the upright soil-pipes at +the farther end of the house-drain at the height of three or four feet +above the floor and pouring water into it, having temporarily stopped +up the drain at the external trap or opening. If the water remain at a +constant level in the upright piece, the sewer is water-tight; if not, +the leakage may be ascertained by the rate at which it sinks. Having +settled this, the next point is to determine whether all the +soil-pipes are air-tight and properly trapped. The test usually +applied for this purpose is the pouring of a small quantity of strong +oil of peppermint, followed by a dash of hot water, into the top of +the soil-pipe, which should always pass through the roof and be freely +opened to the outer air. If the odor of the oil is perceptible in the +house, it indicates a leak, which must be further sought for. Ether +may be used for the same purpose. The smoke test is, however, the +best, but it requires a special apparatus which as yet is little used +in this country. It is applied by a small machine with a fan, by which +the smoke from burning cotton-waste saturated with oil, or of coarse +brown paper impregnated with sulphur, can be blown into the pipes; +this locates leaks with great precision. + +It is not, of course, expected that a physician will personally make +the examination necessary to determine whether the plumbing of a house +is in good order, but he should be able to make it, if necessary, if +for no other purpose than to know whether the inspector employed for +the purpose understands his business. + +The dangers to health from a properly-constructed system of house +{191} sewerage, such as is now generally agreed upon by sanitary +engineers, are so very small as to practically amount to nothing, +being, in fact, less than those of a well-kept yard privy of a country +house, setting aside altogether the question of water pollution. The +real difficulties in the way are the expense of such a system, which +is considerable, and the finding of skilled and honest workmen to +construct it and keep it in repair. Not every one who chooses to style +himself a sanitary engineer or a sanitary plumber is to be regarded as +such, by any means, but the physician should make it his business to +know who are really reliable in this respect, for he will constantly +be called in for advice on this point by those who have learned that +good plumbing is the only true economy, but who do not feel themselves +competent to distinguish between good and bad work. The main points of +a satisfactory system are the following.[3] + +[Footnote 3: For further details consult the following: _American +Sanitary Engineering_, by E. S. Philbrick, N.Y., 1881; _House-Drainage +and Water-Service_, by James C. Bayles, N.Y., 1878; "House-Drainage +and Sanitary Plumbing," by W. P. Gerhard, in _Fourth Annual Report +State Board of Health Rhode Island_, 1882; _The Sanitary Engineer_, a +weekly journal published at 140 William St., New York City.] + +1. All soil- and waste-pipes should be extended up to and through the +roof, and be freely open at the top. The extension of the soil-pipe +should be full size--_i.e._ from four to six inches in diameter. + +2. There should be a fresh-air inlet in the house sewer just outside +the house, and between this inlet and the main sewer should be a trap +so arranged as to permit of inspection. This prevents the ventilation +of sewers through the soil-pipes. If a perfect system of sewers, +uniformity of house-connections, and uniform height of houses could be +guaranteed, this inlet and trap would not be so necessary, although +even then it would be useful. + +3. Every water-closet, wash-bowl, bath-tub, sink, etc. should have a +trap placed as close to it as possible. This trap is desirable, +whether the discharge be into the sewer system or not. For example, a +kitchen sink, the pipe from which passes to the outer air and +discharges there, should be trapped, for this pipe is foul, and if it +be untrapped will act as an air-inlet. + +4. The nearer to the soil-pipe that the fixtures can be arranged the +better. It is especially desirable to avoid the necessity for long +horizontal waste-pipes from stationary waste-bowls and from bath-tubs. + +5. Bell traps, D traps, bottle traps, and mechanical traps are +objectionable. The S trap is, upon the whole, the best, but it should +be provided with a vent-pipe to prevent siphonage. + +6. The best kind of water-closet for general use is probably some form +of what are known as the wash-out closets. They are made in one piece +of earthenware, have no machinery inside them, have a quantity of +water in the basin into which the excreta drop, and do not require a +separate trap beneath them. Each closet must, however, be carefully +tested by itself: a very small warp or twist produced in the baking +may so interfere with the siphonage as to make it practically +worthless, and the basin cannot be altered or repaired. For use in +public places some of the hopper closets are very satisfactory, the +best which I have examined being the Rhoads Hopper and the Hellyer +Hoppers. Where there are no {192} children, and it is certain that the +fixtures will be used with reasonable care, valve closets may be used. +No form of pan closet can be considered as satisfactory, nor have I +found any form of plunger closet that I would specially recommend. + +7. Water-closets should always be flushed from a special tank provided +for the purpose, and never direct from the main system of water-pipes. +The flush must be large and rapid, and this requires a large +supply-pipe, and for many forms of closets a flushing rim. Whatever be +the form of closet, it should not be encased in a wooden box or +closet, as is usually done, but it should stand freely exposed to +light and air. Sanitarians commonly advise that water-closets should +be located in outer walls and have an open window for ventilation. +Such a position is usually impossible, and is not specially desirable +in our climate. The open window acts as an inlet quite as often as it +does as an outlet, and the air of the closet is thus swept into the +house. The room should be ventilated in such a way that the tendency +of the air at the door shall always be from the house into it. This is +to be effected by a shaft passing through the room up and through the +roof; and it is well to have this shaft take its air-supply from just +behind the closet or from beneath the seat. It is best made of +galvanized iron, and at a convenient point should be expanded into a +lantern and have a gas-jet placed in it. The air-supply for the closet +is to be taken at the bottom of the door or through a transom or +louvres. Ventilating pipes from a water-closet should never be run +into a brick flue. While it is not so important as many writers seem +to think that a water-closet should be placed on an outer wall, it is +very important that it should be as light as possible, and the placing +it in a dark corner in the basement or under the stairs is very +objectionable. + +8. No overflow-pipe from any cistern or tank, except the one used for +flushing water-closets, should be connected with the soil-pipe or +sewer. Trapping such an overflow-pipe does not prevent the danger. The +same rule applies to waste-pipes from refrigerators and to the +waste-pipes from the safes which are commonly placed beneath fixtures. + +9. Grease-traps placed inside a house--for instance, beneath the +kitchen sink--are of very doubtful expediency, and if they cannot be +placed outside, they had better not be used at all. + +In an unsewered city one of the first things to be considered in a +sanitary inspection is the manner in which the sewage of the premises +is disposed of. The question is, however, by no means superfluous in +many sewered cities, for cesspools and vaults are to be found in most +of them, and not only in yards, but beneath houses, and houses of the +better class. A privy-vault or cesspool beneath a dwelling or near its +cellar walls is always to be considered as very dangerous, for it is +practically impossible to prevent the passage of gases from it into +the interior of the house. A cesspit is a dangerous thing anywhere, +even in the country; but in a city it is so dangerous that its +existence should not be permitted. + +If the water-supply of a house is derived from a well, and there is +reason to suspect that this may have been contaminated from a +neighboring privy-vault, the first test to be applied to the water is +that for the detection of chlorides. If none are present, the water is +not polluted. If they are present, the quantity is to be noted, and a +peck or two of common salt is then to be thrown into the suspected +vault. If repeated {193} examinations of the water show a marked +increase in the amount of chlorides present, it may be inferred that +the contents of the privy pass to the well. The fact that the water of +infected wells and springs is usually much liked and sought for is to +a considerable extent due to the presence of these chlorides. Wanklyn +recommends the addition of 50 grains of common salt per gallon to +drinking water to render it palatable. Popularity of a certain well is +therefore a reason for suspecting its purity. + +This subject may be dismissed with one caution. Taking the +dwelling-houses of a city or town as they come, it will be found on +examination that over half of them would be described by a competent +inspector as being in a condition which might produce disease. It is +therefore more than an even chance that in any case of disease some +sanitary defect will be found about the premises quite irrespective of +any direct causal connection with the case. Let the physician +therefore be cautious in deciding as to such causal connection, and +not conclude that because a case of diphtheria or typhoid fever and a +leaky soil-pipe occur in the same house, therefore one is the cause of +the other. Such cases occur in houses whose sewerage is perfect and in +houses which have no sewerage, and it is folly to attribute them +exclusively or mainly to sewer gases. + +The same caution applies to investigations into the causes of a sudden +outbreak of disease in a community where a number of cases occur +almost simultaneously or in rapid succession. Such an outbreak may be +due to direct contagion, although sometimes very difficult to trace; +as, for example, an explosion of small-pox in a community largely +unprotected by vaccination, and where, owing to circumstances +connected with the first few cases, a large number of persons have +been exposed to the cause about the same time. The same applies to an +apparently sudden development of yellow fever throughout a city. + +Another cause of such outbreaks is a polluted water-supply, as in some +epidemics of diarrhoeal disease or of typhoid fever. If the outbreaks +of these diseases are pretty sharply localized, and depend upon the +fouling of a well or wells, it will usually not be very difficult to +trace this cause. If, however, the town has water-supply by means of +pipes from a single source, while the outbreak of disease is limited +to a part of the town or to a single large building, it will probably +be almost impossible to establish any connection between the disease +and the drinking water. The possibility of the contamination of a part +only of a system of general water-supply by means of the drawing of +foul air into the temporarily empty pipes connected directly with a +water-closet flush should never be forgotten, for such a case has +actually occurred, and the account of its discovery is one of the best +pieces of sanitary detective work with which I am acquainted. If the +outbreak of typhoid fever cannot be traced directly to the +water-supply, the next point to be investigated is the milk, and after +that other possible modes of the conveyance of the contagium. + +In cases of obscure disease characterized by fever of no definite +type, disorder of the digestive organs, headache, malaise, etc., and +which seem to be connected with residence in a particular house or in +one room in a house, the possibilities of arsenical poisoning from +wall-paper or hangings should be remembered, for much useless +medication and some real danger will be avoided if this cause be +promptly recognized. The effects {194} produced by arsenical dust are +very various, and simulate sometimes some of the specific fevers, +indigestions, or neuroses in a way that is very puzzling if the true +nature of the case is not suspected. The popular notion is that +arsenic is found only in greens (more especially in bright greens in +wall-papers), whereas in fact it is found not only in dull greens, but +in some browns, grays, and dull reds. The test for its presence in +quantity sufficient to be a cause of disease is an easy one, and is +fully given in any manual of chemistry or toxicology. + +VI. OCCUPATION.--While the effects of occupation upon health are no +doubt great, they are in many cases so blended with those of condition +in life, including habitation, food, and intemperance, that it is very +difficult to distinguish them. In attempting to investigate these +effects by means of statistics, it is necessary to beware of a fallacy +which not unfrequently vitiates the conclusions drawn from otherwise +carefully prepared tables intended to show for different occupations +either the relative mortality or the average age at death. This +fallacy lies in the fact that the number of persons engaged in each +business is unknown; that, in this country at least, men often change +their occupations; and that certain trades or professions are chiefly +carried on by persons of certain ages. This last is perhaps best +illustrated by the remark of Dr. Farr, that the fact that the average +age at death of second lieutenants is much less than that of +major-generals proves nothing with regard to the comparative +healthfulness of the two grades. Statistics showing merely the number +of a particular class or grade dying in a given time are absolutely +worthless, unless the number of the same class or trade living at the +same time is also given. + +It is also necessary to bear in mind the power of habit and the +effects of natural selection, especially when the effects of an +unhealthy occupation are immediate and marked upon those unfitted for +them. For example, young men, when first employed as scavengers or in +sewage-pumping works, usually suffer from disorders of the digestive +organs. A certain number find it necessary for their health and +comfort to soon leave the business; some acquire protection by passing +through an attack of fever; and by this process of selection a class +of men are obtained who seem to thrive in the midst of filth and +remain unaffected by effluvia which will promptly cause illness in +those unaccustomed to them. When men find that, to use a common +phrase, they "cannot stand" a particular kind of work, they are apt to +give it up and try something else, especially if the effects are +prompt and well marked. + +Much attention has been given of late years in England, France, and +Germany to the means of protecting both the workmen and the +neighborhood from the ill effects of dangerous and offensive trades, +and the reports of the medical officer of the Privy Council and of the +Local Government Board are a mine of information on this subject. It +may be truthfully asserted that in those trades in which the special +danger is caused by dust of various kinds, or by gases, or by metallic +poisons--and these three include the greater number of the dangerous +occupations--it is almost always possible to so arrange the work as to +make it comparatively healthful and harmless. Overcrowded and +unventilated workrooms are responsible for much disease, and when to +these is added the risk of metallic poisoning, as is the case with +printers, artificial-flower {195} makers, etc., bad results are almost +sure to follow. It is curious that so comparatively little ill effect +seems to be produced by exposure to great heat, as in stokers, +foundry-men, glass-blowers, etc.; but further information is needed on +this point as to the real facts in the case. In some occupations the +chief evils arise from want of out-door exercise, a subject which will +be considered presently. The want of useful or interesting occupation +sometimes becomes indirectly the cause of disease among the wealthier +classes, and the giving a man or woman something to do is in such +cases the best prescription which can be made. This danger is +especially apt to occur in the case of an active, energetic man who +retires from business, intending to spend the rest of his life in +pleasure and in the enjoyment of the fruits of his industry: the +preventive or remedy is obvious. + +VII. FOOD.--The comfort, energy, usefulness, and moral character of a +man depend largely upon his digestion, and this in turn depends +largely on what it has to act upon--viz. food. There are, it is true, +many men who boast that they can digest anything, and who are really +comparatively indifferent as to the kind, or mode of preparation, of +the food set before them, so that the quantity be sufficient; but were +it not that habit and heredity--which is the family habit--combine +with natural selection to adapt men to their food, it is probable that +the frying-pan, the pie, and soda-bread would depopulate large +portions of this country. As it is, there can be no doubt that fried +food swimming in grease, leathery, sodden pie-crust, and heavy bread +tend to make life short and the reverse of merry; and when the effect +of these is combined, as it often is, with those of malaria, damp +soil, and a free use of whiskey, the result is plenty of work for the +doctor and very little to pay him with. This state of things is being +gradually improved, but in all classes of society and in almost all +parts of the country the rule is, that while the raw materials of food +are abundant and of excellent quality, the cooking is bad. This is +due, in part, to an idea that it is to a certain extent discreditable +to a person that he should give much attention to his food, at least +so far as its appearance and taste are concerned, and that a man who +can plan a good dinner must be more or less of a sensualist and a +glutton. + +Another popular error is, that a large amount of disease is due to +overeating, and that abstemiousness in diet is either certain to +secure health, or is, at all events, indispensable for this purpose. +Upon this point the reader should consult a capital paper by Dr. +Austin Flint on "Food in its relations to personal and public health," +which will be found in vol. iii. _Reports American Public Health +Association_, N.Y., 1877. After remarking that many of the popular +errors about food and diet are relics of old and abandoned medical +theories, one of which is embodied in the not uncommon advice that one +should always stop eating before the appetite is fully satisfied, and +that food should only be taken at regular fixed periods, no matter how +hungry one may be, he says: "Physiology, experience, and common sense +are alike opposed to these popular notions relating to food. +Conditions for perfect health are, first, a sufficient appetite; +second, the gratification of normal appetite before the want of food +reaches the abnormal degree expressed by hunger; third, the +satisfaction of appetite by an adequate quantity of food. These +conditions of health are fulfilled by compliance with instructive +provisions for {196} alimentation. But, it will be asked, is appetite +infallible as a guide in dietetics? Following it as a guide, is food +never taken beyond the requirements of health? I answer, It is a +reliable guide under normal circumstances. The inevitable +circumstances of life are often not altogether normal, although +producing no distinct morbid affection. Experience teaches, for +example, that in a state of fatigue or exhaustion (which is not a +normal state) inconvenience may arise from the full gratification of +appetite; that if unusual exertions, mental or physical, are to +follow, a hearty meal may occasion disturbance; and other examples +might be added. Irrespective of abnormal or disturbing influences, if +appetite be not infallible, it is, at all events, more reliable than a +rule based on theoretical ideas, popular notions, or on purely +physiological data. Moreover, it was evidently not intended that the +quantity of food should be accurately adjusted to the needs of the +economy. To do this is impossible, and therefore it is necessary to +elect between the risk of taking either more or less food than is +actually required. Which is to be preferred? Undoubtedly, it is vastly +better to incur the risk of taking too much than that of taking too +little. Nature provides for a redundancy, but there is no provision +against a persistent deficiency. Ex nihilo nihil fit. An ample supply +of alimentary principles is indispensable to nutrition; and inasmuch +as the supply cannot be made to contain precisely the needed amount of +the different alimentary principles, we may say that a superabundance +of food is a requirement for health. + +"As in appetite we have a guide in respect of the times of taking food +and the quantity to be taken, so taste is a guide in respect of the +kinds of food required. The discrimination of food with reference to +the wants of the system is the evident purpose of the sense of taste, +and the enjoyment connected with this sense was designed to afford a +security, in addition to appetite, for adequate alimentation. + +"Among professional men and those who live sedentary lives the mistake +is not uncommon of paying too much attention to the sensations after a +meal, and deciding therefrom whether certain articles of food are +unhealthy or not. If the man who does this is not already dyspeptic, +he will pretty surely become so. The remedies in this case are +exercise and attracting the attention to something else." + +A physician ought to understand something of cooking, and a short +course of practical instruction in what might be dignified as the +culinary laboratory would be of more real value to him than some of +the branches which are now considered indispensable in the medical +curriculum. He should know why oysters are the best thing with which +to begin a dinner, and why a cocktail is one of the worst; how to make +a salad, or a cup of good coffee, or a perfect consomme; and a number +of other things pertaining to gastronomy of which most people are +woefully ignorant. + +It is not within the scope of this paper to give details with regard +to the diet of either the sick or the well, but it seems proper to +remark with regard to the feeding of infants, more especially in our +large cities in the summer months, that all the various patent +preparations for infants' food are more or less pernicious, and should +be discountenanced by all medical men. The proper food of an infant is +milk--human milk if it can be had, cow's milk if it cannot. If it be +remembered that an infant suffers {197} from thirst as well as hunger, +and care be taken to give it enough pure cool water to quench this +thirst, it will be found that in most cases it will thrive on pure +cow's milk. + +With regard to adulterations of food, the only form of such +adulteration found in this country, which has any special interest +from the sanitary point of view, pertains to milk. This adulteration +is in most cases the dilution of the milk by water, and this is very +common in large cities. The danger from the use of such milk is by no +means confined to infants, and it is probable that a larger proportion +of the typhoid fever, diphtheria, scarlet fever, cholera infantum, and +diarrhoeal diseases in our cities is due either directly or indirectly +to the milk-supply than is now even suspected. The possibility of this +mode of origin should always be borne in mind in investigating the +causation of such affections. + +A very large amount of food is now furnished preserved in tin cans, +and it is almost invariably of excellent quality. There is a +possibility of the contamination of such food by the salts of lead or +tin, but such contamination to an extent which is injurious to health +must be so extremely rare as to be hardly worth considering. The +danger from the entrance of parasites, such as trichinae, etc., in the +food is also extremely small--in fact, is nothing where the food is +properly cooked. + +Milk has so often been the cause of disease, and is so universally +used, that it seems worth while to refer to it again. The special +aptitude of milk for absorption of odors has long been known, and of +late years it has been clearly proven in a number of instances that +milk has been the means of conveying the cause of typhoid fever and of +scarlatina. Diphtheria, yellow fever, and intermittent fever have also +been supposed to be conveyed by milk. The variety of nutritive +principles contained in milk, which makes it so valuable as a food, +also gives it the power of sustaining many different sorts of minute +organisms, and it perhaps comes as near being a universal +culture-fluid as anything yet devised for that purpose. The +possibilities of the contamination of milk are so numerous, and +especially in the case of that furnished from small establishments, +that, in the case of outbreaks of typhoid or diarrhoeal diseases in a +town, investigations into causation should always include the milk- as +well as the water-supply. Milk from diseased animals is no doubt often +used without producing bad results, but its effects in conveying to +man the disease known as milk-sickness are well established, and it +has also been known to produce symptoms of the contagious aphthae, or +foot-and-mouth disease, in man, when derived from an animal affected +with that disease. The only danger in the use of the milk of animals +fed upon sewage-grown grass appears to be in the possible +contamination of the milk, after it is drawn, by particles of dust in +the stable, derived from the food or litter of the animal or from +uncleanliness of the exterior of the udder, etc. + +VIII. INTEMPERANCE.--Every one knows that alcoholic drinks are the +cause of a vast amount of disease, crime, and misery in all civilized +countries. No one knows how this is to be prevented, for no one knows +how to make the great mass of the people wise and contented. The +effects produced by excessive use of alcohol are well known to all +physicians, and the remedy is self-evident. I see no use in adding to +the heap of useless rubbish which exists in the shape of the great +mass of existing {198} popular literature on this subject, and +therefore leave the subject to the reader, who is quite sure to know +all that is really important on this subject. + +IX. CLOTHING.--The hygiene of clothing is also a subject which may be +treated summarily in this paper. People wear what they can afford, +made according to the prevailing style. Diseases due to insufficient, +excessive, or badly-fitting clothing occur most frequently in women +and children, and the use of such clothing is for the most part due to +poverty or fashion, either of which is beyond the power of the +physician to successfully cope with. Here and there, in individual and +exceptional cases, he may be able to do a little good by advising +against tight lacing, high-heeled shoes, insufficient covering for the +chest or legs, etc., and he will find that a knowledge of the +peculiarities of the various styles of modern under-clothing will +sometimes be very useful. Men are, as a rule, comfortably and sensibly +dressed to suit their business and surroundings, and require no advice +on this subject. + +X. EXERCISE.--The ease and completeness with which the functions of an +organ or of an organism are performed depend to a great extent upon +the frequency and regularity with which such functions are exercised. +Hence comes the importance of bodily exercise for the preservation of +health, and every physician meets cases of disease due largely to want +of work. + +The term "exercise," or "bodily exercise," is commonly used as if it +referred only to the muscles, and the amount of exercise which a man +should take in a day is stated as equal to a certain number of +foot-pounds. The mere giving work to muscles is not, however, exercise +in the sanitary sense. A better definition is that of Du Bois +Reymond--viz. that "exercise is the frequent repetition of a more or +less complicated action of the body with the co-operation of the mind, +or of an action of the mind alone, for the purpose of being able to +perform such actions better." From this point of view it will be seen +that exercise relates quite as much to the nervous system as to the +muscles. When, for example, a student takes a walk over ground with +which he is familiar, and is at the same time so deeply engaged in +thought as to be practically unconscious of what he is doing, only +being recalled to himself, it may be, by arriving at his own door, the +exercise which he has had is but partial and insufficient. Going to +the extreme, we can, as Du Bois Reymond remarks, conceive of a man +with muscles individually exercised until they were like those of the +Farnese Hercules, and yet who would be unable to walk, much less +execute more complicated movements; for the proper co-operation of the +muscles, which is effected through the nervous system, is quite as +necessary as the force of their contraction. + +The amount of exercise which is necessary for health varies with the +individual and with age, season, etc., so that it is difficult to +state any general rule upon this subject; but if stated in terms of +muscular force only, the estimate of Dr. Parkes seems a fair +approximation--viz. that every healthy man ought to take daily an +amount of exercise equivalent to 150 tons lifted 1 foot, or a walk of +about nine miles. The majority of trades and bodily occupations demand +at least this amount of work, but in some of them the greater part of +the exertion is made only by certain groups of muscles, and they are +carried on in crowded and {199} ill-ventilated shops. Such workmen, as +well as all who are engaged in sedentary pursuits, require exercise in +the open air--exercise which will bring into play the unused muscles +and will break the train of thought of the professional man. + +One of the most important questions with regard to physical exercise +is the extent to, and manner in, which it should be provided for in a +proper system of education. One of the latest and most instructive +articles on this subject is that by Du Bois Reymond in the "Physiology +of Exercise," a translation of which is given in the _Popular Science +Monthly_ for July and August, 1882. He divides the physical training +which is more and more becoming a part of modern systematic education +into three classes: The first, the turning, or gymnastics of the +Germans; the second, the Swedish system, in which the exercises are +limited to very simple though varied movements; and the English +system, or rather want of system, consisting largely of athletic games +and contests of various kinds. His objection to the Swedish system is +that, while it strengthens the muscles, it does not increase the power +over composite movements; in other words, it does not exercise the +nervous system. Naturally, he prefers the German system to any other, +although admitting that the English meets better the demands arising +from our structure. "Were the end masterhood in running, jumping, +climbing, in dancing, fencing, riding, in swimming, rowing, or +skating, then nothing could be more advisable than to practise equally +the necessary concatenations in the actions of the ganglion cells, +without pausing at the not practically applicable preliminary and +intermediate steps of the German turning." + +From a sanitary point of view, the gymnasium, as usually located and +managed, is by no means equivalent to out-of-door sports and contests, +although it is often the best substitute for them. The form of +exercise most used by men whose occupation does not involve bodily +labor is walking, and next to this riding. Whatever mode be selected, +it is very desirable that it should be taken for some other object +than that of the mere making muscular exertion, or otherwise it will +soon come to be looked upon as an unpleasant task, the time spent upon +which is given grudgingly; and it will be partially or wholly +abandoned as soon as the immediate discomfort which induced its use +has ceased. + +It is not an uncommon error among men engaged in mental work to +suppose that they can, and ought to, take the same amount of exercise +which gives good results in those whose occupations involve physical +rather than mental effort, or to think that the more exercise they +take the more study or writing they are equal to. This is a grave +mistake. Expenditure of brain-tissue is not to be repaired by muscular +exertion, but by sleep and food, and exercise in the fresh air +sufficient to produce appetite and sufficient weariness to ensure +restful sleep is all that is necessary. For a time it is true that the +student or writer who has a well-developed body can continue to burn +the candle at both ends, and win literary honors while also standing +high as an athlete; but this surely leads to physiological bankruptcy +in the end. + +It is to be remembered that good muscular development is not +necessarily synonymous with health, and that strength is not a +guarantee against disease. And, while it is true that in this, as in +most other matters of individual hygiene, each man must to a great +extent be a law to {200} himself, and learn by experience what kind of +exercise and how much of it he requires, yet the physician can often +supply the motive which was wanting, or check undue effort. Exercise +for the sake of health and comfort is not an end, but a means; yet if +this means can be made to secure to the patient an end agreeable and +pleasant in itself, so much the better. + +XI. CONTAGION AND DISINFECTION.--By "contagion" we mean the +communication of disease from one person to another, either by direct +contact or through some medium, such as air, water, etc. It therefore +includes "infection," which is now generally used as a synonym for it. +The so-called infective diseases of modern German writers +(Infections-Krankheiten) include, besides what are commonly termed in +English, contagious diseases, the so-called miasmatic diseases. + +The characteristic of a contagious disease is its specificity; that +is, the disease transmitted is always the same in its essential +characteristics. It does not, however, follow that all cases of the +disease are equally liable or have the same power to transmit it; in +other words, the degree of virulence of the contagiousness is not an +essential characteristic. That the same disease sometimes spreads +rapidly and is very fatal, and at other times seems hardly to have any +contagious properties and is very mild, has long been noticed, and has +been attributed to an unknown something called the medical +constitution of the place--the constitution medicale of French +writers. The true cause is probably very complex, but in some cases, +at all events, it seems to be due to difference in the contagion +itself. If we suppose this contagion to be a minute organism, it is +easy to form a theory as to the cause of these differences, but there +is much careful experimental work to be done before we shall have +positive knowledge on this point. The results obtained by Pasteur in +attenuating the virus of chicken cholera and splenic fever indicate +one line which these experiments will take, and the researches of Koch +point out another. + +The diseases which spread by contagion until they form epidemics are +those which have from the earliest times attracted the most general +attention, and which have given rise to organized efforts for +prevention--_i.e._ to public hygiene. + +They are also the diseases which have given rise to the most bitter +controversies among medical men as to the means of their propagation +and the best methods of prevention. Plague, cholera, yellow fever, and +typhus are those with regard to which this difference of opinion has +chiefly occurred--one party considering their chief cause to be +contagion, or specific germs derived directly or indirectly from the +bodies of the sick; the second party declaring that they are due to +filth plus an unknown something, which is variously termed epidemic +constitution, pandemic wave, Providence, or _x_. The great majority of +opinions at present is in favor of the view that they are all +contagious, but not all, or always, contagious from person to +person--that they spread from infected localities, which localities +receive their infection from cases of the disease. The best means of +dealing with them under ordinary circumstances are now tolerably well +understood, and where these means can be commanded--as, for instance, +among troops in time of peace--epidemics of these diseases can be +stopped with great precision and promptness by isolation and +disinfection. + +{201} By "isolation" is meant not only the separation of the sick from +the well, but the isolation of the infected locality or water-supply +until it has been rendered harmless. + +By "disinfection" is meant the destruction of the specific causes of +disease, and more especially of the infectious or spreading diseases. +A disinfectant is not necessarily an antiseptic or a deodorant, nor +are these last necessarily disinfectants. The best practical +antiseptic for sanitary purposes is cleanliness; the best +disinfectants are heat, bichloride of mercury, sulphate of iron, +chloride of zinc, sulphurous acid, chlorine, sunlight, and pure air, +and, for yellow fever, cold. With our present very imperfect knowledge +of the nature of specific causes of disease which we wish to destroy, +we have no means of determining the presence of these causes in or on +an article of clothing or of furniture, or in a room or other +locality, except by the production of their specific effects on man or +by inductive reasoning; in other words, we can only say that it is +more or less probable that such causes are present. This makes it +necessary, or at least expedient, to employ disinfectants in many +cases where the presence of such causes is doubtful. The practical +difficulties are, first, to bring the disinfecting agent into such +relation with the causes of disease that it can act upon them, and act +upon all of them; second, to avoid unnecessary destruction or injury +of things which should be preserved. The majority of the causes of +disease upon which we wish to act by disinfectants are probably minute +particles of solid or semi-solid matter which are living, and may be +conveniently designated by the word "_germs_." In the presence of +moisture the destruction of the vitality of these germs can be +effected with comparative ease and rapidity, but when they have become +dried, or, as in the case of the bacilli, are in the form of spores, +it is a more difficult matter. + +To illustrate the methods to be pursued and the precautions to be +taken, let us suppose the physician to be called on for directions as +to the management of a case of scarlatina, the object being to prevent +its spread. The first thing to be done is to get the patient in a room +by himself, and to leave nothing in this room which is not necessary. +Remove the carpet, curtains, and all stuffed or upholstered furniture. +Let the nursing be done, as far as possible, by one person only, and +do not allow others, and especially children, to enter the room, no +matter if they have had the disease. The danger of contagion depends +upon particles coming from the skin and mucous membranes. All excreta, +and more especially the sputa or discharges from the mouth or nose, +are to be treated as dangerous. The excreta should be received in +vessels containing a solution of sulphate of iron, one and a half +pounds to the gallon. All clothing, towels, bed-linen, handkerchiefs, +napkins, etc. should be placed in a solution composed of four ounces +of sulphate of zinc and two ounces of common salt to the gallon of +water as soon as they are not needed for further use. Especial care +should be taken that none of these articles are removed from the room +while dry, and while they are in the room, and before they have been +moistened, they should not be shaken or disturbed more than is +absolutely necessary. If for any reason the zinc solution above +referred to is not at hand--which should very rarely be the case--the +clothing, etc. should be placed in a bucket, tub, or boiler containing +enough scalding water to entirely cover them, and be removed {202} +from the room in this vessel. All such articles should be boiled at +least one hour. + +No sweeping or dusting in the ordinary way is to be done in the room; +dust and dirt are to be removed by damp cloths, which are to be +treated like the bedding and clothing. The great object is to prevent +as far as possible the production of dust in the atmosphere of the +room. The entire body of the patient, including head, face, and limbs, +should be kept thoroughly anointed with camphorated oil, vaseline, or +some similar substance, and especial care should be taken in this +respect during the period of convalescence so long as any roughness or +desquamation of the skin continues. No toys or books which it is +desired to preserve should be allowed to remain in the room, and under +no circumstances should books or toys be borrowed to amuse the child +if they are to be returned. The best way to disinfect such articles is +to burn them in the room. + +When the patient is fully convalescent and all desquamation has +ceased, cleanse him thoroughly with a warm bath and soap for four +successive days. If at the end of that time no roughness of the skin +remains, he may be dressed in clean clothes and taken from the room, +for he is no longer a source of danger. The room itself and the +furniture are then to be thoroughly cleansed and disinfected. The +ceiling and walls, if of ordinary hard finish, are to be scraped and +whitewashed. All woodwork should be rubbed with damp cloths and the +floor well scrubbed. Care should be taken to remove all dust from the +ledges over windows and doors. All the cloths used in this cleansing +process are to be burned. + +If these directions have been carefully carried out, there is no need +for further disinfection. But if upholstered furniture has been +allowed to remain in the room, or other articles which cannot be +burned or scrubbed or soaked in the zinc solution, it may be desirable +to attempt to disinfect the whole room and its contents by means of +chlorine or sulphurous acid gases. Of these, sulphurous acid gas is +the cheapest, and upon the whole the best, but it must be used in +large quantity, and for a longer time than is customary, if it is to +be relied upon. For this purpose all openings into the room should be +closed, and pillows, mattrasses, upholstered furniture, and articles +which cannot be treated with the zinc solution should be opened, so +that they may be exposed throughout to the fumes. The sulphur should +be burned in an iron pan or pot, placed in a tub containing water or +upon a large surface of sand. About 18 ounces of roll sulphur should +be used to each 1000 cubic feet of space, and after twenty-four hours +12 ounces more should be burned and the room be then closed for +twenty-four hours longer, after which it may be opened and aired. In +case of death the body should at once be wrapped in a sheet thoroughly +soaked with the chloride of zinc solution, and either be placed in an +air-tight coffin at once or be buried without delay. The funeral +should be strictly private, and the sheet referred to should not be +disturbed or the body exposed to view. + +The cases most liable to spread the disease are those in which the +attack is very light and the child is not confined to its bed. It is +desirable that children in a house in which there are cases of scarlet +fever should not be allowed to attend school or mingle with other +children who have not had the disease. + +With regard to disinfectants, it may be well to note that none of the +{203} various patent disinfectants are superior to bichloride of +mercury, chloride of zinc, sulphate of iron, chlorine, and sulphurous +acid; very few are equal to them, and none cost so little. As a +gaseous disinfectant for rooms, etc. chlorine is superior to +sulphurous acid, but it has the disadvantage of injuring metals, is +not so easily applied, and is more costly. It will destroy the +vitality of the spores of the bacilli more rapidly and certainly than +sulphurous acid, which last, to make sure work, must be exhibited for +a much longer period than is customary. I should not feel confident as +to the thorough disinfection by sulphurous acid of the hold of an +infected ship unless the fumes had been applied for sixty hours. +Carbolic acid as ordinarily used is an antiseptic rather than a +disinfectant. Its vapor in a sick room is absolutely useless. When +applied in strong solution it is effective, for a time at least, but +as thus used it is expensive, its odor is unpleasant to many, and +masks the odors from putrefying substances and excreta, etc., thus +preventing the warning which these odors would give. Its use is in +many cases very much like removing the rattle from the rattlesnake. + +The suggestions made above for limiting the spread of scarlatina from +a case to be treated in the residence of the patient apply--with +certain modifications for each form of disease, which will readily +suggest themselves to the physician--to all the affections due to +portable contagia. + +Among the poorer classes, however, it will often be found impossible +to obtain the separate room and service and the constant intelligent +care which are necessary to ensure the desired result; and in such a +case the patient should be removed to a hospital, for his own sake as +well as for that of the community. The utility of small hospitals for +infectious diseases is by no means generally understood, and very few +of our small cities and towns are provided with anything of the sort. +If the subject is urged on the authorities of a place, the reply will +be that it is an unnecessary expense, that the people would not go to +it, and that such an institution is in itself a source of danger. The +facts are, that such a hospital costs very little, and is the cheapest +insurance against epidemics which a town can have; if it is kept clean +and comfortable, the people will use it freely, and if properly +managed it does not offer the slightest danger to the vicinity. This +question will be further discussed in the last section of this paper. + +The principles of isolation as applied to a single case as indicated +above may also be applied to infected localities in case of epidemics. +When taken in time, all diseases which depend upon particulate +contagia for their origin can be stamped out by isolation and +disinfection. Unfortunately, to effect this promptly and successfully +requires money, labor, and the co-operation of the well in the +vicinity; which last it is usually impossible to obtain voluntarily or +to compel sufficiently to secure the desired results. A question which +sometimes arises in case of epidemics, and with regard to the +necessity for which physicians will be consulted, relates to the +closure of the public schools. It is certain that the assemblage of +children in schools exerts a powerful influence on the spread of such +diseases as scarlet fever, diphtheria, and whooping cough. On the +other hand, the closure of the schools infringes upon the rights of a +large number of the community, and if long continued, as it sometimes +must be to be really efficacious, inflicts upon them {204} a permanent +loss. It is, moreover, a confession on the part of the authorities of +inability to induce or compel what must always be a comparatively +small part of the community to take the proper precautions. It is +never justifiable to close schools on account of small-pox, and where +there is a competent health authority supported by the influence of +the medical profession, it must be a very exceptional set of +circumstances which justifies their closure for diphtheria or +scarlatina. + +It is not deemed expedient here to discuss the vexed question of +quarantine. It is more important against yellow fever than any other +disease, because every day of delay of the entrance of the disease +which it secures lessens largely the subsequent mortality, since the +duration of the disease is limited by frost. This is not the case with +cholera, and the mere keeping this disease out of a place for a few +weeks does not diminish its ravages when it has once gained an +entrance. To rely altogether on quarantine, either maritime or inland, +to keep yellow fever, cholera, or any other disease out of this +country is a far greater mistake than to neglect it altogether. The +practical way to isolate and quarantine is to get as close to the +affected spot as possible. Precautions at Havana for yellow fever, or +at Hamburg for cholera, are far more useful to the United States than +the same amount of work at our own ports can possibly be; really good +work in this direction must be not only national, but international. + +XII. MENTAL CAUSES OF DISEASE.--A man may give too much attention to +his health and the means for its preservation, and the doing so is +both a sign and a cause of disease--probably oftener the former than +the latter, except in cases of psychological epidemics. The power of +expectant attention, especially if accompanied by belief or fear, to +produce derangement of function in the nervous system, and through +this to affect the circulatory and digestive systems, is well known to +medical men. The effects of an undue amount of brain-work, and +especially of the anxiety and worry which often accompany this when it +is specially directed to the acquiring of wealth, fame, or power, are +also familiar to physicians in our large cities. The analogies between +mental and physical exertion are close in some respects, and +especially as to the effects of over-exertion in a limited time under +the influence of excitement. + +The danger from simple mental work, such as study, when there is no +excitement from a contest, is small, and depends mainly on lack of +physical exercise and consequent disorder of the digestive organs. The +risk of producing what Fothergill calls "physiological bankruptcy" is +greatest in the youth studying for a prize, the speculator, the man +who feels responsibility which he knows he probably cannot meet. The +danger of injury from overwork under excitement is a very real one in +many of our schools, and, while the evil results are most apparent in +girls of the middle and upper classes, the boys and the young men also +suffer. The system of pass examinations, in which the standing of the +pupil is to be determined, not from the average results of his daily +recitations, but from a single examination at the end of the year, +produces the greatest risks to health; and this is especially the case +where the ambition and pride of the children are stimulated by +competition for prizes, medals, etc. Such systems of grading by a +single final examination should not be used in ordinary schools, and +for some pupils there will always be a risk to health connected with +them even when they are of age. No doubt the stimulus of {205} +competition is useful with the majority of children as well as of +adults, but with some of them it is pretty sure to go too far. + +The symptoms produced by undue mental strain are familiar to all +physicians, and there is usually little difficulty in tracing the +effect to the cause when attention has been directed to the matter; in +fact, the patient himself usually knows very well the cause of his +troubles. The remedy is, of course, rest--but that does not mean +idleness. In speaking of occupation, allusion has been made to the +fact that the physician must at times advise his patient as to the +adoption of some pursuit, and in cases of this kind such advice is +also useful. + +The effects of mental strain are often mingled with, and aggravated +by, those of stimulants which have been used to spur the flagging +energies. Alcohol, tobacco, opium, or coffee used in this way finally +increase the very discomforts which at first they relieved. + + +II. Personal Hygiene in its Relations to the Practice of Medicine. + +In the preceding section have been indicated briefly some of the +principal causes of disease and the methods for their investigation or +removal. We have now to consider some of the practical applications +which may be made of the laws of etiology and prevention of disease in +the treatment of the sick. While the removal of the cause of illness +by no means always effects a cure, yet the importance of a knowledge +of this cause as an aid to diagnosis, prognosis, and therapeutics is +so evident as to require no proof. + +To discuss with anything like completeness the practical applications +of what would be commonly considered as hygienic rules in the +treatment of disease would be to write a treatise on nursing, and +would also include a large part of the practice of medicine, for +regimen is the more important half of practical therapeutics. The +hygienic requirements peculiar to each disease will be pointed out by +the writers upon special subjects, and I shall only venture upon one +or two general remarks in addition to the hints already given in +speaking of the several causes. + +In the acute stages of disease the sensations--or, if the term be +preferred, the instincts--of the patient are usually the best guide to +his regimen so far as they go. In most cases he desires quiet, shade, +but not absolute darkness, and little or no food, although there is +often a craving for drinks, especially of a cooling character. In the +specific fevers which have a tolerably definite period and course it +is important to keep up the nourishment even during the period of +anorexia, in order to provide against the debility which is to follow. +This nourishment is best given in the form of drink, and very +frequently fresh milk is the type of what is required. The old notion +that whatever a sick man desired must be hurtful, and therefore that +the fever patient must be kept hot and refused cool water, has now +almost entirely passed away. + +In convalescence from acute disease and in many chronic cases, the +sensations of the patient are not to be trusted as a guide in the +choice of food. In such diseases as yellow fever and typhoid fever to +allow the convalescent to follow the dictates of his appetite is to +run great risk of a fatal result. In other cases the patient really +has no wish in the matter, but it {206} will often be found that one +who can think of nothing which he desires to eat, and who will even +refuse a dish which he has requested and been thinking about, will eat +with enjoyment some unexpected dainty when presented at the right +moment and properly served as a skilled nurse knows how to do. The +manner of serving the food, independent of its cooking, is not a +matter of such small importance that the physician can afford to +overlook it, and he will succeed best as a practitioner who best +appreciates the influence which cracked goblet, a chipped saucer, a +soiled napkin, or, on the other hand, a hot plate or a touch of color +in the shape of a leaf or flower, may have upon the capricious +appetite of the sick. In ordering diet for convalescence it is not an +uncommon error to select only those articles which are agreeable to +the physician himself, forgetting the old proverb, that what is one +man's meat may be another man's poison, and also that it is above all +things desirable to avoid monotony. One doctor always orders chicken, +another eggs, a third a mutton-chop, etc. The practice in this respect +has probably been unduly influenced by the reports of Beaumont of the +results of his observations on Alexis St. Martin, and we still find +that the relative digestibility of various articles of food is +estimated according to the scale laid down in these reports, with no +allowance for individual peculiarities, previous habits, mode of +cooking, etc. The secret of success in the diet of convalescence lies +mainly in the simplicity of the individual dishes, in varying the +different meals, in the manner of serving, and in carefully observing +the effects on the sick person, and being guided by the results. + +To promote appetite and digestion, and to secure refreshing sleep, one +of the most important things is fresh air, but in many houses a sick +person will obtain but a very limited allowance of this if the +physician does not give special attention to the matter. Except in +cases of contagious disease, the rules for managing which have been +given in a previous section (p. 201), as soon as a patient is +sufficiently recovered to be moved for a short time into another room +his bedroom should be thoroughly aired and cleansed, and this should +be done morning and evening thereafter. + +In treating cases of contagious disease the question often arises as +to means of individual prophylaxis to be used by those who must be +exposed to the effects of the infected locality or of the presence of +the sick. The attempts which have been made to secure this individual +protection in the midst of an epidemic have been numerous and varied, +ranging from the use of the "vinegar of the four thieves" of the +Middle Ages to the employment of the sulphites and chlorates to make +the blood unsuited to the growth and multiplication of the supposed +germs, or of cotton-wool respirators to strain the infected air, or of +supposed specifics for particular diseases, as belladonna for scarlet +fever and vaccination against small-pox. As yet, there is little or no +satisfactory evidence as to the value of individual precautions +against those diseases whose contagion is conveyed through the air, +small-pox alone excepted, but in case of diphtheria in one member of a +family of children it might be well to try the use of chlorate of +potash internally, combined with the local application of the tincture +of the chloride of iron, as suggested by E. M. Hunt. The question is +one to be investigated by careful observation and experiment; and, +though it is improbable that any definite results will be obtained +except in those diseases which are communicable to animals, and +therefore {207} susceptible of direct experiment, still, it is +possible that some advance may be made. In rare and exceptional +cases--as, for instance, in exploring a crowded, filthy, and intensely +infected typhus-fever nest, as a tenement-house, or an infected +yellow-fever ship--it may be worth while for the physician or +inspector who is unprotected by a previous attack of these diseases to +make use of a cotton-wool respirator, which is readily extemporized, +and belongs to that exceedingly valuable and popular class of remedies +which, "if they do no good, can do no harm." In epidemics of typhus, +cholera, or yellow fever one of the most valuable prophylactics is to +have a mind so occupied with other matters that it pays little or no +attention to the danger, while in case of small-pox fear of the +disease is indirectly the best prophylactic, since it leads to careful +vaccination. + +This branch of the subject is closed with the remark that it would be +well if physicians, and especially the younger ones, gave more +attention to the preservation of their own health than many of them +do. The possession of a medical diploma does not prevent the evil +effects of irregular and hurried meals, insufficient sleep, exposure +to inclement weather, and lack of systematic and sufficient exercise; +and too much tobacco, sometimes too much alcohol, and in exceptional +cases too much study and literary work, so often combine with anxiety +about individual patients or with pecuniary worries to damage the +digestion and nervous system of the young practitioner that the wonder +is that so many survive the ordeal. And, in fact, the mortality among +physicians under the age of thirty is higher than that of any other +profession during the same period of life. + + +III. Public Hygiene in its Relations to Physicians. + +An important difference between man and animals is found in the extent +to which he will sacrifice a present pleasure or convenience to secure +a future good or to avoid a future evil. The savage will do this to +only a very limited extent--little more, in fact, than the beaver or +the squirrel--and the lesson is learned but slowly and by sad +experience. This is especially the case as regards matters affecting +health. When a man begins to take special precautions as to his diet +or exercise, having in view rather his future health than his present +comfort and tastes, he has in most cases already begun to suffer from +the effects of his imprudence, and does not commence a hygienic course +of life as a perfectly sound and healthy person. The same is true for +a community. It will not usually submit to the burden of taxation +necessary to secure drains and sewers or a proper registration of +vital statistics, nor to the cost and inconvenience of the machinery +necessary to limit the spread of contagious diseases, until the +neglect of these things has resulted in such an amount of disease and +death as to forcibly call attention to the matter. The result is, that +the burden is far heavier than it would have been had the work been +undertaken in proper season, and individuals may find it to their +interest to leave the place and settle elsewhere rather than remain +and meet their proportion of the expense. + +When a state or municipality has so far advanced in civilization as to +consider it desirable to take measures to protect the public health by +preventing individuals from polluting the air or water liable to be +used by {208} their neighbors, etc., the services of the medical +profession are always called upon. The foundation of public hygiene is +information as to the occurrence of certain forms of disease, the +cause of which can be referred with more or less precision to a +certain limited locality. This information may be very imperfect, +consisting of little more than rumor and opinions as to the existence +of an undue amount of sickness or mortality in a certain place, or it +may consist of precise reports setting forth the number of deaths from +each cause, the proportion of each of these to the population by age, +sex, occupation, etc., and of the whole to births--constituting what +is commonly called the "vital statistics of a place"--and also of +reports of the occurrence of certain preventable diseases; and between +these two the information may be of various degrees of completeness, +but, whatever there be, it is for the most part obtained either +directly or indirectly from medical men. The reliability and +completeness of the information thus obtained by the state determines +to a great extent the direction and character of the work done in +destroying or preventing the causes of disease, and it is also an +important means of increasing our knowledge with regard to the nature +of these causes. + +The character of this information depends largely upon the character +of the physicians who furnish it. In a large part of the country +medicine is legally in the position of any common occupation; that is, +the term "physician" is defined as applied to "any one who publicly +announces himself to be a practitioner of this art, and undertakes to +treat the sick either for or without reward." Under such circumstances +there can be no guarantee that all who call themselves physicians are +properly qualified or competent to furnish reliable information for +registration purposes, and, as a matter of fact, a large number are +not so qualified. It is for this reason that there is such a close +connection between public health authorities, registration of vital +statistics, and the registration of those physicians whose +certificates as to causes of deaths, etc. will be accepted by the +state; and hence the nature of the public health organization of a +state and the personnel of its officials are matters of great +importance to physicians. On the other hand, the efficiency of a +public health service depends very largely upon the relations which it +holds with, and the light in which it is regarded by, the medical +profession. A health officer who is distrusted and disliked by the +physicians of his district cannot effect much unless he can overcome +this feeling, and his tenure of office must always be very insecure. + +The official relations of the practitioner with the health authorities +are usually confined to the subjects of registration of vital +statistics and of checking the spread of contagious diseases. The most +marked exception to this rule is furnished by the States of Alabama +and North and South Carolina, in which the State Medical Society is +the State Board of Health, having been given legislative powers and +the right of selecting the health officers. The most complete +organization of this kind is that of the State of Alabama, where by +the act of 1875 the Medical Association of the State was constituted +the State Board of Health, and the county medical societies in +affiliation with the State Society were made county boards of health, +to be under the general direction of the State Board. These county +boards at first had advisory powers only, and were to be conducted +without expense to the State or the county, except that the competent +legal {209} authorities of any county might invest the county board +with such powers and duties for the promotion of the public health as +might be mutually agreed on; but in such case the right to elect or +appoint those employed in sanitary administration is reserved to the +board of health, while all questions relating to salaries, +appropriations, and expenditures shall be reserved to the legal +authorities. It was further provided "that no board of health, or +advisory or executive medical body of any name or kind for the +exercise of public health functions, shall be established by authority +of law in any county-town or city of this State except such as are +contemplated by the provisions of this act, the object of this +prohibition being to secure a uniform system of sanitary supervision +throughout the State." By an act of 1881 the county board is directed +to elect a health officer, who is to keep a register of the births, +deaths, and cases of pestilential or infectious diseases occurring in +the county, and furnish to physicians, free of charge, reliable +vaccine--to obtain information as to the sanitary condition of his +county, etc. etc. It will be seen that this plan of organization is an +attempt to overcome the practical difficulties in the way of obtaining +from physicians the information necessary for the registration of +vital statistics and the work of preventing the spread of infectious +diseases. + +While the great majority of physicians are willing to furnish the +information as to the cause of death, etc. which is necessary for a +useful registration, there are always some who either neglect or +refuse to do so; and if the law be made compulsory, it provokes +hostility unless compensation is furnished, while as regards the +requiring physicians to furnish information as to the existence of +contagious diseases, this always rouses opposition on the part of a +certain number of medical men, even if payment for such notification +is provided. And while this opposition is no doubt in many cases due +to improper motives, such as personal hostility to the existing +authorities, party politics, or a desire for notoriety, its strength +nevertheless rests upon the fact that it is unjust for the state to +compel the services of any man or class of men without furnishing +compensation. The advocates of health and registration laws are thus +placed between Scylla and Charybdis: if they propose compensation, +which involves appropriations from the public treasury, the law cannot +be passed; if there is no compensation allowed, complete results +cannot be obtained. + +The Alabama law makes compulsory the furnishing by physicians of +information relating to births, deaths, and infectious diseases, and +gives compensation--not in money, but by allowing the medical +profession to have the sole management of the matter and to choose the +health officers to whom they are to report; in other words, they are +allowed to tax themselves. The result in Alabama is yet doubtful. If +competent and faithful health officers and registrars can be obtained +without paying them a fair compensation, it will be contrary to +experience; and if these officers receive a salary, it will be strange +if the positions do not become the reward of partisan political work. + +It should be noted that the requiring a physician to report the births +occurring in his practice stands on a very different basis from the +requiring him to report the cause of death, since there is no special +necessity for the former. It requires no expert knowledge to report a +birth, and the duty should obviously devolve on the householder. + +{210} In those States in which by law only properly qualified medical +men, as determined by examination, have the right to practice, to hold +medical office, or to furnish medical certificates, the State +certainly is entitled to require of all physicians thus registered and +authoritatively recommended to the people as competent, that they +shall furnish, free of charge, certificates of the cause of death in +those cases where they are cognizant of such cause. + +States and municipalities often demand much more than this; as, for +instance, that the medical man shall fill out the whole certificate, +including age, nativity, nativity of parents, etc., and that he shall +furnish the information to the registrar. In some cases it is provided +that any physician having attended a person during his last illness +shall furnish the certificate: this would apply to cases where the +physician may not have seen the case for weeks before death. + +While it is most convenient to have the certificate of cause of death +upon the same form which contains the data necessary to identify the +individual, the certificate should be distinct from the latter, and +the duty of making the return to the registrar should devolve on the +householder or undertaker, and not on the physician. On the other +hand, it is easy for the physician to be hypercritical in these +matters: his certificate is to be considered rather as a statement of +opinion than as a statement of facts within his personal knowledge, +precisely as he would certify as to his own age and birthplace. + +The compulsory notification of infectious diseases to the health +authorities is a matter presenting much greater difficulties than that +of certificates as to causes of death. The state has no right to +require such notification from the physician without giving some quid +pro quo, and it is not expedient to make it compulsory, even with +payment, except from physicians employed by the state or municipality, +to furnish gratuitous medical attendance to the poor. The state has +the right to require such information from the parent or householder, +and it has also the right to require the physician to notify the +parent or householder as soon as he recognizes the existence of such +infectious disease. It is extremely desirable that the health +authorities of a city should receive promptly, and direct from +physicians, notification of the occurrence of such diseases, and there +will usually be no difficulty in obtaining this if the health officer +has tact and discretion and the city is prepared to do its duty. This +duty is not confined to registering the information or placarding the +house, nor will it be properly performed by merely removing the sick +person to a hospital and disinfecting the premises. If the case occur +in a family which can secure its proper isolation, and the attending +physician certifies that it is so isolated and makes himself +responsible for its management (for which responsibility he should be +paid by the patient or his friends), the health officer should not +interfere nor do more than furnish a competent person to secure +disinfection if required. The employment of a trained nurse known by +the health authorities to be competent and reliable would do away with +most of the difficulties connected with such cases in the upper and +middle classes of society; and such nurses should be registered just +as physicians and midwives are. + +Where the case cannot be thus isolated and properly cared for, it +should be removed to a proper hospital. This presupposes that the city +has such a hospital, and if it has not, and is not prepared for such +cases, notification {211} is useless. When the city places a house in +quarantine so as to interfere with business, it should be for the +shortest possible time consistent with securing thorough disinfection +of the premises, and the city should bear not only the cost of such +disinfection, but the cost of caring for the persons in the house in +an isolated place until no further danger is to be apprehended for +them. When the city undertakes to pay all expenses for isolation and +disinfection of such cases, it has the right to require that all such +cases shall be so treated, leaving it to private parties to meet the +cost in case they prefer not to use the buildings and apparatus +provided by the city for that purpose. And when the city does its duty +in this respect, it will be found that physicians and the people will +do theirs, with rare exceptions. + +When a city becomes very unhealthy the usual policy is to conceal the +fact as much as possible, and to attribute the mortality to some other +than the real cause. The influence of the mercantile part of the +community is in such a case strongly exerted on the daily press and on +the health authorities to produce such representations of the +condition of things as will tend to allay apprehensions on the part of +their customers. The healthfulness of a place is usually estimated +from its mortality reports, but the reliability of these is by no +means always what it should be. Yellow fever is called typho-malarial +or pernicious fever, typhoid is reported as diarrhoea or malarial +fever, etc. etc., and great stress is laid upon what is called the +sanitary condition of the place, which is declared to be excellent. + +Unfortunately, this phrase, "sanitary condition," means different +things at different times. When the mortality is low, sanitary +condition means the healthfulness of a place; when it is high, it +means the cleanliness of a place. To a certain extent physicians are +responsible for the truth of the statistical returns, not so much in +relation to the number as to the causes of deaths; but none save those +who have practised in a city liable to epidemics can realize the +enormous pressure which is brought to bear on medical men to induce +them to aid in or wink at concealing the true state of the case. Of +course, this ostrich-like policy is in the long run an exceedingly +unwise one, but neither the average householder nor community can be +expected at present to pursue any other, except under pressure. + +There are many questions as to the best form of public health +organization, and the powers and duties which should be conferred upon +it, which can only be properly answered by taking into consideration +the circumstances in each case. In a large city the health officers +must have great powers if they are to be really efficient. They have +to contend with ignorance, custom, and self-interest, and their action +must in many cases be prompt and unrestricted if it is to be +efficacious. They must sometimes be in conflict with wealthy and +powerful corporations, whose interests are opposed to the reforms +which they urge, and although their business is to protect the most +important interest of the community at large--_i.e._ its +health--against the interests of individuals, yet these last are much +more immediately concerned, and are, naturally, so active that they +are often, although few in number, able to defeat any attempt to +interfere with their occupations. + +It not unfrequently happens that a health board may have all the power +{212} necessary, so far as the laws are concerned, and yet may be able +to accomplish little for want of funds to pay the inspectors and other +officials whose services are necessary. For a city, a health officer +usually does better work than a board of health: his responsibility is +more direct, and he has stronger motives to do good work, than a +board. Of course, a poor health officer is less efficient than a good +board of health, but the general rule is as above stated. The problems +of hygiene require special knowledge, and the man who is to deal with +them requires special training. The folly of treating diseases by +their names with popular or patent remedies is not greater than that +of the attempt to make a healthy house or city by men who are not +architects or engineers or physicians, or who have only the +information possessed by the average architect or engineer or +physician. And, of all professional or educated men, the physician +especially should recognize his own ignorance. When he is asked what +one should take for dyspepsia or pneumonia his answer is, "Take the +advice of a physician;" and so when he is asked how the plumbing of a +house should be arranged, how a hospital should be ventilated, how a +city should be sewered, how a marsh should be dealt with or a +water-supply provided, he should reply, "Get expert advice and +supervision, and be prepared to pay the amount necessary to secure +it." It is the special duty of the physician to exert his influence to +secure properly constituted sanitary authorities for his own locality, +his State, and for the nation, and to support these against the +hostility which they must inevitably arouse if they are efficient. And +he should do this, not blindly and as a partisan, but intelligently +and with due consideration of all the important interests involved. + +The body of educated physicians in a community forms the tribunal by +which the work of sanitary officials is to be judged, and they cannot +judge wisely unless they appreciate the difficulties with which health +officials have to contend. If a city has an incompetent or dishonest +board of health, the medical profession of that city are to a certain +extent responsible for it; if a competent, energetic, and faithful +sanitary officer is crippled and harassed or forced out of office +because he is on the wrong side of politics, or because in the +legitimate and proper exercise of his functions he has come in +conflict with the interests of powerful and wealthy individuals or +corporations, it is the duty of medical men to support him, and to do +this actively and promptly. And I take great pleasure in being able to +say, as the result of somewhat extended observation, that, as a rule, +the physicians of this country do cheerfully and promptly co-operate +with the sanitary authorities where such exist, and are the first to +try to have them properly organized and given the necessary means and +powers to do effective work. + + + + +{213} + +DRAINAGE AND SEWERAGE IN THEIR HYGIENIC RELATIONS. + +BY GEO. E. WARING, JR. + + +For reasons, sometimes sound and sometimes fanciful, the drainage +question often presents itself to the medical practitioner as an +annoying if not as a serious one. It is not necessary for the +physician to make himself an adept in the art of sanitary drainage, +but he can properly meet neither the demands of nervous patients nor +the exigencies of sometimes serious situations without having an +intelligent general idea concerning it. Not only to prescribe +improvement, but frequently to allay ill-grounded apprehension, he +should be able to address himself, intelligently and promptly, at +least to the few simple problems presented in connection with ordinary +houses. I use the expression "ill-grounded apprehension," not because +the drainage in and about houses is generally tolerably good, for it +is not, but because the race seems to have so inured itself to certain +grave defects in plumbing-work that one may reasonably hesitate, and +look elsewhere for the occasion of diseases before accusing the +imperfect sanitary appliances of an average house. + +Anything like a treatise on the technical details of house-drainage +would be quite out of place here. There are note-books easily +accessible to such physicians as care to make a thorough study of the +subject. It does seem worth while, however, to pass in careful review, +in a work of this character, the various conditions of interior and +exterior drainage upon which a physician is frequently called to pass +judgment. + +The perfect drainage of a house, like the perfect drainage of a town, +implies the immediate and complete removal, to a point well beyond its +limits, of all waste matters which are a proper subject of +water-carriage; such a thorough ventilation of the channel which these +matters have traversed as to reduce to a minimum the production of +deleterious gases arising from the decomposition of the film with +which they may have soiled the walls of their conduit; and adequate +provision for the absolute and permanent exclusion from the atmosphere +within the house of the air of the pipe or sewer. This is a brief and +simple statement of the fundamental and absolute requirements of all +good drainage. It is founded on the one grand object which governs all +improvement of this character: the prevention of decomposition of +refuse matters anywhere in house or town. + +Practically, it is safe to say that these conditions are never +complete, and that instances of perfect work are so exceptional as to +need no {214} consideration here. We have to assume, substantially in +every case that is presented, that we are dealing with defective work, +ordinarily with work that is very seriously defective. Most houses +have been built by contractors, and the plumbing is perhaps the item +of the whole structure that it is considered easiest and safest to +scamp or to neglect. Even where the motive of economy has had no +controlling influence, the drainage has almost invariably been planned +by a plumber who has learned his trade and conceived his ideas in the +performance of work which was done at a time when no one realized the +serious consequences of its being improperly done. The absence of +interior ventilation, leaky joints, ill-arranged connections between +the various plumbing appliances and the main outlet from the house, +pipes and traps so large that an ordinary current is powerless to keep +them clean, defects of form, defects of material, and defects of +construction, are met with on every hand. This general statement is of +itself sufficient to show how hopeless it is for the average physician +to prescribe the manner in which the drainage of a house should be +constructed or remodelled. + +If we view the question solely with reference to its bearing on the +causation of disease, we enter a field where neither the sanitarian +nor the physician is ever sure of his footing. The precise relation +between bad drainage and ill-health no man knows. Certain diseases are +undoubtedly traceable to conditions of air or of drinking-water due to +the improper disposal of organic wastes, but the extent and exact +bearing of these influences are still greatly a matter of conjecture. +It is, however, undoubtedly safe to assume--and the assumption is +supported by ample general observation, if not by precisely +ascertained facts--that whether we are considering serious diseases or +the slighter ailments, every argument leads to the enforcement of the +most strenuous requirements of cleanliness. Through all the ages no +one has disputed, and no one has improved upon, the simple sanitary +formula, "Pure air, pure water, and a pure soil." We may safely wait +until the enthusiastic investigators now engaged with the subject +shall have adduced the testimony of positive facts, if we will in the +mean time adhere strictly to the requirements of Hippocrates' +prescription. The physician will surely not go wrong if he treats all +obvious defects of drainage as positive evils, and insists upon their +complete reformation. + +Not to confine ourselves to houses which are provided with the +ordinary modern plumbing-works, but to include all collateral branches +of the subject, we have to consider the following conditions: + + I. THE REMOVAL OF HUMAN EXCREMENT: + (_a_) By water-carriage in houses provided with modern plumbing; + (_b_) By some form of dry conservancy; + (_c_) By the fiendish privy-vault which prevails so generally, + save in the larger cities. + II. THE REMOVAL OF LIQUID HOUSEHOLD WASTES: + (_a_) By delivery to public sewers; + (_b_) By irrigation disposal; + (_c_) By delivery into cesspools. + +Incidentally to the above there must be considered the influences of +the ultimate disposal of all household waste, whether by the public +sewer or the private house-drain. + +{215} I. THE REMOVAL OF HUMAN EXCREMENT.--We are too apt to judge of +the power for mischief of any waste matter by its original +offensiveness, and the world at large regards the solid and liquid +exuviae of the human body as the most dangerous material with which it +has to deal. Doubtless it is so under certain exceptional +circumstances. If impregnated with the infective principle of cholera +or of typhoid fever, for example, its influence for evil may be +widespread and active, but in the absence of such infection these +substances offer a less serious problem, and, as their offensiveness +causes them to be more carefully avoided, their evil influence is +less, and is less widely disseminated, than is that of the +comparatively inoffensive wastes of the kitchen-sink. This is a +consideration important to be borne in mind. Nothing is more common +than the expression of the opinion that the wastes of a population are +offensive and dangerous in proportion to the degree to which +excrementitious matter is allowed to flow away with its general +drainage. The fact is, that the drainage from a house or from a town, +if reasonably diluted with water, is very slightly offensive until it +has passed through a considerable degree of decomposition. The outflow +of a perfectly sewered town, where the whole community uses +water-closets, is less offensive than the neglected back-yard drain of +an average New England farm-house. The trouble begins with the +condition of putridity. Fecal matter and urine are somewhat quicker +than the other wastes of the house to enter into putrefaction, but the +difference is only one of degree, and the latter rapidly overtakes the +former in the foulness of its condition; so that where a house is +provided with two cesspools, one for water-closet matter and the other +for kitchen waste, it is quite impossible to determine from the +character of their contents which is which; therefore examinations of +the drainage of a house should by no means be confined to the manner +in which its excrementitious matters are disposed of. Setting aside, +in this connection, the peculiar liability of these matters to become +the seat of specific infections, it is fair to assume that equally +complete and cleanly arrangements are needed for all else that flows +to waste, as for the discharges of the water-closet. The purpose of +these remarks is of course not to belittle the importance of proper +care in the disposal of human excreta, but to prevent the giving of an +undue importance to this branch of the subject, with too light +treatment of the very serious difficulties presented by the others. + +(_a_) Modern conveniences may fairly be said to be the bane of modern +society, or at least of such of its members as have the questionable +good fortune to be housed within the same four walls with every device +that a misguided talent for invention has led the American mechanic to +provide for the comfort and convenience of the occupant. Properly +regulated, there is no element of modern house-building more conducive +to health than such a system of plumbing as brings within reasonable +limits the labor of supplying abundant water at every point in the +house, and obviates the need for exposure and removes the temptation +to neglect and postponement attending the use of out-of-door houses of +convenience. The spigot and the water-closet are the two essential +sanitary agents which the plumber offers to us. The bath may be +replaced by the sponge, the stationary wash-basin may be, and +generally should be, replaced by the bowl and pitcher of our fathers, +but there is no sufficient {216} substitute for an ample supply of +water on each floor of the house and for a cleanly water-closet placed +within doors. The evil that the plumber has inflicted upon the race is +due very largely to his not having held his hand when he had fairly +provided for our reasonable requirements. When he fills our bedrooms +with stationary basins, connects our refrigerators with the sewer, +provides twenty outlets for water which had better reach the drain +through less than half that number, and incidentally underlays all our +floors with pipes, every foot of which is a possible source of danger, +he turns what ought to be a blessing into what is too often an +unmitigated curse. + +It will not be easy to convert persons who have become accustomed to +the universal diffusion of plumbing-works throughout the house to a +belief that their best sanitary interest, and, perhaps hardly less, +the best requirements of refinement, point to the abandonment of what +is practically superfluous in the way of wash-bowls, bidets, +foot-baths, sitz-baths, urinals, etc.; but one who has given careful +attention to the subject cannot hesitate to recommend that in a house +which is "strictly first class" it would be the part of wisdom to +reduce by at least three-fourths the openings which lead to the +soil-pipe and drain and sewer, and to concentrate upon the remaining +fourth the flushing effect of wastes which are now so widely +distributed. Strenuous effort is being made, not only by those who +write and talk in the interest of the plumber and manufacturer, but by +many who honestly believe that the good the plumber has to give us +cannot be given with too free a hand, to prove that so long as they +are properly constructed and properly arranged we may use plumbing +appliances at every point in the house with the utmost freedom and +with a minimum of danger. The minimum of danger, and often more than +the minimum, does, however, exist. It exists, perhaps, in a constantly +increasing degree with every extension of the work, and it can only be +the part of wisdom to insist, so far as advice can have influence, on +the reduction of all these appliances to the least requirements of +reasonable comfort and economy of labor. My own advice would be, in +all cases, to permit the use of no wash-bowl or bath or other vessel +at a greater distance than a few feet from a vertical soil-pipe, and +not to permit their use in any case in bedrooms or in closets opening +only into bedrooms. + +At the risk of seeming extravagant, I would say that the stationary +wash-bowl as ordinarily used is one of the most uncleanly of modern +household appliances. Long experience in the inspection of houses and +in the examination of waste- and drain-pipes has led me to the belief +that servants, by no means rarely, use these vessels as the most +convenient means of voiding and cleansing chamber utensils. Their +overflow-pipes are coated with soap and with the exuviae of the skin +to a degree which makes them usually the seat of an offensive +decomposition. Their plugs and chains are almost invariably foul, and +those devices which provide for closing the outlets by valves or +plugs, somewhat removed from the strainers at the bottom of the bowl, +bring the water in which the face is washed into an interchanging +communication with a considerable length of foul and uncleanable +waste-pipe--a communication that is made active by the bubbling of the +contained air as the pipe fills with water. The labor of filling +pitchers from a spigot on the same {217} floor, and the labor of +emptying chamber-slops into a water-closet on the same floor, are not +to be considered as compared with the greater cleanliness and the +greater sanitary security that such an arrangement ensures. There is +no serious objection to the placing of wash-basins and baths in the +same apartment with the water-closet, or elsewhere immediately +adjoining the soil-pipe; but it certainly cannot be disputed that the +extension of the drainage system by horizontal lead pipes to remote +points is altogether and wholly to be condemned. + +However, the question more immediately at hand is that of the disposal +of human excreta by the use of water-closets; and it is the +water-closet that first attracts the attention of one who is called +upon to examine the sanitary condition of the work. There are several +radical defects in water-closets, which are so widespread and which +have become so familiar to the world at large as to attract less +attention than they deserve. For example, it is a radical defect of a +water-closet to be tightly encased in carpentry. Nearly all the +water-closets now in use have a somewhat complicated mechanism about +their bowls. They consist in part of earthenware and in part of iron, +generally with an unstable connection between the two. More often than +not they overflow or drip or leak, and whatever may escape from them, +whether foul air or foul water, is confined within an unventilated +space, but a space which is still not absolutely excluded from the +atmosphere of the house. The removal of the "riser" or vertical board +under the front of the seat will usually disclose at once a condition +that suggests at least the need for thorough ventilation. It also +discloses in some cases a complication of machinery and pipes and +levers and chains which makes a thorough dusting and cleansing of the +space difficult, even were it accessible. There are water-closets +which are essentially good in their construction and working, which it +is important to protect by a "riser," but this "riser" should never be +of close work. It should at least be freely perforated with large +holes, or, better still, be made with slats or blinds, so that there +may be the freest possible circulation of air under the seat. If there +is an entire absence of machinery, so that the whole space may be left +open, being well finished with tiles or hard wood or other suitable +material, it is better that it should be unenclosed and that the seat +should be hung on hinges, so that it may be turned back, exposing the +whole space to easy cleansing. It is better too, in all cases, that +the ventilation should not even be interfered with by a cover over the +seat, the freest possible exposure to the air being of great +importance. + +A very large majority of the water-closets in use throughout the world +are either very imperfectly flushed "hoppers," which are generally +foul and which are often defective in their traps, or that worst of +all forms, known as the "pan" closet, where a slight depth of water is +held in the bowl by a hinged pan closing over its outlet. This pan +swings in an iron chamber under the bowl, which is entirely cut off +from ventilation, which is generally foul with adhering fecal matter, +and which as an abomination has no equal in the whole range of +plumbing appliances. The closet of which it forms a part has +everything to condemn it, and only its cheapness and its apparent +cleanliness, and the habit of the world in its use, to commend it. If +flushed, as it usually is, by a valve on the supply-pipe, it is rarely +flushed adequately, and its use not seldom leads to an indraft {218} +of foul air (or worse) into the main water-supply system of the house. +Such closets may be easily inspected as to their condition by shutting +off the water-supply, opening the pan, and lowering a candle into the +container below. Such an inspection will almost invariably disclose an +extremely and dangerously filthy condition. Yet the worst part of the +container, that which never receives an adequate flush, is even then +concealed from view by the pan being thrown back against it. The nose +will here be a good adjunct to the eye, and the odor escaping from +this filthy interior chamber will generally afford convincing +testimony of the impropriety of allowing such a vessel to remain in +use. + +It is a rule almost without exception that closets, except perhaps on +the first floor of the house, which are flushed by valves connected +with the bowls, are to be condemned. However good or however bad the +state of a closet thus supplied with water, its condition will always +be improved by giving it a copious flush from an elevated cistern +delivering never less than two and a half gallons of water at each +use, and delivering it through a pipe so large and so direct as to +secure a thorough cleansing at every discharge. + +It would be out of place here to enter into a detailed description of +the various closets which are and which are not to be recommended for +use. So far as the physician's inspection is concerned, it is perhaps +sufficient to say that wherever an odor, however slight, can be +perceived, and wherever a fouling of the interior surfaces of the +closets or of the spaces under the seat can be detected by the eye, +radical reformation is necessary. The only safety with a water-closet, +as with any other vessel connected with the drainage of the house, is +to secure an immediate and complete washing away of all foul matter of +every kind. Where this result is not attained, it should be insisted +upon. This much lies within the province of the medical attendant; the +manner in which it shall be secured is not necessarily for him to +decide. + +One other branch of this subject is worthy of attention. The +cleanliness and freedom from offence of the water-closet or of a +waste-pipe or drain is in proportion to the frequency with which it is +used and to the abundance of the discharge of water through it. A +dozen closets used by a dozen persons will be quite likely all to be +offensive. If the dozen persons all used only one closet--not a pan +closet--the frequency with which its trapping water is removed and the +frequency with which its walls are washed would secure its tolerable +condition, even if not of the best construction. In this case, as in +all others, simplicity should be the controlling principle. + +(_b_) Dry conservancy next after water-carriage is the best and safest +system for the removal of human excreta. By dry conservancy is meant +the admixture of dry earth, ashes, or similar material with the +matters to be disinfected and absorbed. Theoretically, the effect of +such admixture is entirely satisfactory; under very careful and +intelligent regulation it is practically so. It has been proved, +however, by much experience that under ordinary circumstances--that +is, where no greater care is given than is ordinarily given to a +water-closet or to a common privy--the dry conservancy system is open +to serious objections, though always an improvement on the cruder +privy-vault. The theory of the effect of a sufficient admixture of +earth or ashes with urine and fecal matter is, that by the {219} +admission of air thus secured to every part of the material there is a +complete oxidation of their organic constituents, similar to, though +slower in its operation than, actual combustion in an active fire. In +isolated houses and in hospitals, factories, and other buildings not +provided with sewerage facilities, there is no question that the +earth-closet or the ash-closet affords the best available means for +disposal, if we except a system, to be described hereafter, for the +distribution of water-carried wastes over or under the surface of +suitable ground. + +Incidentally--and this is of special interest to the physician--the +use of dry earth or of dry ashes in the close-stool of the sick +chamber effects not only an immediate and complete deodorization, but +without doubt a complete disinfection as well. A quart of dry earth at +the bottom of the vessel to receive the deposits, and rather more than +a quart with which immediately to cover them, constitutes a means of +relief always available and always efficient. + +Where the house is provided only with an old-fashioned out-of-door +privy the greatest relief and the most complete security may be given +at little cost by filling the vault, and placing under the seat a +movable box to receive the mixture of fecal matter and of the +absorbent material, which, if it is desired to avoid the simple +patented appliances made for the purpose, may be kept in a box or +barrel in the apartment and thrown down after each use of the closet +with the hand-scoop. The objections to the common privy are so +obvious, so universal, and so well understood that the practical value +of such a means of relief should be appreciated without argument. + +(_c_) Privy-vaults are the sole reliance for the disposal of fecal +matter, and often of chamber-slops, of probably 95 per cent. of the +population of this country, and of Europe as well. It is curious, in +examining the recommendations of public health officers and the +requirements of local boards of health, to observe the uniformity with +which this most important subject is passed over with the prescription +that the vault shall be tight, sometimes that it shall be vaulted +over, and sometimes that it shall not be within a certain small number +of feet of a boundary-line or of a drinking-water well. These +prescriptions are most absurd. It is safe to say, that of the millions +of privy-vaults in this country not more than hundreds are really +tight; that a still smaller number are so vaulted over as to prevent +the free exhalation of the gases of decomposition; that those which +are so vaulted over are in all respects of worse sanitary effect than +those which have freer communication with the air, and that their +possibilities of evil reach many times farther than the limits of +distance usually required to intervene between them and the well or +the neighboring property. In view of the universality of their use and +of the completeness with which modern communities are inured to their +presence, it seems almost hopeless to attempt to secure a proper +realization of their great defects. They are always the seat of the +foulest, and even of the most dangerous, decomposition. They taint not +only the air and the soil, but the water of the soil which goes so +often to feed our sources of drinking-water, and their local stench is +of itself sufficient to sicken all who have not by daily and lifelong +habit become accustomed to it. Taking the country at large--farm +houses and village houses as well as the dwellings of cities--it is +not too much to say that the best sanitary service that {220} can be +rendered by those interested in the removal of causes of ill-health +would be in securing the abolition of these barbarous domestic +appliances. In many ways the cesspool is as bad as the vault, but in +some respects the vault is facile princeps as a public and private +nuisance of the most annoying and dangerous character. Wherever a +public or private sewer is available, wherever disposal by irrigation +is possible, and wherever even the crudest attention can be secured +for an automatic or simpler earth-closet, the strongest effort should +be directed to the absolute inhibition of the common privy-vault. + +II. THE REMOVAL OF LIQUID HOUSEHOLD WASTES.--As has been stated above, +the liquid household wastes are of much more serious consequence from +a sanitary point of view, as compared with excrementitious matters, +than the public has been wont to suppose. These, owing to the large +amount of water which they contain, are beyond the reach of any system +of dry conservancy. They consist almost invariably of a flood of water +containing but a small percentage of refuse food, urine, soap, filth +of the laundry, grease--everything, in fact, except fecal matter and +the coarser garbage and ashes--constituting the waste of the +household. Where water-closets are used fecal matter is generally +added to the flow, but its relative quantity is small, and its +presence or absence does not seriously affect the problem of disposal. + +In a house provided with abundant, generally superabundant, plumbing +appliances, with a large consumption of water, the whole apparatus is +constructed on the theory that all manner of filth is to be taken up +by running water and carried well without the house. Where this +theoretical end is completely attained there exists a condition of +drainage rarely met with and little to be criticised. Unfortunately, +the theoretical excellence is rarely secured. Running water confined +within a narrow channel, and so compelled to move with force +sufficient to give an energetic scouring to the walls of its conduit, +may be trusted to carry with it or to drive before it pretty nearly +all foreign matter that may have been contributed to it, but the +moment this vigorous current is checked, that moment the tendency to +excessive deposit begins. It is checked in practice in various ways: + +First. By too great a diameter of the pipe: a volume of discharge +requiring a velocity of 4 feet per second in a pipe 1 inch in diameter +would have a velocity of only 1 foot per second in a channel 2 inches +in diameter, and of less than 6 inches per second in a channel 3 +inches in diameter. Ordinarily, except as the deposits are removed by +decomposition (always objectionable), the deposited matters accumulate +and reduce the original bore to the diameter which will secure a +cleansing flow. It is the part of wisdom to provide only this bore at +the outset or not greatly to exceed it, and it is one of the earliest +recommendations of an experienced sanitary engineer to reduce the size +of too large bores where they exist. + +Second. By the use of traps larger than the pipes leading to them and +from them, thus increasing the natural tendency of all traps to +stagnation and deposit. + +Third. By the use of vertical waste-pipes, which are almost universal, +and which are very often necessary. The velocity of a current measured +along the axis of the pipe is less if the direction is vertical than +if it is laid on {221} a steep slope, because of the tendency of +liquids flowing through vertical pipes, which they do not fill, to +adhere to the walls and to travel with a rotary movement. I have seen +vertical soil-pipes furred with excrement to a thickness of nearly +three-eighths of an inch; I have never seen a corresponding deposit in +a pipe of good slope where the current was direct. This latter point +is rather one of curious interest than of practical value--certainly +from the physician's point of view. Even in original construction it +is rarely possible to give soil-pipes other than a practically +vertical course as they pass from one story to the next. Indeed, the +physician need not trouble himself to consider the question of the +size or of the direction of this main channel. He will often find +occasion to criticise the use of unduly large waste-pipes from single +vessels; as, for example, two-inch pipes leading from bath-tubs; two +and a half-inch pipes leading from laundry-tubs; and three-inch pipes +leading from kitchen-sinks. Where reconstruction is to be undertaken, +he may with advantage exert himself to secure in these lateral +waste-pipes a diameter never exceeding one and a half inches, and from +kitchen- and pantry-sinks, whose outflow is loaded with grease, +preferably not exceeding the diameter of one and a half inches, with +traps of even a little less size. Where several vessels lead into the +same waste-pipe these small diameters may increase the tendency to the +emptying of the traps by siphonage, but if proper mechanical traps are +used for baths, wash-bowls, and laundry-tubs, and if ample flushing +appliances are connected with kitchen- and pantry-sinks, the temporary +removal of the trapping-water by siphonage may generally be +disregarded. It will seldom happen that the removal of water will be +so complete as to prevent the satisfactory closing of the mechanical +valve by capillarity, even if it fails, in itself, to make a perfectly +tight fit. + +A favorite recent requirement of theoretical sanitarians, and one +which has perhaps for business reasons been eagerly accepted by the +plumbing trade, is what is called the "back" ventilation of traps; +that is, the carrying of a vent-pipe from every trap in the house to a +point above the roof. In my judgment, there is more to condemn than +there is to commend this practice, for I believe that the more rapid +emptying of traps by evaporation where they are not constantly +supplied by frequent use, the dangers of accident to lead pipe, which +is generally used for ventilating purposes, and the misapplication of +a large outlay which might better be applied in other directions, +constitute convincing arguments against this favorite new method of +preserving the integrity of the water-seal. There are a number of +traps which are closed by floating balls, or by balls bearing upon the +outlet, which seem to be quite satisfactory and efficient. The worst +waste-pipes, by far, are those of kitchen- and pantry-sinks which pass +a large amount of hot grease. This soon cools sufficiently to congeal, +and it attaches itself to the walls of the pipe, where it does congeal +until the bore is reduced to what is barely sufficient to furnish the +necessary limited water-way. Grease-traps of various forms have been +invented with a view to retaining this obstructing material. After +much experience with all of them that have been in general use, I have +become convinced that the only satisfactory way to avoid the +difficulty in question is to retain the outflow of the sink until a +certain considerable quantity has accumulated, and until its grease +has entirely {222} congealed, then to discharge the whole volume +rapidly through a pipe of small calibre. This may be done with +Carson's grease-trap by throwing in a pail of water to start a siphon +action when the vessel has become filled to its overflow-point. It is +more simply accomplished by a device of my own, wherein the whole +outflow is retained by a plug at the bottom of a large vessel working +after the manner of the plug of a wash-basin, until it is filled to +the level of the sink, and then opening the outlet for its sudden +discharge. + +Good workmanship is as important as, if not indeed more important +than, good arrangement. It seems a very simple proposition to say that +all waste-pipes, whose office it is to carry foul liquids out of the +house, should be made tight in material and in joint. It is a +remarkable fact, however, that leaky joints in soil-pipes and in +drains are by no means rare. Probably there are few houses, very few, +in which they do not occur. The soil-pipe is put together by inserting +the small end of each section into the bell at the top of the section +below it, practically like putting the outlet of one funnel into the +larger upper portion of another. There may be abundant space for +leakage at every joint from the top to the bottom of the house, +without there being the least show of the leakage of water. The foul +air within the pipe may escape freely through a dozen openings, while +the heavier liquid flow takes its easiest and most direct course +downward from the point of one pipe through the bell of the one below. +When we come to the horizontal run of the soil-pipe in the basement, +if an imperfection of the joint occurs on the lower side there is an +obvious drip, which continues at least until closed by rust. Similar +imperfections in other parts of the joint would not be so manifested. +It has recently been demonstrated that there is no safety in the +construction of soil-pipes short of that absolute assurance which can +be secured only by an efficient test. Plugging all the outlets of the +soil-pipe and filling it with water, the slightest leak will be +exposed. + +However defective may be the condition of an iron soil-pipe, vertical +or horizontal, it is perfection itself compared with the usual state +of a drain laid under the cellar floor; and here is a point where the +least experienced inspector of house drainage cannot be mistaken. +Under all circumstances, at least in all work hitherto executed, he +should demand as absolutely necessary that the drains under the cellar +floor be removed, that the earth which has been fouled by the leakage +of its joints and its breaks shall be taken out to the clean untainted +soil below, and refilled with well-rammed pure earth or with concrete, +the drainage being carried through a properly-jointed iron pipe above +the pavement, and preferably with a fall from the ceiling of the +cellar to near the floor at the point of outlet--in full sight for the +whole distance. It sometimes happens that the necessity for using +laundry-tubs or other vessels in the cellar makes the retention of an +underground course imperative. When retained, the drain should be of +heavy cast iron with most securely leaded joints tested under a head +of several feet. When found to be tight and secure, it should not be, +as ordinarily recommended, left in an open channel covered with boards +or flags and surrounded by a vermin-breeding, unventilated and +uninspected space, but closely and completely imbedded in the best +hydraulic cement mortar. Its careful testing before this {223} +enclosure is of course the only condition under which the work can be +permitted. + +Tightness of all waste-pipes being secured, the next point in order is +their proper ventilation. A good deal has been said, and little has +been proved, about the different effects on the human system of the +gases of decomposition which have been produced in the absence of a +sufficient circulation of air, and those produced where the +ventilation and dilution are more complete. The probabilities of the +case are, of course, entirely in favor of the latter condition, and it +is accepted by all sanitarians as an axiom that all water-ways and all +vessels in which organic decomposition, even the decomposition of +adhering slime, takes place, should be ventilated as thoroughly as +possible. Until about ten years ago nearly all waste-pipes were +tightly closed at the top, and were shut from the sewer by a trap at +the foot, allowing absolutely no communication between the outer air +and the atmosphere of the pipe except as fresh air might be carried in +through the water-seals of the traps at each end. At about that time +it was becoming the general custom in the better class of work to +carry a small vent-pipe, often only one inch in diameter, rarely more +than two inches in diameter, through the roof of the house, closing it +at the top and perforating it with a few inefficient holes. This had +undoubtedly the effect of relieving the pressure on the atmosphere of +the pipe caused by the filling of unventilated sewers with tide-water +or storm-water, or by a sudden increase of temperature from the +admission of hot water. Later, it was accepted as a universal rule, +and it became a quite general practice, to carry the soil-pipe above +the roof with its full diameter, providing its summit with some form +of ventilating cowl. All this constituted not ventilation, but +venting. Real ventilation was introduced only with the very recent +improvement of admitting fresh air at the foot of the soil-pipe, so as +to make a complete circulation from one end to the other--a +circulation sufficient to produce, by the diffusion of gases, a very +fair ventilation of lateral waste-pipes of moderate length. It is now +coming to be understood that ventilating cowls, of whatever form, are +an obstruction to the movement of air in the absence of wind, and +that, as what is needed is never a vigorous current, but always a +living one, these cowls had better be dispensed with. We have learned, +too, that the most efficient means for increasing the flow of air +through the top is to increase its diameter at the top, enlarging the +highest length of a four-inch pipe, for example, to a diameter of six +inches. With this arrangement, and with a foot-ventilation four inches +in diameter opening at a point where it can never be obstructed by +rubbish or by snow, there will be secured a condition perhaps more +efficient in improving the condition of an imperfectly drained house +than any other one thing that may be done. + +I have sketched above, in a very hurried manner, the main outline of a +system of house-drainage which may be accepted or which may be +recommended by a physician with confidence of securing a good result. +To go more into detail in technical matters would be out of place in a +paper of this character. Before leaving this subject, however, it is +important to call attention to the fact that what is recognized in our +houses as sewer gas is in far greater degree the product of +decomposition taking place within the house-drains themselves than the +product {224} of decomposition in the distant sewer forced into the +house through its connecting drain. It is emphatically a case of the +beam in our own eye as compared with the mote in the eye of our +neighbor. It is a rule which has exceptions, but they are few, that +the contained air of the house-pipes is far worse than the contained +air of the sewer; and the conviction is growing that the use of a trap +to the main drain between the house and the public sewer is more often +objectionable than advantageous. Such a trap always tends to check the +flow of the drain and to induce deposits whose decomposition is +objectionable. Wherever the abandonment of the trap is anything like +universal the considerable ventilation of the sewer thereby secured +brings its atmosphere to a condition which makes it not objectionable, +and generally useful, as a source of movement in the air of the +interior drain- and soil-pipe. + +(_a_) Public sewers are more or less good or bad entirely according to +their character and condition. As a rule, a well-flushed sewer which +is used for no other purpose than the removal of foul waste, built on +what is called the separate system, and automatically flushed at least +daily, may be considered to be, if well laid and tightly jointed, +absolutely safe. A public sewer of large size and of irregular +construction, receiving not only household wastes, but the wash of +streets as well, may be regarded at least as an object of grave +suspicion. These general statements may be so far qualified by the +character of the sewers of each class as to run very nearly together; +that is to say, separate sewers, with leaky joints, irregular grades, +defective alignment, insufficient flushing, and inadequate restriction +as to the matters they are to receive, will be an intolerable and +dangerous nuisance; on the other hand, a large brick sewer built in +the best manner and of the best material, with sufficient fall and +sufficient supply to maintain itself in a cleanly condition, is free +from the serious drawbacks which usually attach to sewers of this +class. + +With sewerage as with house-drainage it is not worth while to attempt +here to give anything like detailed directions for inspection and for +reformation. It will suffice to call attention to this one broad and +general rule: Every sewer or drain having for its object the removal +of putrescible organic matters must be so arranged as to maintain +itself in a condition of practically absolute cleanliness, without, as +in the case of storm-water sewers, waiting for the flushing effect of +storms, which often come only at long intervals, during which the +worst condition of decomposition may be established. Whether the sewer +be intended for drainage only or for both drainage- and storm-water, +if it contains at any time deposits of any kind, it is defective--more +or less so, of course, according to the extent and duration of the +accumulation. + +Although it should be rigidly insisted upon in every case that the +sewer should maintain itself free from deposits, there will still be, +unavoidably, a certain amount of foul gas produced by the +decomposition of the matters coating its walls, and in order to dilute +and to remove this, and perhaps in order to modify their original +character, the most thorough ventilation is necessary. + +Any sewer or other drain which at any time gives forth the odor of +putrid decomposition is in bad condition and should be at once +rendered inoffensive. So far as I know, there is no exception to this +rule. I have met no conditions in towns of any size where absolute +self-cleansing may {225} not be secured. It is worth while, however, +to repeat here the statement made above, that sewer gas, in so far as +it is a serious factor in connection with the drainage of houses, is +the product of the interior pipes of the house much more frequently +than of the public sewer in the street. + +(_b_) The disposal of liquid wastes by irrigation, so far as this +method is applied to the outflow of public sewers, is not of especial +interest here, but an important modification has been made of the +system of irrigation which is of the greatest consequence in +considering the sanitary improvement of isolated country-houses, of +hospitals, prisons, etc., and of houses in towns about which there is +a small amount of available land. The process which has been found +best suited to the purpose is the invention of the Rev. Henry Moule, +the inventor of the earth-closet. He found it a serious drawback to +the dry-earth system that it was incapable of taking care of the +liquid wastes of the house. He devised a method of conducting the +liquid into very shallow drains made with open-jointed agricultural +drain-tiles, so porous in their character as to allow the liquid +carried by them to escape at the joints into the soil, and thus get +the benefit of its purifying qualities without the unsightly and often +offensive process of allowing the liquid to flow over the surface. The +first use made of this system was about 1866. Since that time its use +has extended very considerably both here and in England, and many +improvements have been made in its details, so that it may now be +accepted as entirely satisfactory. + +The process in its best development, as applied to the drainage of +single houses, may be thus described, many of the appliances used +being the subject of patents: The outflow from the house is delivered +into a settling-basin or grease-trap of sufficient size to still the +flow, to cause solids to settle to the bottom, and grease and other +light matters to float at the top. The outlet from this basin is +through a pipe having its inlet at some distance below its +overflow-point; that is, at the level of the comparatively clarified +liquid, below the grease and above the sediment. The outflow passes +into another vessel known as a flush-tank, where it accumulates until +it reaches the summit of a self-acting siphon. This height being +reached, any considerable addition to the flow sets the siphon in +action, and the whole contents of the flush-tank are discharged with +rapidity into the drain beyond. The discharge completed, air is +automatically admitted to the siphon, and no further flow can take +place until the flush-tank has again been filled. The drain, of iron +or vitrified pipes tightly joined, is continued to the edge of the +ground prepared for purification. It here delivers into a series of +open-jointed agricultural tiles, laid with their bottoms not more than +ten inches below the surface of the ground. The total length of these +tile-drains is regulated according to the discharging capacity of the +flush-tank, with a view to their becoming entirely filled at each +discharge. Within a short time after the flow has ceased the liquid +has all left the pipes and entered the soil, its impurities being +retained and its filtered water settling away into the porous or +artificially drained ground below. During the interval between the +discharges of the flush-tank, a day or more, the process of +purification (oxidation) of the retained impurities goes on in the +soil, and its thorough aeration prepares it to purify the next +discharge. This method of {226} disposal is now employed in connection +with hundreds of houses, and its use, which has in some cases +continued for a dozen years, is constantly increasing. Its application +implies a certain amount of fall, but this amount need not be great. +The discharging height of the tank need not be more than twelve +inches. The main outlet need not fall more rapidly than at the rate of +1 to 300, and the absorption-drains ought not to fall more rapidly +than at the rate of 1 to 600. If the tank can be built on the top of +the ground, an average surface fall of 1 to 400 can usually be made to +meet all the requirements. Where waste matters are to be removed from +cellars and basements below the level of the ground, a greater fall is +necessary, or the wastes which are there collected must be thrown to +the tank by pumping or otherwise. + +Where there is a bit of grass-land a little removed from the house +(and from sight), it answers a perfectly satisfactory purpose to +dispense with the absorption-drains and to deliver the main outlet +directly on to the surface of the ground. The effect in both cases is +entirely different from what it would be were the flow of the drains +not regulated by the use of the flush-tank. The moment we have a +constant slight discharge, either on the surface of the ground or into +the absorption-drains, we establish a condition of constant saturation +which leads to the over-fouling of a small area, which is rarely if +ever purified by aeration. For an intermittent discharge some form of +flush-tank is an absolute necessity. It is often found in practice, +where the flow from the house is considerable, that the discharge of +the house-drains into the settling-basin produces such an agitation of +its contents as to set in motion and to carry into the flush-tank bits +of paper partly macerated, grease, etc. This has been met by a recent +improvement, which consists in building a transverse wall in the +settling-basin, which checks the current from the house-drain and +causes the flow from the house side of the wall to pass over its top +in a thin small current which does not materially agitate the contents +of that part of the basin from which the outflow pipe is fed. + +(_c_) The cesspool is still the chief reliance of the world at large. +There is nothing to be said in its favor save what may be based on the +old adage that "what is out of sight is out of mind." There is +everything to be said in its condemnation, whether we regard its +contents as a great mass of putrefying and infecting filth, as the +source of oozings which travel through crevices of rocks, through +layers of gravel, through seams in clay, or through lighter soils into +and under cellars and into drinking-water wells and defectively +constructed cisterns, or as an ever-active gas-retort supplying the +pipes of the house with the foulest products of putrefaction. It is in +all respects and under all circumstances a curse, unless placed far +away from the possibility of tainting the air we breathe or the soil +over which we live, or from which we or others take our +drinking-water, and even then it had better be abandoned. + +The simple drainage of the soil involves a question of the greatest +importance. If the ground under the house or about it is at any time, +unless perhaps immediately after heavy rains, saturated with moisture, +we have to apprehend a condition of insalubrity more or less serious +in proportion to the degree of saturation and the degree of foulness +with which this is associated. The drainage requirements of land +outside of the house are less easily determined, but it requires +nothing more than a casual {227} examination of the cellar in +ordinarily wet weather to determine whether or not an improvement of +its soil-water drainage is necessary. If it is at such times wet, or +even persistently damp, thorough drainage is demanded; and it is only +necessary to say that this should be secured by some process which can +under no circumstances bring the air of the cellar into communication +with the air of a sewer or foul drain. + + * * * * * + +I have purposely abstained in the foregoing remarks from invading the +province of the physician or the physiologist by discussing the +influence of bad drainage on the health of those living subject to it. +It may safely be assumed that physicians who care enough about the +subject to interest themselves in investigating the condition of local +or general drainage have convictions concerning it which could not be +strengthened by the opinion of one belonging to another profession. +The assumption is also confidently made that no intelligent medical +man will hesitate for a moment to accept the dictum that the site of +the house must be dry, and that it and its neighborhood must be +entirely exempt from the influence of foul organic decomposition. + + + + +{229} + +GENERAL DISEASES. + + +FROM SPECIAL MORBID AGENTS OPERATING FROM WITHOUT. + + SIMPLE CONTINUED FEVER. + + TYPHOID FEVER. + + TYPHUS FEVER. + + RELAPSING FEVER. + + VARIOLA. + + VACCINIA. + + VARICELLA. + + SCARLET FEVER. + + RUBEOLA. + + ROTHELN. + + MALARIAL FEVERS. + + PAROTITIS. + + ERYSIPELAS. + + YELLOW FEVER. + + DIPHTHERIA. + + CHOLERA. + + PLAGUE. + + LEPROSY. + + EPIDEMIC CEREBRO-SPINAL MENINGITIS. + + PERTUSSIS. + + INFLUENZA. + + DENGUE. + + RABIES AND HYDROPHOBIA. + + GLANDERS AND FARCY. + + MALIGNANT PUSTULE. + + PYAEMIA AND SEPTICAEMIA. + + PUERPERAL FEVER. + + BERIBERI. + + + + +{231} + +SIMPLE CONTINUED FEVER. + +BY JAMES H. HUTCHINSON, M.D. + + +DEFINITION.--A continued, non-contagious fever, varying in duration +from one to twelve days, and in temperate climates almost invariably +ending in recovery. It may arise from any non-specific cause capable +of producing a temporary derangement of one or more of the important +functions of the body, is generally easily distinguished from the +other continued fevers by the absence of the characteristic symptoms +of these diseases, and presents in fatal cases no specific lesions. + +SYNONYMS.--Synocha, vel Synochus Simplex, Febricula, Ephemera or +Ephemeral Fever, Irritative Fever, Ardent Continued Fever, Sun Fever. + +HISTORY.--Much difference of opinion continues to prevail, even at the +present time, in regard to the existence of a simple continued fever, +which, on the one hand, occurs independently of local inflammations or +traumatic causes, and, on the other, is distinct from typhoid, typhus, +and relapsing fevers; many observers contending that the condition to +which this name is given is only a mild or modified form of one or +other of the graver varieties of continued fever, from which the +characteristic symptoms are absent. Prominently among modern writers, +Dr. Tweedie[1] has taken this view of the subject, for, after +reviewing the arguments for and against the recognition of simple +continued fever as a distinct disease, he asserts that there is not +sufficient evidence to justify us in encumbering our nosology with a +doubtful novelty. If, however, there is room for doubt as to its right +to a place in the list of diseases, there is certainly no good reason +for characterizing it as a novelty, since it has been referred to, +according to Murchison,[2] by many authors from the time of +Hippocrates down to the present day, who not only separate it from the +graver forms of fever, and give a very accurate description of its +symptoms, but seem to have been perfectly familiar with the causes +which give rise to it, and to have had very correct notions as to its +proper management. Thus, Riverius[3] was aware of the existence of two +forms of simple fever--the ephemeral, which lasts, as its name +implies, only a single day, and the Synochus Simplex, arising from the +same causes, but in which the fever continues for from four to seven +days. Strother[4] and Ball[5] also allude to this fever in terms that +leave no doubt upon the mind but that they distinguished it clearly +from other forms of continued fever. {232} Among more recent writers +who have made this distinction may be mentioned Lyons,[6] Jenner,[7] +G. B. Wood,[8] Flint,[9] Murchison,[10] and J. C. Wilson.[11] Indeed, +the weight of authority is decidedly on the side of those who claim +for it a recognition as a distinct and separate disease. + +[Footnote 1: _Lectures on the Continued Fevers_.] + +[Footnote 2: _A Treatise on the Continued Fevers of Great Britain_, +London, 1873.] + +[Footnote 3: _The Practice of Physick, being chiefly a Translation of +the Works of Lazarus Riverius_, London, 1678.] + +[Footnote 4: _A Critical Essay on Fever_, 1718.] + +[Footnote 5: _A Treatise on Fevers_, London, 1758.] + +[Footnote 6: _A Treatise on Fever_, London, 1861.] + +[Footnote 7: _Medical Times_, March 22, 1851.] + +[Footnote 8: _A Treatise on the Practice of Medicine_, Philadelphia, +1855.] + +[Footnote 9: _A Treatise on the Principles and Practice of Medicine_, +Philadelphia, 1868.] + +[Footnote 10: _Ibid._] + +[Footnote 11: _A Treatise on the Continued Fevers_, New York, 1881.] + +Unquestionably, many cases which have been classed under the head of +simple continued fever, are really mild or abortive cases of typhoid +or typhus fever, in which, in consequence of partial protection on the +part of the patient, the characteristic symptoms of these diseases +have not been developed. Such cases are seen in numbers during +epidemics of these diseases. But, making due allowance for this source +of error, there yet remain many cases which cannot be thus explained. +Moreover, the disease occurs at times when no such epidemics exist. It +may, therefore, be safely assumed that there is such a fever, and +that, consequently, it must be accorded full recognition. + +CAUSES.--Any non-specific cause which is capable of producing a +profound derangement of one or more of the important functions of the +body may give rise to simple continued fever. It may follow, +therefore, upon excesses of the table, extreme mental or bodily +fatigue, exposure to the direct rays of the sun, or to great heat or +cold, or upon the suppression of a secretion. One of its most frequent +causes is over-exertion in warm weather. James C. Wilson has called +attention to its frequent occurrence as a consequence of the combined +influence of the excitement, the physical exhaustion, and the exposure +to the direct rays of the mid-day sun which are attendant upon +surf-bathing. It is often due in young children to the irritation +involved in the process of teething or to that caused by the presence +of worms in the alimentary canal. Wood taught that it might also +sometimes occur during the prevalence of contagious diseases as an +effect of the epidemic influence in those who were partially protected +by a previous attack of the disease, or from some other cause, but it +is more probable that cases arising under these circumstances are +either mild cases of the prevalent disease or else are attributable to +fatigue from nursing or to over-anxiety. The disease is more common in +the young than in the old, and in children than in adults--probably +from the greater impressionability of the nervous systems of the +latter. + +The causes of the ardent continued fever of the tropics, which is +usually recognized as a form of simple continued fever, do not differ +materially, except in degree, from those of the simpler forms of the +disease; but exposure to the direct rays of the sun would seem to be +especially prone to give rise to the disease in those who are +unaccustomed to the heat of a tropical climate. Robust young Europeans +lately arrived in a warm country are, it is said, peculiarly liable to +suffer from it.[12] It is most common in those parts of India which do +not experience much of the benefit of the monsoon rains, and whose hot +season is not tempered by regular breezes from the sea. It is hence +more frequently met with {233} in inland districts in which the +temperature is high, but in which malaria-generating conditions are +absent. + +[Footnote 12: Morehead, _Clinical Researches on Diseases in India_, +London, 1856; also Twining, _Clinical Illustrations of the More +Important Diseases of Bengal_, Calcutta, 1835.] + +SYMPTOMS AND COURSE.--Simple continued fever occurs in this country +only as a sporadic disease, and almost invariably ends in recovery; in +tropical climates, however, it may prevail epidemically, and sometimes +presents symptoms of a very grave character. In its mildest form it +not infrequently runs its course in a few hours, and is rarely +prolonged much beyond twenty-four, and is hence called ephemera. It +then usually begins somewhat abruptly with a chill, but in a few +instances this is preceded by feelings of languor and weariness. +Febrile reaction is soon established, and is generally well marked; +the pulse is quick and full, the temperature rises rapidly, and the +face is flushed. The tongue is coated with a whitish fur, the urine is +scanty and high-colored, and the bowels are constipated. Other +symptoms are excessive thirst, headache, restlessness, and +sleeplessness, or, on the other hand, a tendency to somnolence. +Vomiting is not common except in those cases which follow upon an +error of diet, but there is generally some nausea and anorexia. +Muscular pains are also occasionally present, and may give rise to a +good deal of distress. The subsidence of these symptoms is often quite +as abrupt as their onset, the crisis being frequently marked by a +copious perspiration. + +In other cases, however, the fever is more prolonged, and the +symptoms, although not differing in kind, are apt to be more severe +than those above detailed. The pulse is often full, hard, and +bounding; the headache throbbing or darting in character; the tendency +to somnolence increases, or gives place to delirium; and the pyrexia +is more marked. Frequently an eruption of herpes is observed upon the +lips and upon other parts of the face, from which circumstance the +disease is sometimes called herpetic fever. Davasse[13] also observed +in a few cases pale bluish spots, not elevated above the surface and +not disappearing under pressure, which are identical with the taches +bleuatres sometimes seen in typhoid fever and other diseases, and +therefore have no diagnostic value. In this form the duration of the +disease may be from four to ten or twelve days. The defervescence is +usually less rapid than the rise in temperature, and is generally +accompanied by a free perspiration, diarrhoea, a copious deposit of +urates in the urine, or less frequently by hemorrhage from the uterus +or rectum,[14] or from the nose, mouth, or urethra. This constitutes +the synocha or inflammatory fever of the older writers. In children in +whom there is no reason to suspect malarial poisoning the disease +sometimes assumes a remittent form, and then constitutes a variety of +the infantile remittent fever of authors--a name, however, which, it +must be remembered, has been made to include a great many distinct +diseases.[15] + +[Footnote 13: Quoted by Murchison.] + +[Footnote 14: Murchison.] + +[Footnote 15: Lyons.] + +When the disease occurs in individuals who are broken down in health +from any cause[16]--as, for instance, previous illness, deficient +food, long-continued anxiety, or great fatigue--it not infrequently +presents symptoms of an asthenic character. The febrile reaction is +then less intense, and the pulse feebler and more frequent, than in +the variety just described. The duration of the disease in this form +is also generally longer. Murchison has proposed for it the name of +simple asthenic fever. + +[Footnote 16: Wood.] + +Under the name of ardent continued fever, Indian medical writers have +described a variety of the disease which is frequently met with in +tropical {234} countries, and which is usually much more severe than +the varieties already referred to. In addition to the symptoms +presented by these, Morehead[17] says that there is often intolerance +of light and sound, contracted and subsequently dilated pupils, +ringing noises in the ears, anxious respiration, pains in the limbs +and loins, and a sense of oppression at the epigastrium. The bowels +are sometimes confined; at others vitiated bilious discharges take +place. The tongue is white, often with florid edges, and the urine +scanty and high-colored. At the end of from forty-eight to sixty hours +the febrile phenomena may subside, the skin become cold, and death +take place from exhaustion and sudden collapse. In some cases the +symptoms of cerebral disturbance are greater in degree, and in these +coma may soon supervene upon delirium. Convulsions, epileptiform in +character, with relaxation of the sphincters and suppression of urine, +also frequently occur, and occasionally cerebral hemorrhage. In other +cases the symptoms of gastritis are more prominent, or jaundice may +appear and aggravate the disease. + +[Footnote 17: _Clinical Researches on Disease in India_, London, 1856. +See also "Croonian Lectures," by Sir Joseph Fayrer, _Brit. Med. +Jour._, April 29, 1882.] + +Symptoms closely resembling those just described are occasionally met +with in this country in patients who have been exposed for some time +to the direct rays of the summer sun, but who have escaped a +sunstroke. Indeed, a few writers have been so much impressed with the +general resemblance which this latter condition bears to the fevers +that they have insisted upon including it in this group, and have +given it the name of thermic or heat fever. This view of the pathology +of sunstroke has, however, never been generally accepted. + +One of the most characteristic symptoms of the disease in all its +forms is the rapid rise of temperature, which may in ephemera be as +great as from four to seven degrees in the course of a few hours, and +which may be followed in a few hours more by an equally abrupt +defervescence. When the fever is more prolonged, although the +temperature rises rapidly, it may not attain its greatest elevation +for from forty to sixty hours after the onset of the symptoms, and its +fall will be more gradual than in the preceding variety. +Unfortunately, there are no reliable thermometric records of ardent +continued fever. The urine is usually scanty and high-colored during +the height of the fever, especially in the severer forms of the +disease. Its specific gravity is high, and it contains a large amount +of solids, especially of urea. With the fall of the temperature it +rapidly increases in quantity, and is very apt to let fall a copious +lateritious sediment on cooling. According to Parkes,[18] who closely +observed six cases with the view of determining this question, +albuminuria does not occur at any stage of the disease. Convalescence +is usually rapid, and is not liable to be interrupted by the +occurrence of sequelae. + +[Footnote 18: _The Composition of the Urine_, by Edmund A. Parkes, +M.D., London, 1860.] + +DIAGNOSIS.--The diagnosis in those cases of simple continued fever in +which the connection between the disease and some one of the +conditions which have been referred to above as capable of exciting it +has been distinctly made out, presents little difficulty. It is +otherwise, however, when this relationship is not apparent. Indeed, +the symptoms of the disease so closely resemble those of an abortive +or mild attack of typhoid or typhus fever, in which the characteristic +eruption is wanting, that the {235} physician may sometimes remain in +doubt as to the nature of the disease he has been called upon to +treat, even after the recovery of the patient. This difficulty will of +course be especially likely to present itself during the epidemic +prevalence of these diseases. Simple continued fever may, however, +generally be distinguished from either of the latter by the much +greater severity of its initial symptoms, and particularly by the +rapid rise of temperature--a rise of from four to seven degrees in the +course of a few hours--which does not take place in these fevers, but +which, it must be remembered, may occur in erysipelas, measles, +pneumonia, and some other diseases. The absence of a characteristic +eruption, although it would not render it certain, would be in favor +of the diagnosis of simple continued fever, as would also the absence +of diarrhoea in cases in which there was difficulty in deciding +between this disease and typhoid fever. On the other hand, Murchison +regards the presence of an herpetic eruption on the lips as almost +pathognomonic of simple continued fever; but in this country such an +eruption is not an infrequent attendant upon fevers of malarial +origin, and many observers attach great importance to it in the +diagnosis of these diseases. + +Simple continued fever is not likely to be mistaken for relapsing +fever, except during epidemics of the latter disease. It may be +discriminated from relapsing fever, the first paroxysm of which it +closely resembles, by the absence of severe articular pains, of +tenderness in the epigastric zone, of enlargement of the liver and +spleen, and of jaundice. It may be mistaken for tubercular meningitis, +especially in those cases in which the nervous symptoms are more than +usually prominent, or in which a hereditary predisposition to +tuberculosis exists; but its true nature may generally be recognized +by its more abrupt commencement, and by the absence of the constant +vomiting, screaming fits, strabismus, and paralysis so characteristic +of the latter disease. + +It is scarcely necessary to add that a local inflammation or a +traumatic cause may give rise to symptoms simulating those of simple +continued fever, and that the diagnosis of this disease must be +uncertain until these conditions have been positively ascertained to +be absent, or, if present, until they have been proved to be +complications, and not the causes of the disease. + +PROGNOSIS.--The prognosis of this disease, as it is met with in this +country, is favorable. Indeed, when uncomplicated it may be said to +end invariably in recovery, except in the aged and feeble, in whom, +when it occurs during the great heat of the summer season, it is apt +to assume the asthenic form, and to be accompanied by symptoms of a +grave character. The ardent continued fever of the tropics, on the +other hand, not infrequently terminates fatally, or may leave the +sufferer from it a chronic invalid for life, which is frequently +shortened by obscure cerebral or meningeal changes, which give rise to +irritability, impaired memory, epilepsy, headache, mania, partial or +complete paraplegia, or blindness.[19] + +[Footnote 19: Sir Joseph Fayrer, K.C.S.I., M.D., F.R.S., _Brit. Med. +Jour._, April 29, 1881, p. 607.] + +ANATOMICAL LESIONS.--Death so rarely occurs in this latitude from +simple continued fever that the opportunities for making post-mortem +examinations do not often occur. There are, however, a sufficient +number of such examinations on record to show that the disease gives +{236} rise to no specific lesions. According to Murchison and +Martin,[20] inspection in fatal cases of ardent continued fever +usually reveals the presence of great congestion of all the internal +organs and of the sinuses of the brain and pia mater, of an increased +amount of intracranial fluid, and occasionally of an effusion into the +abdominal cavity, and more rarely into the thoracic cavity. + +[Footnote 20: _The Influence of Tropical Climates on European +Constitutions_, by James Ranald Martin, F.R.S., London, 1856.] + +TREATMENT.--In the milder forms of the disease little or no treatment +is required--a fact which seems to have been recognized and acted upon +long ago, since Strother remarks that the cure of it is so easy that +physicians are seldom consulted about such patients. An emetic when +the attack has been caused by excesses of the table, and there is +reason to believe that there is undigested food in the stomach, a +purgative when constipation exists, and cooling drinks, the +effervescing draught or some other saline diaphoretic, are usually the +only remedies that are called for. In cases in which the febrile +action is more intense and prolonged, in addition to the use of these +remedies an effort should be made to reduce the heat of the skin and +the frequency of the pulse by sponging with cold water and by the +administration of digitalis and aconite. The headache which is often a +distressing symptom may usually be relieved by the application of +evaporating lotions, and restlessness quieted by the bromides. +Subsequently, quinia may be given with advantage. The patient should +be restricted to liquid diet during the continuance of fever. + +In the asthenic form quinia and the mineral acids, nutritious food, +and very frequently alcoholic stimulants, must be given from the +beginning. In the treatment of the ardent continued fever of the +tropics the cold affusion or the cold bath, with quinia, would appear +to be indicated, but Morehead and other Indian physicians advise the +use of evacuants with copious and repeated venesections, cupping, and +leeches, aided by tartar emetic, till all local determination and the +chief urgent symptoms are removed; and Murchison expresses the belief, +founded on his own observations, that life is often sacrificed by +adopting less active measures. + + + + +{237} + +TYPHOID FEVER. + +BY JAMES H. HUTCHINSON, M.D. + + +DEFINITION.--An endemic infectious fever, usually lasting between +three and four weeks, and associated with constant lesions of the +solitary and agminate glands of the ileum, and with enlargement of the +spleen and mesenteric glands. Its invasion is usually gradual and +often insidious. Sometimes the only symptoms present in the beginning +are a feeling of lassitude, some gastric derangement, and a slight +elevation of temperature; at others there are slight rigors or chilly +sensations, headache, epistaxis, diarrhoea, and pain in the abdomen. +The principal symptoms of the fully-formed disease are a febrile +movement possessing certain characters, headache passing into delirium +and stupor, diarrhoea associated with ochrey-yellow stools, +tympanites, pain and gurgling in the right iliac fossa, a red and +furred tongue, which later often becomes dry, brown, and fissured; a +frequent pulse; an eruption of rose-colored spots, occurring about the +seventh or eighth day, slightly elevated above the surface, +disappearing under pressure, and coming out in successive crops, each +spot lasting about three days; prostration not marked in the +beginning, but rapidly increasing; and occasionally deafness, sweats, +and intestinal hemorrhages. When recovery takes place, the +convalescence is usually tedious, and may sometimes be protracted by +the occurrence of one or more relapses. + +SYNONYMS.--The following are a few of the many names which have been +given to the disease at different times. Most of them have ceased to +be applied to it, and only three or four of them are at present in +general use: Febris Mesenterica, 1696; Slow Nervous Fever, 1735; +Febricula or Little Fever, 1740; Typhus Nervosus, 1760; Miliary Fever, +1760; Typhus Mitior, 1769; Synochus, 1769; Common Continued Fever, +1816; Gastro-Enterite, 1816; Entero-Mesenteric Fever, 1820; Abdominal +and Darm Typhus, 1820; Typhus Fever of New England, 1824; +Dothienterie, 1826; Enterite-folliculeuse, 1835; Infantile Remittent +Fever, 1836; Enterite Septicemique, 1841; Mucous Fever, 1844; Enteric +Fever, 1846; Intestinal Fever, 1856; Ileo-Typhus, 1857; Pythogenic +Fever, 1858; Mountain Fever, 1870. + +NAME.--It has been objected to the name "typhoid fever" as a +designation for this disease that it tends to perpetuate among the +laity the mistaken impression that typhoid fever is only a modified +typhus fever, and also that the word typhoid has been generally +applied to a condition of system which is common to a great many +different diseases, {238} and which is not of necessity present in +this. In spite of these objections, and although it must be admitted +that they are not without force, I prefer to retain the name typhoid +fever, and for the following reasons: 1st. It was the name given to +the disease by Louis, to whom we owe the first full and accurate +description of it. 2d. It is the name by which it is best known to the +profession, not only in this country but abroad. 3d. No other name has +been proposed for it which is not quite as much open to criticism. +Thus the term enteric fever, originally suggested by the late George +B. Wood, and adopted by the London College of Physicians in its +_Nomenclature of Diseases_, is objectionable because it brings into +undue prominence the intestinal lesions and implies that they are the +cause of the fever. The same objection may be urged against the name +"intestinal fever," proposed by Budd. The name "pythogenic fever" +rests upon a theory of the disease which has never been proven, and is +regarded by most observers as untenable. Under these circumstances +even the influence of its distinguished proposer, the late Dr. +Murchison, has been insufficient to secure its adoption by the +profession at large. + +HISTORY.--Certain passages in the writings of Hippocrates have been +appealed to by Murchison and other physicians in support of the +opinion that typhoid fever was a disease of at least occasional +occurrence in ancient times; but, although from the nature of its +causes it is probable that it has occurred in all ages and wherever +men have congregated in towns and villages, the descriptions given by +the Father of Medicine in the passages alluded to are not sufficiently +full to render it at all certain that typhoid fever had ever come +under his observation. Indeed, there is no author of an earlier date +than Spigelius[1] whose writings furnish any positive evidence that he +ever met with the disease. Spigelius, however, in spite of the doubt +thrown upon his observation by Hirsch,[2] would seem to have had +opportunities for examining the bodies of those who had died of it, +since he gives an account of several autopsies, in which he says that +the small intestine was inflamed and that that part of it next to the +caecum and colon was frequently sphacelated. Panarolus[3] also says +that the intestines had the appearance of being cauterized +("apparebant tanquam exusta") in some cases observed by him in Rome a +little later in the same century. Willis[4] would certainly appear to +have been familiar with two forms of fever, which, from the +description he gives of them, could have been nothing else but typhoid +and typhus fevers. Sydenham[5] also described a fever in which the +prominent symptoms were diarrhoea, vomiting, delirium, a tendency to +coma, and epistaxis, and which was distinguishable from the febris +pestilens by the absence of a petechial eruption. Baglivi[6] of Rome +in the latter part of the seventeenth century described the +haemitritaeus of previous writers {239} under the title of febris +mesenterica, and maintained that it was always accompanied by and +dependent on inflammation of the intestines and enlargement of the +mesenteric glands. A similar observation was made soon after by +Hoffmann,[7] and by Lancisi[8] in 1718. The latter seems to have fully +recognized the characteristics of the eruption, for he says that it +consisted of "elevated papules which disappeared completely on +pressure." In 1759, Huxham described, under the title "slow, nervous +fever," a disease which there can be no doubt was typhoid fever. He +moreover pointed out very clearly the distinctions between this +disease and another to which he gave the name of "putrid, malignant, +petechial fever," and which was unquestionably typhus. Sir Richard +Manningham[9] also described typhoid fever under the title of +"febricula, or little fever." In the preface of his work he calls +attention to its insidious origin, and to the fact that its gravity +was often underrated at its commencement, "till, at length, more +conspicuous and very terrible symptoms arise, and then the Physician +is sent for in the greatest hurry, and happy for the Patient if the +Symptoms, which are most obvious, do not, at this Time, mislead the +Physician to the Neglect of the little latent Fever, the true Cause of +these violent Symptoms." About the same time Morgagni[10] described +certain post-mortem examinations in which the lesions of the +intestines were evidently those of typhoid fever. Other authors, whose +works bear evidence that they were familiar with the symptoms or +lesions of typhoid fever, are Riedel, Roederer and Wagler, Stoll, +Rutty, Sarcone, Pepe, Fasano, Mayer, Wrenholt, Sutton, Bateman, Muir, +Edmonstone, Prost, Petit and Serres, Cruveilhier, Lerminier, and +Andral. + +[Footnote 1: _De Febre Semitertiana_, Frankf., 1624; Op. Om., +Amsterdam, 1745. Quoted by Murchison.] + +[Footnote 2: _Handbuch der Historisch-Geographischen Pathologie_, von +Dr. August Hirsch, Stuttgart, 1881.] + +[Footnote 3: _Observat. Med. Pentecostae; Romae_, 1652. Quoted by +Murchison.] + +[Footnote 4: _Dr. Willis's Practice of Physick_, translated by Samuel +Pordage, London, 1684.] + +[Footnote 5: _The Works of Thomas Sydenham, M.D., on Acute and Chronic +Diseases_, with a Variety of Annotations by George Wallis, M.D., +London, 1788.] + +[Footnote 6: _Opera Omnia Medico-practica et Anatomica_, Paris, 1788.] + +[Footnote 7: _Opera Omnia Physico-Medico_, 1699. Quoted by Murchison.] + +[Footnote 8: _Opera Omnia_, Geneva, 1718.] + +[Footnote 9: _The Symptoms, Nature, etc. of the Febricula or Little +Fever_, London, 1746.] + +[Footnote 10: Quoted by Hirsch.] + +To Bretonneau[11] of Tours appears to belong the credit of having +first distinctly pointed out the association between certain symptoms +and the lesions of the solitary and agminated glands of the ileum. He +regarded the disease of the intestinal glands as inflammatory, and +therefore gave to it the name "dothienenterie" or "dothienenterite" +(from [Greek: dothien], a tumor, and [Greek: enteron], intestine), +but, unlike Prost, fully recognized the fact that there was no +necessary relation between the extent of the intestinal lesions and +the gravity of the febrile symptoms. Hirsch, however, claims this +honor for Pommer, whose little work on _Sporadic Typhus_ he thinks has +not received the consideration its merits deserve. Louis, to whom for +his careful study of typhoid fever we owe a large debt of gratitude, +was also fully aware of the lesions of the intestinal glands which +occur in this disease. + +[Footnote 11: Quoted by Trousseau, _Archives Generales_, 1826.] + +The progress in pathology which observers were making was temporarily +impeded about this time by the fact that while typhoid fever was of +frequent occurrence in Paris, typhus fever was comparatively rarely +met with and had not been epidemic there for several years. +Bretonneau, Louis,[12] Chomel, and indeed the greater number of +contemporary French physicians, therefore fell into the error of +supposing that the fever which was then common in England was +identical with that which they were describing, while the English +physicians of the period, with but few {240} exceptions, contended +with equal strenuousness that there was but one form of continued +fever, and that this was very seldom associated with disease of the +intestines. In the second edition of his work Louis abandoned his +former opinion, and admitted that the typhus fever of the English was +a very different disease from that which formed the subject of his +treatise; but the confusion which existed in England in regard to this +disease was not completely dispelled until the appearance in 1849 and +the following two years of several papers on this subject by Sir +William Jenner,[13] in which it was conclusively demonstrated that +typhoid and typhus fevers were separate and distinct diseases. In +Germany, however, the non-identity of these diseases was recognized as +early as 1810. Murchison says that the names by which they are still +generally known in that country, typhus exanthematicus and typhus +abdominalis, were given to them not long after. + +[Footnote 12: _Researches Anatomiques, Pathologiques et Therapeutiques +sur la Maladie connue sur les Noms de gastro-entente, etc._, par P. C. +A. Louis, Paris, 1829.] + +[Footnote 13: _Med. Chir. Trans._, vol. xxxiii.; _Edinburgh Monthly +Jour. of Med. Sci._, vols. ix. and x., 1849-50; and _Med. Times_, +vols. xx., xxi., xxii., xxxiii., 1849-51.] + +The contributions made by American physicians to the knowledge of +typhoid fever have been both numerous and important. In 1824 it was +described by Nathan Smith[14] under the name of typhus fever of New +England, and in 1833, E. Hale, Jr.,[15] of Boston, published in the +_Medical Magazine_ for December an account of three dissections of +persons considered by him to have died of the disease. In reference to +these cases, Bartlett[16] says that if the diagnosis could be looked +upon as certain and positive they would constitute the first published +examples of intestinal lesion in New England. In February, 1835, +William S. Gerhard of Philadelphia, who was then under the impression +that the two diseases were identical, reported two cases under the +name of typhus fever, the symptoms and post-mortem appearances of +which he showed differed in no respect from those he had been +accustomed to see in the cases of typhoid fever he had observed with +Louis during his studies in Paris. The year after Gerhard had, +however, the opportunity of observing an epidemic of true typhus +fever, and was at once struck with the difference between the symptoms +of the cases which then fell under his care and of those he had seen +in Paris. In an admirable paper which appeared in the numbers of the +_American Journal of the Medical Sciences_ for February and August, +1837, he points out very clearly the differential diagnosis between +the two diseases. He particularly insisted on the marked difference +between the petechial eruption of typhus and the rose-colored eruption +of typhoid fever. He showed that the latter disease was invariably +associated with enlargement and ulceration of Peyer's patches and with +enlargement of the mesenteric glands, and that these conditions were +never presented in the former. He also fully recognized the fact that +typhus fever was eminently contagious, while, on the other hand, he +was fully aware that typhoid fever was not contagious under ordinary +circumstances, "although in some epidemics," he says, "we have strong +reason to believe it becomes so." The appearance of this paper marks +an epoch in the history of typhoid fever. Murchison, when speaking of +it, says that to Gerhard, and Pennock (who was associated with Gerhard +in his observations) certainly {241} belongs the credit of first +clearly establishing the most important points of distinction between +this disease and typhus fever, and M. Valleix alludes to it in terms +equally complimentary. It is undoubtedly owing to it, more than to any +other cause, that the differential diagnosis of these two diseases was +perfectly understood by the great body of the profession in this +country long before the question of the relation which they bore to +each other was definitely settled in Great Britain,[17] or even in +France. + +[Footnote 14: _Medical and Surgical Memoirs_, Baltimore, 1831.] + +[Footnote 15: _Observations on the Typhoid Fever of New England_, +Boston, 1839.] + +[Footnote 16: _The History, Diagnosis, and Treatment of the Fevers of +the United States_, 1842.] + +[Footnote 17: The honor of having first clearly pointed out the +distinguishing characters of typhoid and typhus fevers has been +recently claimed for Sir William Jenner, but, as we have seen above, +his papers on this subject were not published until thirteen years +after that of Gerhard.] + +Bartlett gave in the _Medical Magazine_, June, 1835, a short account +of the entero-mesenteric alterations in five cases of unequivocal +typhoid fever, which alterations, he said, corresponded exactly to +those described by Louis. In the same year, James Jackson, Jr., of +Boston, published an account of the intestinal lesions observed by him +in cases during the years 1830, 1833, and 1834; and again in a _Report +of Typhoid Fever_, communicated to the Massachusetts Medical Society +in June, 1838, says that the alterations of Peyer's patches had been +noticed at the Massachusetts General Hospital previous to 1833 in +cases which were carefully examined. In 1840, Shattuck of Boston +published in the _American Medical Examiner_ an account of some cases +of typhoid and typhus fever which he had observed at the London Fever +Hospital during the previous year. In this paper, which had been +already communicated to the Medical Society of Observation of Paris, +and which had unquestionably exerted a marked influence upon medical +thought there, he pointed out very fully the distinguishing +characteristics of each disease. In 1842, Dr. Bartlett issued the +first edition of his work on _The History, Diagnosis, and Treatment of +the Fevers of the United States_, which contains very full +descriptions of both of these diseases, and of the means by which they +may be distinguished from each other. Since then there have been +numerous additions in this country to the literature of typhoid fever, +among the most important of which may be mentioned the chapter on the +disease in the respective works on _The Practice of Medicine_ by +Professors Wood and Flint, the article on typho-malarial fever in the +_Transactions_ of the International Medical Congress of 1876, and the +article in the work on _The Continued Fevers_, by James C. Wilson. +Abroad, the medical press has been no less active. Within the last +twenty or thirty years Jaccoud and Trousseau in France, Liebermeister +and Hirsch in Germany, and Tweedie and Cayley in England, have all +made important additions to our knowledge of the disease. To the late +Dr. Murchison[18] of London, however, is justly due the honor of +having produced the best treatise on typhoid fever in any language, +and the writer cheerfully acknowledges that he has drawn largely upon +it for the material of the present article. + +[Footnote 18: _A Treatise on Continued Fevers_, London, 1873.] + +GEOGRAPHICAL DISTRIBUTION.--Although it will be generally admitted +that the conditions of civilization favor the occurrence and extension +of typhoid fever, yet there is abundant evidence that they are not +absolutely necessary to its production, as there is no country, +whether civilized or not, of the diseases of which we have any +knowledge, in which it has not occasionally made its appearance, being +met with in every variety of climate. It is endemic in North America, +attacking alike the inhabitants {242} of Greenland and British America +and those of Mexico. In our own country it prevails from time to time +in every State of the Union, committing its ravages as well among the +rocks and hills of New England as in the more fertile valleys of the +West and South. In many of the newly-settled portions of our country +malarial fevers are, as is well known, exceedingly rife. In +proportion, however, as towns and cities spring up, and as the land is +properly drained, they diminish in frequency, and are gradually +replaced, to a certain extent at least, by typhoid fever; but the +influences which produced them retain for a long time enough of power +to stamp their impress upon all other diseases. In large portions of +the Western and Southern States typhoid fever is therefore rarely +uncomplicated, and is much more likely to assume the form which will +be fully described later as typho-malarial fever. + +Typhoid fever has also occurred frequently in Central America and the +West India Islands. It has prevailed from time to time in the states +of South America, and occasionally assumed in some of them--as, for +instance, Brazil and Chili--an epidemic form. + +Typhoid fever is endemic in the British Isles, but, according to +Murchison, is most common in England, more common in Ireland than in +Scotland, and in Scotland more common on the west than on the east +coast. It also exists as an endemic disease in every country of the +continent of Europe, from Sweden and Norway on the north to Turkey on +the south, and in some of them--as, for instance, France and +Germany--would seem to be of much more frequent occurrence than in +this country, or even in England. Medical literature is also not +deficient in evidence that it has prevailed at various times in all +the different countries of Asia and Africa and in Australia. Morehead +asserted in the first edition of his _Clinical Researches on Diseases +in India_ that India enjoyed an absolute immunity from typhoid fever, +but in the second edition of this work he acknowledged that a larger +experience had led him to change his opinion on this point. Moreover, +the writings of Annesley, Twining, and other Indian authors furnish +convincing proof that the disease is by no means unknown in that +country. Indeed, even the relative immunity from it which it has been +claimed that tropical and subtropical countries possess has been +found, upon a fuller study of the diseases of these countries, not to +exist to anything like the degree that was formerly supposed. + +The occasional occurrence of typhoid fever in islands separated from +the main land by a considerable distance--as, for instance, the island +of Norfolk,[19] which is situated in the Pacific Ocean four hundred +miles west of South America--is an interesting fact, and one which, +with the present limits to our knowledge on the subject, it is +impossible to explain satisfactorily. + +[Footnote 19: Metcalfe, _Brit. Med. Jour._, Nov., 1880.] + +The ETIOLOGY of typhoid fever may be considered under the heads of--1, +predisposing, 2, exciting causes. + +1. PREDISPOSING CAUSES.--All observers agree that the predisposition +to typhoid fever is greater in childhood and early adult life than +after thirty years of age. Thus, Murchison states that during +twenty-three years nearly one-half the admissions to the London Fever +Hospital were of patients between fifteen and twenty-five years of +age, and that in more than a fourth, the patients were under fifteen +years. On the other hand, {243} in less than a seventh were they over +thirty, and in only one in seventy-one did their ages exceed fifty. +Taking these facts in connection with the circumstance that the entire +population of England and Wales in 1861 was 12,481,323 persons under +thirty years of age and 7,584,901 above thirty, it follows, he says, +that persons under thirty are more than four times as liable to +enteric fever as persons over thirty. Jackson found that the average +age of the patients in two hundred and ninety-one cases observed at +the Massachusetts General Hospital was a little over twenty-two years, +the average age in the fatal cases being somewhat greater than in +those in which recovery took place. Liebermeister, from an analysis of +a large number of cases treated at the hospital in Basle, has arrived +at the same conclusion. No age, however, enjoys a complete immunity +from the disease. Manzini[20] has recorded a case in which lesions of +Peyer's patches similar to those of typhoid fever were found in a +seventh-month foetus which died within half an hour after its birth. +Cases are also on record in which death has occurred from this disease +in the first few weeks of life. I have myself observed several cases +in young children at the Children's Hospital in Philadelphia. The +probability is, that it is of even more frequent occurrence in +children than is generally supposed, as this class of patients is not +often admitted into general hospitals, and as from the absence of some +of its characteristic symptoms when it occurs in the very young the +nature of the disease is often unrecognized. + +[Footnote 20: Quoted by Murchison.] + +On the other hand, the disease occurs not infrequently in advanced +life: 83 cases out of 5911 were observed at the London Fever Hospital +in persons over fifty, 27 in persons over sixty, and in 2 the age was +seventy-five. In a case recorded by D'Arcy the age of the patient was +eighty-six, and in one reported by Hamernyk it was ninety.[21] +Bartlett long ago contended that the disease was not so rare as was +generally supposed among people over forty years of age; and there is +really no good reason to believe that the susceptibility to the causes +of the disease in an unprotected person diminishes with advancing +years, the immunity from this disease which elderly people appear to +enjoy being probably due to the fact that, as the disease is not +uncommon in early life, they are in many instances protected by having +already passed through an attack. + +[Footnote 21: Quoted by Murchison.] + +The mean age of the male patients treated at the London Fever Hospital +was slightly in excess of that of the female, but in the cases +analyzed by Jackson the reverse of this was observed. + +The statistics of all general hospitals, with very few exceptions, +show a greater or less preponderance of males over females among the +typhoid fever patients treated in them. According to Murchison, of +5988 cases admitted into the London Fever Hospital during twenty-three +years, 3001 were males and 2987 were females. Of 891 cases admitted +into the Glasgow Infirmary during twelve years, 527 were males and 364 +females. Liebermeister states that 1297 male typhoid patients and 751 +female were treated in the hospital at Basle from 1865 to 1870. +Occasionally, the difference is even greater than is indicated by +these figures. Thus, of 138 cases observed by Louis, all but 32 +occurred in males. When, however, we consider that the proportion of +men who apply for admission to hospitals when sick is much larger than +that of women, we should hesitate before accepting these statistics as +proof that the former {244} are more liable to be attacked by typhoid +fever than the latter. Indeed, the opinion which Murchison expresses +is generally accepted as correct by authors, that neither sex is more +likely than the other to contract the disease. Liebermeister asserts +that pregnant and puerperal women and those who are nursing infants +enjoy a relative immunity. On the other hand, Nathan Smith says that +while the sexes are equally liable to it, more women are cut off by it +than men, in consequence of its appearance during pregnancy or soon +after parturition. + +It was long ago pointed out by certain French observers that newcomers +are much more liable to be attacked by typhoid fever than persons who +have lived for some time in an infected locality. In 129 cases +examined with reference to this point by Louis, the patients in 73 had +not resided in Paris more than ten months, and in 102 not more than +twenty months. Bartlett noticed that during an epidemic in Lowell +which he had the opportunity of observing the disease attacked the +recent residents in much larger proportion than the old. Liebermeister +also calls attention to this peculiarity of the disease. Murchison's +experience in reference to this point has been somewhat similar, for +he found upon examination of the records of the London Fever Hospital +that 21.84 per cent. of the patients admitted there for typhoid fever +had been residents of London for less than two years. Almost all of +these patients came, he says, from the provinces of England, and were +in good health and comfortable circumstances at the date of their +arrival in London and for some time after. Moreover, a large +proportion of them were first attacked within a few weeks after +changing their residence from one part of London to another. He also +refers to instances in which successive visitors at the same house at +intervals of months, or even years, have been seized shortly after +their arrival with typhoid fever or with diarrhoea, from which the +ordinary occupants were exempt. These facts indicate with sufficient +clearness that habitual exposure to the causes of the disease confers, +to a certain extent at least, an immunity from their effects, just as +it does in the various forms of disease arising from malaria. It is +not unlikely, as has been suggested by Wilson,[22] that one of the +causes of the frequency of typhoid fever in the early autumn in our +American cities among well-to-do people is to be formed in the +circumstance that during an absence of two months or more in the +mountains or by the sea they have to some extent lost the immunity +acquired by habitual exposure to sewer emanations, and return to the +atmosphere of the city unprotected. + +[Footnote 22: The occurrence of typhoid fever in the early fall among +persons who have spent the summer out of town is, however, susceptible +of another explanation. In many instances they have returned to houses +which have been not only unoccupied, but closed, during several +months, and which, in consequence of the more or less complete +evaporation of the water in the traps of the drain-pipes, have been +thoroughly permeated by sewer gas.] + +There is no evidence that any particular occupation acts as a +predisposing cause of typhoid fever. Among the 621 patients treated at +the Pennsylvania Hospital during the last ten years, were +representatives of every branch of industry, and the same fact has +been observed at every general hospital, not only in this country, but +abroad. There is also no reason to believe that the station in life of +itself exerts much influence in predisposing to the disease. The rich +suffer equally with the poor. It would appear, indeed, that since the +recent general introduction of ill-ventilated water-closets and +stationary washstands into the houses of the {245} better classes the +liability of the former to suffer from the disease is greater than +that of the latter. + +Persons recovering from an illness or in an infirm condition of health +do not appear to be more liable than others to be attacked by typhoid +fever. Among the many patients who have fallen under my care only a +very few were in ill-health at the time of their seizure. The same +fact has been noticed by Murchison and other observers. Indeed, +Liebermeister goes so far as to say that typhoid fever attacks by +preference strong and healthy persons, while it avoids those suffering +with chronic ailments. That this latter class of patients enjoys no +immunity from the disease when exposed to its causes is shown by a +fact which he himself records. During his service at the hospital at +Basle from 1865 to 1871 several of the patients in the medical and +surgical wards were attacked by typhoid fever, the cases being +especially numerous in two rooms which were situated one directly over +the other. Upon investigation it was found that a wooden pipe which +extended from the sewer to the roof ran by both of these rooms. The +sewer at the point where this pipe ran into it was of faulty +construction, and was turned at a right angle, so that the refuse +matter collected there. Since this source of infection was made known +repeated cleansings, washings, and disinfections have been followed by +satisfactory improvement, and Liebermeister believes that if the sewer +were entirely altered the infection would disappear. + +It would seem only natural that intemperance, by diminishing the +powers of resistance in the individual, would increase his liability +to contract typhoid fever, but there is no proof that it does so. Few +of the patients who have come under my care were intemperate, and +still fewer were broken down by this cause. There is also no evidence +that grief, fear, or any other depressing emotion is a predisposing +cause of the disease, and the same may be said of bodily fatigue and +overcrowding. On the other hand, much importance has been attached by +writers to idiosyncrasy as a predisposing cause of typhoid fever. What +the peculiarities of constitution are which increase the liability to +the disease are not definitely known, but there can be no question +that it occurs much more frequently, and is much more fatal, in some +families than in others. + +Typhoid fever occurs with the greatest frequency in this country, as +it does with very few exceptions elsewhere, during the latter half of +summer and the early part of autumn. Indeed, its greater prevalence at +this season than at other times has given to it the name of "autumnal" +and "fall fever," by which it is popularly known in many sections of +this country as well as of England. On the other hand, the disease is +usually at its minimum in May and June. The number of cases, however, +does not usually immediately diminish upon the onset of cold weather. +On the contrary, R. D. Cleemann,[23] from a comparison of the +mortality returns of Philadelphia for a period of ten years, observed +that after diminishing in November they not infrequently underwent a +marked increase in December. Of 621 cases treated at the Pennsylvania +Hospital during the last ten years, 89 were admitted during spring, +259 during summer, 182 during autumn, and 91 during winter. Of 5988 +cases treated at the London Fever Hospital,[24] 759 were admitted in +the {246} spring, 1490 in summer, 2461 in autumn, and 1278 in winter. +Of the whole number, 27.7 per cent. were admitted in the two months of +October and November, and in April and May only 7.3 per cent. +Hirsch[25] has published statistics which do not differ materially +from these. He also mentions the interesting fact that in Rio Janeiro +the maximum of the disease occurs in the months from March to June, +or, in other words, in the season which in that latitude corresponds +to our autumn. There are, however, some exceptions to the general rule +of the greater prevalence of the disease during the autumn. Bartlett, +who was aware of its greater frequency at that time, refers to an +extensive and fatal epidemic which occurred in the city of Lowell in +Massachusetts during the winter and early spring; and similar +visitations have been observed in other places. + +[Footnote 23: _Transactions of the College of Physicians of +Philadelphia_, 3d S. vol. iii.] + +[Footnote 24: Murchison.] + +[Footnote 25: _Handbuch der Historisch-Geographischen Pathologie_, +Stuttgart, 1881.] + +Most authors agree with the statement made by Murchison, that typhoid +fever is unusually prevalent after summers remarkable for their +dryness and high temperature, and that it is unusually rare in summers +and autumns which are wet and cold. Certainly, the severest epidemic +of the disease which has been observed in Philadelphia in several +years occurred in the year 1876, during and after a summer of +exceptionally high temperature, and one characterized by a decidedly +diminished rainfall. Still, there can be no question that the +increased prevalence of the disease at this time was due, in part at +least, to the crowded condition of the city consequent upon the +Centennial Exhibition. In 1872, although the mean of the summer +temperature was slightly higher than that of 1876, the disease did not +prevail in an epidemic form. This may be explained by the fact that +the rainfall of the summer months of this year was decidedly greater +than the average. Hirsch, however, attaches much less importance to +temperature as a factor in the production of typhoid fever than most +other authors. He says that he has found, from a comparison of a large +number of epidemics, that the disease occurs almost as often in cool +as in hot summers, in cold as in warm autumns, and in mild as in +severe winters. Murchison, moreover, admits that mere dryness of the +atmosphere is not conducive to an increase of typhoid fever. On the +contrary, he says, warm, damp weather, when drains are most offensive, +is often followed by an outbreak of the disease. + +The relation which temperature and moisture bear to the causation of +typhoid fever is therefore not definitely ascertained. It is certain, +however, that the largest number of cases does not occur at the period +of the greatest heat, but is usually not observed until from six weeks +to two months afterward, and the minimum is not reached until about +the same length of time after that of the most intense cold. This +difference in time Murchison explains by the hypothesis that the cause +of the disease is exaggerated or only called into action by the +protracted heat of summer and autumn, and that it requires the +protracted cold of winter and spring to impair its activity or to +destroy it. On the other hand, Liebermeister, who believes that the +breeding-places of typhoid fever lie deep in the earth, holds that the +time is consumed in the penetration of the changes of temperature to +the place where the typhoid poison is elaborated, in the development +of the poison without the human body, and in the period of incubation. +In some places the maximum of the disease is observed earlier in the +year than in others. In Berlin, for {247} instance, the largest number +of fatal cases occurs in October, while in Munich it does not occur +until February. This depends, he thinks, upon the difference in the +distance beneath the earth's surface of these breeding-places in +different localities, and the deeper they are the longer, he says, +will it be before they are affected by the heat of summer or the cold +of winter, since the changes of the temperature of the air are +followed by corresponding changes in the temperature of the earth more +and more slowly the deeper we go beneath the surface. + +Buhl and Pettenkofer have, as the result of a series of observations +carried on in Munich over a number of years, reached the conclusion +that an intimate relation exists between the variations in the degree +of prevalence of typhoid fever and the rise and fall of water in the +soil. When the springs were low they found that there was a marked +increase in the number of cases; when, on the other hand, they were +high, there was just as decided a diminution. Out of this fact they +have evolved the theory that the cause of typhoid fever lies deep in +the soil, and has the power of multiplying itself there, and that this +property is very much increased when the water-level sinks, and the +upper layers of the earth are consequently exposed to the air. It is, +on the contrary, diminished when the water-level rises and the earth +is again saturated with moisture. It is unquestionably true, as has +already been stated, that it is principally after hot and dry weather, +when the springs are of course low, that typhoid fever is most +prevalent, and that it very frequently subsides after the occurrence +of very heavy rains; but it is not necessary to adopt the theory of +Buhl and Pettenkofer to explain these facts. It seems quite as +probable that the increased prevalence of the disease after dry +weather is due, as suggested by Buchanan and Liebermeister, to the +greater amount of solid matter which is then suspended in the water of +the springs. A larger proportion of the germs of the disease, if there +should be any present in the soil, will therefore be contained in any +given quantity of the drinking-water. The theory fails to account, as +pointed out by Murchison, for the connection which is frequently +observed between defective house-drainage and outbreaks of typhoid +fever, occurring irrespectively of any variations in the subsoil +water. And, moreover, outbreaks of the disease have occurred under +precisely opposite circumstances, as the outbreak at Terling in 1867, +recorded by Thorne,[26] which was coincident with a rise in the +subsoil water after drought. + +[Footnote 26: Quoted by Murchison.] + +It is believed in many parts of our country that there is an +antagonism between typhoid fever and the various forms of malarial +fever, and it is unquestionably true that in many districts in which +the latter were formerly prevalent they have ceased to be frequent, +and have been replaced apparently by the former. In the cultivation of +the soil the causes of malarial fever disappear, or at least become +less potent. On the other hand, the increase of population and the +neglect of all sanitary laws in the building of towns, and the +construction of sewers with their house connections, seem to favor the +occurrence of typhoid fever. But there is no real antagonism between +the diseases. During the recent Civil War typhoid fever was not +infrequently developed in soldiers suffering from malarial disease. +Indeed, so frequent was it to have the manifestations of the two +diseases in the same individual that many observers at that {248} time +supposed they had a new disease to deal with, to which they gave the +name of typho-malarial fever. + +2. EXCITING CAUSES.--Much diversity of opinion has existed in times +past and to a certain extent continues to exist, in regard to the +contagiousness of typhoid fever. In the early part of this century +there was quite a number of good observers, including Nathan Smith in +this country, and Bretonneau and Gendron of Chateau du Loir in France, +who held the opinion it was an eminently contagious disease. Indeed, +Smith went so far as to say that its contagiousness was as fully +demonstrated as that of measles, small-pox, or any other disease +universally admitted to be contagious. This was also the opinion of +William Budd, who maintained that the contagious nature of typhoid +fever was the master truth in its history. The late Sir Thomas Watson +was also a warm supporter of the same view. At the present time, +however, the large majority of physicians, whose opportunities for +observation give weight to their opinions, do not regard the disease +as contagious in the strict sense of the word. During the past +twenty-four years I have been almost uninterruptedly connected with +large general hospitals, and during that time have had a large number +of cases of typhoid fever under my care, and a still larger number +more or less under my observation. During all this time I have never +known but one case to originate within a hospital, and that occurred +in a servant whose duties did not bring her in immediate contact with +the sick. Murchison's experience with a much larger number of cases +has been very similar. In twenty-three years, in which 5988 cases were +treated in the London Fever Hospital, only 17 residents contracted the +disease, and most of these had no personal contact with the sick. +Liebermeister asserts that he has never known a case to originate in a +hospital from direct contagion. When such cases appeared to have +occurred, they could generally be traced, he says, to some defective +sanitary condition of the hospital. + +There are, nevertheless, many facts on record which, unless duly +weighed, appear to lend a good deal of support to the theory of the +contagiousness of typhoid fever. Among the most important of these are +(1) the occurrence in rapid succession of several cases in the same +house, and (2) the limited epidemics which occasionally follow the +arrival of an infected person into a previously healthy locality. +These facts are, however, susceptible of an entirely different +explanation. + +1. In those instances in which several cases of the disease have +occurred in the same house, it not infrequently happens that some +defect in its sanitary conditions is detected, or that the +drinking-water is found to be impure. The same cause which produced +the first case may, therefore, also have produced those which +succeeded it. Indeed, the interval between the cases is sometimes so +short that for this reason alone, if there were no other, they could +scarcely be attributed to contagion. It not infrequently happens that +the seizure of one member of a large family is followed on the next +day by that of another, and on the third or fourth by that of still +another. Now, while it is undoubtedly true that the period of +incubation has appeared in some cases to be very short, we know that +under ordinary circumstances it is usually about two weeks. + +2. The explanation of the second fact is not more difficult, but in +order that it may be clear to the reader it will be well to give in +detail a few {249} of the instances on record in which the arrival of +an individual sick with typhoid fever in a previously healthy locality +has been followed by an outbreak of the disease. Nathan Smith refers +to two cases of this character. In both of these the disease appeared +to be communicated to several individuals by patients who had +contracted the disease elsewhere. So little is said in the reports of +these cases of the water-supply of the localities in which they +occurred, or of the manner of disposing of the discharges of the +patients, that they would scarcely now be used as arguments in favor +of the contagiousness of the disease. The report of a local epidemic +by Austin Flint, Sr., is more satisfactory in this respect, and is as +follows: A stranger was detained in a small village near Buffalo by an +illness which proved fatal in the course of a few days, and which was +recognized as typhoid fever by his attending physicians. Up to this +time, it is stated, typhoid fever had never been known in the +neighborhood. In the course of a month more than one-half of the +population, numbering forty-three, was attacked by the disease, and +ten had died. The family of the tavern-keeper at whose house the +stranger lodged was the first to suffer, and of the families +immediately surrounding the tavern but one wholly escaped, that of a +man named Stearns. Upon investigation, it was ascertained that this +family alone, of all these families, did not use the well belonging to +the tavern, but had its own water-supply. The occurrence of the +disease naturally produced great excitement, and Stearns, between whom +and the tavern-keeper a quarrel existed, was suspected of having +poisoned the well; but an examination of the water showed this +suspicion to be unfounded. There can, however, be little doubt that +the water of the well, which was in all probability contaminated by +the discharges of the stranger, was the means of propagating the +disease; for although it is said that the family of Stearns was cut +off by the quarrel from all intercourse with that of the +tavern-keeper--a fact upon which some stress is laid by Flint--it does +not appear that a similar isolation existed as regards the other +families affected.[27] + +[Footnote 27: _A Treatise on the Principles and Practice of Medicine_, +by Austin Flint, M.D., Philadelphia, 1868.] + +The manner in which the arrival of a sick person may cause the +dissemination of the disease in a previously healthy community is even +better shown by the following histories of local outbreaks:[28] + +"The water-supply pipes of the town of Over Darwen were leaky, and the +soil through which they passed was soaked at one spot by the sewage of +a particular house. No harm resulted till a young lady suffering from +typhoid fever was brought to this house from a distant place. Within +three weeks of her arrival the disease broke out and 1500 persons were +attacked. At Nunney a number of houses received their water-supply +from a foul brook contaminated by the leakage of a cesspool of one of +the houses, but no fever showed itself till a man ill with typhoid +came from a distance to this house. In about fourteen days an outbreak +of fever took place in all the houses." + +[Footnote 28: Wm. Cayley, M.D., _Brit. Med. Jour._, March 15, 1880.] + +There are many other observations which seem to render it certain that +the alvine dejections are a most important medium by which typhoid +fever is communicated to others; and yet there is no evidence that +they possess this power in a fresh condition. They have been +repeatedly examined, and even handled, with impunity, and, as has +already been stated, it {250} is rare for the disease to be imparted +to the immediate attendants upon the sick, or in a well-ventilated +hospital to the other patients in the same ward, provided that the +discharges are disinfected and removed immediately after being passed, +and the bed-linen and clothes of the patient changed whenever they are +soiled. The feces must therefore undergo some changes before they +become possessed of virulent properties. This appears to be shown +conclusively by the following facts: (1) laundresses who wash the +soiled clothes of typhoid fever patients not infrequently contract the +disease; (2) the occupants of houses connected by ill-trapped drains +with sewers into which the discharges of such patients have found +their way often suffer severely from the disease; and (3) the use of +water polluted by such discharges is, as has already been shown, +almost certain to induce the disease in persons not protected by a +previous attack. + +The following histories of outbreaks of typhoid fever will show +clearly how the dejections of patients may be the means of propagating +the disease to others: + +ILLUSTRATIVE CASES--Lausen[29] is a village lying on the railway +between Basle and Olten shortly before coming to the great Hauenstein +Tunnel. It is situated in the Jura, in the valley of the Ergolz, and +consists of 103 houses with 819 inhabitants. It was remarkably +healthy, and resorted to on that account as a place of summer +residence. With the exception of six houses it is supplied with water +by a spring with two heads which rises above the village at the +southern foot of a mountain called the Stockhalder, composed of +oolite. The water is received into a well built covered reservoir, and +is distributed by wooden pipes to four public fountains, whence it was +drawn by the inhabitants. Six houses had an independent supply--five +from wells, one from the mill-dam of a paper-factory. On August 7, +1872, ten inhabitants of Lausen, living in different houses, were +seized by typhoid fever, and during the next nine days fifty-seven +cases occurred, the only houses escaping being those six which were +not supplied by the public fountains. The disease continued to spread, +and in all 130 persons were attacked, and several children who had +been sent to Lausen for the benefit of the fresh air fell ill after +their return home. A careful investigation was made into the causes of +this epidemic, and a complete explanation was given. Separated from +the valley of the Ergolz, in which Lausen lies, by the Stockhalder, +the mountain at the foot of which the spring supplying Lausen rises, +is a side valley called the Furjust, traversed by a stream, the +Furlenbach, which joins the Ergolz just below Lausen, the Stockhalder +occupying the fork of the valley. The Furlenthal contains six +farm-houses, which were supplied with drinking-water, not from the +Furlenbach, but by a spring rising on the opposite side of the valley +to the Stockhalder. Now, there was reason to believe that under +certain circumstances water from the Furlenbach found its way under +the Stockhalder into one of the heads of the fountain supplying +Lausen. It was noticed that when the meadows on one side of the +Furlenbach were irrigated, which was done periodically, the flow of +water into the Lausen spring was increased, rendering it probable that +the irrigation water percolated through the superficial strata and +found its way under the Stockhalder by subterranean channels in the +limestone rock. Moreover, some years before a {251} hole on one +occasion formed close to the Furlenbach by the sinking in of the +superficial strata, and the stream became diverted into it and +disappeared, while shortly afterward the spring of Lausen began to +flow much more abundantly. The hole was filled up, and the Furlenbach +resumed its usual course. The Furlenbach was unquestionably +contaminated by the privies of the adjacent farm-houses; the soil-pits +communicated with it. Thus, from time immemorial, whenever the meadows +of the Furlenthal were irrigated the contaminated water of the +Furlenbach, after percolation through the superficial strata and a +long underground course, helped to feed one of the two heads of the +fountain supplying Lausen. The natural filtration, however, which it +underwent rendered it perfectly bright and clear, and chemical +examination showed it to be remarkably free from organic impurities, +and Lausen was extremely healthy and free from fever. On June 10th one +of the peasants of the Furlenthal fell ill with typhoid fever, the +source of which was not clearly made out, and passed through a severe +attack with relapses, so that he remained ill all summer; and on July +10th a girl in the same house, and in August a boy, were attacked. +Their dejections were certainly, in part, thrown into the Furlenbach; +and, moreover, the soil-pit of the privy communicated with the brook. +In the middle of July the meadows of the Furlenthal were irrigated as +usual for the hay crop, and within three weeks this was followed by +the outbreak at Lausen. + +[Footnote 29: William Cayley, M.D., _British Medical Journal_, Mar. +15, 1880.] + +In order to demonstrate the connection between the water-supply of +Lausen and the Furlenbach, the following experiments were performed. +The hole mentioned above as having on one occasion diverted the +Furlenbach into the presumed subterranean channels under the +Stockhalder was cleared out, and 18 cwt. of salt were dissolved in +water and poured in, and the stream again diverted into it. The next +day salt was found in the spring at Lausen. Fifty pounds of wheat +flour were then poured into the hole, and the Furlenbach again +diverted into it, but the spring at Lausen remained clear, and no +reaction of starch could be obtained, showing that the water must have +found its way under the Stockhalder, in part by percolation through +the porous strata, and not by distinct channels. + +Volz[30] refers to an epidemic which occurred at Gerlachsheim, a +village of Germany, some years ago, in which, in the course of three +weeks, 52 persons residing on one of the principal streets were +attacked by the disease. It was found, upon investigation, that they +all got their water from a well which was polluted by the stools of +the first patient. A. Pasteur[31] reports an epidemic caused by the +contamination of a well by typhoid dejections, and which ceased when +the use of the water was discontinued. Niericker[32] also reports an +outbreak which was found to be due to a similar pollution of the +drinking-water, and which likewise ceased when the water-supply was +derived from another source. + +[Footnote 30: _Schmidt's Jahrbuch_.] + +[Footnote 31: _Revue med. de la Suisse_, Mars 15, 1881.] + +[Footnote 32: _Schweiz. Corr. Bl._, ix. 1, 1879.] + +An outbreak of the disease which occurred in a farm-house situated +about eight miles from the city of Philadelphia came under my own +observation. The first case occurred in a young girl of sixteen, who, +with the exception of an occasional visit to the city, had not been +away from her own home for several months before she was {252} taken +ill. The disease ran in her a severe course, and eventually terminated +fatally. About three weeks afterward four other members of the family +were attacked, one of whom died. Two other persons, living in a house +on the opposite side of the road, but who were in the habit of +drinking water from the same well, also took the disease. There was no +other case of typhoid fever in the immediate vicinity, nor had there +been for some time. The farm-house is situated in a cup-shaped +depression, so that water flowed toward it from all directions. The +cellar was constantly filled with water during the winter, and just +before the outbreak had contained not only an unusually large +quantity, but also a large amount of decaying vegetable matter. The +well from which the family drew their drinking-water is situated +within a few feet of the kitchen door, and at some distance from the +cesspool used by the family, so that there was no reason to believe +that there was any communication between the two. The wall of the well +was found to be very much loosened by the roots of two trees growing +in the immediate vicinity. As the ground was also very much cut up by +the burrows of rats, the water used for the various household +purposes, and which was habitually thrown into a gutter which ran past +the well, found a ready access to it. There would seem to be but +little doubt that the first patient contracted the disease in some way +during her visits to the city, and that the disease in the other +patients arose from their drinking the water of the well which had +been polluted by that used in washing her soiled linen. + +Ballard[33] has shown very clearly that milk may also be a medium of +communication of the disease. He found that an epidemic which occurred +in the parish of Islington, London, in 1871 was (1) almost entirely +confined to a district comprised within a circle having a radius of +not more than a quarter of a mile; (2) that out of 62 families living +within this district, who were known to have suffered from typhoid +fever, 54 were constantly supplied with milk from a particular dairy, +and it was satisfactorily proved that at least three of the remaining +eight had occasionally partaken from the same source; and (3) that out +of 142 families, comprising all the customers of this dairy, and +living not only within the district above specified, but in other +parts of the parish, 70, or very nearly one-half, were invaded by +typhoid fever within the ten weeks during which the outbreak lasted. +Upon a visit to the farm from which the milk came it was ascertained +that a member of the dairyman's family had been ill with typhoid +fever, and that the water of the well which supplied the family with +drinking-water had been polluted by his discharges. Although the +dairyman denied that this water had ever been mixed with the milk, he +admitted that it had been used to wash the milk-pans. Murchison was +also able, in an outbreak which occurred in another district of +London, to trace the disease to the same source. + +[Footnote 33: _On a Localized Outbreak of Typhoid Fever in Islington_, +London, 1871.] + +Typhoid fever may be likewise propagated in consequence of the +contamination of the atmosphere by the typhoid poison. This may be the +result of allowing the undisinfected stools, or linen soiled by them, +to remain for some time exposed to the air, or may arise from +pollution {253} of the soil from the same cause or from defective +sewage. Hermann Schmidt[34] refers to several epidemics breaking out +in garrisons which he believed to be due to pollution of the soil. In +the citadel of Wurzburg typhoid fever occurred through several years, +and persisted in spite of the cutting off of the water-supply, which +was believed to be impure. It was finally found that the ground upon +which it was built was saturated with all kinds of impurities. Volz +refers to outbreaks of the disease from the same cause. + +[Footnote 34: _Die Typhus Epidemie in Fusillier Bat. zu Tubingen in +Winter 1876-77, enstanden durch einathmung, giftiger Grundluft_, +Tubingen, 1880.] + +But perhaps the most striking example of this mode of propagation of +the disease is that recorded by Budd,[35] and is as follows: Two +adjacent cottages, which for the sake of convenience may be designated +as Nos. 1 and 2, had a privy in common, which was in the form of a +lean-to against the gable end of No. 2. Through this privy there +flowed with very feeble current a small stream which formed the +natural drain for it. Having already performed this office for some +twenty or thirty other houses higher up its course, the stream had +acquired all the character of a common sewer before reaching the +cottages in question. About a quarter of a mile farther on it acted as +a drain for a privy, common as before, for two other cottages, Nos. 3 +and 4. Notwithstanding the condition of the stream, which was so foul +that it was said that the stink from it was often enough "to knock a +man down," no evil result appeared to have occurred until a man living +in No. 1 contracted typhoid fever--elsewhere, it was believed. As a +matter of course, all his discharges were thrown into the common +privy. In this way for more than a fortnight the stream which passed +through it was daily fed with the specific excreta from the diseased +intestines of the patient. No further cases occurred until the latter +end of the third week or the beginning of the fourth week, when +several persons were simultaneously attacked by the same fever in all +four cottages. From first to last, the outbreak was confined to these +four cottages, and there was no other case of typhoid fever at this +time in the neighborhood. + +[Footnote 35: _Typhoid Fever: Its Nature, Mode of Spreading, and +Prevention_, by William Budd, M.D., F.R.S., London, 1873.] + +The mattrass used by typhoid-fever patients, their bed-linen and +clothes, have each been the medium by which the disease has been +communicated to others. This is, as has already been pointed out, +unquestionably due to the fact that these articles are generally +soiled by their discharges, and that time has been allowed for the +latter to acquire infective properties. It seems not improbable that +the few cases in which the disease appears to have been contracted +from the dead body may be explained in the same way. The statistics of +the London Fever Hospital show that laundresses are more liable to +contract typhoid fever than the immediate attendants upon the sick. +This liability is greatest in those cases in which the bed-linen and +clothes of patients are not immediately disinfected after use. +According to Budd, the sputa in cases of typhoid fever where +bronchitis is excessive may sometimes contain the germs of the +disease, and mentioned a case in which he believed they were the means +by which the disease was propagated. + +The question naturally arises here, whether this is the only way in +{254} which the disease can originate. This is a subject which has +given rise to a good deal of controversy, and therefore demands some +consideration at our hands. On the one hand, it is argued that typhoid +fever never occurs in the absence of the specific poison or germ of +the disease, and that this is contained principally, if not wholly, in +the alvine dejections. On the other hand, it is contended that it may, +and often does, originate spontaneously, and that all that is +necessary to produce it is the presence of decomposing fecal or other +organic matter, and the consequent contamination of the food, drink, +or atmosphere. Both of these views have found able advocates. Among +the upholders of the latter view is Murchison, who cites the histories +of several outbreaks of typhoid fever which occurred in localities +which had not been visited by it for many years, and which, after a +careful investigation of all the circumstances attending them, he was +forced to conclude had no connection with any previous case of the +disease, and could only be explained by admitting that it might +occasionally have an independent origin. Among the more remarkable of +these outbreaks is the following, which we give in Murchison's own +words: + +"In August, 1829, 20 out of 22 boys at a school at Clapham within +three hours were seized with fever, vomiting, purging, and excessive +prostration. One other boy, aged three, had been attacked with similar +symptoms two days before, and had died comatose in twenty-three hours; +another boy, aged five, died in twenty-five hours; all the rest +recovered. Suspicions were entertained that they had been poisoned, +and a rigorous investigation ensued. The only cause which could be +discovered was, that a drain at the back of the house, which had been +choked up for many years, had been opened two days before the first +case of illness, cleared out, and its contents spread over a garden +adjoining the boys' playground. A most offensive effluvium escaped +from the drain, and the boys had watched the workmen cleaning it out. +This was considered to be the cause of the disease by Latham and +Chambers, and by others who investigated the matter, and also by Sir +Thomas Watson. The morbid appearances in the two fatal cases were +described as like those of the common fevers of this country. Peyer's +patches and the solitary glands of the small and large intestines were +enlarged like 'condylomatous elevations,' and in one case the mucous +membrane over them was slightly ulcerated. The mesenteric glands were +enlarged and congested." + +"A remarkable instance of a circumscribed outbreak of fever was +recorded by Sir R. Christison in 1846. It occurred in an isolated +farm-house in the thinly-peopled county of Peebles, N.B. Every one of +the fifteen residents was seized with fever, and three died. Many of +the servants who worked during the day at the farm were also affected, +but none communicated the disease to their families who did not visit +the farm. There was no evidence that the disease was imported from +without, and the only explanation of the outbreak was, that the drains +and sewers were found all closed and obstructed with the accumulated +filth proceeding from the privies and farm-yard, the effluvia from +which was very offensive." + +"About Easter, 1848, a formidable outbreak of fever occurred in the +Westminster School and the Abbey Cloisters, and for some days there +{255} was a panic in the neighborhood respecting the 'Westminster +fever.' No case of fever had occurred in the Abbey Cloisters for three +years, and there was no evidence of its having been imported. Within +little more than eleven days it affected thirty-six persons, all of +the better class, and in three instances it proved fatal. Shortly +before its first appearance there occurred two or three days of +peculiarly hot weather, and a disagreeable stench, so powerful as to +induce nausea, was complained of in the houses in question. It was +found that the disease followed very exactly in its course the line of +a foul and neglected private sewer or immense cesspool, in which fecal +matter had been accumulating for years without any exit, and into +which the contents of several small cesspools had been pumped +immediately before the outbreak of fever. This elongated cesspool +communicated by direct openings with the drains of all the houses in +which it occurred; the only exception was that of several boys, who +lived in a house at a little distance, but who were in the habit of +playing every day in a yard in which there were several gully-holes +opening into the foul drain." + +The following cases would seem, however, to furnish stronger evidence +in favor of the occasional spontaneous origin of typhoid fever than +any of those referred to by Murchison. The first is recorded by P. +Herbert Metcalfe,[36] and occurred in Norfolk Island in the Pacific +Ocean, 400 miles from the nearest inhabited land. The patient was a +gentleman who had come from England four months previously. To +Metcalfe's certain knowledge, there had been no typhoid fever on the +island for fifteen months. Three years previously a man is reported to +have died of it, and in 1868 there had been an epidemic of fever, but +he could not ascertain of what kind. Upon inquiry, he found that his +patient had been drinking water from a well which had the reputation +of being unclean, and that he was the only person who had done so. He +also found that at a distance of seven feet there was an open sewer, +and that just opposite to the well much of the sewage-water became so +stagnant as to form an offensive cesspool. The well was cleaned out, +and at the bottom of it were found four feet of stinking sewage mud, +the skeleton of a duck, a pig's jaw, etc. The well was so situated +that had there been any typhoid fever previously to this case the +water could not have been contaminated by the specific poison, as the +above-named sewer only conveyed water from the kitchen, which is a +building detached from the dwelling-houses of the mission, and is far +from and on a higher level than the open closets in use. + +[Footnote 36: _British Medical Journal_, Nov. 6, 1880.] + +In the second case, which is reported by R. Bruce Low,[37] Medical +Officer of Health, Helmsley, Yorkshire, occurred in a lad who had not +been away from his home for months. No stranger had visited his house, +and there was no fever in the district, the last case having occurred +eight months previously in a sequestered valley eight miles away. The +patient's habits and those of his family were revoltingly dirty. The +garden privy was in bad repair, the filth level with the seat, and the +smell from it very offensive. Thirty years before there had been five +cases of slow typhus in the house. In his remarks on this case Low +says: "This case did not owe its origin to direct infection, and the +question naturally arises, was this a case originating de novo, or had +the poison {256} been due to infection in some way or another from the +cases which occurred thirty years previously?" + +[Footnote 37: _Brit. Med. Jour._, 1880.] + +There can be but little doubt that in many of the cases cited by +Murchison as instances of the spontaneous origin of typhoid fever +there was an introduction of the germs of the disease from without. At +all events, the evidence to the contrary is by no means convincing. +For example, in the account of the outbreak at the Westminster School +it is expressly stated that "the contents of several small cesspools +had been pumped before the outbreak of the fever" into the large +cesspool, the emanations from which it was believed had caused the +fever. It does not seem that it was positively ascertained that none +of these small cesspools had been used by a typhoid-fever patient, or +that typhoid stools had not found their way into them in some other +way. Moreover, in diseases generally admitted to be contagious it is +not always possible to ascertain positively the source of infection in +a particular instance. But after the elimination of all doubtful cases +there yet remains a certain number in which it is reasonably certain +that there has been no recent importation of the typhoid-fever germs, +as in the case which is reported by Metcalfe and which occurred on +Norfolk Island, and in that recorded by Low. The assumption does not +seem an unwarranted one that in these cases the poison of the disease, +which had been present before in a latent condition, had been suddenly +called into activity by favoring influences. The following observation +of Von Gietl[38] shows the length of time typhoid-fever stools may +retain their infective properties: "To a village free from typhoid an +inhabitant returned suffering from the disease, which he had acquired +at a distant place. His evacuations were buried in a dunghill. Some +weeks later five persons, who were employed in removing dung from this +heap, were attacked by typhoid fever; their alvine discharges were +again buried deeply in the same heap, and nine months later one of two +men who were employed in the complete removal of the dung was attacked +and died." If we assume--and there is no reason to doubt that this +point was fully investigated by Von Gietl--that the patient in the +latter case had not been otherwise exposed to the causes of the +disease, the observation shows that the stools in typhoid fever retain +their virulence for nine months. If for nine months, why may they not +do so for a much longer period--for as many years, for example? No +probability is violated by this hypothesis. On the contrary, it is in +full accordance with what we know of some of the lower forms of life, +and will serve to explain many outbreaks of the disease which would +otherwise be inexplicable--for example, the outbreak at Clapham +referred to by Murchison. Admitting that the disease in this instance +was really typhoid fever--and this has been denied by some observers, +among whom is Sir Thomas Watson--the assumption does not seem an +unwarrantable one that the germs of typhoid fever had been present in +this choked-up drain long before it was cleared, but that in +consequence of their exclusion from the air their infecting power was +at a minimum. It was, on the contrary, much increased when the +contents of the drain were exposed to the vivifying influence of the +atmosphere. + +[Footnote 38: Quoted by Cayley, _Brit. Med. Jour._, Mar. 15, 1880.] + +On the other hand, it is alleged that an individual may be exposed to +the direct emanations of sewers or of foul privies, or even drink +water {257} contaminated by leakage from them, without contracting +typhoid fever, so long as they do not contain the specific germ of the +disease. Every physician in large practice, either in the city or +country, can call to mind instances in which the air of houses or the +water-supply has been polluted in this way, and yet no typhoid fever +has occurred. Let, however, the specific cause of the disease be +introduced from without, and this immunity almost invariably +disappears. There is no reason to believe that the contamination of +the water used by the family which suffered in the outbreak of the +disease which has been already referred to as having come under my own +observation last year was of recent origin. On the contrary, there was +evidence to the contrary, and yet no disease occurred until it was +imported by a member of the family who was in the habit of making +frequent visits to the city. Even more strongly corroborative of this +view is the history of the epidemic reported by Ballard, in which milk +was the medium of communication. The water which had been used with +impunity to wash the milk-pans, or perhaps to dilute the milk, became +a source of danger only after the occurrence of the disease in the +family of the dairyman. + +Several epidemics of typhoid fever have been recently reported in +which the disease appears to have been caused by the use of the flesh +of diseased animals or of meat in a condition of putrefaction. In some +of these the symptoms were rather those of irritant poisoning than of +typhoid fever, and consisted principally in violent vomiting and +purging coming on very shortly after the ingestion of the unwholesome +food. There yet remains a certain number in which the symptoms cannot +be thus explained.[39] One of the most remarkable of these occurred in +1878 at a festival which was held at Kloten, a place about seven miles +north of Zurich, of which the following is a condensed description: +Out of 690 persons who sat down to the collation, 290 were taken ill; +378 other persons, who did not attend the festival, but who partook of +the meat provided for it, were also affected. In addition these, 49 +secondary cases occurred--_i.e._ of persons who subsequently became +affected without having eaten of the meat. All other sources of +infection could be certainly excluded, as Kloten was quite free from +typhoid fever at the time, and as it was clearly shown that the water +was not the cause of the outbreak. All the visitors at the festival +who ate no meat escaped, as did also several persons who drank wine to +excess and subsequently vomited. The period of incubation was short, +as in other epidemics arising from the same cause. Some of the people +were ill on the second day, with loss of appetite, nausea, headache, +pain and swelling of the belly, and slight fever. These cases were +slight, and generally ended in recovery. The greater number were +affected between the fifth and ninth days. The symptoms in these +cases, which usually ran a rapid course, and generally ended in +recovery, were chills, fever, diarrhoea, great prostration, frequently +violent delirium, and also profuse intestinal hemorrhage. The +rose-colored eruption was present in almost all of them, and in a few +the taches bleuatres were detected. On post-mortem {258} examination +the characteristic appearances of typhoid fever were found. With +regard to the meat supplied, the following facts were ascertained: +Forty-two pounds of veal were furnished by a butcher at Seebach, taken +from a calf which appears to have been at the point of death when it +received the coup de grace from the hands of the butcher. All the +flesh of the animal was sent to supply the festival at Kloten, but the +liver was eaten by an inhabitant of Seebach, and he was attacked by +typhoid fever. The brain was sent to the parsonage at Seebach, and all +the household became affected by the same disease. It was also +ascertained that another of the calves was diseased. The veal from +this calf had been kept fourteen days, and was in a decomposed state. +All the meat was placed together in the meat-receptacle of the inn at +which the festival was held. This receptacle was in a horribly filthy +state, and Cayley thinks there can be no doubt that the putrefying +flesh of this last calf, together with the state of the receptacle, +would rapidly excite decomposition in the whole supply. + +[Footnote 39: _On Some Points in the Pathology and Treatment of +Typhoid Fever_, by William Cayley, London, 1880; also Prof. Huguenin, +_Schmidt's Jahrbuch_, from _Schweiz. Corr. Bl._, viii. 15, 1878; Carl +Walder, _Schmidt's Jahrbuch_, from _Berl. klin. Wochenschr._, xv. 39, +40, 1878; George R. Shattuck, M.D., Supplement to _Ziemssen's +Cyclopaedia_, New York, 1881.] + +Geissler, it is true, doubts whether the epidemic above described was +really typhoid fever, and points out that the symptoms occurred too +soon after the ingestion of the diseased meat, and reached their full +development too rapidly. The cases were also accompanied by more pain +in the abdomen than is generally met with in typhoid fever. The +proportion of recoveries also appears to have been unusually large. +Unquestionably, the patients in the Kloten epidemic were in a large +number of instances simply suffering from the action of an irritant +poison; but the presence of the characteristic lesions of typhoid +fever in some of the fatal cases renders it certain that this disease +also existed in the village at the same time. + +In the report of this epidemic it is not stated that either of the +calves which furnished a part of the meat for the entertainment were +suffering from typhoid fever at the time they were slaughtered. It is +now known positively that this animal is liable to be attacked by this +disease, and a certain number of cases are on record in which the +eating of the flesh of such animals has been followed by typhoid +fever.[40] That it does not oftener occur from this cause is probably +due to the fact that a certain time must elapse before the flesh of +such an animal acquires infective properties, and that it is usually +used as food before this has been allowed to pass. + +[Footnote 40: _Medical Times and Gazette_, Feb. 8, 1879, p. 149, from +_Berl. klin. Wochenschrift_, No. 39, 1878.] + +Ludwig Letzench[41] asserts that he has produced some of the +intestinal appearances of typhoid fever, as well as a high degree of +pyrexia, in rabbits by the subcutaneous injection of the sputa and +stools of typhoid fever patients. + +[Footnote 41: _Arch. f. exper. Pathol. u. Pharmak._, 1878 and 1881.] + +THE BACILLUS TYPHOSUS.--From what has preceded, it will be seen that +the writer is disposed to range himself with those who hold that the +exciting cause of typhoid fever is an organized germ, or, in other +words, a contagium vivum. Although this view cannot be regarded as +positively proven as yet, it has recently received some support +through the investigations of Klebs, Eberth of Zurich, and others,[42] +who believe that they {259} have found in the bodies of those who have +died of typhoid fever a micro-organism peculiar to that disease. + +[Footnote 42: Klebs (_Philadelphia Medical Times_, Dec. 3, 1881, from +_Archiv fur experimentelle Pathologie und Pharmakologie_, Bd. xiii. H. +5 and 6) claims that he has proved "that there exists in typhoid fever +a separate and distinct bacillus--the _Bacillus typhosus_; that it +undergoes certain transformations, consisting at first of little rods +and small fine threads, containing a spore in the centre and often at +the end, which spores divide off and form new bacilli. It later +assumes a larger thread-like form, twisted at the end, and frequently +taking a beautiful spiral shape; that the bacilli are observed first +in the masses of epithelial cells which accumulate in the alimentary +tract or in the air-passages; that they later penetrate the tissues, +and are carried along by the blood-vessels and the lymphatics, and +form a large network among the tissues they invade; that under a +certain procedure, which never causes this same staining in any other +living organism or tissue, they appear of a blue color; that they are +found only in enteric fever, in which disease every part of the human +body is the seat of masses of these bacilli, their quantity +corresponding exactly with the severity of the symptoms; and that they +produce, when carried into the system of animals, exactly the same +disease with the same morbid alterations as in men." He says, further, +that "the Bacillus typhosus enters the system by the respiratory +passages and by the alimentary canal. This is the cause that in some +cases of typhoid fever almost no abdominal symptoms are present, but a +low form of pneumonia, developing from the very beginning, so that the +lung seems alone to bear the brunt of the disease." He has found these +bacilli in greatest numbers in Peyer's patches. + +Eberth (_British Medical Journal_, Nov. 26, 1881, from _Virchow's +Archiv_, Bd. lxxxi. and lxxxiii.) has shown that in typhoid fever the +intestinal mucous membrane, the mesenteric glands, and the spleen +contain rod bacteria, differing, as he believes, from organisms found +in the body in other conditions (among others in phthisis with +extensive ulceration of the intestinal mucous membrane). In seventeen +cases of typhoid these bacilli were found in six and wanting in +eleven. In the six cases the number of bacilli were in inverse +proportion to the duration of the disease. They were not found in the +spleen in the cases of the longest duration, and only scantily in the +mesenteric glands. These bacilli appear not to differ in shape and +size from the ordinary rod bacteria, but Eberth believes that they +differ from them in their small capacity for taking on the staining of +haematoxylon, methyl-violet, and Bismarck brown. + +Wernich's views (_Vjhrschr. f. Off. Geshpfl._, xiii. 4, p. 513, 1881) +in regard to the nature of the Bacillus typhosus differ from those +held by the two authors just quoted. He regards the specific Bacillus +typhosus as nothing but the ordinary Bacillus subtilis of the large +intestines, which under certain circumstances acquires the power to +accommodate itself to the small intestines, to undergo a higher +development and to become the exciting cause of disease.] + +PERIOD OF INCUBATION.--The conditions under which typhoid fever occurs +in large cities render it difficult, if not impossible, to arrive at a +definite conclusion as to its period of incubation. Occasionally, +however, the time which has intervened between the exposure to the +cause and the invasion of the disease may be ascertained with +precision in the outbreaks which occur in small towns or in isolated +country-houses. Under these circumstances it has been found to vary +within very wide limits. In the three cases related by Griesinger the +attack began the day after exposure to the infection, and in the +outbreak at the school at Clapham, referred to by Murchison, twenty +out of twenty-two boys were seized with the disease within four days +of exposure to the causes. Other instances of a similar character are +on record. In cases like the above the rapidity with which the attack +follows upon exposure to the cause is no doubt due to the intensity of +the poison--a view which is to a certain extent at least supported by +the fact that the invasion of the disease under these circumstances is +very apt to be abrupt; the attack being often ushered in with vomiting +and purging or with grave cerebral symptoms. Sometimes, indeed, the +gastro-intestinal symptoms have been so violent as to have given rise +to suspicions of criminal or accidental poisoning. In the majority of +cases, however, the period of incubation is probably very much longer +than in those above referred to. In the outbreak which recently +occurred in a farm-house about seven miles distant from {260} +Philadelphia, the history of which has already been given in detail, +the second case began three weeks after the first, the other six +following in rapid succession. In the celebrated epidemic which +occurred at Lausen in Switzerland in 1872, and which is referred to by +Cayley,[43] the first ten patients were attacked within three weeks of +the time when the contamination of the spring which supplied the +village must have taken place, and these ten cases were followed in +the course of nine days by fifty-seven others. In the town of Over +Darwen 1500 persons were seized with typhoid fever within three weeks +after a patient suffering from this disease was brought to a +particular house, the sewage of which was allowed to soak into the +ground through which the water-supply pipes of the town passed, and at +a point at which they were leaky. Lothholz observed in an epidemic +which occurred in the neighborhood of Jena that the average period of +incubation was three weeks, the shortest period eighteen days, the +longest twenty-eight days. Haegler found in three cases produced by +contaminated water a period of at least three weeks.[44] There are, +however, epidemics on record in which the period of incubation was +under two weeks, as, for instance, that of Basle, referred to by +Liebermeister, in which a few persons were attacked who had only been +in the city from seven to fourteen days. Cayley also refers to +localized outbreaks of the disease, as those of Calne and Nunney, in +which persons were attacked within fourteen days of their exposure to +the cause. C. J. C. Muller of Posen[45] says that the average period +of incubation of the disease is fourteen days; that it may be not more +than ten days, or, on the other hand, as long as from three to four +weeks; and that he has known a case in which it was thirty-four days. +Murchison believed that it was most commonly about two weeks, and +William Budd arrived at the conclusion, from the observation of a +large number of cases, that it varied from ten to fourteen days. + +[Footnote 43: _Brit. Med. Jour._, Mar. 15, 1880.] + +[Footnote 44: _Ziemssen's Cyclopaedia_, vol. i.] + +[Footnote 45: _Neue Beitrage zur Aetologie des Unterleibs-Typhus_, +Posen, 1878.] + +From this review of the opinions of various authors the conclusion +would seem to be justifiable that the period of incubation in typhoid +fever is usually between two and three weeks, but that in many cases +it does not exceed ten days, and in rare instances has unquestionably +been very much less. On the other hand, there are authentic cases on +record in which it is said to have reached, or even exceeded, +twenty-eight days. Unfortunately, we do not possess any reliable data +with which to decide the question whether it is shorter or longer when +the poison is imbibed with the ingesta than when it is inhaled. It +would seem, however, that there is a difference in the susceptibility +of different individuals to the poison of this disease, in many +persons a single exposure to the cause being sufficient to induce an +attack, while in others the disease is contracted only after repeated +exposure. + +MORBID ANATOMY.--As a thorough knowledge of the morbid anatomy of +typhoid fever is absolutely necessary to a correct understanding of +its pathology, it seems to me better to deviate from the order usually +observed in systematic treatises and to proceed at once to a +description of the former, rather than to defer it, as it is usual to +do, until after the symptomatology of the disease has been discussed. + +Rigor mortis is generally more marked and more prolonged than after +{261} typhus. Emaciation is often extreme in cases in which death has +taken place after the third week, especially if they have been +attended by much diarrhoea and fever. No traces of the characteristic +rose-colored eruption are found after death, no matter how profuse it +may have been during life. Sudamina, on the other hand, persist, and +discolorations of the dependent portions from settling of blood are +always present in the dead body. + +The lesions of typhoid fever may be divided into two classes. The +first class includes certain changes in the glands of Peyer, the +solitary glands of the intestines, the spleen, and other lymphatic +structures of the body. These changes, which consist essentially in a +medullary infiltration of these glands, will be minutely described +presently. They are peculiar to the disease, and are just as +characteristic of it as the condition of the lungs and their membranes +found in pneumonia and pleurisy are characteristic of those diseases. +They are usually most developed in grave cases, but occasionally they +are slight and but little marked in cases in which the general +symptoms were severe. They therefore cannot be regarded as the sole +cause of the latter. It is more probable that they are themselves the +results of the local action of the typhoid poison, and bear somewhat +of the same relation to typhoid fever that the eruption in small-pox +does to that disease. The second class is made up of lesions which are +met with not only in this disease, but in other diseases accompanied +by high fever, and are therefore unquestionably the result of the +general process. They consist essentially of parenchymatous +degenerations of various organs and tissues, and are generally more +marked in typhoid fever because the pyrexia is not only of high grade, +but also of longer duration than in other diseases. + +We shall first consider the lesions peculiar to typhoid fever. Among +the most important of these are the changes which occur in the +agminated and solitary glands of the intestines. These have been +usually described as passing through four stages, as follows: (1) the +stage of medullary infiltration; (2) the stage of softening or +sloughing; (3) the stage of ulceration; (4) the stage of +cicatrization. These stages are said to last almost a week, and +correspond to certain definite periods of the disease, but it is not +uncommon to find in the same intestine glands in two or more of these +stages. Indeed, the same gland may sometimes be found ulcerating at +one side while cicatrization is going on at the other. + +In the first stage the agminated glands are enlarged, each patch +preserving its oblong shape, and being flattened on the surface and +elevated from half a line to two lines above the surrounding mucous +membrane, from which it is separated by an abrupt border, and which it +may in a few cases overhang like a fungous growth. The solitary +follicles are also swollen, and may vary in size from a hempseed to a +split pea. In very severe cases all the glands may be more or less +involved, but in mild cases the changes may be limited to three or +four of the patches of Peyer, although the solitary glands rarely +wholly escape. It is uncommon also for the latter to be alone +affected, but a few such cases have been reported. In these the mucous +membrane appears to be studded with pustules, and hence Cruveilhier +designated this variety as the forme pustuleuse. The mucous membrane +covering the affected glands is reddish-green in color, and that in +their immediate vicinity is {262} often injected. The changes above +described occur early in the disease--Murchison has seen them in two +cases in which death took place at the end of the first day--and they +are often well marked at the end of the third or fourth day. They are +usually limited to the glands in the lower part of the ileum, the +agminated glands being often found perfectly healthy four feet above +the ileo-caecal valve. In mild cases, indeed, the lesions may be +confined to those nearest to this valve. So, too, the changes in the +solitary glands may be confined to the last twelve inches of the +smaller intestine, but this is by no means universally the case, for +these glands are not only often found enlarged higher up in the small +intestine, but also occasionally in the caecum. The agminated glands +are sometimes found enlarged in the bodies of those who have died of +measles and of some other diseases, but the degree of enlargement is +rarely as great as in typhoid fever, and the further changes presently +to be described are never found except in the latter disease. + +Under the microscope the medullary infiltration upon which the +enlargement of the glands depends is found to be due to proliferation +of the cellular elements. In the case of the agminated glands this +proliferation may be limited to the follicles or it may extend to the +intercellular tissue, and even to the adjacent mucous membrane. In the +former case the patches have a reticulated aspect; they are soft and +but little elevated. These are the plaques molles of Louis and the +plaques reticulees of Chomel. In the latter they are harder, smoother, +and more elevated. To this variety Louis has given the name of plaques +dures, Chomel that of plaques gauffrees. The morbid process is also +very apt to extend from the solitary follicles to the surrounding +mucous membrane. + +In a large number of the glands in many cases, and probably in all of +them in the abortive form of the disease, the changes never advance +beyond the first stage, a restoration to their normal condition taking +place by colliquative softening.[46] The morbid material upon which +their enlargement depends breaks down into an oily debris which is +gradually absorbed. This retrograde process takes place faster in the +follicles than in the interfollicular tissue, and, as pigment is very +apt to be deposited in the depressions thus formed, the patches +acquire an appearance which has been compared to that of a recently +shaven beard. This appearance is met with, however, in other diseases, +and is therefore not peculiar to typhoid fever. + +[Footnote 46: Rindfleisch, _Pathological Histology_, Sydenham Society +Translation, vol. i. p. 441.] + +The description of the changes in these glands in the subsequent +stages of the disease which follows is taken mainly from Rindfleisch's +work on _Pathological Histology_. + +In the stage of necrosis small portions of single Peyerian patches, +varying in size from that of a lentil to from three-quarters of an +inch to an inch and a quarter in diameter, assume a yellowish-white, +opaque tint instead of their former reddish and translucent aspect, +gradually become separated from the surrounding tissue by a sharp line +of demarcation, and then pass into a state of cheesy necrosis. Here +and there the same changes are observed to have taken place in the +solitary glands. When once this has occurred, recovery can only take +place by expulsion of the necrosed parts and consequent ulceration. +Necrosis of the glands {263} probably rarely occurs before the +beginning of the second week, but it has occasionally been observed +much earlier. Murchison reports cases in which he saw it as early as +the first and second days. The process usually involves the mucous +membrane only, but it may extend to the muscular and even to the +peritoneal coats. + +In the third stage the dead parts are gradually thrown off, the +process of separation usually occupying several days. At first an +increased degree of congestion, followed by suppuration, is observed +at the edges of the sloughs, which before their complete detachment +may often acquire a yellow, green, or brown color from the imbibition +of bile. The ulcers which result correspond in size and form with the +sloughs. They are, therefore, in the case of the agminated glands +elliptical in shape, with their long diameter corresponding to the +axis of the intestine. Their edges are swollen and overhanging, and +their floor is generally formed by the deepest layer of the submucous +connective tissue. They sometimes penetrate much more deeply, and may +even extend to the peritoneal coat, and thus give rise to perforation +of the bowel. The ulcers which result from sloughing of the solitary +glands are, as a rule, small and round. Murchison says that ulceration +may also be produced in the following way: The mucous membrane becomes +softened, and one or more superficial abrasions appear on the surface +of the diseased patch, which extend and unite into one large ulcer, +and this ulcer proceeds to various depths through the coats of the +bowel, and even to completed perforation, but Rindfleisch and other +recent German writers do not allude to this process. + +The fourth stage, or that of cicatrization, usually commences with the +beginning of the fourth week. The swelling of the edges of the ulcers +gradually diminishes, and they become adherent to the tissues beneath. +The floor of the ulcers covers itself with delicate granulations, +which in course of time are converted into connective tissue. This is +ultimately coated with epithelium, but neither the villi nor the +glands of the mucous membrane are ever reproduced. The resulting +cicatrices may be recognized by the affected parts of the bowel being +thin and more translucent than in health, and may retain these +characters after the lapse of several years. They never give rise to +contraction of the bowel. The time occupied in the cicatrization of +each ulcer is said to be about two weeks. It occasionally happens that +while cicatrization is taking place at one end of the ulcer the +process of necrosis and ulceration is still going on at the other, so +that two or more ulcers may occasionally run together. This form of +ulcer may often retard recovery, and may sometimes end in perforation +of the bowel, even after convalescence seems to have been established. + +The color and consistence of the mucous membrane of the caecum and +colon are in a large proportion of cases normal. In a few the membrane +is paler than in health, and in others it is of an ash-gray color. It +is also sometimes injected and softened. The solitary glands are +frequently enlarged and ulcerated, like those of the ileum. In the +former case the mucous membranes of the large intestine throughout its +whole extent, but especially that of the caecum and of the part of the +colon adjacent to it, is studded with minute elevations about a line +in diameter. When ulceration has occurred the ulcers are generally +round {264} and small, but they may occasionally be oval and of +considerable size. In the latter case their long diameter will +correspond in direction with that of the circular fibres of the +intestine. Murchison has known them to measure fully an inch and a +half in length. The colon is generally found much distended with +flatus. + +Enlargement of the mesenteric glands from cellular hyperplasia and +hypertrophy of the connective tissue is constantly associated with the +morbid changes of the intestines just described. This enlargement +varies in different cases. In some the glands are not larger than a +pea or bean; in others they are said to have reached the size of a +hen's egg. It is always more marked in the glands which lie in the +angle between the lower end of the ileum and the caecum, and usually +bears some proportion to the intensity of the local disease; but it is +not to be regarded merely as a result of the local irritation, as it +has been observed in parts of the mesentery corresponding to perfectly +healthy portions of the intestine, and as the meso-colic glands have +been involved in cases in which the colon was free from disease. It +has, moreover, been observed in cases in which death has occurred very +early in the disease, and there can therefore be little doubt that it +is as much the result of the infective process as the infiltration of +Peyer's patches. In addition to being enlarged, if death has taken +place before the end of the second week the glands are hyperaemic and +of a purplish color. Later than this, when the sloughs become detached +from Peyer's patches, the swelling of the glands diminishes; they lose +their color and become pale, and if convalescence ensues they return +finally to their former healthy condition. Still, Murchison has seen +them shrivelled and pale or bluish for some time after convalescence. +In other cases the substance of the glands softens, with the formation +of a puriform liquid. If the softening only involves a small part of +the glandular structure, restoration to health may take place through +the absorption of this liquid. If it is more extensive, the whole of +the glands may break down into this puriform liquid, which, when the +patient recovers, undergoes caseous and finally calcareous +degeneration. Occasionally, a gland in this condition is the cause of +death from rupture and extravasation of its contents into the cavity +of the peritoneum. + +The glands in the fissure of the liver, the gastric, lumbar, inguinal +glands, and indeed all the lymphatic glands in the body, have +occasionally been found swollen and congested, but their enlargement +cannot be classed among the specific lesions of the disease, but is +merely the result of a local irritation. Thus, Jenner says that in the +case of extensive ulceration of the oesophagus which came under his +observation there was marked enlargement of the oesophageal glands. +Liebermeister says that the lymphatic follicles which surround the +glands at the root of the tongue and in the tonsils are often affected +in the same way as the glands. In most cases after a time the swelling +disappears, but sometimes softening and rupture take place. + +The spleen is almost invariably found to be increased in volume and to +have undergone changes in consistence and color. The degree of +enlargement and the other changes vary of course with the stage of the +disease at which death has occurred. The enlargement occurs with less +frequency in elderly than in young people, and is most marked at the +height {265} of the disease, the organ being then often twice or three +times its normal size, and in some cases, it is said, even larger. +Later, and especially during convalescence, the enlargement has +generally very much diminished. During the first ten days of the +disease the spleen is generally tense and firm, engorged with blood, +and dark red in color. Between the tenth and thirtieth days its +appearance remains the same, but the organ is found to be soft and +friable. During convalescence it becomes paler and firmer again, and +is often so shrunken in size that its capsule is relaxed and wrinkled. +Hemorrhagic infarctions are often met with. These sometimes soften and +break down into a puriform liquid, which may sometimes cause +peritonitis by rupture into the peritoneal cavity. Rupture of the +spleen is also said to have occurred from mechanical violence. These +changes are due in part to variations in the amount of blood, and in +part to a medullary infiltration of Malpighian corpuscles similar to +that which takes place in Peyer's patches and the glands of the +mesentery. + +LESIONS WHICH ARE NOT PECULIAR TO TYPHOID FEVER, BUT ARE OF MORE OR +LESS FREQUENT OCCURRENCE.--The mucous membrane of the pharynx and +oesophagus may present a perfectly healthy appearance, but +occasionally it is congested and the seat of ulcerations which are for +the most part superficial. Sometimes, however, they have been found to +extend to the muscular coat, but they have never been known to +penetrate all the coats of these organs. Jenner refers to one case in +which there was extensive ulceration of the oesophagus, but usually +the number of ulcers is not large. In a few cases the mucous membrane +of the pharynx is coated with diphtheritic false membrane, and the +submucous tissue is infiltrated with serum and pus (Murchison). + +The stomach and the upper part of the intestinal tract present no +lesions which are at all peculiar to typhoid fever. In a certain +number of cases congestion, softening, and even superficial +ulceration, of the mucous membrane of the stomach, and less frequently +of that of the duodenum, have been found. The mucous membrane of the +jejunum and of the upper part of the ileum is not usually much +reddened, and may be even paler than in health. In cases which have +been protracted it may be of an ashy-gray or slate color. The contents +of this part of the intestinal tract, which is rarely much distended +by flatus, do not differ materially in appearance or consistence from +the matter which generally composes the typhoid stool. The bowels may, +of course, be found filled with blood in cases in which a recent +hemorrhage has taken place. Invaginations of the small intestines, +unaccompanied by any evidences of inflammation, are occasionally met +with in the bodies of those who have died of typhoid fever. They are +produced, there is good reason to believe, during the death agony, but +are not peculiar to this disease, as they occur in many other +diseases. + +Enlargement of the liver has been found in only a few cases after +death from typhoid fever. Softening is more common, but even this is +not a frequent result of the disease, for it was absent in 41 out of +73 cases examined with special reference to this point by Louis, +Jenner, and Murchison. The organ is occasionally hyperaemic, and +darker in color than in health, but it is oftener pale or normal in +appearance. Even, however, where it appears to be perfectly healthy to +the unassisted eye, {266} the microscope shows that its cells are very +granular and filled with oil-globules which often render the nucleus +indistinct or completely conceal it. When death has taken place at an +advanced stage of the disease many of the cells are found to be +completely broken down into a granular detritus. These changes are +usually proportional to the degree of pyrexia which has been present +during life. Rarer lesions of the liver are pyaemic deposits, +embolism, abscess, and emphysema. + +The mucous membrane of the gall-bladder has been found to be the seat +of ulcers by Jenner and numerous other observers. It also occasionally +presents the evidences of catarrhal or diphtheritic inflammation. The +gall-bladder usually contains a pale watery liquid of a less density +than bile. When, however, inflammation of its lining membrane has +existed, its contents are mixed with pus and shreds of false membrane. + +The mucous membrane of the larynx is sometimes found to have been the +seat of catarrhal or diphtheritic inflammation, and sometimes also of +ulceration. Jenner says that in typhoid fever laryngitis independent +of pharyngitis is extremely rare, but the German writers express a +different opinion. Griesinger estimated that laryngeal ulcers were +present in one-fifth of the fatal cases. Hoffmann found them +twenty-eight times in two hundred and fifty autopsies, and that the +ulcers had extended to and involved the cartilages in twenty-two out +of the twenty-eight cases. They are most commonly found in the +posterior wall of the larynx, and may involve the vocal cords. These +are often discovered after death in cases in which their existence was +not suspected during life. They were formerly supposed to be the +result of typhoid infiltration of the laryngeal glands, but careful +investigation has shown that they are the consequence of diphtheritic +inflammation of the mucous membranes. Inflammation and ulceration of +the trachea are comparatively rare. Hypostatic congestion and +infarction of the lungs are not uncommonly found after death from +typhoid fever, and less frequently the lesions of pneumonia. Evidences +of recent pleurisy are also discovered in a few cases. Acute miliary +tuberculosis of the lungs is more often met with as a sequela than as +a complication. + +The changes in the brain and its membranes caused by typhoid fever are +few and unimportant, even in cases attended by severe nervous +symptoms. Those most frequently found are adhesions of the dura mater +to the inner surface of the cranium, injection or oedema of the pia +mater, congestive oedema, and sometimes softening of the brain and +effusion at the base of the brain. The microscopic changes do not +appear to have been carefully studied. Liebermeister says that the +gray substance of the cortical portion of the brain and of the +interior is sometimes of a rather yellowish-brown color, and that he +noticed besides diffuse yellow and blackish-brown spots in different +places, particularly in the corpus striatum and thalamus opticus. In +such places, he says, the microscope shows a diffuse yellow +coloration, a deposit of small brown pigment-granules, and also, +especially in the optic thalamus and corpus striatum, the +ganglion-cells thickly crowded with brownish or blackish +pigment-granules in such numbers as to conceal the outlines of many of +the cells. These changes Hoffmann,[47] who has specially studied them, +is inclined to place by the side of the parenchymatous degeneration of +other organs. {267} The ganglion-cells of the sympathetic ganglia are +said by Virchow also to contain an unusual amount of pigment. + +[Footnote 47: Quoted by Murchison.] + +The muscles are frequently the seat of marked changes in typhoid +fever. Their macroscopic appearances vary with the stage of the +disease at which they are examined. When death takes place in the +first or second week they are usually dark red or reddish-brown in +color, and very dry. If it is delayed until later, they "present a +peculiar fawn or yellow tint permeating the ordinary red in patches +and veins not unlike the appearance of veined marble." Their +consistence is also so much diminished that the finger may be readily +passed through them. Occasionally, pseudo-abscesses and hemorrhages +into the muscular sheath are found, and Dauve and B. Ball[48] report +cases in which, in addition to these changes, rupture of muscles had +occurred. Zenker, who was the first to call attention to them, ranged +the changes seen under the microscope under two heads: (1) granular or +fatty degeneration; (2) waxy degeneration. In the first variety the +transverse striae disappear and the sarcolemma appears filled with +finely granular matter. In the second variety the striated muscles +become, as it were, pervaded by a coagulating material which sets, and +in contracting breaks up the fibres into great numbers of short +waxy-looking lumps, not unlike a certain variety of casts of the +tubuli recti of the kidneys. When recovery takes place the affected +fibre is believed to be regenerated by a cell-growth within the +sarcolemma. These changes occur in most fevers, as typhus, small-pox, +scarlet fever, and are attributed by authors generally to the +hyperpyrexia which is a frequent accompaniment of these diseases. +Hayem, however, asserts that he has found them well marked in cases +not characterized by a high temperature, and that, on the other hand, +they are sometimes absent in cases where this has been present. The +waxy form of degeneration may affect all the striped muscles, but is +oftenest seen in the muscles of the abdominal walls, the adductors of +the thigh, the muscles of the diaphragm, and tongue. + +[Footnote 48: _L'Union Medicale_, 1866, quoted by _Biennial Retrospect +of Medicine and Surgery and their Allied Sciences_, for 1865-66.] + +The heart, in common with the other muscles of the body, suffers from +both the forms of degeneration above described, but the granular form +appears to be more common than the waxy. In protracted cases it is +usually much softened, and when thrown upon a plate no longer retains +its form. It has usually lost its normal color and acquired the tint +described by the French as feuille morte (faded leaf). Upon minute +examination the degeneration is found to have taken place in patches, +the diseased fibres being found alongside of others which have +scarcely undergone any alteration. These patches are especially common +in the papillary muscles of the mitral valve--a fact which explains +the occasional presence of systolic murmurs in typhoid fever. In +addition to the microscopic appearances of the muscles already +described, Hayem[49] has observed in his examinations of the heart a +cellular infiltration of the connective tissue and a proliferation of +the muscle nuclei. These changes are sufficient in his opinion to +establish the existence of myocarditis. The same observer thinks he +has also found evidences of the frequent occurrence of endoarteritis +in the multiplication of the cellular elements {268} of the internal +coat of the small arteries, which he has discovered under the +microscope. + +[Footnote 49: _Lecons cliniques sur les Manifestations cardiaques de +la Fievre typhoide_, Paris, 1875.] + +Some discrepancy of opinion exists in regard to the condition of the +blood in typhoid fever. Trousseau, for instance, speaks of it as being +profoundly altered and in a state of dissolution; Liebermeister says +that at the height of the disease the blood is very dark-colored, and +that after coagulation it presents a small and soft clot; and +Murchison, that a dark, liquid condition of the blood is rarer than in +typhus, and that fine white coagula are more common. Harley too has +frequently found firm colorless clots of fibrin in the heart and roots +of the great vessels in subjects dead in the third week of the +disease. Forget concludes from an examination "of one hundred and +twenty-three specimens of blood derived from patients in all stages of +the disease that an appreciable alteration of the blood in the several +periods of enteric fever cannot be accepted as a general fact; that +the blood is rarely altered in the first period; that the alteration +is more marked in proportion as the disease is more advanced; that the +alteration is not always in proportion to the gravity of the +disease."[50] I have myself seen the disorganization of the blood as +complete in severe cases of typhoid fever which have rapidly proved +fatal as in cases of diphtheria or of other malignant diseases. On the +other hand, in protracted cases and during convalescence the blood is +often thin and watery. + +[Footnote 50: Quoted by Harley, Reynolds's _System of Medicine_, vol. +i.] + +The kidneys are sometimes engorged with blood, sometimes pale and +flabby. Under the microscope the appearances are similar to those just +described as occurring in the liver, and it is therefore unnecessary +to refer to them more fully here. As a rule, the epithelium becomes +granular earlier and to a marked degree in the cortical than in the +tubular portion. The absence of albuminuria must not always be +accepted as proof of a healthy condition of the kidneys, as this +symptom has been wholly wanting in cases in which the organs have been +extensively diseased. + +Analogous changes have also been observed in the salivary glands and +pancreas, except that, according to Hoffmann, a cellular proliferation +precedes the degenerative process. + +CLINICAL DESCRIPTION.--The invasion of the disease is usually so +gradual that it is often impossible to obtain from patients exact +information as to the time of the beginning of their illness. Among +those who present themselves for treatment at the Pennsylvania +Hospital it is not uncommon to find that many have suffered for +several days, it may be as long as a week, or even longer, before +taking to their beds, from vague feelings of discomfort, from headache +more or less intense, aching pains in the back or limbs, or from +sensations of chilliness alternating with flashes of heat. In other +cases derangements of the digestive system are more prominent, such as +nausea, or even vomiting, diarrhoea, or irritability of the bowels. +Notwithstanding these symptoms, and the indisposition to exertion +engendered by them, they have frequently continued to follow their +usual avocations up to the time of their application at the hospital +for admission. There is generally, however, no difficulty in +recognizing at once the nature of their disease. Upon examination the +pulse is found to be frequent, the respiration accelerated, the tongue +furred, the skin hot and dry, and the abdomen tympanitic. + +{269} Among patients whose position in life enables them to pay +greater attention to trifling symptoms than those who are compelled to +seek hospital relief, opportunity is frequently afforded to the +physician to study the disease at a period less remote from its +commencement. The symptoms it presents when seen as early as the +second day are generally of a very indefinite character. There may be +a feeling of malaise, headache with a tendency to giddiness, pain in +the back and limbs, a slightly coated tongue, thirst, and anorexia. +The patient may complain of chilly sensations alternating with flashes +of heat, but it will rarely be found that the attack has commenced +with a decided chill. Diarrhoea may also be present at this time, or +may not supervene until later. Even in cases in which it is absent the +bowels will generally act inordinately after the administration of a +gentle purgative. Occasionally, the attack begins with vomiting, but +this is not, in my experience, a frequent mode of commencement. If the +visit be made in the morning, the febrile symptoms will be little +marked, the pulse being only slightly accelerated and the temperature +being rarely more than from a half to a degree above the normal. In +the evening, however, the thermometer usually indicates a greater +elevation of temperature. + +At subsequent visits the same symptoms are presented. It will be +observed, however, that the fever is decidedly remittent in character, +the evening temperature being always from a degree to a degree and a +half higher than that of the morning, while the temperature of each +succeeding day is a little higher than that of the day which preceded +it. The patient is restless and wakeful at night, or sleep, when +obtained, is unrefreshing and disturbed by dreams. He grows dull and +slightly deaf, and although able to answer questions intelligently +when roused, does so with an effort, and soon after lapses into his +former condition. Although obviously growing weaker every day, it is +sometimes difficult to get him to take to his bed. The diarrhoea +continues and increases in severity; the stools become watery in +character and ochrey-yellow in color; they may exceed six, or even +twelve, in the twenty-four hours. Epistaxis either consisting of a few +drops of blood only, or so profuse as to endanger life, may also occur +during the first week. Examination of the abdomen toward the middle or +close of the first week will almost always reveal the existence of +tympany and of tenderness and gurgling in the right iliac fossa, and +very frequently also of slight enlargement of the spleen. The urine at +this stage of the disease is dense, scanty, and of high color. The +tongue too will be observed to be more heavily coated than at first, +and to be dryish, the fur being disposed on the middle of the dorsum +of the organ, while the tip and edges are free from it and abnormally +red in color. Usually, toward the close of the first week, the pulse +will be found to be between 100 and 120 in frequency. It often, +however, does not attain this frequency, and in some cases does not +exceed 50 throughout the whole of the attack. At the same time, the +thermometer generally indicates a temperature of from 102 degrees to +104 degrees, and in bad cases even one much higher than the latter. + +These symptoms are not pathognomonic, but Murchison regards their +existence in a young person as warranting the suspicion that he is +suffering from this disease. About this time, however, or, to speak +more accurately, usually from the seventh to the twelfth day, a new +symptom occurs {270} which is more characteristic. This is an eruption +of isolated rose-colored spots, the taches roses lenticulaires of +Louis, occurring principally upon the surface of the abdomen, but not +infrequently seen also upon the chest, back, limbs, and even, +according to some authors, upon the face. They are round in shape, +with a well-defined margin, usually about a line in diameter, but +sometimes considerably larger, slightly elevated above the surface, +and disappearing upon pressure, but returning when the pressure is +removed. They can almost always be found at this stage of the disease +if diligently sought for. + +If the disease tends to run a severe course, all the symptoms become +aggravated toward the end of the second week. The tongue grows dry and +brown, the pulse more frequent, feeble, and markedly reduplicated in +character, the diarrhoea still more severe, and the fever higher than +before, with little or no tendency to remit in the morning. The +nervous symptoms also come into prominence. The headache may grow more +violent or may be replaced by increased dulness, which may sometimes +be so decided as to render it difficult to fully rouse the patient. At +other times delirium is a prominent symptom. This may only occur at +night, but not infrequently is observed during the daytime as well. It +is usually more active in character than that which accompanies +typhus. Trembling of the tongue and of the limbs is not uncommon at +this time. The urine becomes more abundant, paler, and less dense than +before. Even in cases characterized by symptoms as severe as those +above detailed some improvement is, however, often observed to take +place between the fourteenth and twenty-first days. The morning +remission becomes more decided, the evening temperature less high than +that of the preceding day; the stools lessen in number, and gradually +assume a more healthy appearance; the pulse diminishes in frequency +and gains in force; the tongue becomes moist, and shows a tendency to +throw off its fur; the trembling grows less marked; the dulness and +delirium lessen; and the patient falls into a refreshing sleep. In +other cases, in many of which recovery eventually takes place, there +is at this time, instead of an improvement, a still further +aggravation of the symptoms. The pulse becomes more feeble and +frequent; the tongue is not only excessively dry and brown, but +shrivelled and fissured; the lips and teeth are encrusted with sordes; +the stools contain shreds of membrane, and often blood; the subsultus +tendinum increases; carphololgia, or picking at the bed-clothes, +occurs. The prostration becomes so extreme that the patient frequently +slips down in bed from sheer weakness. The active delirium of the +previous stage is replaced by the low muttering form, or the patient +lies upon his back with his eyes half closed in a semi-unconscious +condition, from which he is with difficulty aroused, and which may +deepen into coma. Occasionally, however, the active delirium +continues, and is associated with an obstinate wakefulness; the urine +and feces are passed involuntarily, or, with an apparent incontinence +of the former, there may be retention, which is very apt to be +overlooked. If these symptoms continue for any length of time, +bed-sores may form not only over the sacrum, but on other parts +subject to pressure, and the patient, worn out by long-continued +suffering, dies from exhaustion. + +Occasionally, in the midst of these symptoms, and sometimes even in +cases in which the condition is not so alarming, prostration +approaching {271} collapse, without obvious cause, suddenly +supervenes. The pulse becomes a mere thread, the surface is bathed in +a clammy sweat, and the temperature is found to have fallen from four +to seven degrees, and in some cases even more. These symptoms almost +always indicate that intestinal hemorrhage has taken place, and are +followed by the discharge of blood either in the course of a few hours +or not until a day or two subsequently. If the hemorrhage be moderate +in amount, and does not recur, reaction usually takes place in a short +time; but if, on the other hand, it is profuse or frequently repeated, +death may occur, either immediately or later, as the result of the +exhaustion it has induced. Very much the same set of symptoms attend +the occurrence of perforation of the bowel, an accident which is also +liable to happen in the course of typhoid fever, but which may +generally be distinguished from intestinal hemorrhage by its being +accompanied by a sharp pain in the abdomen, which is frequently so +severe as to cause the patient to cry out, by its not being attended +with the same reduction of temperature, and by the absence of blood in +the discharges. In a day or two all doubt will be set at rest, if the +case be one of perforation, by the occurrence of general peritonitis. + +A fatal termination is by no means the usual result, even in cases in +which the disease has assumed its worst features. Indeed, it may be +said that there is no condition in typhoid fever so grave that +recovery from it is impossible. Many authors would make perforation of +the bowel an exception to this general rule, but there are +observations on record which would seem to show that this accident is +not invariably fatal. Even in cases in which the patient has lain +helplessly on his back in a semi-unconscious or comatose condition, +passing his discharges under him, the physician will often be +gratified to find at one of his visits some evidence of improvement, +trifling as it will probably be. It may be only a slight change of +position, an inconsiderable fall of temperature, or a scarcely +appreciable moistening of the tongue; but these changes, insignificant +as they apparently are, are sufficient to indicate to the practised +eye of the observant physician the approach of convalescence. Next day +there will be a still further reduction of temperature, a more decided +moistening of the tongue, a sensible diminution of the nervous +symptoms, and a reduction in the frequency of pulse. In this +condition, however, as may be readily imagined, convalescence may be +retarded by numerous accidents, and life may hang trembling in the +balance for several days, or even weeks, before it is fully +established. It is not necessary to recount here the various steps by +which a return to health is reached, as they are essentially the same +as those which mark the convalescence of the less severe variety of +the disease, and have already been fully referred to in the +description of that form. + +But even after the establishment of convalescence, and after the +patient has been free from fever for several days, febrile attacks +lasting for a day or two, or even longer, may occur as the consequence +of very slight causes, such as undue excitement, or fatigue of any +kind, or the immoderate indulgence of the appetite, which in this +condition frequently needs to be restrained. These attacks are usually +spoken of as recrudescences of fever, and do not differ materially +from attacks of irritative fever occurring under other circumstances. +They usually subside under appropriate treatment with the removal of +their cause, but leave the patient somewhat {272} weaker than they +found him. In other cases, it may be a week or ten days after the fall +of the temperature to the normal, and frequently at a time when all +danger seems to have been passed, a true relapse of the disease +occurs. In this, of course, all the symptoms of the primary attack are +reproduced, including even the eruption of rose-colored spots. The +temperature usually, however, attains the maximum more rapidly, and +the duration of the fever is generally shorter, than that of the +original attack. A second relapse is also not very uncommon, and even +a third may occur. Various complications and sequelae also occur in +the course of typhoid fever, which will be referred to fully +hereafter. + +Another form of the disease, which it may be well to allude to briefly +here before closing the general description of the disease, is the +abortive form. In this variety the attack begins and runs its course +up to a certain point, including often even the occurrence of the +eruption, as it does in the majority of cases; but at a period which +varies between the seventh and fourteenth day the symptoms suddenly +subside and the patient rapidly convalesces. In some cases it may be +difficult to distinguish this form from an attack of simple continued +fever, and, in fact, in cases in which the eruption is absent it will +be impossible, unless other cases of typhoid fever have occurred in +the same house or family, or unless the patient has been unmistakably +exposed to the influences under which the disease arises. + +In a few cases the disease begins abruptly with a chill, intense +headache, or with gastro-intestinal symptoms, which have in rare +instances been so violent as to have suggested to the mind of the +attending physician the possibility of corrosive poisoning. This, +according to Chomel, is the most frequent mode of commencement, but +his experience on this point is opposed to that of the great majority +of observers. + + * * * * * + +I shall now proceed to describe in detail some of the most important +of the symptoms presented by the disease. + +Even in the beginning of an attack of typhoid fever the face has a +listless and languid expression, although the eyes are usually bright +and the pupils dilated. In mild cases no further alteration of the +physiognomy than this may be noticeable throughout the whole course of +the disease, but in bad cases, when the typhoid condition is fully +developed, the expression becomes dull and heavy. There is, however, +never the general suffusion of the face seen in typhus. On the +contrary, the face is often pallid, or there is at most a +circumscribed flush on one or both cheeks, which is most marked during +the exacerbations of fever or after the administration of food and +stimulants. During convalescence the effects of the long illness are +fully visible in the face. + +Prostration, or loss of muscular strength, is present from the +beginning in a large number of cases of typhoid fever, but is +generally not so marked in the early stages as in typhus fever. It is +usually most intense in grave cases, but to this rule there are +numerous exceptions. It is not rare to find patients, in whom the +other symptoms are severe, able to sit up in bed, and even to rise to +stool, throughout the attack. Bartlett records a case in which the +patient did not confine herself to bed until the occurrence of +perforation, and I have had under my care a man who, supposing he was +suffering only from a slight diarrhoea, performed the duties {273} of +a nurse in a military hospital until two days before his death, +although the autopsy showed very extensive ulceration of the +intestine. Several cases have come under my care in the second week in +which patients have walked a considerable distance to make application +for admission to a hospital. Generally, however, the prostration +becomes extreme in the third and fourth weeks of bad cases, the +patient lying helplessly on his back, and frequently slipping down in +bed from sheer weakness. + +Epistaxis may occur at any stage of typhoid fever, but is most common +in the forming stage. Observers differ in opinion in regard to its +frequency. Murchison noted it in only 15 of 58 cases, and gives it as +his belief that it is more common in France than in England or this +country. Flint found that it had occurred in 21 only of 73 cases, and +Jenner in 5 of 15 fatal cases. On the other hand, Bartlett says that +it is quite a common symptom, and Wood and Gerhard, from the frequency +with which they had met with it in the beginning of the disease, were +accustomed to regard its presence as of importance in a diagnostic +point of view. Part of this divergence of opinion is probably due to +the fact that it is usually small in amount, and therefore very apt to +be overlooked. I have in many cases, after having been told there had +been no epistaxis, found the evidence of it upon the fingers or +bed-clothes of the patient. It may, however, be so profuse as to +endanger life and render necessary the use of the tampon. Except in +the latter case it is without influence upon the course of the +disease. + +The skin may be almost constantly dry as well as warm throughout the +whole course of the fever in a small proportion of severe cases. But, +on the whole, perspiration occurs with greater frequency in typhoid +fever than in any other acute disease, unless it be rheumatism. It +takes place most commonly at night after the evening exacerbation, or +in the morning when the patient awakes from sleep, but it is not very +rare to find the skin clammy at other times. The sweating is usually +general, but in a few cases it is local only. When colliquative, it is +frequently exhausting, and is then a grave symptom. It is sometimes +prolonged into convalescence, when it is not only annoying, but in +consequence of the prostration it induces may sometimes retard the +restoration to health. + +I have never been able to satisfy myself that any peculiar odor is +given off by the skin in typhoid fever, and most observers make a +similar statement. Chomel, however, asserted that the perspiration has +a strong acid odor, and Bartlett agreed with Nathan Smith in thinking +that typhoid fever patients exhale a peculiar odor, not pungent and +ammoniacal, like that of typhus, but "of a semi-cadaverous and musty +character," which is especially noticeable during the later stages of +severe and fatal cases. + +The eruption is one of the most characteristic symptoms of the +disease. Indeed, in many cases, without it the diagnosis would be +impossible. It is rarely absent in a well-developed case. Murchison +says that it was noted in 4606 cases only out of 5988 admitted into +the London Fever Hospital in twenty-three years, but admits that it +would probably have been found in some of the others if it had been +properly looked for. Wood says that he has seldom met with cases in +which it was absent. It is oftener absent in children than adults--a +circumstance which makes the diagnosis of the disease in the former +often a matter of great difficulty. It consists of isolated +rose-colored spots, slightly elevated above {274} the surface, +circular in form or nearly so, having well-defined margins, usually +about a line in diameter, but sometimes varying from half a line to +two and even three lines in diameter, and disappearing on pressure, to +return when the pressure is removed. They are generally first observed +some time between the seventh and fourteenth days, but cases are on +record, especially in children, in which they are said to have +appeared much earlier, and others in which they could not be +discovered until the twentieth day. In the latter cases, however, it +is not improbable they had really been present at an earlier period, +but had escaped detection. The eruption occurs in crops at intervals +of three or four days, each spot lasting from three to five days, and +the whole duration of the eruption being usually from ten to twenty, +and varying of course with the severity of the attack. It may continue +to appear as late as the twentieth day, and in cases of relapses very +much later. Spots are sometimes seen on the abdomen or elsewhere after +the subsidence of fever, and whenever seen indicate that the diseased +process is not at an end. They are usually scattered over the lower +part of the front of the chest and the abdomen, but are also not +infrequently met with upon the back, and if they are not found upon +the abdomen, the patient should be gently turned upon his side and +this part of his body carefully examined. When very abundant they are +often also seen upon the extremities, and occasionally even upon the +face. Wood has seen them abundant on the upper and inner part of the +thigh, and confined to that place. When tardy in making their +appearance, they may often be brought out by application of a mustard +plaster or by that of heat in any form; and it is probably, therefore, +owing in large measure to the warmth of the bed that they are often so +fully developed upon the back. In number they may vary from two or +three to several hundred. In one case Murchison counted one thousand, +and in three cases which came under my care in the winter of 1881-82 +the body was so thickly covered by spots of an unusually large size +that when I first saw the patients I directed them to be isolated +under the fear that the disease would prove to be typhus fever. When +very numerous the edges of two or three of the spots may run together, +giving the eruption an irregular character. No relation between the +copiousness of the eruption and the severity of the disease has ever +been proved to exist. While the prevailing impression, therefore, that +cases in which the eruption is freely developed are apt to be of a +mild character, is true in many instances, it is by no means so in +all. The three cases above referred to all ran a severe course, and +one of them proved fatal. The spots disappear after death, and are +rarely converted into petechiae, but in bad cases I have seen purpura +spots, and even vibices, developed independently of them. Sometimes +the appearance of the eruption is preceded for a day or two by a +delicate scarlet rash, which Tweedie says resembles roseola and has +been mistaken for scarlet fever. + +Sudamina, so called from their resemblance to sweat-drops, also occur +not infrequently in this disease. They are minute vesicles, often not +larger than a pin's head, but sometimes two lines in diameter, and +occasionally, in cases in which two or three have coalesced, much +larger. They usually contain at first a clear serum, which may, +however, subsequently become turbid, and when very minute must, in +consequence of {275} their transparency, be viewed obliquely to be +seen. Frequently, when they cannot be distinguished by the eye, they +are readily detected by the touch. They rarely occur before the +twelfth day, and often not before the close of the third week. Their +most usual seat is the neck, the folds of the axillae, and the groin, +but there is no part of the body except the face in which they may not +occur. They are most frequently seen in those cases attended by +profuse sweating, and are by no means peculiar to typhoid fever, but +are met with in other diseases--as, for instance, acute +rheumatism--which are attended by this symptom. They are generally +followed by branny desquamation of the cuticle in the position they +have occupied. + +Spots of a delicate blue tint--the "taches bleuatres" of French +writers--are sometimes observed on the skin in cases of enteric fever. +They must be of infrequent occurrence in this country, for, although I +have looked carefully for them in every case that has come under my +care, I have rarely been able to detect them. According to Murchison, +"they are of an irregularly rounded form and from three to eight lines +in diameter. They are not in the least elevated above the skin, nor +affected by pressure, even at their first appearance. They have a +uniform tint throughout their extent, and they never pass through the +successive stages observed in the spots of typhus. Two or three of +them are sometimes confluent. They are most common on the abdomen, +back, and thighs." They are said in some cases to be distributed along +the course of the small cutaneous veins, and to occur most frequently +in cases which are mild. They are met with in other diseases, and +usually precede in appearance the characteristic eruption of typhoid +fever. + +The hair is very apt to fall out after an attack of typhoid fever. The +nails suffer in their nutrition in common with other parts of the +body--a fact which may be recognized by the peculiar markings which +are found upon them after recovery, and to which attention has been +particularly drawn by Morris Longstreth in a paper in the +_Transactions_ of the College of Physicians of Philadelphia, vol. +iii., 3d Series. + +The circulation is usually accelerated from the beginning of an attack +of typhoid fever. The degree of acceleration is commonly proportioned +to the severity of the other symptoms, and especially to the elevation +of the temperature, and is generally more marked in the evening than +in the morning. It is subject, however, to numerous variations, not +only in different cases, but even in the same case from day to day, +and even from hour to hour. Murchison refers to a case in which the +pulse sank to 37, and never exceeded 56 during the fever, although it +rose to 66 during the convalescence. I have never had the opportunity +myself of observing such an infrequent pulse in the febrile period of +the disease, but have had cases under my care in which the pulse often +fell below 60, and in which it never exceeded 80 until after the +commencement of convalescence. A comparatively infrequent pulse may +coexist with a high temperature. Thus, for example, a pulse of 80 was +noted in one of my cases at the same time that the thermometer showed +that the temperature was 105 degrees, and on another occasion in the +same case the pulse was 82 and the temperature 104-1/2 degrees. As a +rule, the pulse is more frequent in cases which terminate fatally than +in those which end in recovery; but to this rule there are numerous +exceptions. In eight of Louis's cases it never {276} went above 90, +and in some of my own it did not reach 100 on more than one or two +occasions. On the other hand, in mild cases the pulse may be +exceedingly frequent, reaching, and even exceeding in many cases, 120. +When the disease is prolonged and the prostration is extreme, a pulse +of from 140 to 150 is not uncommon. In the majority of cases which +have come under my care the pulse has varied in frequency from 80 to +120. In some cases the range has been between these two figures, in +others it has been very much less. + +During convalescence the pulse usually gradually diminishes in +frequency, and may sometimes fall below the normal standard. I have +known it in a few instances to fall to 38, and have often met with +pulses ranging between 40 and 60 at this period. In other cases, on +the contrary, the pulse continues frequent during convalescence, or +readily becomes so after a slight exertion or excitement of any kind. +A slow pulse during convalescence has been in my experience most +frequent in men whose health previous to the attack was good, and a +frequent pulse in women and delicate men. If the convalescence is +retarded by a complication, the pulse will maintain its frequency +until this is removed. + +The pulse will of course present other changes than those above +referred to. It is in the beginning firm and full, but after the first +week becomes small and compressible, and acquires the peculiarity +known as reduplication. Sometimes, when this is not well developed, it +will be rendered quite distinct by elevating the patient's arm. +Irregularity or intermission of the pulse, although not commonly +observed in this disease, occasionally occurs. The heart's action will +also be observed to grow feeble in the course of severe cases, and its +first sound indistinct, but neither of these changes is as marked in +typhoid as in typhus fever. Hayem asserts that in a certain number of +cases a systolic bellows murmur, with its point of greatest intensity +at the apex, is heard during the course or at the close of the second +week. This murmur is sometimes soft in the beginning, but becomes +harsh and intense later, or may have these characters from the start +to such a degree as to give the impression that endocarditis exists. +During convalescence an anaemic murmur is not infrequently present. + +The respiratory movements are accelerated in typhoid fever, as they +are in all febrile conditions, independently of any disease of the +lungs, and their frequency is generally proportional to that of the +pulse. In looking over my records of cases I find that the former are +less liable to fluctuate from day to day than the pulse, and that when +the latter becomes abnormally infrequent they do not sink below the +standard of health. In several cases of which I have notes the +respiration was from 20 to 28, while the pulse was below 60, and in a +case referred to by Murchison the pulse was 42 at the same time that +the respirations, although no pulmonary lesion could be discovered, +were 48. The respiration is often, as in the case just alluded to, +very much accelerated when the most careful examination of the chest +will not lead to the detection of any disease there. This is sometimes +the consequence of very great tympanites, which, by interfering with +the descent of the diaphragm, gives rise to dyspnoea, but it may also +occur as a purely nervous phenomenon. The air expired by patients has +been examined, and has {277} been found sometimes, in the later stages +of the disease, to contain ammonia. + +Bronchitis is so common an accompaniment of typhoid fever that +auscultation rarely fails to reveal its presence in some form or +other. In some cases there may be only slight harshness of the +respiratory murmur at the base of the chest, but in a large number of +cases the auscultatory signs will be sonorous, sibilant, and mucous +rales. The last named may be so numerous that I have known the disease +in the beginning mistaken for acute bronchitis, and even acute +phthisis, by accomplished diagnosticians. + +Headache is one of the most constant symptoms of typhoid fever. +Bartlett says that it is rarely absent, Louis found it in all but 7 of +133 cases, and Jackson noted it in nearly all his cases. It is often +the first symptom of which the patient complains, and, when not +present at the beginning of the attack, makes its appearance soon +after. It is almost as common, although less severe, in mild cases as +in grave ones. It sometimes persists throughout the attack, but +oftener subsides at the close of the first week or toward the middle +of the second, or the patient may cease to complain of it in +consequence of the dulness which is very apt to supervene. It is +usually referred to the forehead and temples, but may extend over the +whole head. It is usually dull and heavy, but in a few cases is +throbbing. It is said by authors rarely to be severe, but I have known +it so intense and acute as to cause the disease at its commencement to +be mistaken for meningitis, and Jackson asserted that it is sometimes +so severe that local bloodletting, and even venesection, had to be +employed for its relief. It would appear to be as common in children +as adults. + +The headache is sometimes accompanied by vertigo and dizziness, and +even by retraction of the head. Distressing pains in the back and +limbs may also occur, and in rare cases even contraction of the hands +and feet. + +In the beginning of an attack of typhoid fever the patient usually +suffers from wakefulness and restlessness at night, and it +occasionally happens that the wakefulness becomes a distressing +symptom. But in a great many cases, sooner or later in the course of +the disease, drowsiness supervenes. In mild cases this symptom is late +in making its appearance, and is generally slight and evanescent, but +in grave cases it may come on as early as the eighth day, and when +once present may gradually become more profound until it deepens at +last into unconsciousness. It usually persists until the occurrence of +death or of convalescence, but may alternate with periods of delirium, +the delirium being more frequent at night and the somnolence by day. +It is as frequent in children as in adults. Occasionally, the +wakefulness of the earlier stage may reappear at the beginning of the +third week, and coexist with muttering delirium, or occasionally with +delirium of a more violent character. It then constitutes a most +unfavorable symptom, the patient frequently passing several days and +nights in incessant agitation, and sinking finally from exhaustion due +to want of sleep. + +Some degree of mental hebetude is rarely absent, even in the mildest +cases of typhoid fever, and is usually among its earliest symptoms. It +may, however, be absent occasionally in cases which run a severe +course. It exhibits itself in the beginning in an indisposition to be +disturbed, a slight inability to fix the thoughts, or a loss of +memory. Generally, the {278} patient will be able at first, by an +effort, to rouse himself from this apathy, but the moment he relaxes +this effort will lapse into his former condition. As the disease +progresses the hebetude becomes more profound and is overcome with +greater difficulty. In mild cases it may continue until the occurrence +of convalescence, but in grave cases it is soon lost in delirium. This +is one of the commonest symptoms of the disease. If I should rely +solely upon my own experience, I should say that it was rare for any +but the mildest cases to run their course without its occurring at +some time or other. Louis found, however, that it was absent in 32 +cases, 8 of which were fatal, out of 134 cases, and Murchison in 33 +cases, 3 of which ended in death, out of 100 cases. In 8 of these +fatal cases death was due to perforation--a fact which would seem to +show, as suggested by James C. Wilson, that this symptom is not +dependent upon the intensity of the local disease alone. The delirium +of course varies with the severity of the other symptoms, and +especially with the intensity of the fever. In its mildest form it +consists of a slight confusion of ideas, which is readily dissipated +by fixing the patient's attention, and is most apt to occur in the +night or when he first wakes up from sleep. In other cases it is much +more marked; occasionally it is violent and noisy; the patient may +talk wildly and incoherently, he may break out into a paroxysm of +screaming, or, possessed with a sudden terror, he may leave his bed +and attempt to rush from the room or to jump from the window. Later in +the course of the disease the active delirium subsides, and low +muttering delirium takes its place. The latter may go on until +convalescence occurs, or the patient may gradually fall into a +comatose condition, which very often ends in death. + +The delusions from which the patient suffers are various. I have known +in two instances a perfectly pure young girl call loudly for her baby, +which she accused her mother and sister of keeping from her. Very +frequently patients insist that they are in a strange place, and beg +piteously to be taken to their home and friends; occasionally, in +grave cases, the patient declares that there is nothing the matter +with him. This Louis was accustomed to regard as a bad symptom, having +never known recovery to take place after it. Delirium generally first +makes its appearance some time in the course of the second week, but +occasionally the invasion of the disease is marked by maniacal +excitement. I have known delirium to occur on the second or third day. +Louis records two cases in which it was present during the first +night, and Bristowe[51] one in which it was noted on the fourth night. +It is sometimes so prominent a symptom in the beginning of an attack +that the patient has at first been supposed to be affected with acute +mania. M. Motet[52] indeed refers to a case in which a man was +actually admitted into an insane asylum before the true nature of his +disease became known. On the other hand, delirium may not occur until +much later in the disease--sometimes not before the close of the third +or even the fourth week, when it may suddenly make its appearance when +least expected. I have known it to be present in a marked degree +during a relapse when it had been wholly wanting in the primary +attack. + +[Footnote 51: _Trans. Path. Soc. Lond._, vol. xiii.] + +[Footnote 52: _Archiv. gen. de Med._, 1868, quoted by Murchison.] + +During convalescence, especially in cases in which there has been much +{279} mental disturbance during the febrile period, the intellect may +be weak, and continues so in some cases even after recovery in other +respects is complete; but it is rarely permanently impaired. Insanity +may also occur during the convalescence or after recovery, but it is +usually under these circumstances amenable to treatment. In some cases +the moral sense appears to be weakened after an attack, as in the case +reported by Nathan Smith, in which a young man of previously good +habits developed thieving propensities after his recovery. + +Hyperaesthesia of the skin exists, according to Murchison, in about 5 +per cent. of the cases, and may occur at any stage of the disease. It +is chiefly observed in the abdomen and lower extremities, and is more +frequently met with in women and children than in adult males. In a +case which was partially under my care during the past summer the +slightest touch made the patient, a boy of fifteen years, cry out with +pain, and the administration of an enema gave him excruciating agony. +Occasionally, the tenderness over the abdomen is so great that it is +sometimes difficult to distinguish it from that due to peritonitis, +except by the coexistence of hyperaesthesia in other parts of the +body. It is very often associated with spinal tenderness, and +sometimes with other spinal symptoms. Murchison does not regard it as +a formidable symptom. + +Cutaneous anaesthesia may also occur, but it is certainly less common +in the earlier stages than hyperaesthesia. Rilliet and Barthez look +upon it as of grave diagnostic import when it occurs in children. + +Muscular tremor is also a common symptom of typhoid fever. A little +tremulousness of the tongue when protruded may often be detected +before the close of the first week. A little later the hands will be +observed to tremble when held up, and still later twitching of the +tendons at the wrist may be appreciable while the pulse is being felt. +When muttering delirium supervenes this subsultus tendinum becomes +constant, and extends to other parts of the body. The hands of the +patient are frequently then in constant motion, either picking at the +bed-clothes--a very unfavorable symptom--or moving in an objectless +manner through the air. This condition presents many points of +resemblance to that often seen in delirium tremens, and is said to +come on earlier and to be more marked in those who are addicted to the +abuse of alcoholic liquors. Hiccough is occasionally observed toward +the close of grave cases, and is justly regarded as a bad symptom. + +Spasmodic contraction of various groups of muscles is occasionally +observed in severe cases, but is less frequent than muscular tremor, +and in my experience is generally met with in the earliest period of +the disease. The muscles of the extremities, especially those of the +legs, are oftenest affected, but I have known the head as rigidly +retracted as in tubercular meningitis, and have seen cases in which +strabismus has been an early symptom. Murchison has had patients under +his care who have suffered from constriction of the pharynx to such an +extent that they could not swallow. He also reports cases in which +trismus and spasm of the glottis have been present. General +convulsions are not common, but occasionally do occur. Although a very +grave symptom, they are not invariably fatal. Recovery took place in +one of two cases which came under my own observation, and in four of +the six recorded by Murchison. They are not always associated with an +albuminous {280} condition of the urine. In neither of my cases was +there albuminuria, and in only one of the four of Murchison's cases in +which the urine was examined was it present. In one of my cases--the +fatal one--the convulsions seemed to have been induced by giving the +patient improper food; in the other no cause could be discovered. + +Ringing or buzzing noises in the ears are present in the early stage +of the disease in a large proportion of the cases, and may sometimes +persist until the disease is well advanced. Usually, however, after a +few days they subside and give place to deafness. This is a very +common symptom, and may either affect both ears or be limited to one. +In the former case it is probably generally due to the blunted +perceptions of the patient, although in a few instances it may be +caused, as suggested by Trousseau, by inflammation of the Eustachian +tube. When only one ear is affected the deafness is of more serious +import, as it is then dependent upon the presence of local +inflammation, which may possibly extend to the meninges. It is, as a +rule, most marked in the severest cases. Unless there has been a local +inflammation it is not followed by permanent impairment of the +hearing. It has even been regarded by some observers as a favorable +symptom, but this opinion does not appear to rest upon a more +substantial basis than the observation of Louis, that the most +profound deafness adds nothing to the gravity of the prognosis. + +Imperfect or perverted vision occasionally occurs in the course of +typhoid fever. In a case which was recently under my care, and which +has already been referred to in another connection, there was double +vision associated with strabismus. Sometimes haziness of vision, and +sometimes even visual illusions, are observed. Bartlett and Murchison +have often known intolerance of light present in cases characterized +by active febrile excitement. As a general rule, the pupils are widely +dilated and the conjunctiva pearly white--a condition which is in +marked contrast with what is seen in typhus fever. When, however, +stupor supervenes in bad cases, the pupils are frequently as much +contracted and the conjunctivae as much injected as in the latter +disease. In a few cases unequal dilatation of the pupils has been +noticed. Trousseau was accustomed in his clinical lectures to call +attention to the frequency with which sloughing of the cornea occurred +in the condition known as coma vigil, in which the patient lies with +his eyes wide open. He attributed this accident to the fact that the +eye in this condition is not kept constantly moist by the occasional +closure of the eyelids, and hence, as its innervation is also +impaired, is especially prone to take on ulcerative inflammation. In +other cases there is a free secretion of viscid matter, which often +glues the eyelids together. + +The sense of taste is often lost or perverted. This is partly due to +impaired innervation of the tongue and palate, and partly to the thick +deposits which usually cover the mucous membrane of these organs. + +Frequent observations of the temperature in typhoid fever not merely +give most important information in a diagnostic and prognostic point +of view, but also often furnish valuable indications for treatment. +From a close study of a large number of cases, Wunderlich and other +physicians have discovered that the pyrexia has certain characters +which distinguish it from other fevers, and which, being present in a +case in which the other symptoms are obscure or ill defined, will +often enable us to recognize {281} its true nature. The pyrexia may be +divided into three periods, each having its own peculiarities. It is +usually said that each period lasts about a week, but in severe cases +the second and third periods extend over a longer time than this, and +the occurrence of a complication or of any other disturbing influence +will have its effect in producing either a prolongation of any one or +more of these periods, and especially of the last two, or an unwonted +elevation or fall of temperature. During the first period there is a +progressive rise of temperature, but the rise is never so abrupt as in +typhus or in many of the phlegmasiae. As there are morning remissions, +ranging from a degree to two degrees in extent, corresponding to the +morning fall in the daily variations of temperature, the tracing upon +the temperature chart will be a zigzag line, each evening temperature +being from a degree and a half to two degrees higher than that of the +preceding evening, while the same difference will be observed in the +morning temperature. The temperature ought, therefore, never in an +uncomplicated case to be much over 100 degrees on the first evening or +102 degrees on the second. A temperature of 104 degrees at any time +during the first or second day will consequently exclude typhoid fever +from the diagnosis. From six to eight days are usually occupied before +the maximum is reached. I have seen it attained as early as the fourth +day in mild cases, and, on the other hand, not until much later in +severe ones. It is usually 104 degrees or 105 degrees, but will of +course vary with the gravity of the other symptoms. The temperature +rarely rises higher than 106 degrees at this period. On the other +hand, I have known cases in which it never exceeded 103 degrees during +their whole course. It would therefore be wrong to exclude typhoid +fever from the diagnosis, as Wunderlich does, if this temperature is +not reached by the sixth, or at latest the eighth, day. + +[Illustration: FIG. 12. Chart of typical range of temperature in +typhoid fever, after Wunderlich.] + +In the next period the temperature usually ceases to rise, but has a +tendency to oscillate about the maximum temperature of the previous +period as a fixed point, occasionally not quite reaching it, at other +times rising a little above it. The morning remissions, too, become +less decided. In other words, the fever now becomes continuous. This +period, although usually lasting about a week, may extend over more +than two weeks, even in the absence of complications, in cases which +run a severe course, and when it is prolonged from this cause the +temperature may again show a tendency to rise, and may even attain an +elevation considerably above that of the preceding period. The +prognosis in all such cases in which the temperature rises after the +middle of the second week is grave. Temperatures of 108 degrees, and +even of 110.3 degrees, have been noted at this time. Death invariably +follows such high temperatures as these, but before death actually +occurs a considerable fall of temperature very often takes place. +Wunderlich has also called attention to the fact that it is not +uncommon for a sudden and temporary remission of temperature to take +place at this stage, varying from one degree to two degrees and a +half, which may last from ten to twelve hours, and which usually has +occurred in his experience from the sixteenth to the eighteenth day. +Toward the close of the second period the morning remissions will be +observed to be more decided, while the evening temperature remains +about the same as before. The beginning of the third period is +indicated by a diminution of the evening exacerbation, while the +morning remissions become still more marked. The diminution is +progressive, but slow, the {282} temperature each evening falling +short by from half a degree to a degree of the point it reached the +preceding evening. The morning remissions, on the other hand, each day +become greater, a fall of three and a half degrees being not uncommon. +The lysis, therefore, occupies usually a longer time than was required +by the pyrexia in reaching its maximum. Toward the close of this +period the morning temperatures may be normal, as even subnormal, +while an elevation of temperature may continue to take place in the +evening. Occasionally, however, an abrupt defervescence takes place. +The duration of this period will be very much prolonged if +complications are present or if the intestinal ulcers are slow in +healing. I have known it to last for more than three weeks. During +convalescence the temperature is frequently subnormal even in the +evening, but the slightest cause is often sufficient to produce a +considerable though temporary elevation of temperature. I have known +the temperature in one case to rise from 99 degrees F. to 105.6 +degrees in a few hours in consequence of an indiscretion in diet, and +in another from 100 degrees to 104 degrees from the suffering and +excitement caused by a severe attack of toothache. Indiscretions in +diet are a fruitful source of these recrudescences of fever. The fever +of the third period has all the characters of an irritative fever, and +is probably kept up by the irritation arising from the intestinal +ulcers. On the other hand, that of the first two periods is due to the +action of the specific poison upon the nervous system and the other +tissues of the body, and corresponds exactly with the primary fever of +the eruptive diseases. + +{283} [Illustration: FIG. 13. Chart showing recrudescence of fever +from indiscretion of diet.] + +The febrile movement, however, rarely follows a perfectly typical +course, and I consequently find, in looking over the temperature +sheets of a large number of cases, very few which bear, except during +the first period, anything more than a general resemblance to the +chart which {284} Wunderlich has prepared as typical. A very slight +cause will exercise, as has already been said, a disturbing influence +upon the course of the fever, and serious complications or accidents +will of course produce a still more marked effect. An intestinal +hemorrhage, for example, will cause a rapid and decided fall of +temperature. I have often known it to fall from 104 degrees to the +normal temperature, or even below it. This depression, unless the +bleeding continues and the case ends fatally in the course of a few +hours, is only temporary, the temperature rising within twenty-four +hours to its former height, and sometimes even beyond it. A free +epistaxis or a copious diarrhoea will in the same way cause a fall of +the temperature, but it is rarely so marked as in the preceding case. +The same effect is produced by the administration of large doses of +quinia or by the application of cold water either in the form of the +bath, the douche, or any other form, to the surface of the body. On +the other hand, the occurrence of a complication will cause a rise of +temperature, often considerably above the maximum of the first period. + +[Illustration: FIG. 14. Chart showing fall from intestinal +hemorrhage.] + +The thermometer should be used at least twice daily. In this country +it is generally introduced into the axilla, and less frequently into +the mouth, for the purpose of making an observation. In other +countries it is not infrequently inserted into the rectum, and even +into the vagina. The best hours for making the thermometric +observations are eight in the morning and eight in the evening, since +it has been ascertained from {285} frequent observations that the +daily remissions are more marked between the hours of 6 and 8 A.M., +and that the temperature usually reaches its maximum some time between +those of 7 and 12 P.M. + +Loss of appetite is, except in mild cases, one of the earliest +symptoms of the disease, and usually persists as long as the fever +lasts. It is sometimes accompanied by positive loathing for food, but +generally there is no great difficulty in persuading the patient to +take the necessary amount of nourishment. During convalescence the +appetite returns, and is occasionally immoderate, so that it is +frequently necessary to curb it lest harm should be done by over +indulgence. + +Thirst, usually proportionate to the degree of fever, is also present +in the beginning of the fever. Later, when the patient sinks into a +semi-unconscious condition and becomes insensible to the wants of the +system, he will cease to call for water, although it is still urgently +needed. + +Nausea and vomiting sometimes occur at the beginning of the disease, +but they have not been such frequent symptoms in my experience as they +would appear to have been in that of Murchison, who says that they are +of such common occurrence that the patient is often supposed at first +to be suffering merely from a bilious attack. He does not regard them, +when occurring at this stage, as serious symptoms. Indeed, he +expresses the belief that the subsequent course of the disease is +sometimes favorably modified by them. They may also occur later in the +disease, and are then of grave import, as they are not infrequently +the consequence of peritonitis. Louis regarded vomiting as a grave +symptom, but it is probable it occurred in the cases from which he +makes his deductions late in the course of the disease. It may +sometimes occur during convalescence, and may then interfere very +materially with the proper nutrition of the patient. The matter +vomited usually consists of a greenish bilious fluid, with the food +last taken. In some cases blood has been thrown up. + +The tongue at the beginning of an attack of typhoid fever is usually +moist and coated with a thin white fur, and in mild cases may retain +these characters until the close. Even in some cases which terminate +fatally in the course of the second week, the tongue, with the +exception of being less moist than in health, may present no marked +deviation from this appearance. Generally, however, as the disease +progresses, and sometimes as early as the tenth day, it becomes dry +and brownish, and is protruded with a tremulous motion. Still later it +tends to cover itself with a thick brown coating. This coating is +disposed principally along the middle of the organ, leaving uncovered +the edges and tip, which are very apt to be unnaturally red in color. +The bare portion at the tip is often rudely triangular in shape--a +point which is regarded as of some importance in the diagnosis of the +disease by Da Costa. In bad cases, during the course of the third week +the tongue is frequently crossed by cracks and fissures, which are the +cause of much discomfort to the patient, and when deep may bleed and +leave behind them scars which are recognizable during the remainder of +his life. In other cases the tongue is dry, brown, and shrivelled, or +covered with a tenacious, viscid secretion which renders it difficult +to protrude it. + +In favorable cases, as convalescence approaches the tongue regains by +degrees its normal appearance. At first the only noticeable change may +{286} be that the organ is a little less dry than before. In a few +days it will be observed to have become moist and to be gradually +throwing off its coating. The process is, however, a slow one, and +one, moreover, subject to frequent interruption. Very often, when it +seems nearly completed it will be suddenly arrested, and the tongue +become dry and brown. Sometimes, instead of cleaning itself gradually, +the tongue throws off its coating in large flakes, leaving the mucous +membrane red and shining, as if deprived of its papillary structure. +Wood was accustomed to teach that if the tongue when thus cleaned +remained moist convalescence might be expected, but would always be +tedious. This is an observation the correctness of which I have had +abundant opportunity to confirm. If anything happens, however, to +interfere with the progress of convalescence, it not infrequently +becomes dry and coats itself over again. When the restoration to +health is retarded by the continuance of diarrhoea or by the +occurrence of any intercurrent affection, the tongue will often become +pale and flabby and be the seat of superficial ulcerations or of +aphthous exudations. + +The mucous membrane of the posterior fauces is also often red and dry +and covered with a glutinous secretion, which often materially +interferes with swallowing. The lips and teeth are in bad cases +encrusted with sordes, and the former are dry and cracked, and bleed +readily when picked. + +Meteorism or tympanites is observed in the greater number of cases of +typhoid fever, having been noted by Murchison in 79 out of 100 cases, +and by Hale in 130 out of 179 cases, and in only 43 of the remainder +of his cases is it expressly stated to have been absent. My own +experience leads me to believe that it is present in even a larger +proportion of cases; in fact, that it is rarely absent. It is, as a +rule, later in making its appearance than the other abdominal +symptoms, showing itself usually about the end of the first or the +beginning of the second week. It is generally most marked in grave +cases, especially those attended by severe diarrhoea, but I have seen +it highly developed in cases in which the symptom was not present at +all or but little developed. It may vary, moreover, frequently in +degree at different times in the same case, but when once present +generally persists until convalescence is established or death occurs. +When extreme, it may give rise to distressing dyspnoea by preventing +the descent of the diaphragm. + +The meteorism is usually preceded and accompanied by gurgling and +tenderness on pressure in the right iliac fossa. The former of these +symptoms is most marked in cases in which diarrhoea exists, and is +caused by the presence of liquid and gas in the lower part of the +ileum. The tenderness is unquestionably due to the presence of ulcers +in the same part of the bowel. There is also occasionally pain in the +region of the umbilicus, but this is a much less frequent symptom. + +Enlargement of the spleen was noted by Hale as being present in some +of the cases which he has described. It is a frequent symptom of the +disease, and may be generally demonstrated by percussion in the course +of the second week. It has not, however, often happened to me to be +able to feel the organ enlarged through the abdominal walls, as +Murchison asserts he has been able to do. Indeed, tympanites is +usually present in a sufficient degree to render this difficult. The +enlargement {287} occurs more frequently in persons under thirty years +of age than in those over it. + +Diarrhoea is one of the most frequent symptoms of the disease, +especially in severe cases, and there are very few mild cases in which +it does not occur at some period of their course. Louis noted it in +all but three of his fatal cases, Murchison in 93 out of 100, and M. +Barth in 96 out of 101. It varies in different cases in severity, in +duration, and in the time at which it appears. It may be one of the +earliest symptoms, presenting itself frequently on the first day, and +often being the only one which occasions uneasiness to the patient or +his physician. At other times its appearance may be postponed until +the end of the first week, or even until the patient is apparently +entering on convalescence. It may be mild in the beginning and become +more severe as the disease progresses, or after having been at first +acute may cease spontaneously in a few days to occasion any +uneasiness. In degree it may vary from two stools to three or four, or +even twenty, in the course of the twenty-four hours. It is absent in a +few cases, but in many even of these cases the bowels will be found to +act inordinately after a very moderate dose of purgative medicine. I +have known, for instance, the administration of a single teaspoonful +of castor oil to be followed by five or six stools in an adult. +Constipation does, however, actually exist in a certain number of +cases. Murchison has known the bowels in cases in which a relapse has +occurred to be constipated in the primary attack and relaxed in the +relapse. There is no relation between the severity of the diarrhoea +and the extent of the local lesion. Although oftenest met with in mild +cases, constipation has existed in cases in which perforation of the +bowel or intestinal hemorrhage has occurred during life, or very +extensive lesions been found after death. + +The stools are fetid and ammoniacal, and are alkaline in reaction, +instead of acid as in health. They are usually liquid and of the color +of yellow ochre. Murchison says that they separate, on standing, into +two layers--a supernatant fluid and a flaky sediment--but that, +occasionally, instead of being watery they are pultaceous, frothy, and +fermenting, and so light as to float in water. I have myself often +seen the appearance which Bartlett compares to that of new cider. They +may contain blood, and when they do, occasionally present the +appearance of coffee-grounds. They are not infrequently, in grave +cases, passed involuntarily. + +Intestinal hemorrhage is fortunately not a frequent symptom of typhoid +fever. It may occur as early as the fifth or sixth day, but is more +common after the middle of the second week or in the third or fourth +week. In 60 cases observed by Murchison in which the hemorrhage +exceeded six ounces it began during the second week (mostly toward its +close) in 8; during the third week in 28; during the fourth in 17; +during the fifth in 1; during the sixth in 3; during the seventh in 1; +and during the eighth week in 1; while in one case the date of its +occurrence is not noted. In the cases observed by Liebermeister and +Griesinger, 113 in all, the bleeding took place in a much larger +proportion of cases at an early period of the disease, occurring in as +many as 43 in the second week, and in only 27 during the third. In 7 +cases in which I had the opportunity of observing it in patients under +my own care it occurred on the seventeenth day in 1; on the +twenty-third day in 1; during the {288} third week in 2; during the +fifth week in 2; and on the fifth day of a relapse in 1. There may be +a single hemorrhage, or the bleeding may be repeated one or more +times. In 5 of my cases there was a second hemorrhage, and in 2 of +them a third; and in several of Murchison's cases it recurred at +varying intervals after its first appearance. + +When the bleeding occurs early in the disease it is usually +insignificant in amount, and is due either to extreme congestion of +the mucous membrane of the intestine, giving rise to rupture of the +capillaries, or to disintegration of the blood, allowing its ready +passage through the walls of the vessels. In the latter case it +usually coexists with petechiae or a hemorrhage from some other part +of the body, as, for instance, epistaxis or hematuria. After the +middle of the second week the hemorrhage is generally the result of +the laying open of a small artery, either by the detachment of a +slough from one of the glands of Peyer or by the involvement of its +walls in the ulcerative process. It is then often profuse, and may +even reach several pints in quantity. Murchison has, however, seen +profuse hemorrhage at such an early stage of the disease that it was +impossible that ulceration could have taken place. The blood is not +always voided immediately after a hemorrhage has taken place; it may +be retained for some days. Indeed, if the amount be large the patient +may die within a few hours of its occurrence without any appearance of +blood externally. This is, however, rare; it is more usual for the +hemorrhage to be repeated before death takes place, but the occurrence +of the bleeding may be suspected in such cases by the abrupt fall of +temperature, sometimes below the normal standard, and by the extreme +prostration and pallor which come on suddenly without other assignable +cause. The depression of the temperature does not continue long. It +generally reaches its former elevation, or even exceeds it, in the +course of twenty-four hours. + +There would appear to be a slight difference in the frequency with +which intestinal hemorrhage occurs in different times and at different +places. Murchison noted it in 58 cases of 1564, or 3.77 per cent.; +Louis in 8 cases of 134, or 5.9 per cent.; Liebermeister in 127 cases +of 1743, or 7.3 per cent.; Griesinger in 32 cases of 600, or 5.3 per +cent.; and I have noted it 7 times in 81 cases, or in about 8.5 per +cent. Liebermeister makes it twice as frequent in women as in men. It +seems to be much less common in children than in adults, for in 252 +patients under fifteen years of age observed by Taupin, Rilliet, and +Barthez it occurred in 1 only. There is considerable diversity of +opinion among observers in regard to the importance of this symptom. +Murchison lost 32 of his 60 cases. In 11 of the 32 fatal cases the +immediate cause of death was peritonitis; in 14 of the remaining 21 +cases the patients died within three days of the bleeding, and in 8 of +the 14 within a few hours. Of Liebermeister's 127 cases 49, and of +Griesinger's 32 cases 10, terminated fatally; 3 of my own cases ended +in death, but none of them until several days had elapsed after the +bleeding. In the face of facts such as these there have not been +wanting authors to assert that the effect of the hemorrhage was +sometimes beneficial. Chief among these are the celebrated Irish +physician Graves and his devoted admirer Trousseau. There may +occasionally be a slight subsidence of the nervous symptoms upon the +occurrence of a hemorrhage, consequent upon the reduction of +temperature {289} which usually accompanies it, but this relief is +only temporary, and procured at too great expense to be really of +service to the patient. + +The bleeding is most frequently observed in bad cases. All the cases +which were under my care in which it occurred were of great severity +from the very start. In 18 of Murchison's 60 cases the antecedent +symptoms were mild. In 3 of my cases there was severe diarrhoea. In 2 +of the other cases, 1 of which was fatal, the bowels were constipated, +and in another one, also fatal, they were slightly loose. In 8 of +Murchison's cases, 6 of which were fatal, the bowels had been +constipated up to the time of its occurrence. The blood, if voided +immediately after its escape into the intestines, is generally fluid +and bright red in color. When retained for a day or two it is passed +in dark clots, and if retained longer than this it is usually mixed +with fecal matter when discharged from the bowels, and gives the +stools a tarry appearance and consistence, which is not always +recognized by inexperienced attendants as due to blood. + +It has been asserted that intestinal hemorrhage has become more +frequent since the introduction of the cold-water treatment, but +Liebermeister shows this to be an error, for he has found that of 861 +cases treated before the introduction of this treatment, 72, or 8.4 +per cent., had intestinal hemorrhage, but that of 882 cases treated +since its introduction hemorrhage occurred in 55, or in 6.2 per cent. +Other methods of treatment have also been charged with inducing a +tendency to hemorrhage, but probably not upon more substantial grounds +than the above. + +The occurrence of perforation may be suspected when the patient is +suddenly seized with acute pain in the abdomen, accompanied by +symptoms of collapse and occasionally by rigors. The fall of +temperature is often considerable. Liebermeister refers to one case in +which it was as much as 5-1/2 degrees, or from 104 degrees to 98-1/2 +degrees. Very soon the abdomen becomes tender on pressure, and, if it +were not so before, hard and tympanitic; the pulse grows frequent, +small, and sometimes almost imperceptible; the breathing is thoracic; +the physiognomy expresses great suffering; the features are +contracted, and the face is bathed in profuse perspiration. Nausea and +vomiting come on soon after inflammation has commenced, and rapidly +exhaust the patient. The decubitus is dorsal, and the legs are +generally drawn up so as to relax the abdominal muscles. Prostration +rapidly increases until death puts an end to the patient's sufferings. +Occasionally, the symptoms are more obscure. Pain and rigors may both +be wanting, and nothing but the extreme prostration, the frequent and +feeble pulse, and the distended condition of the abdomen will indicate +the gravity of the danger. This is not infrequently the case in +delirious patients. Death may take place during the collapse, but this +is rare. It more frequently takes place on the second or third day; on +the other hand, it may be postponed until much later. Liebermeister +and Murchison refer to cases in which there was an interval of two or +three weeks between the first symptom of perforation and the fatal +result. + +Perforation of the intestine was formerly regarded as an inevitably +fatal accident, but this view is no longer entertained. I have had +under my observation cases in which all the symptoms of this accident +were present, and in which recovery took place. In some of these cases +there {290} may have been an error of diagnosis, but all of them will +not admit of this explanation. Moreover, cases of a similar character +have been reported by physicians whose skill in diagnosis is +universally recognized. Thus, Murchison reports six such cases, +Tweedie two, and Wood one. Liebermeister and Bristowe[53] also both +say that recovery is possible. This view is sustained by the results +of certain autopsies. In one of these, reported by Buhl,[54] a +perforation was found completely closed by adhesions to the mesentery, +and in others reported by Murchison partial adhesion had taken place +between the edges of the perforation and the abdominal walls or to an +adjoining coil of intestine. Occasionally, the inflammation excited by +the perforation may be circumscribed and terminate in an abscess, +which may permit recovery by discharging itself into the bowel or +externally. At other times, however, it ruptures into the peritoneal +cavity, when death speedily ensues. + +[Footnote 53: _Transactions of the Pathological Society of London_, +vol. xi. p. 115.] + +[Footnote 54: Cited by Murchison.] + +Perforation is, fortunately, not a frequent accident in typhoid fever. +It was the cause of death in 20 only of 250 fatal cases collected by +Hoffmann. It occurred, according to Liebermeister, in only 26 cases, 3 +of which ended in recovery, in more than 2000 cases observed at the +hospital at Basle. Murchison observed it 48 times in 1580 cases, +Griesinger 14 times in 118 cases, and Flint twice in 73 cases. +Murchison found that in a total of 1721 autopsies, the details of +which were collected from various sources, it was the cause of death +in 196, or 11.38 per cent. It would appear to be rather more common on +the continent of Europe than in England or in this country. +Perforation is much more frequently met with in men than in women. The +patients were men in 15 of 21 of Liebermeister's cases, in 51 of 73 of +Murchison's, and in 72 of 106 cases collected by Nacke. It is rarer in +children than in adults. Rilliet, Barthez, and Taupin met with it only +three times in 232 children under treatment. Murchison has, however, +had a fatal case in a child of five years of age. It is also not +common after forty years of age, but does occasionally occur, although +the contrary has been asserted. + +Perforation is most likely to happen during or after the third week of +the disease, but it has been met with as early as the eighth day, as +in a case reported by Peacock. On the other hand, in three cases cited +by Morin[55] it did not occur until the seventy-second, seventy-sixth, +and one hundred and tenth day, respectively. Instances are on record +in which it has taken place after the patient was supposed to be +thoroughly convalescent and had returned to his occupation. When it +occurs early it is due to the separation of a slough. After the middle +or end of the third week it is probably always the result of the +extension of the ulcerative process to the peritoneal coat. In a large +proportion of cases the perforation has been preceded by symptoms of +great gravity, such as severe diarrhoea, great tympany and tenderness +of the abdomen, and intestinal hemorrhage, but in a certain number of +instances the cases in which it has occurred have been of a mild +character, the patient in many of them not considering himself sick +enough to take to his bed or even to abstain from his daily labor. +After death the perforating ulcer has been found to be the only one. + +[Footnote 55: Quoted by Murchison.] + +The most frequent causes of perforation are the irritation arising +from {291} indigestible and unsuitable food, distension of the bowels +by feces or gas, vomiting, and movements on the part of the patient. +Liebermeister calls attention to the frequency with which ascarides +are found in the intestines of those who die of perforation, and is +inclined to think they may have something to do with causing it. +Morin[56] reports a case in which the perforation appeared to be +caused by the administration of an enema. + +[Footnote 56: Quoted by Murchison.] + +For our knowledge of the changes in the composition of the urine we +are largely indebted to Parkes and certain German observers. As the +disease generally begins insidiously, the condition of the urine +before the attack and during the first two or three days has not been +ascertained with certainty. During the latter part of the first week +the amount of water is greatly diminished, occasionally falling to +one-fourth or one-sixth of the usual quantity. In the second and third +weeks it increases, and at the end of the fourth week may again be +normal. The amount may, however, vary from day to day, but its +variations do not stand in close relation to those of the febrile +heat; that is, the thermometer may mark one day 104 degrees, and the +next day 100 degrees, while the amount of urine remains the same. +Still, when the temperature begins to fall permanently it increases at +once, or, according to Thierfelder, two or three days after. The +specific gravity is usually high in almost all cases in which the +urine is scanty, and may be as high 1038. With the establishment of +convalescence the specific gravity often diminishes before the water +begins to increase. In other words, the lessening of the solids of the +urine frequently takes place prior to the increase of the water. + +The reaction of the urine is very acid in the beginning, but the +acidity is not due to an increased secretion of acid, but simply to +concentration. Later it may become alkaline, and even ammoniacal. The +color of the urine is darker than in health during the early part of +the febrile period. This is due partly to concentration, and partly to +increased disintegration of the blood-corpuscles, which is a +consequence of the fever. + +The quantity of urea is augmented during the fever, and especially +during the first week, when the water and chlorides of sodium are most +diminished. As a general rule, the higher the temperature the greater +the amount of urea. It may, however, be very much diminished during +the presence of inflammatory complications. On the other hand, it is +not affected by diarrhoea. Uric acid is uniformly increased, the +amount of increase being relatively greater than that of the urea; it +is often doubled, and sometimes the increase is even more than this. +This increase takes place, according to Zimmer, up to the fourteenth +day. It diminishes after this, and during convalescence may fall below +the normal amount. Copious deposits of urates may occur at any time in +the course of the disease. The chloride of sodium is usually +diminished in amount. This diminution is partly due to a less amount +of this salt being taken with the food, and partly to the fact that +large quantities of it pass away with the stools. As the diminution +cannot always be fully accounted for in this way, it would appear that +it is also stored up in the body during the fever. In cases in which +sweating and purging are absent the sulphuric acid is increased in +amount. The phosphoric acid is at first slightly diminished, but later +undergoes an increase. The hippuric acid is also diminished. + +{292} Parkes found albumen in the urine in 7 out of 21 cases. In 5 of +these it was temporary, and entirely disappeared before the patients +left the hospital. Becquerel found it in 8 out of 38 cases, Andral in +only 4 out of 34 cases. Griesinger found it commonly, though it was +usually temporary. He met with only four or five cases in which it was +never present. Kerchensteiner found albumen in a fourth part of the +severe cases. Brattler noticed it in 9 out of 23 cases. I have very +frequently found it myself, but it has always been in my cases a +temporary phenomenon. Desquamative nephritis may occur occasionally in +the course of typhoid fever, and give rise to the appearance of a +large amount of albumen in the urine, and also occasionally of blood. +Renal epithelia and casts are sometimes seen in cases in which there +is albuminuria, but usually soon disappear. Zimmermann asserts that in +all but very slight cases casts may be found even when no albumen can +be detected. The statement is probably too general, but there is no +doubt of the occasional presence of casts under these circumstances. +Bladder epithelia and pus-cells are seen in a few cases in small +quantities, but decided cystitis is rare, unless it has ensued upon +retention of urine. Sugar has not been found except in the urine of +diabetic patients, who may have happened to contract typhoid fever. In +these patients the sugar diminishes, and is sometimes wholly absent +during the continuance of the fever. Leucin and tyrosin have been +found by Frerichs, but at present no observations have been made as to +the frequency or import of their occurrence. + +In many cases, when the prostration is extreme, the urine is passed +involuntarily, but in some of these cases the incontinence of the +urine is only apparent, and is really the result of over-distension of +the bladder. This is a condition which is very apt to be overlooked, +and I have known paralysis of the bladder to result in consequence of +this neglect, and to continue sometimes after convalescence has been +established. + +COMPLICATIONS AND SEQUELAE.--Although cerebral symptoms are among the +commonest manifestations of the disturbing effects produced in the +economy by the typhoid fever poison, they are almost always +independent of inflammation of the brain and its membranes. In a few +cases, however, the lesions of meningitis have been found after death. +In some of these it has come on without assignable cause, in others it +has been the consequence of pyaemia, of tubercles, or of the extension +of inflammation from the petrous portion of the temporal bone. +Occasionally, during convalescence, some impairment of the intellect +is observed. This may consist in simply some loss of memory or +childishness of manner. At other times delusions of a mild form are +present, or else the patient is liable to attacks of acute mania, +sometimes violent, coming on suddenly and without fever. In a few +instances the moral sense seems to have been perverted, as in the case +reported by Dr. Nathan Smith, already referred to, in which a young +man of previously good character developed a propensity to steal after +his attack. Recovery with the re-establishment of the physical health +almost occurs in these cases. Murchison says he knows of no case in +which this condition has been permanent. On the other hand, Dr. C. M. +Campbell,[57] who had the opportunity of observing an attack of +typhoid fever among some insane patients {293} at the Durham County +Asylum, reports that the mental state was in no case injuriously +affected by the disease, but, on the contrary, underwent a marked +improvement in several of the cases. Indeed, in two of the cases, in +which the prognosis had become very unfavorable, mental recovery began +during the attack of fever. + +[Footnote 57: _The Journal of Mental Science_, July, 1882.] + +Paralysis, muscular tremors, and chorea are also occasionally observed +after attacks of typhoid fever. According to Murchison, paralysis does +not supervene until several weeks after the commencement of +convalescence. It may last for several weeks or months, but recovery +in the majority of instances eventually takes place. According to +Nothnagel,[58] the most common form is paraplegia, but it may also +take the form of hemiplegia, strabismus, paralysis of the portio dura, +motor paralysis of individual spinal nerves, such as the ulnar or +peroneal, or local anaesthesia. On the other hand, neuralgias and +disturbances of sensation are not common sequelae of typhoid fever. + +[Footnote 58: Cited by Murchison. See also article by Paget, _St. +Bartholomew's Hospital Report_, vol. xii.] + +Degeneration of the muscular tissue of the heart is probably present +in some degree in every case of typhoid fever, being, of course, most +marked in the severest cases. There would seem, however, to be no +special tendency to disease of its valves or membranes. Arterial +thrombosis or embolism, giving rise to gangrene of the part supplied +by the obstructed artery, is of occasional occurrence. Patry,[59] +Hayem,[60] Trousseau,[61] and others report or refer to several cases +in which gangrene of the leg, hand, or cheek was observed, and among +others a case in which sphacelus depending upon obstruction of the +carotid artery, the result, as Patry thought, of arteritis, commenced +in the left ear, and extended from there to the forehead and +cheek.[62] A. Martin[63] reports the case of a woman who expelled from +the vagina a fetid-smelling structure of cylindrical form, which +proved to be the cervix of the uterus, with the upper part of the +vagina, and in whom menstruation was not re-established until after +the performance of an operation. Spillmann[64] has also called +attention to the occurrence of gangrene of the vagina and vulva in +cases of typhoid fever. {294} This complication is generally met with +toward the end of the febrile period. + +[Footnote 59: _Archives generales de Medicine_, 1863, vol. i. pp. +129-549.] + +[Footnote 60: _Loc. cit._] + +[Footnote 61: _Clinique medicale_.] + +[Footnote 62: Since the above was written Barie has called attention +in the _Revue de Medicine_, Jan. and Feb., 1884, to the frequency with +which acute inflammation of the arteries occurs as a sequel of typhoid +fever. The author, whose investigations were limited to the larger +arteries, found that the vessels generally implicated are in the order +of their frequency, the posterior tibial, the femoral, and the dorsal +artery of the foot. The affection is usually unilateral, appears +during convalescence or when the patient leaves his bed, and occurs +just as often after light as after severe cases. He distinguishes two +varieties: 1, acute obliterating arteritis, and, 2, acute parietal +arteritis. The first variety is characterized by embryonal +infiltration of all the tissues, by disappearance of the smoothness of +the intima, which becomes uneven and granular, and by the formation of +a secondary thrombus, and almost invariably terminates in dry +gangrene. The second is merely an inflammation without such a clot, +and always terminates in recovery without gangrene. + +The symptoms of obliterating arteritis are--pain, more or less sudden +in its onset, directly over the course of affected vessels, and +increased by pressure, by the erect position, and by walking; +diminution, and then absence, of pulsation; swelling of the limb, +without oedema or redness; and, later, the appearance of bluish +mottling of the surface, and, more rarely, of patches of purpura; +lowering of the temperature, with or without troubles of sensibility, +such as formication, anaesthesia, etc., and the appearance of a hard +and painful cord, due to the formation of the thrombus. In the +parietal form the diminution of the pulsations is sometimes preceded +by a considerable exaggeration of their amplitude, and, while the +temperature on the affected side is usually lowered, it may sometimes +be increased.] + +[Footnote 63: _Centralblatt f. Gynakol_, 1881.] + +[Footnote 64: _Archives generale_, Mars, 1881.] + +Venous thrombosis, the result of weakness of the heart's action, is +more frequently observed. It occurs generally during the convalescence +of cases which have run a severe course, and usually affects the veins +of the lower extremities. I have seen both the femoral veins +obstructed from this cause at the same time. All the cases which have +come under my own observation have ended in recovery, and only 2 of 31 +collected by Liebermeister terminated fatally. Death occurred in 3 of +the 17 cases collected by Murchison, but in none of them was this +result attributable to this complication alone. There is, however, +always danger of a portion of the thrombus becoming detached and +producing embolism of the pulmonary artery. + +Pyaemia is said by Murchison and other authors to be an occasional +complication, but it is certainly rare in this country. In the milder +cases abscesses form during convalescence beneath the skin in +different parts of the body. In the more severe cases pus is deposited +in the joints or in the internal organs. Albert Robin[65] has reported +two cases in which there was suppurative joint affection. In one of +these the joints of the fingers and toes, with the sheaths of the +corresponding extensor tendons and both knee-joints and one +shoulder-joint, were affected. In the other the left knee was filled +with pus. In both cases the fever soon assumed an adynamic character. + +[Footnote 65: _Gazette de Paris_, 1881.] + +Laryngitis may sometimes occur in the course of typhoid fever, and +when it assumes the diphtheritic form and runs on to the formation of +ulcers is a very serious complication of typhoid fever, as it is not +infrequently accompanied by oedema of the glottis and gives rise to +the necessity for tracheotomy. It is fortunately, at least in its +worst forms, rare in this country. In Germany, judging from the number +of cases collected by Hoffmann and Griesinger, it is of more common +occurrence. The ulcers are oftener met with in some epidemics than in +others. During the winter of 1860-61, which I passed in Vienna, the +frequency with which they occurred was the subject of remark among +those who were in attendance upon the various clinics. + +I have already called attention to the frequency with which bronchitis +in some form or other attends upon typhoid fever. When it invades the +smaller bronchial tubes it occasionally gives rise to lobular +pneumonia or to collapse of some of the lobules of the lung. Lobar +pneumonia may also occur in the course of typhoid fever. It was +observed 52 times in 1420 cases of typhoid fever under treatment at +the Basle hospital from 1865-68. When it comes on late in the disease, +especially if the patient is comatose, or even semi-conscious, it may +be entirely overlooked, unless the lungs are carefully examined, as it +often does not reveal itself to us by any of the ordinary symptoms. It +may, however, occur early, and I have known it so prominent in the +beginning of an attack that the existence of typhoid fever was not +suspected. It sometimes terminates in abscess or gangrene, but is more +usually followed by chronic pneumonia, which may eventually either end +in recovery or lay the foundation for phthisis. Pleurisy with effusion +is also not an uncommon complication. It was observed, according to +Liebermeister, at the hospital at Basle 64 {295} times in 1743 cases +of fever. It is also a serious complication, as 21 of the 64 cases +terminated fatally. Murchison refers to three cases in which it was +followed by empyema. Other morbid conditions of the respiratory organs +which may occur as complications of typhoid fever are oedema, +infarction, hypostatic congestion of the lungs, emphysema, and +pneumothorax. Acute miliary tuberculosis is also an occasional +complication, but is oftener met with as a sequel. According to +Liebermeister, the tendency to pulmonary complications has diminished +since the introduction of the cold-water treatment. + +Catarrhal or diphtheritic inflammation of the fauces and pharynx +occurs in a large number of cases, and frequently gives rise to a +great deal of difficulty in swallowing. Indeed, it has been so +frequently observed in some epidemics that a few writers have regarded +it as a symptom rather than a complication of the disease. Either of +the varieties of inflammation may extend through the Eustachian tube +to the middle ear and be the cause of deafness, which usually passes +off as the inflammation subsides. Occasionally, however, the affection +of the middle ear gives rise to perforation of the tympanum or to +caries of the petrous portion of the temporal bone. + +Murchison says he has known the symptoms of and lesions of dysentery +to coexist with those of typhoid fever in several cases, and +Liebermeister asserts that diphtheria of the intestinal mucous +membrane is an occasional sequel to severe cases, especially when +other mucous membranes are the seat of diphtheritic inflammation. In a +few instances which have come under his observation it had given rise +to perforation of the bowel or to gangrene of the intestinal mucous +membrane. + +Jaundice occasionally occurs in the course of the disease. I have +never happened to see this complication, and am inclined to think it +is rare in this country. Liebermeister, however, met with it 6 times +in 1420 cases, and Griesinger 10 times in 600 cases. Hoffmann found it +in 10 of 250 fatal cases, and Murchison was able to collect 9 cases, +all of which but one terminated in death. Several of Griesinger's +cases, however, ended in recovery. In a few cases the jaundice may be +attributed to catarrh of the biliary ducts, but this solution of the +question will not explain those cases in which the feces remain +colored throughout. In fatal cases marked degeneration of the liver +has been found, which Liebermeister regards as of similar character to +that which occurs in acute yellow atrophy. In two of Murchison's cases +the liver was small and its secreting cells loaded with oil. In most +cases it does not appear until late in the disease, but it has been +observed as early as the fifth day. + +Abscess of the liver and diphtheritic inflammation of the mucous +membrane of the gall-bladder are among the rarer sequelae of typhoid +fever. + +Peritonitis is the most serious of all the complications of typhoid +fever. Its most common cause is perforation of the bowel, but it may +also be due to the extension of inflammation to the peritoneal +membrane without ulceration. Liebermeister believes that it is +sometimes the result of the typhoid infiltration so frequent in +various tissues of the body taking place in the serous membrane. In +other cases it arises from the rupture of softened mesenteric glands, +of softened {296} infarctions in the spleen, or of the abscesses which +are sometimes the consequence of the circumscribed inflammation by +which perforation is occasionally prevented from proving immediately +fatal. Less frequent causes of it are rupture of the gall-bladder, +with the escape of gall-stones into the cavity of the abdomen, +abscesses of the ovary, and abscesses in the walls of the urinary +bladder. It is said by Murchison to have been in one case the result +of a pseudo-abscess in the sheath of the rectus muscle bursting +inward. + +Swelling of the parotid gland occasionally occurs in typhoid fever, +but is much less common than in typhus. It is most frequently met with +in bad cases about the end of the third week or later, and generally +involves one side only. The swelling is hard and firm in the +beginning, and may terminate in resolution or suppuration. I have seen +it three times only, twice in my own practice, and once in that of a +medical friend. One of my cases was fatal, the other ended in +recovery, as did, I believe, the third case. Murchison saw it in only +6 cases, 5 of which were fatal. According to Hoffmann,[66] 16 cases of +suppurative parotitis were found at Basle among about 1600 typhoid +fever patients, 7 of the 16 ending fatally. Parotitis without +suppuration occurred three times. In 15 cases the attack was confined +to one side, 9 times to the right and 6 to the left; in 4 it was +double. Trousseau[67] looks upon these swellings as a very grave +accident, and says that he has scarcely ever seen a case recover in +which it has occurred, either in the course of typhoid fever or any +other disease. Chomel, on the other hand, is said to have regarded +them as critical and auspicious. + +[Footnote 66: Quoted by Liebermeister.] + +[Footnote 67: _Clinique medicale de l'Hotel Dieu_, t. i. 1861.] + +Menstruation occasionally occurs during typhoid fever, and may be +profuse. Bartels,[68] who has investigated the histories of 172 +patients in reference to this point, says that the catamenia always +appear if the menstrual period falls within the first five days of the +fever, and that they do so in two-thirds of the cases if they are +expected between the sixth and fourteenth days. On the other hand, +menstruation does not occur if the time for it falls in the third +week. He says also that the catamenia generally appears about the time +they are expected, or later, and very seldom earlier. Liebermeister, +on the contrary, says that they often occur prematurely. Other uterine +hemorrhages seldom occur, and never in those who have ceased to +menstruate or in whom the function has not been established. + +[Footnote 68: _Petersb. Med. Wochenschr._, 1881.] + +Suppuration of Bartholini's glands is said by Speilman to have taken +place in one case.[69] In the fourth week the patient complained of +violent pains in the right nympha, which, upon examination, was found +to be swollen. A tumor as large as a nut, which was red and painful on +pressure, could also be felt in the vagina. + +[Footnote 69: _Arch. generales_, Mars, 1882.] + +Pregnancy was formerly thought to confer an entire immunity from +typhoid fever, but recent and accurate investigations have shown that +if this immunity really exists, it is only relative, not absolute. +Gusserow[70] says that the disease is more frequently met with in the +first half than in the latter half of pregnancy. Abortion under these +circumstances commonly occurs. Gusserow says that it takes place in +from 60 {297} to 80 per cent. of the cases. He believes it to be due +to the high temperature, which causes the death of the foetus, which +is then expelled from the uterus. In a few cases, however, the child +is born living. Of Murchison's 14 cases, 10 recovered, and two of the +ten patients carried the child, at the fourth and eighth months +respectively, throughout the attack. All the others miscarried or +aborted, only one of them being delivered of a living child. Out of 18 +pregnant women[71] treated in the hospital of Basle for typhoid fever, +between the years 1865 and 1868, 15 miscarried or aborted. In the +three years following the introduction of the anti-pyretic treatment +only five cases of abortion occurred, and but one of these proved +fatal. This accident generally happens during the second or third week +of the fever. It is always a serious complication, and if it occurs in +the first three months of pregnancy it generally gives rise to profuse +hemorrhage, which is usually followed by a fall of temperature as +marked as that observed in hemorrhage from the intestines. Just as in +the latter case, the fall is only temporary, being soon succeeded by a +rapid rise of the temperature to its former height, or even beyond it. + +[Footnote 70: _Schmidt's Jahrbuch_, Bd. 193, No. 1, 1880, from _Berl. +klin. Wochenschr._, 1880.] + +[Footnote 71: Liebermeister, _loc. cit._] + +The danger of bed-sores occurring in typhoid fever is in consequence +of the impaired nutrition of the tissues, the length of time the +disease lasts, and the great emaciation which usually attends +it--greater than in any other acute disease. They constitute a very +serious and troublesome complication, and may occur on any part of the +body subjected to pressure, but are most frequent over the sacrum and +trochanters. Oedema of the lower extremities from feebleness of the +circulation is occasionally observed in the convalescence from +protracted attacks. Lendel has published a series of 7 cases observed +at Rouen, in which the entire body became very oedematous in the +second or third week of the attack or during convalescence. In none of +the cases was the urine albuminous. All the patients recovered except +one, who died of peritonitis. Similar cases have been reported by +other observers. Barthez and Rilliet have seen several cases in +children. + +Periostitis is an occasional sequel. I have seen it in one case only. +Sir James Paget,[72] who appears to have met with it in several cases, +says that it never occurs in the continuity of the fever, but always +when the patient is apparently convalescent, when his temperature is +normal and constant, and he is beginning to move about and to grow +stronger and stouter. Its most usual seat is the tibia, but it is also +met with in the femur, ulna, and parietal bone. Except in one case, +Sir James has never seen it in more than one bone in the same person. +It is always circumscribed within a space of from one to three inches +in extent, and usually subsides without necrosis or other abiding +change of structure; but in some cases the patient has remained for +some time subject to repeated attacks of pain and swelling of +periosteum. In the few cases, he says, in which the periostitis is +followed by necrosis the extent of dead bone has always been less than +that of the inflammation over it. Murchison, however, refers to two +cases of necrosis of the tibia, to one of the temporal bone, and to +two in which extensive necrosis of the lower jaw occurred. Gay[73] +also reports a case of extensive necrosis of the thigh-bone in a child +three years old, following an attack of typhoid fever. + +[Footnote 72: _St. Bartholomew's Hospital Report_, vol. xxi.] + +[Footnote 73: _Path. Trans. Lond._, vol. xx., p. 290.] + +{298} Very frequently after an attack of typhoid fever the patient +evinces a tendency to grow stout, which is either continuous or else +is gradually lost after he fully recovers his health. This increase in +flesh is not always accompanied by a corresponding gain in physical +strength, and he may remain for a long time after convalescence is +apparently complete incapacitated for much bodily or mental exertion. +Sometimes, on the other hand, the patient, instead of gaining flesh +and strength, may continue weak and emaciated, even when he is taking +a full amount of nourishment, which he is, however, unable to +assimilate. Cases of this kind may terminate in phthisis, but they +occasionally prove fatal, without any discoverable lesion after death +except an abnormally smooth appearance of the mucous membrane of the +ileum and a shrivelled condition of the mesenteric glands.[74] + +[Footnote 74: Murchison.] + +Patients suffering from typhoid fever may occasionally contract other +specific diseases. Murchison has notes of eight cases in which the +eruption of this disease coexisted with that of scarlatina, and says +that it was not uncommon in the London Fever Hospital for a patient +suffering from the former disease to contract the latter. Similar +cases are recorded by other observers. Typhoid fever may also be +complicated with rubeola, pertussis, diphtheria, variola, and +vaccinia. I have repeatedly seen children convalescent from typhoid +fever in the hospitals of Paris contract one or other of the eruptive +fevers. + +VARIETIES.--A great variety of forms of typhoid fever has been +described by various authors, but as many of them present few points +of difference from the usual form of the disease, it will not be +necessary to discuss them at any length. They derive their names from +some peculiarity of the mode of seizure, from the prominence of some +one symptom or set of symptoms, or from the presence of complications. +They are--(1) The adynamic form, in which prostration is marked in the +beginning and throughout the attack. (2) The ataxic or nervous form, +which is characterized by the predominance of delirium, subsultus +tendinum, and other nervous symptoms. (3) The hemorrhagic form, in +which there is a special tendency to hemorrhage from the different +mucous membranes. (4) The abdominal form, in which the abdominal +symptoms, such as diarrhoea and tympanites, are well developed. (5) +The thoracic form, so called from the presence of some thoracic +complication. (6) The gastric or bilious form, in which the disease is +complicated at its commencement by gastro-intestinal catarrh. La forme +muqueuse of French authors is probably identical with the above. (7) +The acute form, in which the disease begins abruptly and with great +violence, and runs a very rapid course, terminating usually in death +before the end of the first week or early in the second, before +ulceration can have taken place. Delirium is an early and prominent +symptom in this form, so that it has sometimes been mistaken for +meningitis. + +Certain forms of the disease deserve a little fuller consideration. +One of the most important of these is the abortive form, in which, as +its names implies, the fever is cut short in its course, and in which +there is every reason to believe that infiltration of Peyer's glands +takes place as usual, but that the subsequent course of the disease is +different, the glands undergoing resolution instead of advancing to +ulceration. The majority {299} of observers agree that in the +beginning there is nothing to distinguish such attacks from those +which follow their usual course. Liebermeister and Jaccoud state, +however, that their commencement is usually more abrupt than in the +ordinary variety, the former asserting that the temperature generally +reaches its maximum earlier, and the same opinion is expressed by +other authors. They are occasionally characterized by severe symptoms, +including a high temperature. In the few cases which have come under +my own observation the symptoms have been mild, but they were +sufficiently developed to leave no doubt on the mind as to the nature +of the disease. In a case which aborted on the twelfth day there were +hebetude, diarrhoea, tympany, and rose-colored spots persisting even +after the subsidence of the fever. Constipation would appear, however, +to be more frequent than diarrhoea in this class of cases. The +subsidence of the fever may occur at any time between the seventh and +fourteenth days; Griesinger has seen it occur as early as the fifth +day. Sometimes the defervescence occurs abruptly, with copious +perspiration; at others it is gradual and similar to that which takes +place in ordinary attacks. Between the abortive form of typhoid fever +and simple continued fever there are, of course, many points of +resemblance, but cases of the former may generally be recognized by +the presence of this rose-colored eruption and enlargement of the +spleen, or, where these are absent, by their occurring in the same +house or under the same circumstances as typical cases of the disease. + +Liebermeister has called attention in his article on typhoid fever in +_Ziemssen's Cyclopaedia_ to a class of cases which, he thinks, is also +caused by the typhoid infection, and of which the prominent feature is +the insignificance of the fever or the entire absence of it which +characterizes them. Such cases appear to be of frequent occurrence in +Basle. Many of them, he says, never show during their entire course +any rise of the temperature, or occasionally a slight elevation only, +but an enlargement of the spleen could generally be detected, and +occasionally an unmistakable rose-colored eruption. The action of the +bowels was usually irregular; sometimes there was diarrhoea, and +sometimes, on the other hand, obstinate constipation. The other +symptoms were prostration, pains throughout the body, often headache, +persistent loss of appetite, with more or less swollen and furred +tongue, and markedly diminished frequency of the pulse, which +disappears with convalescence, while its quality is not appreciably +altered. The long duration of an apparently trifling indisposition he +considers as especially characteristic. Cayley also refers to cases, +and even epidemics, of typhoid fever in which the temperature has been +below the normal throughout the whole course of the attack. Strube[75] +had the opportunity of observing such an outbreak during the siege of +Paris by the Germans in 1870. "In many of the cases," he says, "the +temperature throughout was subnormal, and in others never exceeded the +normal point. The roseola was usually profuse; the nerve symptoms were +of marked severity, and were in inverse ratio to the temperature, +consisting of violent delirium alternating with stupor; the duration +of the fever was very short, defervescence usually taking place at the +end of a fortnight. Of the 23 fatal cases, in 20 death took place +during the first fourteen days. The abdominal {300} symptoms were +slight, but the characteristic lesions were found on post-mortem +examination. All the cases were characterized by great prostration. +These cases presented some features which were probably due to this +peculiarity of the temperature; thus, the pulse was but little +accelerated, seldom exceeding a hundred; the tongue did not become dry +and brown; and the enlargement of the spleen was either absent or much +less marked than usual. Strube attributed the peculiar features of +this epidemic to the depressed condition of the troops; they had been +exposed to great hardships on the way to Paris, over-fatigued by +forced marches, and very insufficiently supplied with food." + +[Footnote 75: Quoted by Dr. Cayley.] + +A mild form of the disease has been described by certain authors, in +which the symptoms, although not severe, are characteristic, and in +which there is therefore, with due care, little danger of making a +mistake in diagnosis. It therefore seems an unnecessary refinement to +set apart such cases under a separate head. + +The latent form, or the typhus ambulatorius of the Germans, is of more +importance from the fact that the symptoms are so mild, or that so +many of the ordinary symptoms are wanting or masked by those due to +complications, that there is great danger of regarding the attack as +of little moment. In many cases there is no symptom present but +prostration and fever to indicate that the patient is ill, and these +may be so slight that he may positively refuse to go to his bed, and +may even insist upon pursuing his ordinary avocation, in the midst of +which he is often suddenly seized with alarming symptoms, such as +violent delirium, intestinal hemorrhage, or, what is more common, +those due to perforation of the bowel. Still, even in these cases a +careful examination will often disclose the presence of some symptom +which had failed before to attract attention, and which will often +reveal to us the true nature of the disease. I was myself the subject +of such an attack nearly twenty years ago. Supposing that the +excessive prostration from which I was suffering was due to overwork +at a large army hospital in the neighborhood of Philadelphia, I +determined to seek repose in travel and in change of scene. On the eve +of doing so I fortunately sent for a medical friend, who, after a +thorough investigation of my symptoms, succeeded in finding a few +rose-colored spots upon my abdomen. The attack subsequently ran a mild +but well-marked course. Occasionally, the symptoms due to a +complication so predominate over those arising from the disease itself +that they completely mask it. I have known bronchitis so severe as to +divert in this way the attention of a skilful diagnostician from the +primary disease. When vomiting, together with other symptoms of +hepatic derangement, is especially prominent in the beginning of +typhoid fever, the mistake is not infrequently made of attributing +these symptoms to a "bilious attack." + +TYPHO-MALARIAL FEVER.--Under this name, which was originally suggested +by J. J. Woodward, Surgeon U.S.A., early in the summer of 1862, as a +designation for a class of cases in which the symptoms of typhoid +fever are associated with those of remittent, and which was especially +common among the soldiers of the United States Army during the late +Civil War, are probably included at least two distinct conditions: +1st, remittent fever, in which the disease, on account of the +depressing circumstances surrounding the patient, assumes {301} a +typhoid form; and, 2d, typhoid fever, occurring in a patient who has +also been exposed to malarial influence. This association of diseases +is of course not new, or even undescribed before this name was +suggested for it. Woodward thinks that he has found enough in the +description of Roderer and Wagler to justify him in concluding that +the epidemic which occurred at Gottingen in 1762 was really of this +character. There would seem also to be no doubt from the descriptions +of Dawson[76] and Davis[77] that the fever which decimated the British +army in the Walcheren expedition was typhoid fever, modified by the +malarial influence to which the soldiers were subjected. The latter of +these authors says that the ileum and jejunum in the bodies of those +who died of this disease were frequently found interspersed with +tubercles, inflamed and ulcerated in different parts. + +[Footnote 76: _Observations on the Walcheren Diseases_, Ipswich, 1810, +by G. P. Dawson.] + +[Footnote 77: _A Scientific and Popular View of the Fever of +Walcheren_, J. B. Davis, London, 1810.] + +In our own country the occasional association of these two diseases +has also long been recognized. Drake describes it under the name of +remitto-typhoid, and Dickson seems to have been perfectly familiar +with it, for he says that typhoid lesions will sometimes be found in +the bodies of those dead of bilious remittent. Levick recognized the +presence of the symptoms of both diseases in some patients who were +under his care as early as the spring of 1862, and proposed the name +of miasmatic typhoid fever for this class of cases in the following +June.[78] Meredith Clymer has also frequently met with cases in which +the symptoms of the two diseases were coexistent.[79] + +[Footnote 78: _Med. and Surg. Reporter_, June 21, 1862.] + +[Footnote 79: _The Science and Practice of Medicine_, by William +Aitken, M.D., 3d Amer. ed.; with additions by Meredith Clymer, M.D., +Philadelphia, 1872.] + +As is indicated by the name given to it, the symptoms in this form of +typhoid fever are modified by the presence of malarial poisoning. The +cases always manifest a decided tendency to periodicity, the evening +exacerbations are more decided than in the ordinary form, the +remissions are often ushered in with a profuse sweating, gastric and +hepatic derangements are more marked, and headache is more severe. +There is frequently less mental hebetude or dulness than in ordinary +typhoid fever. In some of the cases observed by Levick[80] the +symptoms were those of pernicious congestive remittent fever, such as +copious serous discharges, not unlike those of Asiatic cholera, +colliquative sweats, and other symptoms of exhaustion. + +[Footnote 80: _Amer. Journal of the Med. Sci._, April, 1864.] + +TYPHOID FEVER IN CHILDREN.--It was formerly thought that infants and +very young children were not often the subjects of typhoid fever, but, +so far is this opinion from being correct, it is now known that they +are especially liable to suffer from it. The rose-colored eruption is +more often wanting in them than in adults, and the fever more apt to +assume a distinctly remittent type; and hence, no doubt, the +difficulty which is often experienced in diagnosticating this fever +from other forms of fever in children. There is no doubt that many +cases which have been described by authors under the head of infantile +remittent fever are really examples of typhoid fever modified simply +by the age of the patient. It may occur in infants not more than six +months old, and is not infrequent in {302} children of two or three +years of age. Henoch,[81] who has had the opportunity of observing a +large number of cases, says that the rise of temperature is commonly +more abrupt in children than in adults, and that the disease generally +runs its course in a shorter time. The pulse is more frequent, and may +be as high as 144 in cases in which the prognosis is not grave. +Dicrotism is very rare. Slowness and irregularity of the pulse, like +that observed in basillar meningitis, he has never seen. The nervous +symptoms are not so pronounced even when the temperature is high, and +they bear no relation in severity to the height of the temperature. +Diarrhoea in the cases observed by Henoch was often absent during the +whole course of the attack, and the stools were often brownish or +greenish instead of yellow. + +[Footnote 81: _Charite Ann._, 1875.] + +TYPHOID FEVER OF AGED PERSONS.--The modifications which the disease +undergoes when it occurs in patients advanced in life are precisely +those to be expected from the diminished activity of the processes of +life in them, as compared with those of younger persons. The febrile +movement is generally prolonged, although of low grade, the +temperature rarely rising high, and frequently during convalescence +sinking below the normal. The diarrhoea is commonly not so severe, the +delirium so violent, or the rose-colored eruption so often present. On +the other hand, adynamic symptoms, such as excessive prostration, +tremors, subsultus tendinum, and the like, are frequently prominent +from the beginning of the attack. + +Several authors, among whom may be mentioned Arnat,[82] +Hornburger,[83] and Greenhow,[84] have described a renal form of +typhoid fever. In this form the urine is blood red in color or like +dark broth. It often contains albumen during the first week of this +disease, usually hyaline or more or less granular casts, and +occasionally red blood-discs, white cells, epithelia of kidneys and +bladder, and epithelial detritus. The specific gravity is high, and +the quantity is usually diminished. The prominent symptoms are pain in +the region of the kidneys, oedema of face, tense and frequent pulse, +great prostration, profuse epistaxis, violent delirium, and +hyperpyrexia. The temperature may be 105.8 degrees. On the other hand, +the intestinal symptoms are less marked. In fatal cases the lesions of +intestinal nephritis have been found at the autopsy. + +[Footnote 82: Thesis, _Sur la Fievre typhoide a forme renale_.] + +[Footnote 83: _Berlin klin. Wochenschrift_, 1881.] + +[Footnote 84: _Transactions of Clinical Society of London_, 1880.] + +RELAPSES.--Much difference of opinion will be found to exist among +authors in regard to the frequency with which relapses occur in +typhoid fever, and this difference does not appear to be due to any +greater frequency of this accident in some countries than in others, +since Liebermeister met with them in 8.6 per cent. of the cases +treated at the hospital at Basle, while, according to other German +observers quoted by him, they occur in 6.3 per cent. (Gerhardt), in 11 +per cent. (Baumler), and in 3.3 per cent. (Biermer). Murchison noted +them in 80 of 2591 cases in the London Fever Hospital, or in 3 per +cent., and Maclagan in 13 of 128 cases at Dundee, or in 10 per cent. +about. Immermann[85] of Basle says that they occur in 15 per cent. of +the cases, and that in very unfavorable years the proportion may be as +high as 18 or 19 per cent. Prof. Henoch[86] observed relapses in 16 +cases out of 96, or 16.6 per cent. In my own {303} practice they have +not been very numerous. I find that in 80 cases of which I have full +notes they are recorded five times, or in 6.25 per cent., and I +believe this ratio correctly represents the frequency with which they +have happened in all the other cases which have come under my care. +Part of this difference of opinion is unquestionably attributable to +the fact that under the term relapse are sometimes included two +distinct conditions: (1) Mere recrudescences of fever, which occur +during the stage of defervescence or that of convalescence, and which +are provoked by errors of diet, mental or bodily fatigue, or some +other irritating cause. They usually last a day or two, and are +entirely distinct from (2), true relapses, in which all the +characteristic symptoms of the primary attack are reproduced, and +which commonly occur some time after the disease has apparently run +its course. There is occasionally no distinct apyretic interval +between the two attacks, but in by far the greater number of instances +the relapse occurs in the second or third week, or even later, after +the establishment of convalescence. In 20 cases reported by W. M. Ord +and Seymour Taylor[87] the relapse occurred in the third week of the +disease in 1; in the fourth week in 5; in the sixth week in 3; in the +seventh week in 7; in the eighth week in 3; in the ninth week in 1. +James Jackson refers to a case in which the date of the relapse is not +given, but in which he was able to detect the rose-colored eruption in +the sixty-sixth day[88] from the commencement of the disease. In my +five cases the relapse occurred on the seventh, eighth, ninth, +eleventh, and twentieth day after the apparent establishment of +convalescence. In these cases the duration of the relapse was 11, 13, +17, 20, and 13 days respectively. The highest temperature noted in any +of the relapses was 105 degrees, which occurred in two cases. In both +of these this temperature had also occurred in the original attacks. +In one of the others, however, a temperature of over 104 degrees F. +was repeatedly observed in the relapse, while in the primary attack it +had never risen above 102 degrees. + +[Footnote 85: _Schweiz. Corr. Bl._, viii. 1878.] + +[Footnote 86: _Charite Ann._, ii. 1875.] + +[Footnote 87: _St. Thomas's Hospital Report_, vol. ix., London, 1879.] + +[Footnote 88: Since the above was written I have had under my care a +case of typhoid fever in which a third relapse occurred nearly four +months after the patient, a woman aged thirty years, was first taken +ill. The following is a brief abstract of the history of this +remarkable case: The original attack began about Sept. 20, 1883, was +of moderate severity, and lasted between three and four weeks. +Convalescence, which seems to have been nearly complete, as the +patient had left her bed, was interrupted on Nov. 1st by a relapse, +during which she was admitted into the Pennsylvania Hospital. This +relapse was severe, and before it had entirely run its course was +itself interrupted, on Nov. 17th, by an intercurrent relapse, which +lasted two weeks. During these two relapses extensive bed-sores formed +upon the nates, occasioning more or less irritation and consequent +febrile reaction. On Jan. 11, 1884, a third relapse occurred. This +relapse was accompanied by diarrhoea, rose-colored spots, tympany, dry +and brown tongue, and other characteristic symptoms of typhoid fever, +the diagnosis being fully concurred in by my colleague, Dr. Morris +Longstreth, who saw the case with me. Convalescence was again +interrupted on Feb. 13th by fever, which continued for two weeks, but +which possessed none of the characters of typhoid fever, and was +clearly due to imprudence on the part of the patient. The patient is +now (April 25, 1884) entirely well, and will shortly be discharged +from the hospital.] + +The onset of a relapse is usually much more abrupt than that of the +original attack. It is rarely preceded by prodromata. The temperature +rises more rapidly and attains its maximum earlier, which may be much +greater than in the original attack. In one case under my care it +reached 105 degrees on the evening of the first day, and temperatures +of 103.5 degrees and 104 degrees on the evening of the second day are +not infrequent. + +{304} The rose-colored eruption appears earlier. In 38 cases +investigated by Murchison with reference to this point, it appeared on +the third day in 7; on the fourth in 8; on the fifth in 7; on the +sixth in 2; on the seventh in 12; and at a later date in 2. In the +case the history of which is given below it was detected on the second +day. The delirium also comes on sooner. The relapse is usually less +severe, and is of shorter duration, than the primary attack. All my +cases terminated in recovery. Occasionally, however, it is much more +severe. In one case in which the primary attack was so mild that the +patient could scarcely be persuaded to remain in bed, the relapse was +so severe that for many days it was uncertain whether the patient +would recover. In another intestinal hemorrhages to an alarming extent +occurred on two occasions. Moreover, of Murchison's 53 cases, 7 were +fatal; in 2 of the cases death was due to perforation; in 2 to +peritonitis, induced by infarction of the spleen; and in 1 to +abortion; and of Ebstein's 13 cases, 3 were also fatal. Occasionally, +a second, and it is said even a third, relapse is noted. In one of Da +Costa's cases hemorrhage from the bowels took place during a second +relapse. + +[Illustration: FIG. 15. Pulse.] + +The following histories and temperature charts illustrate the +prominent peculiarities of relapses occurring in typhoid fever: + +TYPHOID FEVER (with a relapse).--G---- L----, aet. 20, single, seaman, +Italian, admitted March 6, 1878; April 30, 1878, left in ward. Patient +is unable to speak English. The following history is obtained through +an interpreter: His family history is good, and he is naturally a +healthy man, never having had any serious illness--no venereal +disease, no cough or rheumatism, no intermittent fever, and he has not +been in the habit of drinking to excess. His vessel has been lying off +Gloucester Point, and two seamen have recently been similarly affected +on another vessel anchored near by. For about two weeks he has had +malaise, but not until three days ago was he so ill that he was +obliged to give up work. He was then taken with cough, chills followed +by fever, diarrhoea, headache, and pain in the abdomen. Has had no +epistaxis or vomiting. + +Upon admission patient has fever, his face is flushed, his tongue +coated with a brown fur in the centre, dry, fissured, and red and +glossy at the tip and edges. He has hebetude and some delirium, though +not very active; he is deaf. His abdomen is somewhat tense and +tympanitic, and covered with very numerous rose-colored spots, which +disappear momentarily on pressure; they are also distributed over +thighs and chest. There seems to be no tenderness on pressure over +abdomen, and there is no gurgling felt. Has moderate diarrhoea, having +about three stools daily, which are light yellow in color and are +loose and fetid. Urine cloudy orange red, acid, 1021. No albumen. + +{305} _3.7_. Ord. Ol. Terebinth. gtt. x; Acid. Muriat. dil. gtt. v +every two hours, with Quinine gr. viij daily, and restricted diet. + +_3.8_. Tongue not so dry; is better. Whiskey fl. oz. ij. + +_3.9_. Temperature elevated. Ord. to be sponged. + +_3.10_. Has had four stools in the last twenty-four hours. Some +sonorous rales over chest posteriorly. Sponging to be repeated when +temperature rises. + +_3.11_. There is some subsultus. There are more numerous rales heard +over chest posteriorly. + +Ord. whiskey fl. oz. v daily; turpentine stupes to chest. His +diarrhoea is better; considerable hebetude. + +_3.12_. Tongue is not so dry, and is cleaner. The spots over his body +are beginning to assume more the appearance of petechiae. They are +found everywhere on his body. Has had but one stool within the last +twenty-four hours. + +_3.13_. He is brighter; skin feels better; tongue cleaner; pulse but +80. Fewer rales heard in chest. No change in his treatment. + +_3.14_. Spots disappearing. Two stools in last twenty-four hours, not +so loose in character. Pulse dicrotic. + +_3.15_. There is no tympany. Had one natural stool yesterday. +Sudaminae over abdomen. + +_3.16_. Doing well. Pulse very slow. + +_3.17_. Tongue moist and clean; no diarrhoea. + +_3.18_. No diarrhoea; spots are still to be seen, but are fading every +day. + +_3.20_. Takes a little lemon-juice, as the gums are disposed to be a +little spongy. + +Stop turpentine and muriatic acid. + +_3.25_. Bowels somewhat constipated. + +Ord. enema of castor oil. + +_3.26_. Stop quinine; give whiskey fl. oz. iij only. Allowed chicken +and two eggs daily. + +Ord. Tr. Cinch. Co. fl. drachms ij s.t.d. + +_4.4_. Slight chill, headache, and pain in side. Temp. 101 degrees. + +_4.5_. Temp. normal again; as well as before. + +_4.8_. Has been up for a week, and steadily gaining in strength, +except the slight attack on the 4th, when to-day, without his having +taken any indigestible food, or indeed any reason to which it could be +assigned, he was seized with a relapse, his temperature rising to 105 +degrees, but being reduced a half degree by sponging. + +_4.9_. Spots have again appeared in great numbers, and they are very +large. Last evening his temperature reached 104-3/4 degrees, and was +reduced to 101 degrees by sponging. + +_4.10_. Doing very well; spots are still making their appearance. + +_4.12_. Diarrhoea not at all excessive. + +_4.15_. Spots are very numerous. + +_4.20_. Temperature nearly normal. + +_4.25_. Doing perfectly well; up and about. + +_4.30_. Left in ward, upon completion of my term of service. + +{306} [Illustration: FIG. 16. Chart of temperature in typhoid fever +with relapse.--Original attack.] + +[Illustration: FIG. 17. Chart of temperature in typhoid fever with +relapse.--Relapse.] + +ABORTIVE ATTACK, FOLLOWED BY TYPICAL ATTACK.--Thomas Rogers, October +15, born in Philadelphia, assistant nurse. Admitted {307} January 25, +1883; discharged March 26, 1883, cured. Father died of hemorrhage from +the lungs; mother living and healthy. Two years ago he sustained a +compound fracture of the left leg from a bale of cotton falling on +him; otherwise he has always enjoyed good health. For the past three +months he has been assisting the nurse in the receiving ward of this +hospital. Four days before admission, without unusual exposure, he had +a slight chill, and felt cold for several hours. This was followed by +fever and a feeling of weakness. He also had slight headache and the +bowels were constipated; no epistaxis. + +Upon admission patient has a good deal of hebetude, face flushed, +temperature 102 degrees, pulse 106, tongue slightly coated, moist. Has +slight pain in right lumbar region, but no distension of abdomen. +Urine negative. + +Ord. quinine gr. viij. daily; liq. ammon. acet. fl. drachms ij. q.q.h. + +_Jan. 29th_. More hebetude; tongue more coated with brownish fur, red +at tip; bowels continue costive; opened by an enema. + +_31st_. Is brighter and better. One doubtful rose-colored spot seen on +abdomen. + +_Feb. 4th_. The morning temperatures for the past two days have been +subnormal and the evening rise is very slight. All the symptoms also +indicate the approach of convalescence. + +_6th_. More fever; pulse weaker; functional murmur heard over heart; +sudamina out over abdomen. Ord. whiskey fl. oz. ij. + +_8th_. Some fulness of abdomen; had three loose yellowish-colored +stools in the last twelve hours. + +_9th_. A few doubtful rose spots out over abdomen and back; sudamina +still abundant. + +_10th_. More tympany; numerous rose-colored spots out over abdomen and +back; slight epistaxis and bronchitis. + +_11th_. Pulse more feeble; still slight diarrhoea. Increase whiskey to +fl. oz. iv. + +_15th_. Has a good deal of hebetude, but no headache; fewer spots; +pulse weaker; temperature lower. Increase whiskey to fl. oz. vj. + +_17th_. Temperature high again; most of the spots have disappeared; +slight epistaxis and subsultus; no delirium; bowels not open for two +days. + +_20th_. Temperature falling; spots disappearing; still fulness of +abdomen. + +_25th_. Temperature has been subnormal for several days, and he is +doing well; tongue cleaning. Has emaciated a good deal, and is weak. + +_March 1st_. Is convalescent; tongue has lost its redness. + +_8th_. Continues to improve; allowed semi-solid food. + +_17th_. Is now quite well; has gained a good deal in flesh, and is +stronger. + +{308} [Illustration: FIG. 18. Temperature chart of typhoid +fever.--Abortive attack, followed by typical attack.] + +The examination of the bodies of those who have died during a relapse +reveals the presence of two sets of lesions in the cicatrizing ulcers +of the primary attack and the recent ulcerations of the relapse. The +latter are usually less extensive, and are found to be situated at a +greater distance from the lower end of the small intestine, than the +former, for the reason that the Peyer's patches most remote from the +ileo-caecal valve are least apt to be affected in the primary attack. + +No satisfactory explanation of these relapses has as yet been +discovered. {309} They occur in patients of both sexes and of all ages +with about the same frequency. They have been attributed to errors of +diet, mental and bodily fatigue, and the like, but, while we know that +causes of this character often provoke recrudescences of fever, and +can understand that they may act as exciting causes of a relapse in +cases in which the predisposition exists, it does not seem possible +that they should by themselves be able to bring back all the +characteristic symptoms of a specific disease. It has been maintained +by some authors that a relapse indicates that a new infection has +taken place; but this hypothesis, even if we admit that it accounts +for those cases in which the patient is allowed to remain in the place +in which he has acquired the disease, does not explain those in which +he is removed during the first attack to a hospital where all the +sanitary arrangements are presumably perfect. Griesinger has +endeavored to explain relapses occurring in hospitals by suggesting +that they may possibly be due to a fresh contagion from other patients +with typhoid fever in the same ward; but this explanation is rendered +improbable by the fact that relapses have occurred when cases have +been thoroughly isolated. As I have already said, during a long +connection with the Pennsylvania Hospital I have only known a single +case of typhoid fever to originate within its walls, although relapses +probably occur in its wards with the same frequency as in other +hospitals. To adopt Griesinger's explanation, it would therefore be +necessary to assume that a patient just recovered from an attack of +the disease is more susceptible to the action of its contagion than +patients suffering from other disease; which seems improbable, to say +the least. It has also been maintained that relapses are due to the +inoculation of the previously healthy Peyer's patches by the typhoid +poison which is thrown off with the sloughs from those first affected. +Maclagan alleges that relapses are more frequently met with in cases +in which constipation is present in the primary attack, a condition +which he regards as favorable to absorption; but this is opposed to +the experience of almost every one who has paid any attention to the +subject. In the cases which have come under my own observation it +certainly was not the case, diarrhoea having been present in all of +them. It is more likely, as suggested by Liebermeister, that part of +the poison remains latent somewhere in the body, not developed, +destroyed, nor expelled during the first attack, but brought later +into activity by some exciting cause. Da Costa adopts this view, and +says that relapses of typhoid fever are not unlike the outbreaks of +malarial fever which occur after worry or fatigue and when there has +been no chance for a fresh infection. Different plans of treatment +have at various times been charged with increasing the predisposition +to relapses. This is especially true of the cold-water treatment, and +the records at the hospital at Basle show that the proportion of +relapses and the number of deaths from them are both increased under +the use of cold water. Liebermeister thinks, however, that this does +not necessarily prove that this treatment favors the occurrence of +relapses, since before the introduction of this plan of treatment many +more typhoid fever patients died in the first attack of the disease. +Employing those cases only for statistical purposes in which the +patients have survived the first attack, he finds that the difference +at once disappears, there being 9 per cent. of relapses before the use +of cold water, and 10.3 per cent. after its use. + +{310} Gerhardt[89] asserts that in cases in which relapses occur the +enlargement of the spleen does not diminish during the non-febrile +period that intervenes between the original attack and the relapse. + +[Footnote 89: _Ziemssen's Cyclopaedia_, vol. i. p. 193.] + +Da Costa[90] has shown that the appearance of the white line and +furrow left by the primary attack, to which attention has already been +drawn, may sometimes be of service to us in diagnosis when we see the +patient for the first time during the relapse. In a case which was +recently under my care their appearance certainly rendered the nature +of the previous illness from which the patient had suffered much +clearer than it would otherwise have been. + +[Footnote 90: _Transactions of the College of Physicians of +Philadelphia_, 3d S., vol. iii.] + +DURATION.--The mode of invasion of typhoid fever is generally so +insidious, and the first symptoms so little pronounced, that the +patient, even if free from mental hebetude and confusion at the time +when he first comes under the care of a physician, is usually unable +to fix with certainty the time of the beginning of his illness. This +inability is of course most marked in what are known as walking cases, +in which, notwithstanding that the disease is far advanced, the +patient continues to pursue his ordinary avocations or at least +refuses to go to bed. In a few cases, however, either in consequence +of the violence of the first symptoms or from some other cause, +opportunity is afforded to the physician of observing the disease from +its onset. In many others the date of commencement may be +approximately ascertained. The average duration of such cases, if +uncomplicated, has been found to be between three and four weeks. +According to Bartlett, the average duration of 255 cases at the +Massachusetts General Hospital between the years 1824 and 1835, +inclusive, was twenty-two days. It was a little less than this in +patients under twenty-one years of age, and a little more in those +over. As these cases occurred before the introduction into use of the +clinical thermometer, and as the commencement of convalescence is +fixed in them at the time when the patients were able to take a little +solid food, it is possible the fever may have continued in them some +time after convalescence was supposed to have been established. Of 200 +cases which ended in recovery, and in which Murchison was able to +ascertain with precision the date of commencement, the duration was 10 +to 14 days in 7 cases, 15 to 21 days in 49 cases, 22 to 28 days in 111 +cases, and 29 to 35 days in 33 cases. The mean duration of these 200 +cases was 24.3 days, while that of 112 fatal cases was 27.67 days. +From the same author we learn that the average stay in hospital of 500 +cases which recovered was 31.24 days, and of 100 fatal cases was 16.52 +days, while the average duration of the illness before admission in +the 600 cases was 10.78 days. During the twenty years from Jan. 1, +1862, to Dec. 31, 1881, 621 cases of typhoid fever, 121 of which were +fatal, were admitted into the Pennsylvania Hospital. No notes of many +of these cases were taken, and of some of the others the notes are +incomplete or inaccessible, so that they cannot, unfortunately, be +used for the purpose of determining the duration of the disease. The +books of the hospital, however, show the length of time each patient +remained in the wards. From these we learn that the average stay of +the 500 patients who recovered was 43.5 days, while that of the 121 +patients who died was only 8.75 days, and that of these a large number +(28) died within {311} 48 hours after their admission to the hospital. +As a rule, patients are retained at the Pennsylvania Hospital until +they are fully able to return to work, while at the English and +continental hospitals it is usual to discharge them when they cease to +need active treatment. This circumstance probably explains the much +greater average duration of the cases admitted to the Pennsylvania +Hospital than that of the cases referred to by Murchison. In the +abortive form the duration of the disease may not exceed ten days, and +there are authors who contend that it may occasionally be very much +less. + +Death may occur at almost any time in the course of typhoid fever. I +have never seen it myself take place before the seventh day. Murchison +reports two cases in one of which the disease terminated fatally +within twenty-seven hours of its commencement, and in the other on the +second day. Instances are more numerous in which death has occurred on +the fourth, fifth, or sixth day, but still they are comparatively +infrequent, and, as a rule, the fatal termination takes place most +frequently during the course of the third week. On the other hand, +death may sometimes occur at a very much later period. This is, of +course, the case when it occurs during a relapse, but if the fever +continues after the third week the patient may sometimes die from +exhaustion or from the intercurrence of a complication. Death may also +be the result of a sequela long after the disease has run its course. + +DIAGNOSIS.--The insidious invasion of typhoid fever, together with the +absence of pathognomonic symptoms in the beginning, always renders the +diagnosis difficult, and sometimes impossible, during the first week. +Still, even at this time the existence of the disease may be suspected +if the frequent use of the thermometer reveals from day to day a +gradual increase of the fever and the existence of evening +exacerbations followed by morning remissions, the temperature rising +each evening from a degree to two degrees higher than it had done the +preceding evening. If in addition to this character of the pyrexia +there are diarrhoea with ochrey-yellow stools or an increased +susceptibility to the action of cathartic medicines, epistaxis, +enlargement of the spleen, slight fulness of the abdomen, with +tenderness and gurgling in the right iliac region, slight hebetude and +some confusion of ideas upon awakening, the diagnosis becomes more +probable. During the next week the symptoms are usually much more +characteristic. The presence of marked abdominal symptoms, together +with the eruption of rose-colored spots, will generally render the +recognition of the disease at this time an easy matter. There are, +however, a few cases in which no rose-colored spots can be found, and +in which the abdominal symptoms, if they exist at all, are so little +marked that they do not arrest attention. Even in these cases the +temperature record, when carefully studied, will often throw a good +deal of light upon the nature of the disease. If the febrile movement +resembles that usual in typhoid fever, if it has continued for more +than a week, if the patient has not been recently exposed to malarial +influences, and presents no symptoms of local disease, the diagnosis +may still be made with at least an approach to certainty. + +The following are the diseases which are most likely to be mistaken +for typhoid fever: + +Typhus fever has a course which is so essentially different from {312} +that of typhoid that in well-marked cases it would scarcely be +possible to mistake one for the other. Cases, however, do occur which, +in consequence of a very profuse and dark-colored eruption in the +latter, or of the existence of abdominal symptoms in the former, +present at first a good deal of difficulty in diagnosis. The invasion +of the former is more abrupt and its duration shorter than in typhoid +fever. The eruption is usually also much more copious, and appears in +the former as early as the fourth, fifth, or sixth day, while that of +the latter is rarely observed before the seventh day. The fever in the +former is much more nearly continued in type than that of the latter. +Defervescence occurs in the former by crisis; in the latter, by lysis. +The expression of the physiognomy is different in the two diseases. In +typhus there is a uniform dusky hue of the face, with injection of the +conjunctivae and contraction of the pupils. In typhoid fever the +pupils are often widely dilated, the conjunctivae clear, and the face +pallid, with the exception of a circumscribed flush on each cheek. +Diarrhoea is much less frequent in the former than in the latter, and +when it does occur is not accompanied by ochrey-yellow stools. +Epistaxis, tympanites, pain, and gurgling in the right iliac region, +and intestinal hemorrhage, common symptoms in the latter, are very +infrequently met with in the former. On the other hand, petechiae and +vibices, which are of almost constant occurrence in the former, are +rarely met with in the latter. The circumstances also under which the +two diseases are contracted are different. Typhus originates from +overcrowding or is due to direct contagion. The origin of typhoid +fever is often involved in more obscurity, but it can generally be +traced either to a polluted water-supply or to defective drainage. + +Relapsing fever, with due care, is not likely to be confounded with +typhoid fever. The abrupt commencement of the former, the high fever, +lasting for from five to seven days only, and terminating by crisis +with a profuse sweat, and the period of complete apyrexia of a week's +duration, followed by the relapse in which the temperature rises even +higher than in the primary paroxysm, and which also terminates by +crisis, form a chain of symptoms which has no counterpart in the +latter. The mind in relapsing fever is usually clear, there being none +of the hebetude and mental confusion commonly observed in typhoid +fever. The rose-colored eruption is, moreover, wanting, and diarrhoea +and tympanites are absent. On the other hand, jaundice and tenderness +in the epigastric zone are more common than in typhoid fever. + +Influenza sometimes, Murchison says, when epidemic, closely simulates +typhoid fever, but as the two diseases occur in this country the +resemblance between them is not often sufficiently strong to lead the +careful observer astray. In both there are fever, prostration, +sleeplessness, delirium and sweating, and occasionally deafness, +diarrhoea, epistaxis, and a dry red tongue; but the onset of the +attack in the former is more abrupt, its duration shorter, and +subsequent convalescence more rapid than in typhoid fever. The +prostration, too, is more decided in proportion to the degree of fever +present. Coryza and bronchial catarrh are much more marked symptoms in +the former than in the latter, while hyperaesthesia of the surface, +which is present in almost every case of influenza, is only rarely met +with in typhoid fever. + +Remittent and typhoid fevers often prevail together in the malarious +{313} districts of this country, and, as they present many points of +resemblance, they are sometimes with difficulty distinguished from +each other. They both may begin with nausea and vomiting; abdominal +and cerebral symptoms are common to both, and so is enlargement of the +spleen. The typhoid state may supervene in either, and in both the +febrile movement is remittent in character. In remittent fever, +however, the remissions are more marked, and are usually accompanied +with more profuse sweating, than in typhoid fever. Jaundice and other +symptoms of hepatic derangement are also more common, and the pains in +the back and limbs are more frequent and more severe. The effect, too, +of quinine in producing a permanent reduction of the temperature, is +generally more decided. On the other hand, the rose-colored eruption +of typhoid fever is never present in pure remittent fever. +Occasionally, in cases of the variety of typhoid fever known as +typho-malarial fever, the symptoms of the latter may be so prominent +as entirely to mask those of the former. In such cases the discovery +of a few rose-colored spots somewhere on the surface will clearly +reveal the true nature of the disease. + +Epidemic cerebro-spinal meningitis differs from typhoid fever by its +more abrupt invasion, by the retraction of the head which rapidly +supervenes, and by the appearance a short time afterward upon +different parts of the body of petechiae, which are not likely, even +at first, to be mistaken for the rose-colored spots of typhoid fever. +The fever has, moreover, no constant character, but is remarkable, on +the contrary, for its great irregularity. The duration of the disease +is in fatal cases much shorter, death taking place not infrequently +within the first week, and occasionally as early as the second or +third day. On the other hand, the duration in cases which recover may +be even longer than in typhoid fever. + +Simple continued fever may readily be mistaken in the beginning for +typhoid fever, especially in those cases complicated by diarrhoea, +but, as a general rule, the different character of the febrile +movement, its more abrupt commencement and termination, and its +shorter duration, together with the absence of the rose-colored +eruption, will usually serve to distinguish it. + +The eruptive fevers are always readily distinguishable at the period +of invasion from typhoid fever, and the mistake of confounding them +with the latter disease may generally be avoided by a close study of +the character of the pyrexia. In the eruptive fevers the temperature +rises abruptly, frequently attaining its maximum in the course of +twenty-four hours, and sometimes in very much less time. There are +also in all of them early symptoms which indicate pretty clearly their +true nature, as, for instance, the sore throat of scarlatina, the +naso-pulmonary catarrh of measles, and the rachialgia of small-pox. +The uncertainty, moreover, is of short duration, as the characteristic +eruption appears in all of them before the fourth day. + +Acute tuberculosis of the lungs is the condition which in my +experience has been the most difficult to distinguish from typhoid +fever. Indeed, in some cases which have come under my observation +physicians of recognized skill as diagnosticians have been unable to +make the discrimination until after the death of the patient. Muscular +prostration, a dry brown tongue, delirium, stupor, bronchitic rales, +dyspnoea, and even cyanosis, are symptoms frequently met with in both +diseases, so that when the {314} rose-colored eruption and enlargement +of the spleen happen to be wanting in typhoid fever, or diarrhoea and +tympany present in acute tuberculosis, as they may be, the distinction +is often impossible. The diagnosis may, however, even in these cases, +be sometimes made after a careful study of the temperature range, +which in acute tuberculosis is irregular and rarely presents any +resemblance to that which is typical of typhoid fever. + +Acute tubercular meningitis has also many symptoms in common with +typhoid fever, such as high fever, headache, vomiting, delirium, and +stupor, but in the former disease the rose-colored eruption, +epistaxis, enlargement of the spleen, and intestinal hemorrhage do not +occur. Diarrhoea is also rare, and the abdomen, instead of being +tympanitic, is flat, and in many cases even scaphoid. The headache, +too, is much more acute than in typhoid fever, and is very apt to be +associated with retraction of the head. Here, again, the frequent use +of the thermometer will yield very important results in diagnosis, as +the temperature range in tubercular meningitis is always irregular and +does not present any resemblance to that usually observed in typhoid +fever. + +Several of the inflammations, especially when associated with the +typhoid state, have so many symptoms in common with typhoid fever that +they may very readily be mistaken for one another by a careless +observer. I have known, for instance, the general disease to be +entirely overlooked in a case of typhoid fever complicated by +pneumonia, and, on the other hand, it has sometimes been supposed to +be present in a case of pure typhoid pneumonia. Gastro-enteritis is +another disease which is also occasionally confounded with typhoid +fever. The diagnosis in these cases will rest principally upon the +presence or absence of epistaxis, enlargement of the spleen, +tympanites, the rose-colored eruption, and of a temperature range +presenting some similarity to that usual in typhoid fever. + +Trichiniasis is not likely to give rise to much difficulty in +diagnosis, for although vomiting, diarrhoea, and the typhoid state +occur in it as well as in typhoid fever, the former disease may +usually be recognized by the severe muscular pains and the local +oedema which are constant accompaniments of it, and by the absence of +the characteristic symptoms of the latter. + +PROGNOSIS.--There is no other disease in which the physician should be +more careful in making a positive prognosis than in typhoid fever. On +the one hand, accidents of a fatal character frequently occur in cases +which are apparently progressing favorably, and, on the other, +recovery has often taken place after all hope of it had been +abandoned. But, although it is impossible to foretell with absolute +certainty the result in any particular case, there are certain +symptoms which furnish very important indications for prognosis, and +the proper appreciation of which will generally enable us to arrive at +a correct conclusion as regards the gravity of the disease. Prominent +among these is the character of the pyrexia. A fever characterized by +high temperature should always give occasion for great anxiety. This +is very fully shown by the statistics of the hospital at Basle. Thus +of those patients in whom the temperature did not reach 104 degrees, +only 9.6 per cent. died; of those in which it reached or exceeded 104 +degrees, 29.1 per cent. died; and, finally, of those in whose axilla +the temperature rose to or above 105.8 degrees, more than half died. +{315} Wunderlich has arrived at very nearly the same conclusions, for +he says that the prognosis is very unfavorable when the temperature +rises to 106.16 degrees, that the deaths are almost twice as numerous +as the recoveries when it rises to 107.06 degrees, and that recoveries +are rare when it rises to 107.24 degrees. Murchison has, however, +known recovery to follow a temperature of 108 degrees. The highest +temperature recorded in any of my cases was 106 degrees F. In this +case, which proved fatal, the temperature reached 105 degrees F. five +times. In three other cases, in all of which recovery took place, a +temperature of 105.5 degrees F. was observed. In twelve cases the +temperature reached 105 degrees F. on more than one occasion. Six of +these ended fatally; in the others the patients recovered. + +The prognosis is more unfavorable in a fever in which the temperature +is continuously high, and in which the morning remissions are slight +or wanting, than in one in which the daily fluctuations are greater, +even though the temperature may reach a higher point during the +evening exacerbations in the latter variety than is attained at any +time in the former. Occasional remissions, even if produced by quinia +or other remedies, are to be regarded as favorable omens, as they +indicate that the fever tends to subside. A high morning temperature +ought, therefore, to give rise to more alarm than a high evening +temperature. The prognosis is grave when the morning temperature rises +to 104 degrees or is persistently above 103 degrees. Murchison says +that recovery is rare after a morning temperature of 105 degrees. +Fiedler[91] saw, with a single exception, all patients die whose +temperature in the morning rose to or exceeded 106.25 degrees, while +of those whose temperature in the morning rose to 105.44 degrees, if +only on one day, more than half died. Any marked deviation from the +usual temperature range in the course of the fever is unfavorable. A +rapid rise of temperature indicates increased danger: it may be due to +the occurrence of a complication or of some other cause acting +unfavorably upon the patient. A sudden and decided fall should excite +even more alarm, as it is generally the consequence of a free +intestinal hemorrhage. A temporary abatement of the fever, with +amelioration of the other symptoms, occurring between the tenth and +twentieth days, and giving rise to the hope that convalescence is +about to commence, but followed by a return of the symptoms in an +aggravated form, is also unfavorable. Such cases, according to Chomel, +Louis, Bartlett, and Murchison, almost invariably terminate fatally. + +[Footnote 91: Quoted by Liebermeister.] + +The prognosis is bad in cases in which coma or wild or violent +delirium comes on early. A moderate amount of delirium, especially +when it occurs only at night or upon wakening in the morning, and is +readily dissipated by attracting the patient's attention, or stupor +which disappears when he is thoroughly roused, is not unfavorable. +Insomnia, subsultus tendinum, carphologia, slipping down in bed, +incontinence of the urine or feces, and retention of urine, are all +symptoms of bad omen. Rigidity of the limbs is also a bad symptom; Dr. +Jackson reports six cases in which this symptom occurred, only one of +which recovered. Excessive subsultus is especially unfavorable, as it +is generally most marked in cases in which the ulcerations of the +intestines are most extensive. Extreme deafness occurs in mild as well +as severe cases; it is therefore without significance in prognosis. + +{316} In estimating the importance, in a prognostic point of view, of +these various nervous symptoms, it is important to bear in mind that a +degree of fever which produces no disturbance of the mental functions +in a phlegmatic person will give rise to active delirium and other +marked cerebral symptoms in a person of an excitable temperament. + +A change in the character of the pulse and of the action of the heart +is often the earliest indication of the approach of danger in typhoid +fever, and both pulse and heart should therefore be carefully examined +at every visit. The first change is usually a diminution in the +intensity of the first sound of the heart. This is significant, as it +is frequently the earliest premonition of cardiac failure, to which a +large proportion of the deaths in typhoid fever is due. A pulse of 120 +and over, especially if it is at the same time feeble, is also +unfavorable. The important part which the frequency of the pulse plays +in the prognosis is shown by the following observations made by +Liebermeister at the hospital in Basle: Of 63 cases in which the pulse +rose to or above 120, 40 were fatal, or nearly two-thirds. Among these +63 were 37 in which it did not rise to 140; of these, 19 were fatal, +or about one-half; in 26 it rose above 140; of these, 21, or about +four-fifths, were fatal. In 12 patients it rose above 150; of these, +11 died. Of those in which the pulse rose to 160, the only case that +ended in recovery was that of a girl twenty-one years old suffering +from an imperfectly developed typhoid. Intermittence of the pulse is +unfavorable, especially, according to Hayem,[92] when it occurs during +the first week of the disease. In convalescence intermittence is not +to be regarded as an unfavorable symptom. The prognosis is bad also in +those cases in which, with excessive weakness of the pulse, there are +other evidences of cardiac failure, as, for instance, congestion of +the lungs, cyanosis of the surface, coldness of the extremities. A +very frequent pulse is not so unfavorable in a child as in an adult, +or in a person of a nervous temperament as in one of a different +disposition. + +[Footnote 92: _Loc. cit._] + +Other unfavorable symptoms are a dry, brown tongue, excessive +tympanites with great abdominal tenderness, severe diarrhoea, vomiting +when it occurs late in the disease, intestinal hemorrhage, and +colliquative sweats. The delusion sometimes observed in very severe +cases, in which the patient declares that he is not ill, is a very bad +sign, many authors, and among them Louis, asserting that they have +never known recovery to take place after it has been manifested. +Peritonitis is a very serious complication, whether due to perforation +or to some other cause. Still, it would appear not to be invariably +fatal, since recovery has occurred in cases in which all the symptoms +of this complication were present. + +Favorable symptoms, on the other hand, are a gradual decrease of the +temperature with increasing morning remissions, moistening and +cleansing of the tongue, a lessening of the delirium, and other +nervous symptoms, reappearance of an intelligent expression, +recognition by the patient of friends and attendants, and a diminution +of the diarrhoea. A copious eruption is also regarded by many as a +favorable symptom. Cases in which constipation exists generally do +well. Nathan Smith never knew a patient to die whose bowels were +constipated throughout the attack. + +The death-rate of typhoid fever is found to vary very considerably in +different years and in the different seasons of the year, as will be +seen {317} from the two following tables. Statistics as to the +mortality of the disease to be reliable must therefore be based upon a +large number of cases extending over a series of years. + +The following table shows the number of cases admitted into the +Pennsylvania Hospital during each of the twenty years ending Dec. 31, +1881, and the ratio of mortality among them: + +TABLE NO. 1. + + -------+------+------+------+------+--------+--------+-------+------- + | | | | | | | |Percen- + | | | | | | | |tage of + | | | | | | | | deaths + | | | | | | | | after + | | | | | | | |deduct- + | | | |Number| | | | ing + | | | | of | | | | cases + | | | |deaths| Average| | | fatal + | | | |within| stay | | | within + | | | | 48 |in cases| | | 48 + | |Number|Number| hours| ending | Average| | hours + |Number| of | of | of | in | stay |Percen-| of + | of |recov-| dea- |admis-| recov- |in fatal|tage of| admis- + YEAR. |cases.|eries.| ths. | sion.| ery. | cases. |deaths.| sion. + -------+------+------+------+------+--------+--------+-------+------- + 1862 | 89 | 68 | 21 | 7 | 54-1/3 | 8 | 23.6 | 17.7 + 1863 | 36 | 33 | 3 | 2 | 32-1/5 | 3-1/3 | 8.3 | 2.9 + 1864 | 43 | 35 | 8 | 1 | 38-1/2 | 8 | 18.6 | 16.3 + 1865 | 36 | 31 | 5 | 1 | 38-1/2 | 5-1/2 | 13.9 | 11.4 + 1866 | 23 | 17 | 6 | 0 | 45-2/3 | 9 | 26.0 | + 1867 | 24 | 20 | 4 | 0 | 37-1/3 | 6-1/2 | 16.6 | + 1868 | 27 | 23 | 4 | 0 | 44-3/4 | 10 | 14.8 | + 1869 | 21 | 16 | 5 | 1 | 35-1/2 | 14 | 23.8 | 20.0 + 1870 | 24 | 19 | 5 | 1 | 47-1/2 | 11 | 20.8 | 17.4 + 1871 | 32 | 26 | 6 | 1 | 37-3/4 | 13-1/2 | 18.8 | 15.0 + 1872 | 21 | 16 | 5 | 3 | 37-1/2 | 4-1/2 | 23.8 | 11.1 + 1873 | 12 | 8 | 4 | 2 | 34 | 9 | 33.3 | 20.0 + 1874 | 16 | 12 | 4 | 0 | 54-1/2 | 9-3/4 | 25.0 | + 1875 | 20 | 18 | 2 | 1 | 48 | 4-1/2 | 10.0 | 5.3 + 1876 | 30 | 21 | 9 | 2 | 45-1/2 | 11 | 30.0 | 25.0 + 1877 | 48 | 34 | 14 | 4 | 48-1/2 | 12-1/2 | 29.2 | 22.7 + 1878 | 8 | 5 | 3 | 0 | 49 | 5-2/3 | 37.5 | + 1879 | 17 | 15 | 2 | 0 | 53-1/3 | 8 | 11.8 | + 1880 | 40 | 35 | 5 | 2 | 47 | 10-1/2 | 12.5 | 8.0 + 1881 | 54 | 48 | 6 | 0 | 41-3/4 | 8 | 11.1 | + -------+------+------+------+------+--------+--------+-------+------- + Totals,| 621 | 500 | 121 | 28 | 43-1/2 | 8-3/4 | 19.5 | 15.7 + -------+------+------+------+------+--------+--------+-------+------- + +Out of the 621 cases admitted, 121 were fatal. This gives a death-rate +of 19.5 per cent.; but if we deduct the 28 cases in which the patients +died within forty-eight hours of their admission, it falls to 15.68 +per cent., or about the same ratio as Murchison found to exist among +the cases treated at the London Fever Hospital. Other observers have +obtained slightly different results. Thus, the mortality was 11.16 per +cent. in 197 cases analyzed by Dr. Hale, and 13.5 per cent. in 303 +cases collected by Dr. James Jackson. Dr. Cayley[93] found the +death-rate of the several hospitals in London to be 17.8 per cent., +and Geissler[94] that it was in all the German hospitals 12.8 per +cent. in 1877, and 13.5 per cent. in 1878. Flint had 18 deaths in 73 +cases, or 24.4 per cent. According to Liebermeister, the ratio of +mortality at the hospital at Basle during the twenty-two years from +1843 to 1864, or before the introduction of a {318} systematic +anti-pyretic treatment, was 27.3 per cent., and only 8.2 per cent. +during the six years immediately following its adoption. As the +results obtained at the Pennsylvania Hospital are apparently not so +favorable as those reported at some of the continental hospitals, it +is only proper to state that a large proportion of the cases were +severe, that many of them were far advanced in the disease when +admitted, and that very few of the patients were under twenty-one +years of age. These are all circumstances which influence very +decidedly the prognosis in typhoid fever. In no other city are the +laboring classes able to surround themselves with so many comforts as +in Philadelphia. This fact, fortunate as it is in the main, often +operates to the disadvantage of the patient by enabling his family to +indulge for a time the reluctance which it naturally feels to part +with a member when sick. In the case of the young this reluctance is +so hard to overcome that children with acute affections are rarely +brought to hospitals for treatment. There were also special causes for +the large mortality in certain years. This was particularly the case +in 1862, when a large number of soldiers fresh from the battlefields +of Virginia, and suffering from the typho-malarial form of the +disease, were admitted into the hospital. Many of them were moribund +upon admission, and others, exhausted by the fatigue incident to +transportation here and by previous hardships, soon succumbed to the +disease. + +[Footnote 93: _Med. Times and Gaz._, 1880.] + +[Footnote 94: _Schmidt's Jahrbuch_.] + +Table 2 gives the number of cases, with the number of deaths occurring +in each season, at the Pennsylvania Hospital during the last twenty +years: + +TABLE NO. 2. + + -------------------------+---------+---------+---------+--------- + | Spring. | Summer. | Autumn. | Winter. + -------------------------+---------+---------+---------+--------- + Number of cases | 89 | 259 | 182 | 91 + Recoveries | 73 | 191 | 163 | 73 + Deaths | 16 | 68 | 19 | 18 + Percentage of mortality | 18.0 | 26.2 | 10.4 | 19.8 + -------------------------+---------+---------+---------+--------- + +It will be seen from this table that the highest death-rate occurred +in the summer and the lowest in autumn, while there was only a slight +difference between the death-rate of spring and that of winter. +Murchison's experience, based on a much larger number of cases, has +led him to conclude that while the disease is a little less fatal in +autumn, the difference in the mortality at different seasons is very +inconsiderable. Chomel believed that the percentage of deaths was +highest in France during the winter months, and Bartlett held the same +opinion as regards America. Epidemics of great severity have +undoubtedly prevailed in winter, as the in Lowell, Mass., referred to +by Bartlett, but there can be little doubt that the death-rate is +highest in this country during the warm months of the year. Dr. +Cleemann[95] found that the monthly average mortality in Philadelphia +for the ten years from 1866 to 1875 was highest in August, and next +highest in September, confessedly the two months of the year when the +heat in this city is most exhausting. I feel very sure I have lost +patients with typhoid fever in these months {319} and in July who +would probably have recovered if the weather had been cooler. With a +temperature often rising above 90 degrees F. at midday, and sometimes +for several days at a time never falling below 80 degrees, all +radiation of heat from the surface of the body is arrested, and death +frequently occurs as the result of hyperpyrexia. + +[Footnote 95: _Transactions of the College of Physicians of +Philadelphia_, 3d S., vols. ii. and iii.] + +The stage of the disease at which efficient treatment is begun has a +manifest influence upon the result. This is strikingly shown by some +observations of Jackson: 90 cases were admitted into the Massachusetts +General Hospital during the first week--of these 7 died, or 1 in +12.85; 139 cases were admitted in the second week--of these 16 died, +or 1 in 8.68; 46 cases were admitted in the third week--of these 10 +died, or 1 in 4.60; and 21 cases were admitted in the fourth week, and +of these 5 died, or 1 in 4.20. Convalescence also occurred much +earlier in those who were admitted early. + +Murchison found that in a large number of cases the death-rate varied +at different ages as follows: Under ten years it was 11.36 per cent.; +from ten to fourteen years it was 12.86 per cent.; from fifteen to +nineteen years it was 15.48 per cent.; from twenty to twenty-nine +years it was 20.46 per cent.; from thirty to thirty-nine years it was +25.90 per cent.; from forty to forty-nine years it was 25 per cent.; +and above fifty years it was 34.94 per cent. + +According to Liebermeister, among the 1743 patients treated for +typhoid fever in the hospital at Basle from 1865 to 1870, inclusive, +there were 130 who were more than forty years old; of these 39, or 30 +per cent., died, while the mortality among the patients under forty +amounted only to 11.8 per cent. Among the cases of typhoid fever in +individuals over forty years of age collected by Uhle, more than half +proved fatal. According to Friedrich,[96] there were, among 16,084 +children treated in the Children's Hospital at Dresden, 275 cases of +typhoid fever, of which 31, or not quite 11 per cent., proved fatal. +Age, therefore, exercises a positive influence upon the mortality of +typhoid fever. Its influence is less decided in this disease than in +typhus, in which the death-rate does not reach 4 per cent. until after +the age of twenty, when it rapidly rises from 12.34 per cent. until it +reaches 57.03 per cent. in patients above fifty years of age. The +comparatively slight mortality of typhoid fever among children is +probably due to the fact that the temperature is less often +continuously high in them than in adults, and that while hyperpyrexia +is frequently present, it is generally better borne and less likely to +produce paralysis of the heart. Liebermeister says that the only case +which he has seen recover after the temperature had repeatedly risen +to 107.5 degrees F. was that of a girl fourteen years of age. It is +also said that the intestinal lesions are not so severe, and the +liability to complications and sequelae less marked, in children. + +[Footnote 96: Quoted by Liebermeister.] + +Typhoid fever appears to be a slightly more fatal disease in women +than in men, for while in some local epidemics the percentage of +deaths is greater among the latter than among the former, the reverse +is found to be the case when the records of a large hospital for a +number of years are carefully examined. According to Murchison, the +mortality at the London Fever Hospital was about 1 per cent. higher +among the female than among the male patients, and about the same +difference in the death-rate {320} of the two sexes has been reported +by continental physicians. A greater disparity even than this has been +observed by Liebermeister at the hospital at Basle, where the +death-rate for women was 14.8 per cent., and only 12 per cent. for +men. Murchison says that this excess of mortality among the former +cannot be accounted for by the influence of child-bearing upon the +course of the fever, since it is much more decided between the ages of +five and fifteen than in the period of child-bearing. + +The rich are not only as liable to contract typhoid fever as the poor, +but the disease is also quite as fatal among them. Murchison found +from the statistics of the London Fever Hospital that the mortality is +not greater among the destitute than among the better class of +patients, and expresses the opinion that in private practice enteric +fever is probably more fatal among the upper classes than among the +very poor. Chomel and Forget seem to have reached a similar +conclusion. + +All authors agree that the prognosis is unfavorable in corpulent +persons, not only on account of the diminished power of resistance to +disease generally which such persons exhibit, but also because the +febrile movement is often intense in them, and the degenerative +changes of the muscles and organs of the body which it induces are +generally early developed and of high grade. Liebermeister goes so far +as to say that even in the case of ill-nourished, anaemic, or +chlorotic individuals the chances for life are better than in the +corpulent. Murchison has also expressed the opinion that a large, +muscular development is likewise an unfavorable element in prognosis, +having seen the strong and robust succumb to the disease oftener than +the feeble. The mortality from the disease appears to be greater in +certain families than in others. This has been ascribed by some +writers to peculiarities of constitution, but it may be due to other +causes, as, for instance, difference in the intensity of the poison. +The disease is also often very fatal among the intemperate, who +usually bear the disease badly in consequence of the presence of +various degenerations of one or more of the important organs of the +body caused by the excessive indulgence in alcoholic stimulants; +paralysis of the heart being not an infrequent cause of death among +them. + +Certain epidemics have been exceedingly fatal, while in others the +percentage of deaths has been very small. There can be no doubt that +in most of these cases there has been a difference in the virulence of +the poison. Recent residence in an infected locality has been shown by +Murchison and other writers to have a decided influence in increasing +the fatality of the disease. Second attacks are, on the other hand, +usually mild. Some diversity of opinion exists among authors in regard +to the effect that pregnancy has upon the course of the disease. +Murchison believes that it is a far less formidable complication than +is usually thought, while Liebermeister, on the contrary, holds a +directly opposite opinion. He also regards the prognosis as +unfavorable when the disease occurs in childbed or a short time +afterward. Individuals with disease of the heart, emphysema, or +bronchial catarrh who contract typhoid fever are said to be more +liable to paralysis of the heart than others, hence the existence of +these diseases materially diminishes their chances of recovery. + +TREATMENT.--Inasmuch as the spread and propagation of typhoid fever +may be prevented to a great extent, if not entirely, by the {321} +employment of judicious sanitary measures, it is proper, before +entering upon the discussion of its curative treatment, to devote a +few words to the prophylaxis of the disease. + +Whether the physician accepts the theory so ably advocated by +Murchison, that typhoid fever may arise from exposure to the products +of the fermentation of healthy feces, or adopts the view now held by a +large number of investigators, that the disease is never generated in +the absence of the specific germ, he will admit the great importance +of an efficient system of sewerage, with a thorough flushing of the +sewers at regular and frequent intervals, for disposing of the fecal +discharges of the population of all towns, no matter how +inconsiderable in size. No less important is it that the drains of +every dwelling should be well constructed and kept in good order. They +should be trapped just before they empty into the sewer, and should be +provided with the means of thorough ventilation between the trap and +the walls of the house by a free communication with the outer air. The +soil-pipe should be carried up three or four feet above the top of the +house, and every water-closet, bath-tub, stationary washstand, and +sink should have its own separate trap, and none of them should be +placed in rooms unprovided with a window or with some other sufficient +means of ventilation. Physicians should, as sanitarians, urge upon the +authorities of all cities and towns the importance of deriving their +water-supply from a source unpolluted by sewerage or by any other +substances likely to be deleterious to health. They should also see +that when water is stored in a tank inside of a house the overflow +pipe does not communicate directly with the drain, since if this is +allowed to occur the water may very soon become contaminated with +sewer gas, and consequently unfit for internal use. + +In the case of isolated country-houses and of small villages some +other means of disposing of the fecal discharges of the inhabitants +than by sewers has to be found. In the great majority of instances no +better way presents itself than by the ordinary cesspool. Care should, +however, be taken that this is so constructed and situated that there +can be no filtration of its contents into wells from which water for +drinking is obtained. + +As the alvine dejections of the sick are beyond question the medium by +which typhoid fever is most frequently communicated to others, the +importance of thoroughly disinfecting them before they have acquired +the power of imparting the disease cannot well be overestimated. +Liebermeister recommends that the bottom of the bed-pan should be +strewed, each time before being used, with a layer of sulphate of +iron, and that immediately after a passage crude muriatic acid should +be poured over the fecal mass, as much as one-third or one-half of the +bulk of the latter being used. He also urges, whenever it is +practicable, that the contents of the bed-pan should be emptied into +trenches dug anew every two days and filled up when discarded, care +being of course taken that they are not located anywhere in the +vicinity of wells. Murchison seems to prefer carbolic acid to other +chemical agents as a means of preventing fecal fermentation. For this +purpose the liquid carbolic acid may be diluted with water in the +proportion of 1 to 40 to 1 to 20, or it may be mixed with sand or +sawdust. I have myself employed as a disinfectant with success the +solution of the chlorides sold under the name of Platt's chlorides. As +the discharges must in cities, in the great majority of instances, be +emptied into {322} water-closets, these should be freely flushed with +water after every time they are used; and it is well to impress upon +the attendant on the sick the importance of doing this. The bed-linen +of the patient and his clothes, if they are soiled by his discharges, +should be removed as soon as possible, and subjected to a high degree +of heat (248 degrees F.) or soaked in a solution of the chlorides or +of carbolic acid for several hours before being washed. If these +precautions are observed, cases of typhoid fever may be treated in the +wards of general hospitals without danger to the other patients. + +In the doubt and obscurity which generally envelop the diagnosis of +the disease when the physician is first called upon to treat it, it is +impossible to lay down any positive rules for the management of +typhoid fever at its commencement. But even in those cases which begin +insidiously, if the patient is carefully examined enough of the early +symptoms of typhoid fever will be detected to put the physician on his +guard. The thermometer will show the existence of fever, which has a +tendency to increase at night. There will generally be found to be a +little diarrhoea, or at least an increased susceptibility to the +action of purgative medicines; perhaps a little tympany and tenderness +in the right iliac fossa, and moreover a prostration which is out of +all proportion to the other symptoms. + +These symptoms, it is true, are not infrequent concomitants of many +diseases besides the one under consideration; but when their presence +cannot be otherwise satisfactorily explained, especially if they have +continued for several days, it is a safe rule in practice to regard +the case as one of typhoid fever, and to regulate the treatment +accordingly. The patient must be put to bed at once, and not allowed +to leave it on any pretext, not even to empty his bladder, after the +first week. This is a rule which should be rigidly enforced in every +case, no matter how mild the symptoms may be. Its non-observance, +either through the neglect of the physician or the ignorance or +wilfulness of the patient, has been the cause of some disastrous +results; in illustration of which it is only necessary to refer to the +frequency with which perforation of the bowel occurs in walking cases +of typhoid fever. Perfect quiet should be maintained in the sick room. +Visitors should be excluded from it, and the attendants limited in +number to those actually necessary to carry out the directions of the +physician. All unnecessary talking is to be avoided, and especially +conversation carried on in a low tone of voice, which is always +annoying to the sick. + +There is only one condition under which I should be disposed to break +the rule of absolute quiet and rest laid down above, and that is when +called upon to treat typhoid fever in the built-up portion of our +large cities during the summer season. If the patient were still in +the first week of the disease, if his circumstances were sufficiently +affluent to enable him to surround himself with every comfort, and if +it did not involve a journey of more than a few hours, I should +unhesitatingly send him to the sea-coast. I have so often seen cases +prove fatal in summer in consequence of the great heat of the city--a +heat, too, which is sometimes almost as great at night as in the +day-time--that I should feel that I was giving him an additional +chance of life by sending him where the heat was, at least +occasionally, tempered by cool breezes from the ocean. During the late +war numbers of soldiers were frequently sent in the early stages of +{323} typhoid fever from the camps in the South to their homes or +hospitals in the North, and it is fair to say that they did at least +as well as those who remained behind. But when the journey may be +accomplished by means of Pullman cars and the other appliances of +modern travel the risk, and even discomfort, it involves to the +patient is reduced to the minimum. + +As the disease is usually one of long duration, the patient being +rarely able to leave his bed under four weeks, and more frequently +being obliged to keep it for a much longer time, the sick room should, +wherever practicable, be large, airy, and provided with an open +fireplace, which is a much more efficient means of securing thorough +ventilation than an open window, while it is not liable to the +objection sometimes applicable to the latter of causing a direct +draught upon the patient. It is well, however, for the physician to +remember that the danger from this source is very much exaggerated by +the laity, and that patients in the febrile stage of typhoid fever do +not readily take cold. Still, the same end may generally be attained +without the least risk to the patient by opening a window in an +adjoining room. The temperature of the sick room should be steadily +maintained at between 65 degrees and 68 degrees F. + +The careful regulation of the diet is also a point of great importance +in the management of typhoid fever; for in this disease there are not +merely the high fever and other exhausting symptoms, speedily inducing +excessive prostration, loss of strength, and emaciation, common to +many fevers, but there is also the peculiar ulceration of the bowels, +which gives rise to danger of its own and demands special +consideration in treatment. The food must therefore be not only +nourishing, but also readily digestible, and not likely to create +irritation in its passage through the intestines. All solid food +should therefore be excluded from the dietary of the patient as long +as the fever lasts. Indeed, it is better to continue this prohibition +even after the subsidence of the fever if rose-colored spots are still +to be seen on the abdomen or elsewhere, or if there exists a tendency +to diarrhoea or any other symptom indicating that the disease has not +fully run its course. Having myself seen some rather disastrous +results from a too early return to solid food, I have been accustomed +in my own practice to interdict its use until at least two weeks after +the beginning of convalescence. Jaccoud also lays much stress upon +this point, saying that the early administration of meat always gives +rise to fever, to which, from its cause, he gives the name of febris +carnis. On the other hand, Flint[97] and Peabody have recently +advocated the giving of solid food immediately after the cessation of +fever, in the belief that recovery is thereby promoted. Milk as an +article of diet is unquestionably to be preferred to all others in +typhoid fever. It is open, it is true, to the objection of +occasionally forming tough curds in the stomach, but this may +generally be prevented by giving the milk in small quantities at a +time, diluted with lime-water or barley-water or mixed with some +farinaceous substance. No positive general rule can be laid down as to +the amount to be given. This will be found to vary not only in +different cases, but also in the same case at different times. Indeed, +in those cases which begin abruptly with symptoms of gastro-intestinal +irritation, if it is forced upon the patient in large quantities it is +not only usually rejected, but also causes an aggravation of the +symptoms, while after {324} this irritation is allayed it will be +digested without difficulty. As a general rule, most adult patients +will be able to take from a quart and a half to two quarts of milk +daily, given in quantities of from four to six ounces every two or +three hours. It should be remembered, however, that if more is taken +than can be assimilated it will act as an irritant and increase the +diarrhoea. If, therefore, the stools contain undigested milk, the +quantity should be diminished. Patients are occasionally met with, but +not in as great number as is often asserted, with whom milk habitually +disagrees. In these cases it must of course be replaced in whole or in +part by some other article of food. Under these circumstances some one +of the liquid preparations of beef may be given with advantage, +although it may be objected to them also that they sometimes occasion +an increase of diarrhoea. Beef-tea or beef-essence, made from the +fresh meat whenever this can be obtained, is to be preferred to all +others; but when it cannot, that made from the preparations of +Johnston or Brand is the best substitute. When the stomach is very +irritable, Valentine's meat-juice, in consequence of the smaller bulk +in which it is given, often answers an admirable purpose. + +[Footnote 97: _Medical News_, Mch. 29 and Apl. 5, 1884.] + +Various farinaceous substances, such as farina, corn-starch, and +arrowroot, are also occasionally given in typhoid fever, and, although +the last named would seem to be indicated in cases in which diarrhoea +is a prominent symptom, their tendency to cause flatulence is so great +that their use in the acute stage of the fever has not found favor +among physicians generally. In convalescence, on the other hand, they +are generally perfectly well borne. + +The subject of the administration of alcoholic stimulants in typhoid +fever may be conveniently considered in this connection. Some +difference of opinion exists in regard to the quantity in which they +should be given, and indeed in regard to the necessity for their use +at all in many cases, as, for instance, in those of young persons +whose health and habits had been good previously to the attack. I have +myself treated several such cases without alcohol, and have not been +able to perceive that their duration was longer and the result less +favorable than in cases in which it was given in the usual amount. It +is, moreover, not necessary to prescribe it always, even in very +severe cases, at the beginning of an attack. When given at this time, +it not infrequently does harm by increasing the fever. It should be +reserved, therefore, until the action of the heart grows feeble and +the first sound becomes indistinct. It is not possible to lay down any +general rule as to the amount to be given, even in severe attacks. +This will vary in different cases, and to a certain extent will be +determined by the effects it produces. If the pulse grows stronger and +the delirium diminishes under its use, it is doing good and should be +continued; if, on the other hand, there is increase of delirium and +restlessness, the quantity should be diminished. + +In cases in which only a gentle stimulus is required wine in the form +of wine-whey will often be found to meet the indication fully. +Generally, however, it will be necessary to have recourse to whiskey +or brandy. The choice between these may usually be left to the +patient's fancy; brandy is, however, to be preferred in cases in which +diarrhoea is a prominent symptom. These stimulants should be given in +small quantities frequently repeated. In many cases a dessertspoonful +every two or three hours, {325} either diluted with water or, when the +stomach is irritable, with carbonic acid water or given in the form of +milk punch, will be sufficient. In others a tablespoonful every two +hours, or even at shorter intervals, will be required, but it will +rarely be necessary to exceed eight ounces a day for more than a few +days at a time. + +Although the physician will not often be called upon at the present +day to encounter and combat the prejudice so common formerly against +the free administration of water in the febrile condition, he will +frequently find nurses and others not sufficiently alive to the +importance of supplying it when the patient, having fallen into the +typhoid state, ceases to ask for it. The high temperature which is +generally present in this condition, and the rapid combustion of +tissue which it causes, make a full supply of liquid an urgent +necessity which it is dangerous to disregard. Water is the best of all +diuretics, and it is important in this disease, as indeed it is in +many others, that the functions of the kidneys should be kept active, +so that the products of the combustion of the tissues may be +eliminated with their secretion. Care, however, should of course be +taken, as pointed out by Da Costa,[98] that water is not given in such +quantity that the desire for and capability of digesting food is +destroyed by it. + +[Footnote 98: Preface to Wilson's _Treatise on the Continued Fevers_.] + +In the few cases which begin abruptly with symptoms simulating those +of a so-called bilious attack the practitioner will usually content +himself with the administration of medicines calculated to allay the +irritability of the stomach and bowels. For this purpose I have found +the bicarbonate of potassa in solution, to which lemon-juice is added +at the moment it is taken, so as to produce an extemporaneous +effervescing draught, often an admirable remedy. In other cases I have +used with advantage small doses of calomel or blue mass, followed, if +necessary, by a gentle saline purge. When the symptoms have occurred +soon after a hearty meal, or when there is evidence that the stomach +is overloaded, it will occasionally be necessary to have recourse to +an emetic. Usually, the indications for treatment at the beginning of +an attack are much less definite, and even in the class of cases just +referred to they become so after the subsidence of the +gastro-intestinal symptoms. Indeed, the treatment in the larger number +of cases must be purely symptomatic until the nature of the disease +has fully declared itself. The presence of fever will suggest the use +of the neutral mixture, effervescing draught, or spirit of Mindererus, +combined, if there is decided tendency to evening exacerbations, with +sulphate of quinia in full doses. If there is much diarrhoea, Hope's +camphor mixture or opium in some other form may be given; if delirium +is a prominent symptom, ice or cloths wrung out of cold water should +be kept constantly applied to the head. + +But even after all doubt in regard to the diagnosis has been dispelled +and the existence of typhoid fever has been recognized, the treatment +most in favor with physicians is in large measure symptomatic in +character. It is true that various specific treatments, to which +fuller reference will be made hereafter, have been lately proposed, +but the results obtained by them up to the present time where they +have been fairly tested are not so favorable as to induce the body of +the profession to adopt them to the exclusion of all other methods. It +is certain that no remedy or plan of {326} treatment has yet been +discovered which has the power of cutting the disease short, although +this power has been claimed at different times for several. Thus, at +one time quinia in very large doses was believed to possess it, at +another venesection, and at another cold baths. But experience has +shown that these and other perturbating remedies often do harm, and +there is good reason to believe that the apparent good which has +followed their use in a comparatively small number of instances may be +better explained by supposing that an error of diagnosis has been made +than by attributing to them the power of arresting the progress of the +disease. Medicines are, however, by no means useless in the treatment +of typhoid fever. There is no question that the disease is not only +generally conducted to a favorable issue, but that its duration is +often materially shortened, by their judicious use. It is evident, +however, that the treatment must vary with the severity of the attack. +In a few cases it is scarcely necessary to interfere with the course +of the disease by the administration of medicines. In others, on the +contrary, it is necessary to act promptly and energetically in order +to save life. + +When called upon to treat typhoid fever, if the case is a mild one +with no bad symptoms, such as excessive diarrhoea, delirium, tremors, +and the like, and especially if the temperature does not rise higher +than 102 degrees F., I am accustomed, after giving minute directions +as to the diet and general care of the patient, to prescribe from two +to three grains of sulphate of quinia four times daily. No great power +in reducing the temperature of the body can, of course, be claimed for +these doses, but experience has shown that the impression which they +make is useful, and they do not interfere with the administration of +the drug in larger quantities should this become necessary. Their +action, too, is tonic, and, as they rarely produce cinchonism, the +objection often made to the use of larger doses does not apply to +them. I am also in the habit of adding to each dose of quinia from ten +to fifteen drops of one of the mineral acids. These acids were +originally prescribed in typhoid fever under the impression that they +neutralized the cause of the disease, which was supposed to be an +alkaline poison. Although the results of recent research, which tend +to show that the cause of the disease is an organized germ, give no +support to this theory, they continue to be used by a large number of +physicians of experience. I do not know that any satisfactory +explanation of their action in typhoid fever has ever been given. They +are certainly tonics, and are therefore indicated, if not in the +beginning of the disease, as soon as the strength begins to fail. If, +as the disease progresses, the tongue becomes dry and fissured, and if +there is much tympany, it will be well to give, in addition to the +quinia, ten drops of the oil of turpentine in mucilage every two +hours. This was a favorite remedy of the late George B. Wood, the +distinguished professor of the Theory and Practice of Medicine in the +University of Pennsylvania, who attributed the improvement in the +symptoms which generally follows its use to a direct influence of this +medicine upon the ulcers in the intestines. Although inclined to +believe that the correct explanation of this improvement is its +stimulating action upon the circulation and secretions, I fully agree +with him in regard to its usefulness in many cases. Under its use I +have often seen the dry, fissured, and shrivelled tongue {327} grow +moist and throw off its coating much earlier than in all probability +it would otherwise have done. + +No other than this simple treatment is required in a large number of +cases, but even in mild cases symptoms occasionally arise which render +necessary some modification of it. It will, however, be more +convenient to postpone the discussion of this part of the treatment of +typhoid fever until after the treatment of the more serious forms of +the disease has been considered. + +When typhoid fever assumes a severe type, the success of the physician +in the management of the disease will depend largely upon the +readiness with which he detects indications for treatment and the +promptness with which he meets them. Usually, one of the first +symptoms to demand attention is the high temperature. This is not only +an early symptom in many bad cases, but may continue throughout the +attack; or it may suddenly supervene in cases in which the fever has +previously been moderate in degree, and when excessive may be the +direct or indirect cause of death. The reduction of the temperature is +therefore an indication the importance of which cannot well be +overestimated. Fortunately, there are several methods by which this +end may be accomplished. It will, however, be necessary for our +purpose to consider only two of them in detail: 1, the cold-water +treatment; 2, sulphate of quinia in full doses. + +The cold-water treatment is not new, since it was practised in the +form of cold effusion in the treatment of fevers as long ago as 1787 +by Currie of Liverpool, who may be said to have introduced it, and who +asserted that it had the power not merely of moderating the symptoms +of these diseases, but also, in many cases, of cutting them short. It +enjoyed at first a high degree of popularity, which lasted for from +twenty to thirty years, but finally fell into disuse, probably in +consequence of the exaggerated character of the claims which were made +for it by its advocates. Although resorted to from time to time in +various parts of the world, the merit of having brought it again into +notice seems to be due to Brand of Stettin, who published a work on +_The Hydrotherapy of Typhoid Fever_ in 1861. Still more recently, the +recorded observations of Bartels, Jurgensen, Ziemssen, and +Liebermeister in Germany, and of Wilson Fox and others in England, +have so far restored the treatment to professional favor that there +are few physicians either in this country or abroad who do not +occasionally have recourse to it. + +The cold-water treatment may be applied in several different ways: 1, +the cold bath; 2, the graduated bath; 3, cold affusions; 4, the cold +pack; 5, cold sponging; 6, cold compresses; and 7, frictions with ice. +They all act in the same manner, and depend for their efficacy upon +their power of abstracting heat from the body, and are useful just in +proportion as they do this. There is no reason for believing that they +have the power to modify the conditions upon which the production of +heat depends, but there is, on the other hand, no doubt that under +their use distressing and dangerous symptoms, such as coma, stupor, +subsultus, and the like, are often much relieved. They probably act, +therefore, by diminishing the metamorphosis of the tissues, and the +consequent loading of the blood with excrementitious products which +the hyperpyrexia has a tendency to promote. + +The cold bath is the most effective of all the methods of applying the +{328} cold-water treatment. Liebermeister recommends that the bath for +an adult should be at the temperature of 68 degrees F., and its +duration should be about ten minutes; if, however, the patient shows +signs of great weakness, it should not exceed seven. After the bath he +should be wrapped up in a dry sheet or light blanket and put back in +bed. If the pulse should then show signs of failing, or if there +should be shivering or any other evidence of weakness, he should be +given a glass of wine or brandy or a dose of some other diffusible +stimulus, and bottles containing hot water should be applied to his +feet. The process of cooling goes on for some time after the patient's +removal from the bath, for while a thermometer placed in the axilla +will show that the external temperature is immediately affected by it, +the same instrument placed in the rectum will indicate a gradual fall, +which will continue in many cases for at least half an hour. Shortly +after this the temperature will be observed to rise, and in many cases +it will not be more than two hours before it has attained its former +height. Liebermeister therefore recommends that the thermometer should +be frequently used, and that the baths should be repeated as often as +the temperature rises to 103 degrees F. or above it. He has himself +given them as often as every two hours, or as many as two hundred +during an entire illness, but usually finds that not more than six or +eight a day are required. It often requires some persuasion to +overcome the repugnance which most patients feel at first for these +baths, and the shock of being suddenly immersed in cold water is +agreeable to very few. Later, this repugnance, he says, entirely +disappears. Intestinal hemorrhage, perforation of the bowel, and great +weakness of the heart's action are all contraindications to the use of +the cold bath. They are especially to be avoided, according to +Liebermeister, when the force of the circulation is so far reduced +that the surface of the body is cold while the interior is very hot. +On the other hand, the advocates of this plan of treatment contend +that the existence of pneumonia or of hypostatic congestion of the +lungs is not a sufficient reason for abandoning it, the congestion +often disappearing under its use. + +The graduated bath possesses some advantages over the cold bath, as +its use involves less of a shock to the system. It is therefore more +suitable than the latter for nervous and excitable patients, for +persons of advanced age or of general feebleness of constitution, or +for very young children. In it the temperature of the water, which at +the time of the immersion of the patient should be at or above 95 +degrees F., is cooled by the gradual addition of cold water until it +is reduced to 72 degrees, or below this point. These baths, to produce +the same effect as the cold baths, must be of longer duration. They +are contraindicated in the same conditions as the latter, but to a +less degree. + +Although fully willing to admit the good effects of the cold bath in +many cases, having been, of course, myself a witness of them, I am +indisposed to have recourse to it except in cases of hyperpyrexia of +such intensity that death seems imminent and only to be averted by +energetic treatment, or in cases in which other antipyretic remedies +have failed to reduce the temperature; and for the following reasons: +1. In the first place, it is generally possible to produce a decided +effect by the other methods of applying the cold-water treatment, with +much less discomfort to the patient. 2. In a private house it is not +always practicable to have {329} a bath brought to the bedside of the +patient, and in a general hospital to do so often would occasion a +good deal of annoyance to the other patients in the same ward, and I +have seen ill result from carrying him some distance to the bathroom. +But even where the bath is brought directly to his bedside, it +involves so much movement, and is sometimes the cause of so much +excitement, that its good effects are more than neutralized by its +bad. + +Cold affusions, while not nearly so efficacious in reducing the +temperature of the body as the cold bath, are open to many of the +objections which may be urged against the latter mode of treatment. +They are, therefore, rarely employed at the present time. +Liebermeister, however, thinks that they may sometimes be resorted to +with good effect for their brisk stimulating effect on the psychical +functions or the respiration. + +The cold pack possesses the advantage over the cold bath and cold +affusions of involving less movement on the part of the patient and of +being less terrifying to children, and may therefore be resorted to in +cases in which the latter method of applying the cold-water treatment +is contraindicated, as, for instance, in persons of feeble +circulation. It is, however, inferior to either of them in its cooling +effects, and must be longer applied to produce the same effect. +Liebermeister estimates that a course of four consecutive packs, of +from ten to twenty minutes' duration apiece, is about equivalent in +effect to a cold bath of ten minutes. + +Cold sponging is assigned a very low place among the methods of +abstracting heat from the body by many writers. It has, however, often +been in my hands of much service, and its easy application and the +comfort which patients derive from it are certainly strong +recommendations in its favor. I have employed it frequently in cases +of intestinal hemorrhage, and even in cases of great debility, and +have never yet had any reason to repent my having done so. The +addition of a little vinegar to the water has seemed to me to increase +the effect of the sponging. + +Cold compresses, either in the form of cloths wet with cold water or +bladders filled with ice, can only produce a local fall of +temperature, and therefore, except when applied to the head, can be of +little service. + +Frictions with ice are a powerful means of depressing the temperature +of the body, and may therefore be resorted to in cases of intense +hyperpyrexia when for some reason the cold bath cannot be obtained, +and when there are no contraindications to the latter. + +Liebermeister classes cold drinks, the internal administration of ice, +and the injection of cold water among the means of cooling the body in +fevers; but it is doubtful if any great reduction of temperature can +be brought about by any of these remedies in the quantities in which +it would be safe to use them. The first two, and to a less extent the +last, meet a very important indication, that of supplying water to the +system. Their free use, therefore, forms a very important part of the +treatment of typhoid fever. + +Luton of Rheims[99] extols the Diaeta hydrica in the treatment of +typhoid fever. The patient receives absolutely nothing else to drink +but water, which is given in large quantities, for from four to six +days. No nourishment is given until the beginning of the third week, +and first of all milk. If fever returns, the water is given again. +Medicines such as {330} quinia and eucalyptus are given in adynamic +conditions, which Luton says are rare under this treatment. He +believes that the increase of the typhoid germs is prevented by +absolute diet and abundant supply of water. + +[Footnote 99: _Journal de therapie_, Oct., 1880.] + +Quinia to produce a decided antipyretic effect must be given in large +quantities. Murchison says that a dose of from fifteen to twenty +grains causes within an hour or two a fall of the temperature, and, to +a less extent, of the pulse, which may last from twelve to eighteen +hours, and that he has never known any other disagreeable symptoms +result from its use than noises in the ears, temporary acceleration +and irregularity of the respiration, and occasional vomiting. This +quantity will often, however, be found to be insufficient to produce a +notable reduction of the fever, and it is therefore necessary +occasionally to increase it. Liebermeister usually gives to adults +from twenty-two to forty-five grains of the sulphate or the muriate of +quinia, and this dose must positively be taken within the space of +half an hour, or, at the most, an hour, as it is useless, he says, to +expect the full benefit of this dose to appear if the dose is divided +and its administration is extended over a longer time. He never +repeats it in less than twenty-four hours, and, as a rule, does not +give it again under two days. Jurgensen has exceeded the dose of +forty-five grains without observing any bad effects from it. When +these large doses are taken the fall of the temperature usually begins +a few hours after the administration of the medicine, the minimum +being reached in from six to twelve hours, and it is usually not until +the second day that the temperature attains its former height. It is +found in practice that the most decided results are obtained when the +medicine is given in the evening, so that the time of its fullest +antipyretic effects will coincide with that of the morning remission. +When these large doses produce vomiting, as they occasionally will, +the quinia must be given by the rectum or hypodermically. + +Quinia possesses the great advantage over the cold bath that it may be +given in conditions in which it would be dangerous to resort to the +latter. The existence of great cardiac weakness, of perforation of the +bowel, or of intestinal hemorrhage do not usually constitute +contraindications to its use. In my own practice I have not often +found it necessary to have recourse to much larger doses than those +recommended by Murchison, preferring to repeat them if necessary +rather than to give a single dose of even half a drachm. + +It will be well, in this connection, to allude briefly to a few other +remedies which have been given for their antipyretic effect. One of +these is digitalis, which has been administered for this purpose in +very large doses. Thus, Liebermeister recommends that from eleven to +twenty-two grains should be given in the course of thirty-six hours. I +have never used this drug in these doses, and therefore cannot speak +of its effects from personal knowledge of them. I have frequently had +recourse to it, however, in more moderate doses, and I think with +advantage. + +Another is sodium salicylate. This remedy has been used largely in +England and Germany, and to a less extent in this country. It has been +claimed for it that it has the power of destroying the germs of +typhoid fever, but Stricker[100] finds it difficult to accord it this +property in the face {331} of the fact that he has had three cases of +typhoid fever under his observation which occurred in patients just +recovered from rheumatism, which had been treated by this drug. My own +experience with it in the treatment of this disease is small, but has +been unsatisfactory. While it is undoubtedly an antipyretic, the pulse +becomes weak and the inspiration less strong under its use. The brain +symptoms do not diminish under its use. Indeed, it is said to produce +narcotism in some cases. Dr. Jahn[101] and Dr. Jh. Platzer[102] speak +more favorably of it, but admit that its administration is +occasionally attended by the inconveniences above referred to. The +verdict of the profession in regard to it, tersely expressed by one +who had given it a fair trial, appears to be that it is a remedy that +brings nothing but disappointment to the physician and disaster to the +patient. + +[Footnote 100: _Deutsche Milit.-arztl Zeitsch._, 1877.] + +[Footnote 101: _Deutsches Arch. f. klin. Med._, 1877.] + +[Footnote 102: _Bayr. Arztl. Intell. Bl._, 1877.] + +Eucalyptus, in the form of the tincture, is also a favorite remedy +with many practitioners. Dr. Benj. Bell[103] is in the habit of giving +a teaspoonful every three or four hours in a wineglass of water, and +asserts that it diminishes the tendency to diarrhoea and the duration +of the illness. + +[Footnote 103: _Edin. Med. Jour._, Aug., 1881.] + +The different varieties of typhoid fever require slight modifications +only of the treatment laid down above. In the typho-malarial form, +especially in those cases in which the malarial element predominates, +and in which there is a marked tendency to remission, the early +administration of quinia in full antiperiodic doses is urgently called +for. In some cases which he had the opportunity of observing in the +army, A. L. Cox[104] found great advantage from the use of arsenious +acid in rather large doses. When the disease attacks elderly people, +an early resort to alcoholic stimulants is usually necessary, in +consequence of the excessive prostration it induces in them. Henoch +and Steffen[105] assert that cold baths are not so well borne in +children as in adults. Their influence is transitory only, and their +use has sometimes been followed by fatal collapse. In the renal form +dry, and in some cases cut, cups should be applied externally and +saline diuretics given internally. + +[Footnote 104: _Outlines of the Chief Camp Diseases of the United +States Armies_, by Joseph Janvier Woodward, M.D., Philada., 1863.] + +[Footnote 105: _Jahrb. f. Korhde_, 1880.] + +SYMPTOMS REQUIRING SPECIAL TREATMENT.--Vomiting, when it occurs early +in the disease, is usually checked by the administration of an emetic +and by the application of sinapisms to the epigastrium. The use of +emetics is no longer advisable when it occurs after the first week. It +is better then to trust to small doses of hydrocyanic or carbolic +acid, aromatic spirit of ammonia, or bismuth. It will often be found +that lime-water and milk will remain upon the stomach when every other +article of food or medicine is rejected. In some severe cases which +have been under my care the symptom was permanently relieved by the +frequent administration of small quantities of brandy in iced +soda-water. When vomiting is a consequence of peritonitis it usually +resists every form of treatment. + +Diarrhoea, if the number of the stools does not exceed two or three in +the course of twenty-four hours, does not need special treatment. +When, however, it is more severe, prompt measures should be taken to +check it. Under these circumstances laudanum injections have seemed to +me to be {332} by far the best remedy. It is not necessary that these +injections should always contain a large amount of laudanum or that +they should be repeated frequently. In many cases twenty drops once a +day will be found to be sufficient, and it is rarely necessary to +exceed forty drops twice daily. Opium given by the mouth or in +suppository in equivalent quantity does not act with anything like the +same efficacy. If the laudanum injections fail to restrain the +diarrhoea, it will be well to have recourse, in combination with +opium, to the subnitrate of bismuth or the acetate of lead. Nitrate of +silver was at one time much employed in the treatment of typhoid +fever, especially by the late J. K. Mitchell of this city, but was +afterward suffered to fall into neglect. Its use has been recently, to +a certain extent, revived in consequence of the recommendation of +William Pepper,[106] who claims for it the power of modifying the +course of the disease. I have given it in a number of cases, but have +never been able to satisfy myself that it possessed this power. I have +therefore ceased to prescribe it except in the later stages of the +disease, when the symptoms indicate that the intestinal ulcers are in +an atonic condition. Under these circumstances it has appeared to me +to promote their cicatrization. It is important, however, to remember +that diarrhoea is occasionally caused and kept up by more food being +given to the patient than he can assimilate, and it is therefore a +good rule to examine the stools from time to time to see whether they +contain curds of milk or other undigested food. If such is found to be +the case, the amount of nourishment should be diminished, and it will +be well also to prescribe pepsin either in powder or in solution. + +[Footnote 106: _Philadelphia Medical Times_, Feb. 12, 1881.] + +Tympanites also occasionally requires treatment, for in addition to +interference with the descent of the diaphragm and other discomfort it +produces, the distended condition of the bowels directly increases the +risk of perforation. It is usually sufficient to employ embrocations +or stupes of equal parts of sweet oil and oil of turpentine, or of +camphor liniment. If the tympanites coexist with constipation, +enemata, either with or without a small quantity of oil of turpentine, +may often be used with advantage. If it is extreme, an intestinal tube +should be introduced very carefully into the rectum and the gas drawn +off. Charcoal has occasionally been administered in this condition +with a view of preventing decomposition of the intestinal contents. +Tympanites occasionally rapidly supervenes upon the occurrence of +perforation, and must then, of course, be treated with due reference +to the latter condition. + +Intestinal hemorrhage is a symptom which always demands prompt +attention, no matter how slight it may seem to be, for it is to be +remembered that not only is there a danger of its recurrence, but that +the quantity of blood which appears in the stools is by no means a +reliable measure of that actually lost, as more blood frequently +remains in the intestines than appears externally. In estimating its +severity, it is therefore proper to take into consideration the +gravity of the other symptoms which attend it, such as the fall of +temperature, feebleness of the pulse. In many cases the enforcement of +absolute rest, with the administration of cold drink and a small +amount of opium to diminish peristaltic action, is all that is needed. +In cases in which the symptoms are graver it will be necessary to have +recourse to more energetic {333} measures. Under these circumstances +the hypodermic injection of from three to five grains of ergotin, +repeated if necessary, has seldom in my experience failed to check the +hemorrhage. Dilute sulphuric acid, oil of turpentine, and acetate of +lead have also proved themselves useful remedies in my hands. The +application of ice to the surface of the abdomen has also been said to +be attended with good results, but the objections to the use of this +remedy in the condition of collapse, which is so apt to accompany +profuse intestinal hemorrhage, are so evident that it is unnecessary +to discuss them here. Monsel's solution, tannic acid, and various +other mineral and vegetable astringents have been recommended for +their direct effect upon the bleeding surface, but, even admitting +that they can, when administered by the mouth, reach this unaltered or +in a sufficient state of concentration to be active, it is evident +that they could only do so after the loss of valuable time. + +When perforation occurs, it is obvious that the indications for +treatment are to preclude the extravasation of the contents of the +intestine into the cavity of the peritoneum, and to prevent the +peritonitis which is a consequence of this accident from becoming +general. Both of these indications are met by the administration of +opium, which diminishes, and, if pushed, arrests, the peristaltic +action of the intestines. By means of it the bowels may be kept as +free from movement as if "placed in splints." A grain of solid opium +may be given every hour until a decided effect is produced, or if it +is found to disagree with the stomach an equivalent quantity may be +given by the rectum, or it may be substituted by morphia administered +by the mouth or hypodermically. With the same view, food is to be +allowed in small quantities only at a time, and of a character capable +of digestion by the stomach. A light poultice, or, if there is much +evidence of inflammation, ice should be applied to the abdomen. It has +been recommended also, in cases in which the peritonitis has become +general, to apply leeches to the abdomen, but few patients in this +condition will readily bear the loss of much blood. It is very +important not to interfere with the constipation which results from +the above treatment, and which it is one of its objects to promote, +until all inflammatory symptoms have been absent for at least a week, +when a simple enema may be administered. Peritonitis resulting from +other causes than perforation of the intestine does not require any +modification of the above treatment. + +Severe abdominal pain, when it occurs independently of inflammation, +is best treated by the application to the abdomen of light poultices, +to which two or three teaspoonfuls of laudanum may be added. + +Constipation is an occasional symptom, but it rarely calls for active +interference. When it is present so early in the course of the disease +that the diagnosis is still uncertain, and has continued for several +days, it is best to prescribe a small dose of castor oil; a +dessertspoonful is generally sufficient. The late Dr. Gerhard was in +the habit of giving a tablespoonful of sweet oil in this condition. +The inordinate action which frequently follows the administration of +these mild purgatives will often dispel all uncertainty as to the +nature of the disease we have to do with. When it occurs in a more +advanced stage of the disease it is best met by the administration of +enemata, which may contain, if there is much tympanites present, a +small quantity of oil of turpentine. Under all {334} circumstances it +will be well to remember the advice given by Baglivi two centuries +ago, to avoid the use of active cathartics in this disease.[107] + +[Footnote 107: "Fuge purgantia tanquam postem," _Opera Omnia +Medico-Practica et Anatomica_, Georgii Baglivi, 1788.] + +The headache which is sometimes a distressing symptom in the beginning +of the disease is usually relieved by the application to the head of +cloths constantly wet with ice-water or by that of a bladder filled +with ice and lard. If it is very severe and does not yield to these +remedies, a few leeches applied to the temples often have a very happy +effect in moderating the pain. Murchison recommends that the cold +affusion should be administered by simply placing the patient's head +over a basin at the edge of the bed and pouring water on it from a +height of two or three feet. He also says that warm fomentations are +to be preferred to cold in aged and infirm persons of feeble +circulation. Sleeplessness will often disappear under the use of +remedies presented for the relief of the headache and other nervous +symptoms. It is occasionally so persistent as to call for special +treatment. If it occur early in the disease, it will generally be +sufficient to prescribe at bedtime ten grains each of potassium +bromide and chloral, repeated once or twice during the night. Later in +the disease this combination ceases to produce any effect, besides +which chloral cannot be administered with safety after the action of +the heart becomes feeble. It is therefore necessary to have recourse +to opium in some form or other. There are, it is true, theoretical +objections to its use in typhoid fever, such as its interference with +digestion and its tendency to lock up the secretions; but these will +hardly weigh in the balance against the fact that the patient will die +of exhaustion if the insomnia is allowed to continue, and that under +certain circumstances opium is the only drug which will procure the +needed sleep. The form in which it is given is not a matter of much +importance. I prefer the deodorized tincture, twenty or thirty drops, +repeated if necessary in an hour or two, but I have seen good results +from the solid opium and from the hypodermic injection of morphia. +When the insomnia is attended by much tremor and muttering delirium, +camphor may be added to the opium, and given throughout the day as +well as in the evening. Violent delirium is sometimes also relieved by +administration of opium and alcoholic stimulants, and by the +application of cold to the head. It is also much lessened by the +cold-water treatment. When the delirium is so violent that restraint +is necessary, it is better that this should be mechanical than that it +should be left wholly in the hands of ignorant and untrained nurses. A +folded sheet passed over the chest of the patient and fastened to the +sides of the bed is frequently all that is needed. Stupor requires +very much the same kind of treatment as that suitable for the other +forms of nervous derangement. If it is extreme, counter-irritants +should be applied to the nape of the neck and cold to the head. The +late Dr. Wood was in the habit of shaving the hair and applying a +blister to the scalp of a patient in this condition, and I have seen +good in more than one instance result from this treatment. The urine +should also be examined, and if the quantity be insufficient diuretics +should be given. If it contain albumen or blood, counter-irritants and +even cut cups should be applied to the loins. It is also important, if +the patient be in this condition, that the physician should not rest +satisfied with the nurse's {335} assurance that the urine is passed +freely, but should from time to time examine the supra-pubic region +himself. It is not infrequently found under these circumstances that +there is really retention, and that the wetting of the bed upon which +the nurse has based her assurances is really the consequence of the +dribbling of urine from an over-distended bladder. I have known of +serious results, such as cystitis, paralysis of the bladder, having +followed the neglect of this very simple precaution. Convulsions when +they occur are to be treated by the application of cold to the head +and counter-irritants to other parts of the body. + +Epistaxis is rarely so severe as not to yield to the use of simple +remedies, such as the application of ice to the forehead or back of +the neck, or of styptics locally. In a few cases, however, it is +profuse, and it will then be necessary to have recourse to hypodermic +injections of ergotin, as in the case of hemorrhage from the +intestines, or to plug the nostrils. + +TREATMENT OF COMPLICATIONS.--Hypostatic congestion of the lungs, as it +is usually the consequence of feeble action of the heart, is best +treated by frequently changing the position of the patient, and by +remedies calculated to increase the power of the organ, such as +alcoholic stimulants, ammonium carbonate, oil of turpentine, and +digitalis. Recent German authors, however, regard digitalis as a +dangerous remedy when the heart has undergone the granular +degeneration peculiar to fevers. It had, therefore, better not be +given if the congestion occurs late in the disease. I have myself +always found advantage from the application of turpentine stupes to +the chest, and occasionally from the application of dry cups. +Pneumonia when it occurs as a complication does not render necessary a +material modification of the above treatment. It may sometimes be +well, if it occur early in a robust subject, to take blood locally, +but it can rarely be justifiable to do so by venesection. + +Bed-sores may generally be prevented by frequently changing the +position of the patient, by scrupulous attention to cleanliness, and +by bathing prominent parts of his body with whiskey and alum. These +parts should also be protected from pressure by the judicious +arrangement of pillows and cushions. When redness or abrasions appear +the part should be covered with soap plaster smoothly spread upon kid. +This application may be continued even after the formation of sloughs. +As soon, however, as these show a tendency to suppurate poultices +should be applied, and the resulting ulcer treated as if occurring +under other circumstances. + +Thrombosis of the femoral vein is best treated by elevating the +affected leg and enveloping it with flannel cloths saturated with hot +vinegar and water. Thrombosis of other veins is to be treated on the +same general principles. When an artery becomes obliterated, whether +from embolism or thrombosis, the part which it supplies should be +surrounded with cotton wool and every effort made to favor the +establishment of the collateral circulation. If sphacelus occurs, it +should be treated on general surgical principles. + +TREATMENT OF CONVALESCENCE.--The importance of a strict adherence to a +liquid diet in the early part of the convalescence of typhoid fever +has already been alluded to. The ulcers in the intestines often remain +unhealed for some time after the subsidence of the fever, and errors +in diet may therefore readily cause recrudescences of fever, if not +true relapses. {336} These recrudescences are sometimes produced by +very slight causes. I have seen them follow undue mental exercise or +worry, or sitting up too early or too long. It is therefore important +to guard our patients at this stage of the disease from undue fatigue +or excitement of any kind. Medicines calculated to build up the +strength and to improve the nutrition are clearly indicated at this +time. If the diarrhoea should persist, nitrate or oxide of silver, +sulphate of copper, and subnitrate of bismuth in appropriate doses, +given with a little opium, will all be found to be useful remedies. +When, on the contrary, constipation exists, it is still necessary to +avoid the use of drastic cathartics; indeed, even mild laxatives +should be given by the mouth only after enemata have failed to produce +a movement of the bowel. + +SPECIFIC TREATMENT.--The search for a specific remedy in typhoid fever +is not new. It is as old as the theory that the disease is generated +by a specific cause. The hypothesis that this is an alkaline poison +led many years ago to the use of the mineral acids, and it was only +after experience had shown that they were without power to cut the +disease short, or even to control many of its symptoms, that they +ceased in a measure to be prescribed. Calomel also, which was +occasionally resorted to formerly for its antiphlogistic effects upon +the intestinal lesions, has been lately recommended in Germany in the +treatment of typhoid fever on account of its supposed antidotal +properties. Seven and a half grains of the drug, and in some cases a +much larger dose, are given four times daily on alternate days as soon +as the nature of the disease is fully recognized. It is claimed for +this treatment that when it is begun early the rate of mortality and +the duration of the disease are much less under it than under any +other. Its advocates admit, however, that the latter is not always the +case--a variety in the action of the medicine which is attributed to a +difference in the way in which the poison of the disease has been +taken into the body. Salivation is rarely produced by the calomel. The +diarrhoea, which is at first increased by it, subsequently diminishes, +and the administration of each dose is followed by a decided although +temporary reduction of temperature. + +A diminution in the rate of mortality is also said to have been +obtained by the administration of iodine in typhoid fever, although +the results of its use are on the whole less favorable than those of +calomel. Liebermeister recommends that three or four drops of a +solution of one part of iodine, two parts of iodide of potassium, and +ten parts of water should be given every two hours in a glass of +water. + + --------------------------+---------+--------+-------------- + | Number | Number | Percentage of + | treated.| died. | mortality. + --------------------------+---------+--------+-------------- + Non-specifically treated | 377 | 69 | 18.3 + Treated with calomel | 223 | 26 | 11.7 + Treated with iodine | 239 | 35 | 14.6 + --------------------------+---------+--------+-------------- + Total | 839 | 130 | 15.5 + --------------------------+---------+--------+-------------- + +The preceding table, which is taken from Liebermeister's article on +typhoid fever in _Ziemssen's Cyclopaedia_, is based upon the results +of {337} treatment in 839 cases, a part of which were treated with +iodine, a part with calomel, and a part with neither, the rest of the +treatment being exactly alike in all of them, and consisting in the +employment of a partial antipyretic method. + +James C. Wilson[108] has recently used with great success in the +treatment of typhoid fever the following prescription, which was +originally suggested by Roberts Bartholow: Rx. Tinct. Iodinii fl. +drachm ij.; Acid. Carbolici liq. fl. drachm j.--M. Of this, one, two, +or even three drops is given in a sherry-glassful of ice-water after +food every two or three hours during the day and night. In addition to +this prescription his patients were given a dose of calomel varying in +amount from seven and a half to ten grains, which was repeated on +every alternate night until three or four doses had been administered +in the course of the first six or eight days. Of sixteen cases so +treated, none proved fatal, although eight of them were severe, the +temperature reaching or exceeding 104 degrees F. Da Costa[109] has +used carbolic acid in this disease, and has found it useful in +controlling the diarrhoea and in lowering the temperature, but +suggests the use of thymol in doses of from half a grain to one grain +as a substitute, on account of its greater acceptability to the +stomach. C. G. Rothe[110] recommends a mixture of carbolic acid, +tincture of digitalis, tincture of aconite, brandy, and tincture of +iodine. Its use causes a decided fall of temperature and diminution in +the frequency of the pulse. + +[Footnote 108: _Transactions of the College of Physicians of +Philadelphia_, 3d Series, vol. vi., Philadelphia, 1883, p. 221.] + +[Footnote 109: _Ibid._, p. 234.] + +[Footnote 110: _Deutsche Med. Wochenschr._, 1880.] + +My own experience does not enable me to speak with positiveness of the +value of this plan of treatment. Indeed, it has been used in so few +cases, to the exclusion of all other remedies, that it is difficult to +decide how far the result attained in cases treated by them is due to +them, and how far to the other therapeutic means employed. With the +testimony of such competent observers as those above named it is only +proper that the treatment by iodine and carbolic acid should have a +further trial. More caution, it seems to me, is required in the use of +calomel. While it is probable that in a few cases the intestinal +lesions may be favorably modified by the purgation which it induces, +the indiscriminate use of the drug is, I am sure, calculated to do +more harm than good. + + + + +{338} + +TYPHUS FEVER. + +BY JAMES H. HUTCHINSON, M.D. + + +DEFINITION.--Typhus fever is an acute contagious disease, usually +occurring epidemically, lasting from ten to twenty days, and +characterized, among other symptoms, by an abrupt commencement, great +prostration, profound derangement of the nervous system, and a +peculiar eruption which appears between the third and eighth days, and +which, disappearing at first under pressure, soon becomes persistent, +and in severe cases may be converted into and be associated with true +petechiae. When it proves fatal, it generally does so at or near the +end of the second week. The lesions found after death are not specific +in character, and consist mainly of a marked alteration of the blood, +congestions of internal organs, softening of the heart, and atrophy of +the brain. + +SYNONYMS.--Petechial Typhus, Putrid or Malignant Fever, Camp, Jail, +Ship, or Hospital Fever, Spotted Fever, Irish Ague, Contagious Typhus, +Brain Fever, Adynamic or Ataxic Fever, Ochlotic Fever, Catarrhal +Typhus. + +The term typhus was first applied by Sauvages in 1760, and afterward +by Cullen, to certain forms of fever, characterized by marked +prominence of the nervous symptoms, to distinguish them from another +group of cases to which they gave the name synochus, and is derived +from the Greek word [Greek: typhos], which literally means smoke, and +which is employed in the treatise on internal affections attributed to +Hippocrates for a similar purpose. According to Murchison,[1] +Hippocrates used the word to define a "confused state of the +intellect, with a tendency to stupor." The appellation typhus, +therefore, as indicating a very prominent symptom of the disease about +to be described, is perhaps the best that could be given to it. It has +been generally adopted by the physicians in England and in this +country to denote this disease, but on the Continent, and especially +in Germany, it is applied also to typhoid fever, the two fevers being +usually designated there as typhus petechialis and typhus abdominalis, +respectively. + +[Footnote 1: _A Treatise on the Continued Fevers of Great Britain_, by +Charles Murchison, M.D., LL.D., F.R.S., etc., second edition, London, +1873.] + +HISTORY.--As human want and misery and the evils which follow in the +train of war have never been wholly absent from the world, and as +these are the conditions which are now known to be favorable to the +spread, if not to the generation, of typhus fever, it is highly +probable that this disease was the cause of some of the epidemics to +which allusion is made by the sacred and profane writers of antiquity. +Yet their descriptions are too vague to justify us in assuming that +such was positively the {339} case. The records of the first fifteen +centuries of our own era are similarly wanting in details, for, with +the exception of a brief notice of an outbreak of the disease in the +monastery of La Cava, near Salerno, in the year 1083, by Corradi[2] it +may be said to have been practically undescribed before the year 1546, +when Fracastorius[3] published his work, _De Contagionibus et Morbis +Contagiosis_. From the description which this distinguished physician +gives there of the epidemics which prevailed in Verona in the years +1505 and 1508, there can be no doubt that the disease he had the +opportunity of observing was really typhus fever. Not only are the +principal symptoms succinctly described, but its contagiousness and +tendency to early prostration fully recognized. We learn also, from +the same work, that the disease, although previously unknown in Italy, +was one with which the physicians of Cyprus and the neighboring +islands were perfectly familiar. According to the same authority, it +again made its appearance in 1528 in Italy, and from there extended to +Germany. + +[Footnote 2: In _Chron. Cavense Annali_, p. 1, 101, quoted in +_Handbuch der Historish-Geographischen Pathologie_, von Dr. August +Hirsch, Stuttgart, 1881.] + +[Footnote 3: Quoted by Murchison.] + +During the last half of the sixteenth century epidemics of typhus +fever would seem to have been of more frequent occurrence than before +it, since many of the medical authors of this period not only refer to +it very fully, but also give accurate descriptions of the disease. +There is also abundant evidence of the same kind that it frequently +prevailed epidemically in almost every part of Europe during the +seventeenth and eighteenth centuries, following generally in the wake +of famine and of war, and often attaining a high degree of virulence +in besieged towns. The histories of many of these epidemics are +exceedingly interesting, especially those of the so-called Black +Assizes which occurred at different times in several of the towns of +England, and which derived their name from the fact that the disease +was communicated from the prisoners on trial to the judges and other +persons in attendance upon the court; but to give these in detail +would be beyond the scope of this article. Although many of the +authors of these two centuries boldly advocated copious venesection as +the only rational method of treating the disease, there was a not +inconsiderable number who recognized its essentially typhoid nature, +its tendency to early prostration, and the fact that patients +suffering from it bear bleeding badly, as fully as is done by +physicians of the present day. They were also unquestionably quite +aware of the circumstances under which typhus fever generally arises, +for in 1735, Browne Langrish[4] wrote that it originated from "the +effluvia of human live bodies," and that its principal cause was +overcrowding with deficient ventilation, as a result of which "people +were made to inhale their own steams;" and a similar opinion was +expressed a few years later by Sir John Pringle,[5] J. Carmichael +Smyth,[6] and others. + +[Footnote 4: _The Modern Theory and Practice of Physics_, by Browne +Langrish, p. 354, London, 1764.] + +[Footnote 5: _Observations in Diseases of the Army_, London.] + +[Footnote 6: Quoted by Murchison.] + +Epidemics of typhus fever have frequently occurred in various parts of +Europe during the present century, although they have, on the whole, +shown a greater tendency than before to confine themselves to the +place in which they first appeared. The most severe of these began in +1846, and after committing great ravages in Ireland extended to +England, and {340} subsequently to the Continent. The disease proved +much more fatal than the sword in the armies of Napoleon in the towns +besieged by him in the early part of this century, and was the cause +of an immense loss of life in the Russian and French armies in the +Crimea after the fall of Sebastopol. + +In our own country typhus fever has appeared several times during the +present century, but the outbreaks have rarely attained the magnitude +of epidemics, such as are seen in Europe, and have usually been +distinctly traceable to importation from abroad. It was first met +with, according to Wood,[7] in New England in 1807 and in Philadelphia +in 1812, continuing to lurk, this author says, in the lanes and alleys +of that city until the winter of 1820-21, when, as a student of +medicine, he had an opportunity of studying it. Another outbreak of +the disease occurred in the same city in 1836, and is the subject of +an admirable paper by the late Wm. S. Gerhard.[8] Since then epidemics +of moderate severity have repeatedly occurred at different times in +several of the American cities, and have been described, among others, +by Flint, Da Costa,[9] and Loomis. A large number of cases of typhus +fever (1723), with 572 deaths, were reported to the Surgeon-General's +office during the late Civil War, but doubt has been thrown upon the +correctness of the diagnosis of many of these cases by Clymer[10] and +Woodward,[11] and by other army surgeons, who, as the result of their +investigations of this subject, have reached the conclusion that +typhus did not prevail as an epidemic, however limited, among our +soldiers at depots for returned prisoners of war. A like immunity from +this scourge may be assumed to have been enjoyed by the Confederate +forces, since Joseph Jones,[12] one of the most eminent of their +medical officers, has stated positively that no case of true typhus +fever came under his observation during the war in any army, in any +field hospital, general hospital, or military prison, and that the +experience of all of his associates whose opinions on this question he +was able to obtain, either personally or by letter, was the same. It +is therefore most probable that the cases entered upon the sick +reports of both armies as typhus fever were in almost every case, if +not in all, cases of typhoid fever occurring in scorbutic subjects. + +[Footnote 7: _A Treatise on the Practice of Medicine_, by George B. +Wood, M.D., etc., Philada., 1855.] + +[Footnote 8: _The American Journal of the Medical Sciences_, February +and August, 1837.] + +[Footnote 9: _Ibid._, January, 1866.] + +[Footnote 10: _The Science and Practice of Medicine_, by William +Aitken, M.D., Edin.; 3d Amer. ed., p. 462, Philadelphia, 1872.] + +[Footnote 11: _Camp Diseases of the United States Armies_, by Joseph +Janvier Woodward, M.D., Philadelphia, 1863.] + +[Footnote 12: _United States Sanitary Commission's Memoirs--Medical_, +p. 600, New York, 1867.] + +From the foregoing sketch of its history it is evident that typhus +fever has prevailed from time to time in almost all the countries of +Europe. Indeed, it is probable that no one of them has wholly escaped +its ravages, while in others--as, for example, Ireland--it has been +more or less constantly present until within the last few years, when +its visitations have been less frequent as well as less severe. Even +in countries which are popularly supposed to enjoy an immunity from it +there is evidence of an incontrovertible character that it has +occasionally occurred. Such an immunity has been claimed for France, +but in the works of Riverius,[13] {341} Ambrose Pare,[14] and others +will be found descriptions of the disease which leave no doubt upon +the mind of their entire familiarity with it; and Hirsch, in his work +on _Historico-Geographical Pathology_, is able to give references to +several writers who describe outbreaks that have recently occurred +there. The disease has also been observed in Iceland. Typhus fever is +of much less frequent occurrence in the other divisions of the eastern +hemisphere than in Europe. According to Murchison, there are no +authentic records of its having been met in Africa, or, with the +exception of India, in Asia, such as it is seen in England and +Ireland. There are, however, reports of its occurrence in Asia Minor, +Syria, Persia, Egypt, Nubia, Tunis, and Algeria, which Hirsch,[15] on +the other hand, believes place the occasional presence of this disease +in these countries beyond doubt. The same difference of opinion exists +between these two distinguished observers in regard to the accounts +which have been published of typhus fever occurring in Mexico, Central +America, and South America, the latter holding that they are entirely +reliable, the former that the cases described in them were really +cases of malarial or typhoid fever. The disease has never been met +with on the continent of Australia, in New Zealand, or in the valley +of the Mississippi and the States bordering on the Pacific Ocean in +our own country. + +[Footnote 13: _The Practice of Physick_, being chiefly a Translation +of the Works of Lazarus Riverius, London, 1678.] + +[Footnote 14: _Traite de la Peste, de la Petite Verolle et Rougeolle_, +par Ambrose Pare, Paris, 1568.] + +[Footnote 15: _Loc. cit._] + +While Hirsch's researches go to show that the tropical zone has not +been so wholly exempt from the visitation of typhus fever as some +authors have asserted, they establish the fact that it is of much less +frequent occurrence there than in the colder portions of the temperate +zone, where the modes of life are certainly much more favorable to its +extension. Natives of warm climates are as liable to be attacked by it +as others upon coming to places where it is prevailing, and in the +Philadelphia epidemic of 1836, which Gerhard[16] has described, +negroes and mulattoes suffered from it more severely than the whites. + +[Footnote 16: _Loc. cit._] + +ETIOLOGY.--The etiology of typhus fever will be best studied under the +heads Predisposing and Exciting Causes. + +PREDISPOSING CAUSES.--It may be stated, generally, that whatever +impairs the health or reduces the strength of an individual, even +temporarily, or acts depressingly on his nervous system, predisposes +him to typhus fever. But there are among the predisposing causes some +which exert a more special influence on its production than others. +Among the more powerful of these is the overcrowding of human beings, +with deficient ventilation. Indeed, there are some authors who +consider that this has been in many cases alone sufficient to occasion +the disease; and although this opinion, as it involves the admission +that it may be generated de novo, is contested by others, there is +great unanimity among authors in attaching great importance to it. Of +the patients admitted into the London Fever Hospital with typhus +fever, a large proportion came from the more crowded districts of the +city. The disease has always been most prevalent in the poorer +quarters of Glasgow, Dublin, and Edinburgh, and when epidemic in +Philadelphia in 1836 it was confined to a portion of the town which +has always been noted for the squalor and misery of its inhabitants. +Among those admitted during that year to the Philadelphia Hospital +were seven negroes, said by Gerhard to {342} be "the entire population +of a cellar." It is probably largely due to the fact that the better +social condition of the poor in this country prevents the degree of +crowding which often exists in European cities that the disease is +comparatively rare here. The effect of overcrowding is of course much +increased by want of cleanliness, either of the person or of the +clothes. + +Poverty, not merely from its own depressing influences, but also from +the fact that it leads to overcrowding, is a powerful predisposing +cause of typhus fever. Insufficiency of food, which is one of its many +consequences, by impairing his nutrition and thus diminishing his +vital resistance, renders the individual more susceptible to the +action of the specific cause. Gerhard says that of the patients seen +by him in 1836 a very small proportion came from the better class of +mechanics, and Tweedie[17] and Sir William Jenner[18] state that it is +rare to meet with instances of the disease, except in the case of +medical practitioners and students, among those in comfortable +circumstances. Bateman[19] goes so far as to assert that "deficiency +of nutriment is the principal source of epidemic fever;" and there is +certainly a remarkable coincidence in time between outbreaks of this +fever and seasons of want and distress. But, as Murchison has shown, +destitution is not essential to the production of typhus, for the +Dundee epidemic of 1865 was due to overcrowding of the town, brought +about by the inhabitants of the surrounding country flocking into it +in consequence of labor being unusually abundant and wages good. + +[Footnote 17: _Lectures on the Distinctive Character, Pathology, and +Treatment of Continued Fevers_, by Alexander Tweedie, M.D., F.R.S., +London, 1842; and _Clinical Reports on Fever_, by same author, London, +1830.] + +[Footnote 18: _On the Identity or Non-Identity of Typhoid and Typhus +Fevers_, by William Jenner, M.D., London, 1880; also _Lancet_, +November 15, 1879.] + +[Footnote 19: _A Succinct Account of Typhus or Contagious Fever of +this Country_, by Thomas Bateman, M.D., F.R.S., London, 1820.] + +Similar in its action to the above cause is intemperance. Not only is +the habitual drunkard more likely to suffer from typhus fever than the +temperate man, but a single debauch has been followed by an attack in +individuals who had previously resisted the contagion. On the other +hand, the most rigid temperance will not afford in all cases a +complete immunity from its effects. The debility left by an illness is +also a condition favoring the occurrence of an attack of the disease +in those who are exposed to its exciting cause. Fatigue of all kinds +renders the body less able to resist the causes of disease, and typhus +fever is not an exception to the general rule. Overworked nurses are +specially liable to contract it. The depressing emotions also favor +its occurrence. It has been observed during epidemics that those who +exhibit an excessive fear of the contagion are much more likely to +suffer from it than the cheerful and courageous. + +No age enjoys an immunity from the disease. In fact, it is probable +that all ages are equally liable to it. Buchanan[20] has seen it at +the London Fever Hospital in an infant a fortnight old and in a man of +eighty, and attributes the prevailing opinion that children rarely +suffer from it to the fact that they are not often taken to hospitals, +but are retained in their own homes for treatment. Gerhard[21] says +that no children in the asylum attached to the Philadelphia Hospital +were {343} attacked with the disease during the prevalence of the +epidemic there, but the distance of the asylum from the wards in which +the cases were treated was probably the reason of their escaping. In +the few cases which have come under my own observation the patients +were young men, varying in age from twenty-five to thirty-five. The +sexes also suffer from it equally. In some epidemics there may be a +preponderance of one sex over the other, but in others the reverse has +been the case. + +[Footnote 20: _A System of Medicine_, edited by J. Russell Reynolds, +M.D., F.R.C.P., etc., vol. i., article "Typhus Fever," London, 1866.] + +[Footnote 21: _Loc. cit._] + +Occupation, except so far as it brings the individual into immediate +contact with the sick, as in the case of physicians, nurses, and +clergymen, does not predispose to the disease. There would seem also +to be no difference in the susceptibility of the different races to +the contagion. Acclimatization affords no protection from the disease, +as it does in the case of typhoid fever, and change of the habits of +life does not appear to exercise any influence upon the liability to +it. On the other hand, the susceptibility of different individuals, +and of the same individual at different times, varies considerably. +Thus, while in many persons a single exposure to the contagion is +followed by an attack, in the case of an engineer mentioned by +Murchison it did not occur until after fifteen years of continuous +service at the London Fever Hospital. A person who has once suffered +from typhus fever is not likely to contract it again, but this +protection is not complete, as there are a few well-attested instances +of a second attack on record. + +The disease prevails most frequently during the winter and early +spring, principally because the cold weather of these seasons leads to +the closing of windows and all other avenues of ventilation, thus +intensifying its exciting cause. Still, some epidemics of great +severity have occurred in the warmer months of the year, as, for +instance, the one described by Gerhard. It is also doubtful if there +is any relation between variations in temperature and the amount of +moisture in the air and the prevalence of epidemics of typhus fever, +although Hirsch regards a low and damp situation as powerfully +predisposing to the endemic and epidemic prevalence of the disease. It +is usually met with in towns on the sea-coast or on navigable rivers, +but it has also been observed frequently in country districts, and +even in regions at a considerable elevation above the level of the +sea. + +EXCITING CAUSE.--The principal if not the only exciting cause of +typhus fever is a specific contagion developed in the bodies of the +infected and transmitted from them to the healthy by actual contact, +by fomites, or through the atmosphere. The nature of this contagion is +unknown. A careful study of its peculiarities seems to justify the +opinion that it depends upon the presence of a minute organism in the +emanations given off by the sick, which is capable of indefinitely +multiplying itself in the human body. But this is only an hypothesis, +which rests principally upon the analogy between typhus and some other +diseases, as, for instance, relapsing fever and diphtheria, in which +such a growth is thought to have been discovered, and upon the fact +that the contagious principle whatever it may be, is destroyed by a +temperature over 204 degrees F. + +The evidence in favor of the contagiousness of typhus fever is +conclusive, and may be briefly stated as follows: When it breaks out +in a community the disease not only attacks those persons who have +been subjected to the same influence as the sick--as, for instance, +members of {344} their own families, occupants of the same house, +etc.--but also those who have come from healthy localities to visit +them. In fever hospitals it is rare for any member of the household +who has not already had the fever to escape an attack, and the +probability of his suffering is in direct proportion to the intimacy +of his relations with the patients. Thus, the nurses are far more +likely to be attacked than servants whose duties do not take them into +the wards, except those employed in the laundry, who are so often +affected by it that Murchison says it is difficult to find women who +are willing to take the position. The spread of the disease may often +be promptly arrested by the complete isolation of the first few cases, +while free intercourse between the sick and the well is invariably +followed by its extension, not only in the locality in which it first +appeared, but to other localities. But the strongest argument in favor +of its contagiousness is found in the fact that patients taken into a +previously healthy place have frequently become the starting-point of +an epidemic. In this way the disease has often been introduced by +Irish immigrants into the cities on our seaboard, and even into some +of our interior towns. + +Actual contact is not necessary for the communication of typhus fever +from the sick to the well. The contagion may be transmitted through +the atmosphere. How far it will be transmitted in this way will depend +upon many circumstances. In a spacious and well-ventilated ward it is +probable that the presence of one or two patients with this disease +does not seriously endanger the safety of the other patients, and that +the only persons who run much risk of contracting it are the +physicians and nurses, who are often compelled in the performance of +their duties to inhale the emanations from the bodies of the sick. At +the Pennsylvania Hospital, where cases of this disease are +occasionally admitted, it has been usual to isolate them by placing +them in a room a few feet distant only from the dining-room of the +men's medical ward and separated from the ward by a short corridor. +The steward of the hospital informs me that during his connection with +it, which extends over a period of more than sixty years, he has never +known the disease to extend to other persons, except on two occasions. +One of these was during the epidemic described by Da Costa, when an +unusual number of cases was received, and when one resident physician +and two nurses contracted the disease. On the other occasion, which +happened during my own term of service in the spring of 1881, a young +Danish sailor appeared to have taken the disease from two British +seamen. As it was ascertained positively that he had not entered the +room in which these two seamen were isolated, and as his bed in the +ward was one of the farthest removed from the room, and he had not +therefore been more or as much exposed to the contagion as the other +patients, it was difficult to understand why he alone of all of them +should have suffered from it. The explanation was, however, found in +the fact that he had been taken over to the women's ward to act as +interpreter for a countrywoman who was not known at the time to be +suffering from typhus fever, and that he had remained there some time +in conversation with her. Murchison and Buchanan both assert also that +typhus fever has never extended from the London Fever Hospital to the +inmates of adjacent houses, even when it was itself one of a row of +houses. If, on the other hand, several patients with typhus fever are +placed in a crowded and ill-ventilated ward, the contagion will then +be found to have {345} acquired so much more virulence that few of the +other patients will escape its effects. + +There is also no question that typhus fever may be communicated by +fomites. Numerous instances are on record in which the disease has +been communicated by the wearing apparel and bed-clothes of patients, +and we have already called attention to the frequency with which +laundry-women in fever hospitals are attacked by it. The clothes of +persons who are themselves free from the disease, but who have been in +close attendance upon the sick for some time, are often also the +medium of communication. Indeed, Murchison goes so far as to say that +men who have not changed their clothes and "who have been living in +close, ill-ventilated apartments and on short allowance, may at length +have their garments so impregnated with the poison of typhus as to +communicate it to others without being themselves the subjects of it," +even if they have not been brought in contact with fever patients. The +disease was communicated in this way, he thinks, in the famous Black +Assize in 1750 by several prisoners to the court that tried them, +although they were themselves free from it. On the other hand, with +proper precautions there is little danger of the disease being +conveyed by physicians to their own families or to other patients. + +Some difference of opinion exists as to the stage at which typhus is +most contagious. Many authors believe that it is more infectious +during convalescence than at any other time, and base this opinion +upon the fact that the removal of fever patients to the convalescent +ward is very often followed by the occurrence of the disease among its +other occupants; but this is probably due, as Murchison suggests, to +the patients being allowed at this time to wear their own clothing, +which has not been thoroughly disinfected. It is much more likely that +the disease is more contagious during the stage when the febrile +symptoms are most marked than during either the stage of convalescence +or that of invasion. It would appear also, from the observations of +Dr. Gerhard and others, that dead bodies do not readily communicate +the contagion or that the contagious principle is easily counteracted +after death. Still, there are several well-authenticated cases on +record in which individuals have unquestionably contracted the disease +from dissecting the bodies of patients dead from this cause. + +A question of great interest naturally arises here, as to whether or +not typhus fever ever occurs except as the consequence of exposure to +a previous case of the disease. Is it, in other words, ever generated +de novo? Authorities are divided upon this point, many contending that +an independent origin is impossible, and others that it may +occasionally arise in this way. Among the latter is Murchison, who +adduces in support of the position he takes several instances in which +poverty, with overcrowding and deficient ventilation, appears to have +been the only cause of extensive outbreaks of the disease, as in the +case of the Black Assize already alluded to. These cases the opposite +party explain by assuming that the germs of the disease are capable of +lying dormant for a long time until roused into activity by favoring +circumstances. If the disease is caused, as we have shown there is +good reason to believe it is, by the presence of a minute organism, +this view does not seem to be untenable. Pasteur has demonstrated that +the germs of the splenic fever of some of the lower {346} animals may +be deprived of their virulence by cultivation in appropriate liquids. +If their virulence is diminished under certain circumstances, the +assumption does not seem unwarrantable that under others it may be +increased, and if we may draw this conclusion in regard to one form of +microscopic growth, we may do the same for others; and the hypothesis +is therefore not an unreasonable one that the typhus germ needs the +atmosphere engendered by overcrowding for it to acquire the power to +produce the disease. + +PERIOD OF INCUBATION.--The period of incubation of typhus fever +appears to vary considerably in length, but is usually about twelve +days. In some cases the interval between exposure to the contagion and +the occurrence of the first symptoms of the disease is asserted to +have been considerably longer, and in one instance as long as +thirty-one days; but it is probable that there has been in most, if +not in all, of these cases a second exposure which has been +overlooked. On the other hand, it is said to have followed at once +upon exposure, as in cases reported by Gerhard, in one of which a +nurse inhaled the breath of a patient whom he was shaving, and in an +hour afterward was taken with cephalalgia and ringing in the ears, +which were immediately succeeded by the other symptoms of typhus. In +this and other similar cases which are on record it is difficult to +exclude the possibility of a previous infection. In a case, however, +reported by Murchison there would seem to be no reason to suspect that +any such previous infection could have taken place, as the patient, +the matron of an orphan asylum where there was no typhus, was taken +ill immediately after opening a bundle of clothes which a child had +brought with her from a fever hospital, and which had not been +thoroughly disinfected. + +SYMPTOMATOLOGY.--It will facilitate the study of typhus fever to give, +in the first place, as most of the systematic writers on fever have +done, a brief clinical sketch of the disease as it ordinarily occurs, +and then afterward to consider its leading symptoms in greater detail. + +GENERAL DESCRIPTION.--An attack of typhus fever is sometimes preceded +for a few days by prodromata, such as a feeling of malaise, +indisposition to exertion, pain in the head and limbs, anorexia, and +vertigo; but it oftener begins abruptly with a slight chill, or more +rarely with a decided rigor. This is followed in a short time by +headache, by a marked rise of temperature, and by an increased +frequency of pulse and respiration. Nausea is also occasionally +present, and less frequently vomiting. The tongue is at first moist +and covered with a thin whitish fur, but soon becomes dryish, and its +coating is apt to assume a brownish appearance in a day or two. With +these symptoms there are loss of appetite, great thirst, constipation, +a dull, heavy expression of countenance, a dark, dusky hue of the +face, and injection of the conjunctivae. Mental confusion is early +observed, so that, although the patient may be able to answer +questions correctly when thoroughly roused, it is readily seen that +his mind is working with difficulty. The sleep is very often disturbed +by dreams, so that he awakes from it unrefreshed. Prostration and loss +of muscular power are so decided from the very beginning of the +disease that the patient is obliged usually to take to his bed at +once, and it is much rarer to meet with walking cases of the disease +than in typhoid fever. The urine is dense, scanty, and high-colored. + +{347} Usually, about the fourth day of the disease the characteristic +eruption of typhus fever makes its appearance. It consists of numerous +spots of irregular form with ill-defined margins and of a dark red or +purplish color, occurring singly or in groups, and varying in size +from that of a pin's point to two or three lines in diameter. They +disappear at first under pressure, but in twenty-four hours become +persistent, and in severe cases may be converted later into petechiae. +Besides this eruption there is another which consists of a faint, +irregular dusky red, subcuticular mottling. The two eruptions together +constitute the mulberry rash of Jenner, and have been variously +described by different authors under the name of measly or +morbilliform rash. + +As the disease advances the prostration becomes greater and the pulse +grows weaker. The tongue becomes dry and brown and trembles when +protruded. Later, it is so dry and contracted that it can scarcely be +put out of the mouth. Sordes collect about the teeth and lips, and the +surface exhales a peculiar odor. The headache grows more severe or +gives place to delirium, which may at first be active and violent, and +then pass into the low and muttering form, or the delirium may be of +the latter variety from the start. The sleeplessness of the early +stages may continue, and the condition known as coma vigil not +infrequently supervenes. The delirium is usually followed by stupor, +which is more or less profound in accordance with the severity of the +case, and which is accompanied by all the symptoms which characterize +the so-called typhoid state, such as subsultus tendinum, picking at +the bed-clothes, slipping down in bed, retention or incontinence of +urine, and sloughing of the parts exposed to pressure. In this +condition the temperature, although usually still considerably above +normal, is lower than during the first week of the disease. + +Meanwhile, the issue remains in doubt, and may continue uncertain for +several days before any improvement in the symptoms can be observed, +or, the stupor passing into coma, the case may speedily terminate in +death. When death is the result, it usually takes place about the +close of the second week or a little later, but it may occur earlier +in consequence of the violence of the fever, or, when due to a +complication, may be postponed until after the end of the third week. +Fortunately, however, recovery is the rule in this disease. The +beginning of convalescence is often as abrupt as that of the attack +itself. The temperature will often be found to have fallen to the +normal or below the normal, the pulse and respiration to have returned +to a healthy condition, and all confusion of the intellect to have +disappeared in the course of a few hours. Occasionally, however, its +approach is more gradual, and a slight fall in temperature and a +corresponding improvement in the other symptoms may be observed before +it actually occurs. Diarrhoea, an excessive secretion of urine, with a +tendency to the deposition of urates, and moderate sweating, often +take place simultaneously with the cessation of the fever, and were +formerly regarded as critical discharges. The return to health is +usually rapid, and very rarely retarded by the occurrence of +complications or relapses, as in typhoid fever. The disease itself +leaves no tendency to any other disease. + +DESCRIPTION OF SPECIAL SYMPTOMS.--The appearance of a patient with +typhus fever is pathognomonic, and is often alone sufficient to enable +{348} a physician or nurse familiar with it to recognize the disease +when brought in contact with it. The surface generally is congested; +the face is flushed, and in bad cases dusky red or even livid in hue; +the expression is dull and vacant, except during delirium, when it may +be wild or even fierce; the conjunctivae are injected, the eyes +watery, and the teeth encrusted with sordes. The skin is generally hot +and dry, except toward the close of bad cases, when it may be cool and +bathed in a profuse sweat. + +The symptoms connected with the nervous system are among the most +characteristic of the disease, and of them none is more marked than +prostration. It shows itself early, the patient usually taking to his +bed immediately after his seizure or within a few days of it. It is +much rarer than in typhoid fever to meet with walking cases of typhus, +but Buchanan[22] mentions that patients with the rash already out upon +them do occasionally present themselves at the out-door department of +the London Fever Hospital. It generally increases as the disease +progresses, and is often accompanied by a tendency to syncope. It may +attain such a degree that the patient is unable to turn himself in bed +or to help himself in any way. Among the most distressing sensations +which attend this condition of excessive feebleness is a feeling as if +he were sinking into the earth with nothing to support him. Headache +is also an early symptom. It is often observed among the prodromata of +the disease, and when these are absent supervenes directly after the +chill. It is usually frontal, but may be diffused. It is generally +dull and heavy, but is sometimes acute, and may be accompanied by a +tendency to vertigo, increased by sitting up, and by pains in the back +and limbs. It becomes more severe with the progress of the disease +until the occurrence of delirium, when it is, as a rule, less +complained of. With the headache there is generally some dulness of +intellect, except in mild cases. This may be slight at first, and may +continue so throughout the whole course of the attack, exhibiting +itself principally in some confusion as to dates. In more severe cases +it is much more marked, and may finally pass into actual stupor. On +the other hand, it may be entirely absent, even in severe attacks, as +in a case reported by Da Costa and in some cases recently observed by +myself. It is usually soon replaced by delirium, which may be low and +muttering or wild and noisy, the former being the more common. +Delirium is said to occur most frequently among the educated classes +and those oppressed with care and anxiety, but is not rare among those +who occupy a lower position in the social scale, especially the +intemperate. It is, as a rule, most marked at night, and in mild cases +may occur only at that time or upon waking in the morning. When the +delirium is active the patient may shout and scream, or leave his bed +and attempt to throw himself from the window, being endowed apparently +for the moment with strength sufficient to enable him to commit these +acts of violence. After the paroxysm is over he sinks back in bed +exhausted. The confusion of intellect or delirium continues in bad +cases until death supervenes or until the establishment of +convalescence. Indeed, the mental disturbance does not always end with +the latter, and it is not rare for feebleness of intellect to persist +for some time after the patient has in other respects regained his +usual health, and in a few cases insanity has followed an attack of +typhus fever. Among the most {349} formidable of the symptoms of +typhus are convulsions, which are fortunately of infrequent +occurrence. + +[Footnote 22: _Loc. cit._] + +The patient generally suffers from wakefulness, except during the +first few days. When sleep is obtained it may be unrefreshing or +broken and disturbed by dreams. In other cases the opposite condition +of somnolence may be present. Occasionally, after having apparently +slept for hours, he may deny having been asleep at all. This +condition, which constitutes the coma vigil of Chomel, is entirely +distinct from that described by Jenner under the same name, in which +the patient lies with his eyes wide open, gazing into vacuity, his +mouth only partly closed, his face pale and devoid of expression, and +which is invariably fatal. Muscular tremor is more or less present in +all cases of the disease, and in bad cases may be a prominent symptom. +The disease, when this symptom is marked, especially if there is at +the same time low, muttering delirium and a moist skin, presents a +considerable degree of resemblance to delirium tremens. There is very +often intolerance of light, tinnitus aurium, and loss or perversion of +the senses of taste and smell. Deafness is also not uncommon, and is +regarded by many authors as a favorable symptom. In bad cases, in +addition to subsultus tendinum, there are carphologia, incontinence or +retention of the urine, and paralysis of the sphincter ani. + +Some discrepancy is found to exist in the statements of different +authors in regard to the temperature curves of typhus fever. They all +agree, however, in assigning them certain characters, the knowledge of +which is often of great assistance in diagnosis. One of these is a +rapid rise of temperature immediately after the invasion of the +disease. Wunderlich[23] asserts that he has observed a temperature of +104.9 degrees F. on the evening of the first day, and Lebert has found +it as high as 106.4 degrees F. on that of the second. Such +temperatures, occurring so early in the disease, must be infrequent, +as Murchison has never met with them. Usually, the temperature attains +its maximum on the third or fourth day. The maximum is about 104 +degrees or 105 degrees F. Murchison says it scarcely ever reaches 106 +degrees, except in children, in whom it rarely is as high as 107 +degrees, but Lebert states that he has known it to be as high as 107.8 +degrees. On the other hand, it may never exceed 103 degrees, even in +fatal cases. When the maximum is attained early in the disease there +may be for several days, or until defervescence takes place, very +little variation in the evening temperatures, but, as a general rule, +they are slightly less elevated in the second than in the first week. +This usually occurs from the tenth to the fourteenth day, but it may +be postponed until the eighteenth, or even until much later. In some +cases on the day before the crisis a slight fall, and in others a +considerable fall with a subsequent rise of temperature, are observed. +Defervescence is often very rapid, the temperature falling five or six +degrees in the course of twelve hours. A true lysis is rarely +observed. The occurrence of a complication in the course of a disease +will not only cause a decided rise of temperature and a modification +of the temperature curve, but may also postpone defervescence beyond +the usual time. Not infrequently the thermometer indicates subnormal +morning temperatures with slight evening rises for several days after +the crisis, unless complications arise, {350} when fever of the hectic +type may occur. A very slight cause will also often produce a +considerable, although temporary, elevation of temperature in this +condition. The morning remissions are less decided than in typhoid +fever, especially in the first week. As a rule, they do not exceed 1 +degree, but Lebert lays stress upon the fact that in the same curve +variations from 0.3 degrees to 1.8 degrees and from 0.6 degrees to 2.1 +degrees often occur. Cases which terminate fatally are generally +characterized by high fever, with absence of the morning remissions, +which may continue uninterruptedly through the second and even the +third week. During the death-agony there is frequently a rise of +temperature of two or more degrees. A very high temperature in the +first week is often the forerunner of severe cerebral symptoms in the +second, and a fall of temperature unaccompanied by an improvement in +the other symptoms is not always indicative of the approach of +convalescence. + +[Footnote 23: _On the Temperature in Disease_, New Sydenham Society's +translation, London, 1871.] + +Anorexia is generally present in typhus fever from the beginning of +the attack, and may persist until its close. It is not, however, +usually attended by the same repugnance for food as in other fevers. +Patients can generally be persuaded at first to take nourishment. +Indeed, Dr. Gerhard asserts that the negroes who fell under his care +in 1832 frequently asked for solid food. Nausea and vomiting are rare +symptoms; the latter may occur late in the disease, and then, not +infrequently, is caused by irritation of the brain. Thirst is present +in all cases. In the later stages of the disease, when the senses are +blunted, water may not be asked for, although urgently called for by +the condition of the system. The bowels are, as a rule, constipated in +this disease. The exceptions to this rule are, however, more numerous +than is usually thought. Wood[24] says that he has frequently seen +diarrhoea in typhus fever when it occurs in recently-arrived +immigrants. Da Costa[25] mentions that it has occurred in several of +the cases which have come under his care, and Buchanan[26] says that +he has observed it in at least one-third of the patients admitted into +the London Fever Hospital in recent years. When there is no diarrhoea +the stools are of normal color and consistence. When it exists they +are watery and usually dark greenish in color, and never present the +peculiar ochrey-yellow appearance seen in typhoid fever. They are said +to be alkaline in reaction. Tympanites is rare in typhus fever. It may +be present in cases in which there is diarrhoea, and may then be +associated with gurgling in the bowels, but rarely attains the degree +common in typhoid fever. Gurgling when present is, moreover, not +confined to the right ileo-caecal region, but may be produced in +different parts of the abdomen by pressure. There may also be +tenderness in the epigastric and hepatic regions, but the enlargement +of the spleen so constantly observed in typhoid is generally wholly +wanting in this fever. + +[Footnote 24: _Loc. cit._] + +[Footnote 25: _Loc. cit._] + +[Footnote 26: _Loc. cit._] + +The tongue in the beginning of the disease is covered with a thin +whitish fur and is moist, and may continue so throughout in mild +attacks. Generally, however, it soon becomes dryish, and in bad cases +absolutely dry, and is tremulous when put out of the mouth, while its +coating becomes thicker and brownish, and finally brown, or even black +and cracked. It is rare to see the tongue itself fissured as in +typhoid fever. Less frequently it remains red, smooth, and glazed +throughout the attack. Occasionally the tongue is contracted in bulk, +and it may {351} then, in consequence of its dryness and that of the +mouth, be impossible to protrude it. Sordes frequently collect about +the gums and lips in severe cases. + +The pulse is usually increased in frequency in typhus fever, and +varies from 100 to 120, but in many cases it never rises above 90, and +in very severe cases it may be as high as 150. This increase is +observed from the beginning, and generally bears some proportion to +the severity of the fever; but toward the close, when the prostration +is great, the pulse may continue frequent even after a fall in +temperature has taken place, and is always more frequent when the +patient is sitting up than when he is lying down. Occasionally, +however, a very slow pulse is associated with symptoms of great +severity. When this association occurs the prognosis is grave. In the +young and robust the pulse may be full and bounding, but it is more +often compressible or small and weak. It is not so often dicrotic as +in typhoid fever. There is sometimes, according to Lyons, a singular +want of uniformity in the force and volume of the arterial pulse in +different parts of the system, and there may be but one pulsation at +the wrist for two of the heart. A very sudden fall in the frequency of +the pulse without an improvement in the other symptoms is not a +favorable indication, as it may be due to impaired innervation or to +degenerative changes in the muscular tissue of the heart. Usually the +beginning of convalescence is marked by a gradual fall of the pulse. +Later it may fall to 50 or below it, and continue slow for some time, +just as it does in typhoid fever. + +The heart shares in the general enfeeblement of the system. In severe +attacks the impulse soon becomes weak and diffused, and may be +entirely absent for some time even in cases which eventually terminate +in recovery. Stokes long ago called attention to an alteration in the +systolic sound of the heart which he taught indicated the urgent +necessity for the administration of stimulants. This sound is observed +in the progress of the disease to become shorter and less distinct, +and finally inaudible, while the second sound is unaffected. This +modification of the heart-sounds is always an accompaniment of great +prostration. Occasionally the first sound is replaced by a functional +murmur. + +The characteristic eruption of the disease is generally preceded by +the fainter subcuticular mottling already alluded to, and usually +appears between the fourth and seventh days, but it has been observed +as early as the third day, and, on the other hand, its appearance is +said by Wood to have been delayed until the thirteenth. It consists of +minute spots with ill-defined margins, varying in size from that of +the point of a pin to two or three lines in diameter, irregular in +shape, slightly elevated above the skin at first only, and occurring +singly or in groups. They are pinkish in color, and disappear readily +under pressure when first observed. They may then, as Gerhard and +others have pointed out, present a considerable resemblance to the +rose-colored spots of typhoid fever. In the course of twenty-four +hours they become brownish, and later, when the attack is a severe +one, livid in color. In malignant or even severe cases they are +frequently converted into true petechiae. They do not appear in +successive crops, but usually require a couple of days for their full +development. Their duration is variable. In mild attacks they may +disappear in the course of a few days, but in bad cases often {352} +persist until after convalescence, and are recognizable after death. +They are confined to no part of the body, but appear usually earliest +and most abundantly upon the folds of the axilla and upon the abdomen. +Occasionally, however, they are first observed upon the wrists, and in +some cases are more numerous upon the arms and legs than upon the +body. They are rarely found upon the neck and face, but in children +the latter may be so much covered by them that the disease may be +readily mistaken for measles. They present some resemblance to +flea-bites, but the latter may be easily distinguished from them by +the minute discoloration in the centre left by the puncture of the +insect. The eruption is oftenest wanting in young subjects. It is +usually, but not invariably, most copious in severe attacks, but cases +have ended fatally in which it was wholly wanting from beginning to +end. Its color is also to a certain extent an index of the severity of +the attack; the darker and more livid it is, the graver the prognosis. +In malignant cases or those complicated by scurvy, in addition to the +petechiae above referred to, purpura spots and vibices are not +infrequently observed. Some authors assert that the eruption is +followed by a slight desquamation of the cuticle, but this is denied +by others. Sudamina occasionally occur, but they are much rarer than +in typhoid fever. The blue spots described by the French under the +name of taches bleuatres are also sometimes met with. + +A very disagreeable odor is exhaled from the bodies of typhus-fever +patients after the first week. Although readily recognizable by those +who have once perceived it, it is difficult to describe. Gerhard spoke +of it as pungent, ammoniacal, and offensive, especially in fat, +plethoric individuals, and believed that those patients who presented +this symptom in the highest degree were most likely to communicate the +disease to others. Murchison has also expressed the opinion that the +typhus poison is associated with this odoriferous substance. Others +have compared the odor to the smell given off by rotten straw, the +urine of mice, and various other substances. Wood says that he has +often perceived the same odor in badly-ventilated rooms in which a +number of people have been shut up together for some time. + +The sensibility of the skin in cases in which the stupor is not so +great as to render the patients insensible to all external impressions +is said by some writers to be much increased. There is also +occasionally so much tenderness in the epigastric region as to give +the impression at first to the attendant that there is inflammation of +the stomach or liver. + +Pulmonary complications are quite frequent in typhus fever, and, as +they often come on insidiously and give no evidence of their presence +by cough, expectoration, or even more hurried breathing, that is often +seen in uncomplicated cases, it is well to make it a rule to examine +the chest of every patient with this disease. To do this thoroughly it +is not necessary to make him sit up, which, where great prostration +exists, is often attended with danger. If he be turned gently upon his +side the auscultator will usually have no difficulty in ascertaining +the precise condition of his lungs. + +The respiration is usually much more frequent in this disease than in +health. Even in cases in which there is no disease of the lungs it is +often as high as 30, and in cases in which there is such a +complication it may be 60. Its frequency is generally proportional to +the severity of {353} the fever. On the other hand, in grave cases in +which cerebral symptoms are predominant it may be reduced in frequency +much below the normal. When coma or profound stupor exists, it may +become jerking and spasmodic, or even simulate the stertorous +respiration of apoplexy. Bronchitis, if not of such constant +occurrence as in typhoid fever, is certainly not rare. It usually +occurs early in the attack, and makes itself known by the presence of +sonorous and sibilant rales, which give place later to mucous rales. +Expectoration is often absent in these cases; where it exists the +sputa are either mucous or muco-purulent. In mild cases no further +lesion of the lungs occurs. When the attack is more severe hypostatic +congestion is very likely to supervene. This is a condition which is +often attended with danger, and which frequently, as has been said +already, escapes recognition unless the chest be thoroughly examined, +when dullness on percussion, feeble respiration, and subcrepitant +rales may readily be detected. Occasionally the physical signs +indicate the existence of pneumonia. This, when it occurs in the +course of this disease, is always of low grade, and is attended by the +expectoration of mucus streaked with blood. + +The breath of the typhus-fever patient has a very disagreeable odor, +not unlike that given off from the body, and is said by Murchison to +contain an increased amount of ammonia. + +According to Parkes,[27] the changes in the urine are those usual in +ordinary pyrexia. During the fever it is generally diminished in +quantity, dark in color, and of high specific gravity. It contains an +increased amount of urea and of uric acid, the latter of which is not +infrequently spontaneously precipitated. Sulphuric acid is also in +excess. On the other hand, the chlorides are diminished in amount or +entirely absent. This diminution cannot be ascribed to a decrease in +the quantity ingested, for when they are administered with the food +they are not found to be eliminated by the kidney. The amount of +phosphoric acid does not appear to be affected by the disease. The +urine is acid in reaction at first, but its acidity soon diminishes, +and it may become alkaline toward the close of bad cases. It may also +contain albumen, or even blood, the former being present oftenest in +cases characterized by high temperature. According to Da Costa, +tube-casts are more often present than absent in severe cases. Those +seen by this observer were either coated with rather opaque epithelial +cells, many of which were finely granular or covered with granules, +which, when tested with reagents, were sparingly soluble in acetic +acid, and which with very high magnifying powers did not present the +round shape of oil, and were probably the urinary salts collected in +the tube-casts. The crisis is sometimes marked by a copious deposit of +urates. During convalescence the urine is usually increased in +quantity, is pale and limpid, and of low specific gravity, and is +found to contain the chlorides in gradually increasing quantity. + +[Footnote 27: _The Composition of the Urine, etc._, by Edmund A. +Parkes, M.D., London, 1860.] + +VARIETIES.--Many of the varieties of typhus fever recognized by +authors--as, for example, jail fever, ship fever, camp fever, and +hospital fever--really differ in nothing but name and the +circumstances under which the disease has arisen. Others are mere +modifications of it, due to the predominance of one symptom or of a +certain set of symptoms or to the intercurrence of a particular +complication, and likewise do not {354} need a full description here. +To this latter class belong the inflammatory typhus, the nervous or +ataxic typhus, the adynamic typhus, and the ataxo-adynamic typhus of +Murchison. The first variety occurs in young and robust subjects, and, +it is also said, in persons of the upper class. It is characterized by +high fever, intense headache, and active delirium. In the second +variety the nervous symptoms, such as delirium, somnolence, stupor, +and muscular tremblings, are the most prominent. The most marked +feature of the third variety is the excessive prostration, which is +shown in the feebleness of the heart's action and the loss of muscular +strength and of control over the sphincters. In this form the eruption +is dark colored. Purpura spots and vibices also are very apt to +appear, and even hemorrhages from the gums, nose, or other parts to +occur. In the ataxo-adynamic form the symptoms of the ataxic and those +of the adynamic form are found united. In addition to these there are +certain other varieties, arising from differences in degree. These +differences are sometimes owing to diversities in the constitution and +habits of the patient, sometimes to variations in the character of the +epidemic, and are sometimes not readily explainable. One of these is +the mild form, in which the symptoms are those of moderate fever, and +in which the disease may run its course in seven days. In this form +the temperature may never rise above 102 degrees F., the eruption be +absent or very scanty, and the characteristic stupor or dulness be +wholly wanting. Unless complications arise recovery invariably takes +place. A walking form of typhus fever, as has already been said, is +much rarer than of typhoid, but it does sometimes occur, Dr. Buchanan +having often seen the eruption out upon patients who have walked to +the London Fever Hospital to seek admission. In this form the disease, +however, does not always run a mild course, as alarming prostration is +very apt to come on later in its course. Another variety, the abortive +form, has been described by authors. In this an individual, in due +time after exposure to the contagion, may present all the +characteristic symptoms of typhus fever, but the disease, instead of +running its usual course, may terminate abruptly with a critical +discharge of some kind. This form occurs during epidemics, and is +analogous to the abortive attack of scarlet fever or some other +diseases which are occasionally met with. On the other hand, a very +severe form, the typhus siderans of authors, also sometimes occurs. In +this variety the temperature rises rapidly, and soon attains its +maximum; there are frequent pulse and respiration, severe headache, +and early delirium and stupor. The mortality in this form is very +great. Very frequently death takes place so rapidly as often to leave +the physician in some doubt as to the nature of the disease in those +cases in which exposure to the contagion cannot be positively traced. + +COMPLICATIONS AND SEQUELAE.--The complications of typhus fever often +exercise a decided influence upon the course of the disease, for they +not only retard convalescence, but are often the immediate cause of +death. Their early detection, therefore, becomes a matter of the +greatest importance. They will be found to vary in different years, +one epidemic being characterized by complications which are entirely +wanting in the next. Among the commonest of them are several different +conditions of the respiratory organs. Bronchitis, if not quite so +frequent as in typhoid fever, occurs in a large number of cases. It +may come on at any stage {355} of the disease, either immediately +after the beginning of the attack or in its course, or not until +convalescence. In cases accompanied by prostration mucus may +accumulate in the bronchial tubes, and be the cause of the patient's +death by preventing the due aeration of the blood. It would seem to be +an especially frequent complication in Ireland, and it is rather +surprising that so acute an observer as Graves appears not to have +been aware of its real relation to typhus, and speaks of it as if it +were a predisposing cause. "Nothing can be more remarkable," he says, +"than the facility with which a simple cold, which in England would be +perfectly devoid of danger, runs into maculated typhus in Ireland, and +that, too, under circumstances quite free from even the suspicion of +contagion; in truth, except when fever is epidemic, taking cold is its +most usual cause." A much more serious complication than bronchitis is +the form of pneumonia already alluded to as liable to occur in the +course of typhus. This may often occur so insidiously that it may be +considerably advanced before its presence is even suspected; hence the +necessity for examining carefully the lungs of every patient with this +disease who comes under our care. Generally, however, it makes itself +known by giving rise to rapid breathing and great lividity of the +surface, but, as has already been said, both of these symptoms may +exist in cases in which there is no chest complication. This +pneumonia, if it does not immediately prove fatal, may, by becoming +chronic, retard the convalescence. It occasionally is followed by +gangrene, and sometimes by phthisis, which may then run a very rapid +course. Phthisis is, however, a much less frequent sequela of typhus +than of typhoid fever. Pleurisy may also complicate typhus fever, but +it is much more rarely met with than pneumonia. + +Perhaps next in frequency to pneumonia and bronchitis are diseases of +the kidneys. These are very serious complications, whether they +antedate the fever or have occurred in its course. Careful examination +of the urine will generally lead to the discovery of a small amount of +albuminuria in bad cases, but this is fortunately, in the majority of +them, only temporary. The urine should, however, always be re-examined +before the discharge of the patient, as there is good reason to +believe that many otherwise inexplicable cases of chronic albuminuria +have originated in an attack of typhus. The presence of albumen and of +casts in the urine of a patient apparently convalescent from this +disease should therefore make us careful in our prognosis as to his +future health. The occurrence of diarrhoea may also very seriously +affect the patient's chances of recovery. Dysentery has also been +observed in certain epidemics in Ireland, and is not infrequent when +the disease breaks out in besieged towns or when it occurs in summer. +In grave cases or those complicated with scurvy the blood may be so +broken down as to escape readily from the vessels. Under these +circumstances, in addition to the purpura spots beneath the skin, we +may have epistaxis, haemoptysis, haematemesis, intestinal hemorrhage, +or hemorrhage from any other part. Erysipelas, too, may be a +troublesome complication, for not only does it exhaust the strength, +but, when it invades the mucous membrane of the larynx, as it +sometimes does, it may prove rapidly fatal by producing oedema of the +glottis. Degeneration of the muscular structure of the heart may also +take place. This gives rise to a slow and feeble pulse and to a +disposition to syncope. Bed-sores are not so frequent as in typhoid +fever. They {356} do, however, sometimes occur, as does also gangrene +of the toes and of other parts not subjected to pressure. + +Less common complications are jaundice, peri- and endo-carditis, +meningitis, local and general paralyses, cancrum oris, a diffuse +cellular inflammation ending in purulent infiltration, and +inflammatory swellings of the glands, or buboes. The salivary +glands--and especially the parotid gland--are very apt to be affected +by this inflammatory swelling. This occurs rapidly, is very tender, +and in most cases soon runs on to suppuration, although it +occasionally in children spontaneously subsides. It may occur at any +time during the course of the fever, or not until convalescence, and +sometimes affects the glands of both sides of the face. These buboes +form a connecting link between typhus fever and the Oriental plague, +and Murchison says that the distinguished Egyptian physician Clot Bey, +on seeing some cases of the former disease complicated with parotid +swellings, declared that in Egypt they would be regarded as examples +of the latter. + +Many of the above-named complications may occur also as sequelae, and +in addition to these we may have pyaemia, giving rise to purulent +collections in the joints and phlegmasia alba dolens. The last named +is not in itself serious. Its chief danger is from the breaking down +of the clot and the subsequent occurrence of embolism. + +Menstruation is said not to be uncommon in the early stages of typhus +fever, and may be so profuse as to greatly increase the prostration or +even to cause death. According to Murchison, miscarriage does not +inevitably occur when pregnant women are attacked with the disease, +and if it does occur it is not necessarily fatal to either mother or +child. + +POST-MORTEM APPEARANCES.--Emaciation when death has occurred early in +the course of the disease, and is due solely to the violence of the +fever, is usually not well marked, but in those cases which have been +protracted through the intercurrence of complications it may sometimes +reach an extreme degree. Bed-sores, except under the circumstances +just mentioned, are also rare. Rigor mortis is generally not well +developed, and is of short duration. In a few cases it would seem, +however, to have been well marked. The typhus maculae are persistent +after death, and so are any purpura spots and vibices which may have +been present during life, but the subcuticular mottling usually +disappears. The skin of the dependent portions of the body is +discolored by the settling of blood in it, and putrefactive changes +are apt to set in rapidly. + +The only constant lesion observed is a profound alteration of the +blood, which is darker in color and abnormally fluid. If clots are +found at all, they are large, soft, and friable. The fibrin is +diminished in amount. In the early part of the disease the red +blood-corpuscles are said to be slightly increased in number, but +later they are diminished, and under the microscope are observed to be +crenated and not to form themselves readily into rouleaux. The white +corpuscles are increased in number. No accurate chemical examination +of the blood appears to have been made. Many of the post-mortem +appearances which have been described as characteristics of typhus +fever are really the consequence of this abnormal condition of the +blood. + +The respiratory organs generally present evidences of disease; the +lesions of laryngitis, bronchitis, pneumonia, hypostatic congestion of +the {357} lungs, and pleurisy have all been observed after death from +typhus fever. Usually, the traces of previous inflammation of the +larynx are but slight; in a few cases, however, ulceration has been +found, but the ulcers are stated to be always minute and superficial. +Ulcers are also occasionally found in the bronchi, and frequently +indicate by their appearance the pre-existence of a much higher grade +of inflammation. The bronchial mucous membrane is, however, oftener +merely reddened and softened and covered with a tenacious frothy +secretion. True pneumonia is of infrequent occurrence as compared with +that of hypostatic congestion of the lungs, but it nevertheless does +occur, and may be of either the catarrhal or croupous variety. When +pleurisy exists, it is usually accompanied, according to Murchison, by +purulent effusion into the pleural cavity. On the other hand, Lebert +says the variety of inflammation of the pleura oftenest met with is +the plastic. The intestines present no constant lesion. Gerhard says +that in fifty examinations there was but in one case, and that +doubtful in diagnosis, the slightest deviation from the natural +appearance of the glands of Peyer. In a few cases the Peyer's patches +have been found more prominent than usual, but not more so than they +are in measles and in some other diseases. Lebert alone of recent +authors makes a contrary statement. In an epidemic at Breslau, he +says, the solitary glands, as well as the patches of Peyer, were the +seat of small, isolated, and superficial ulcers, which were usually +situated in the vicinity of the ileo-caecal valve. The mesenteric +glands are generally unaffected, but in the Breslau epidemic just +referred to they were not infrequently found moderately swollen. In +cases in which dysentery has occurred as a complication the +characteristic appearances of the disease will of course be observed, +as well as those of typhus fever. The spleen is generally softened and +slightly enlarged. The enlargement is not, however, always present, as +Gerhard found it in one only out of every five or six of the cases +which he examined. Extravasations of blood into its structure are +occasionally met with. The liver is usually congested, somewhat +enlarged, and frequently under the microscope presents the appearances +of commencing fatty degeneration. The kidneys often present +unmistakable signs of renal disease in the swollen granular and more +or less fatty condition of their gland-cells according to the duration +of the disease. The muscles are darker in color than in health. Under +the microscope they are found to have undergone the peculiar granular +or waxy degeneration described by Zenker, and which have been fully +referred to in the article on typhoid fever. Extravasations of blood +are occasionally found in them, which may soften and form +pseudo-abscesses. + +Other post-mortem appearances which are met with less frequently than +those above detailed are inflammation, and even ulceration, of the +mucous membrane, of the bladder, inflammation of the salivary gland, +peritonitis, and congestion of the pancreas and of the stomach. + +The muscular tissue of the heart is generally softened and easily +torn. It is not, however, as stated by some authors, invariably so, +for in several cases in which it was examined by Da Costa it had +undergone this change in one case only, in which there was no reason +to suspect previous disease of the heart. The alteration is similar in +kind to that which takes place in the voluntary muscles. An effusion +of serum, which may be of a deep-red color from the transudation of +the coloring matter of the blood, is {358} sometimes found in the +pericardial sac, as are ecchymotic patches upon the surface of the +heart. The endocardium may be stained from the imbibition of blood. On +the other hand, endo- and peri-carditis are excessively rare. + +Notwithstanding the severity of the cerebral symptoms in typhus fever, +there are few or no important changes found in the brain or its +membranes after death. The sinuses are occasionally filled with dark +fluid blood, and the appearances of congestion of the brain are +sometimes present. In other cases there may be an increased amount of +serum beneath the arachnoid and into the lateral ventricles, but not +more than is often seen after death from other causes. Very rarely a +slight film of hemorrhage has been found in the cavity of the +arachnoid, and sometimes also the evidences of non-inflammatory +softening of the brain. Actual inflammation of the meninges has only +been detected in a very few cases. There may also be congestion of the +spinal membranes, increase of the spinal fluid, and softening of the +cord itself. The ganglia of the sympathetic system appear to undergo a +form of granular degeneration. + +DIAGNOSIS.--The diseases which most closely resemble typhus fever are +typhoid fever, measles, meningitis, and typhoid pneumonia. + +The circumstances under which typhoid and typhus fever occur are +different. Typhoid is never generated by overcrowding, and if +contagious at all is much less so than typhus. Prostration occurs much +earlier and is usually much more marked in the latter. The eruption in +the former does not appear until the eighth day, and comes out in +successive crops, and usually disappears under pressure as long as it +lasts, and therefore may be easily distinguished from that of the +latter. The duration of typhus is from ten to twenty days; that of +typhoid is rarely less than twenty-one. Nevertheless, cases are +occasionally met with in which it is impossible to arrive at a correct +conclusion as to their nature unless some light is thrown upon it by +the existence of other and more characteristic cases in the same house +or neighborhood. I have recently had under my care a case which +eventually proved to be typhoid fever, but which I and many others who +saw it at first believed to be typhus in consequence of the presence +of an abundant eruption, which did not disappear under pressure, and +was finally converted into petechiae. + +The eruption of typhus is sometimes found upon the face, especially in +children, and then presents a considerable similarity to that of +measles, which, however, usually appears a little earlier. There is, +moreover, rarely the same amount of prostration or stupor in the +latter disease, which is also attended by coryza and more bronchial +catarrh than is often present in the former. The eruptions in the two +diseases differ. In measles it is crescentic in shape, and is more +elevated than in typhus. It is also brighter in color, disappears +under pressure, except in malignant cases, as long as it lasts, and is +followed by free desquamation of the cuticle, which is not often +observed in typhus. The temperature may be high in the former, but it +usually falls upon the sixth day. + +In meningitis the headache is much more severe, and does not disappear +upon the occurrence of delirium. It may be so severe as to cause the +patient to cry out. The senses are painfully acute. There are +intolerance of light and sound, and some hypersensitiveness of the +surface, {359} strabismus, inequality of the pupils or some other +local paralysis, and retraction of the head. Nausea and vomiting are +more common than in typhus, while the utter prostration of the latter +disease is wholly wanting, and so is of course the characteristic +eruption. The tache meningitique is wanting in the latter, but too +much reliance should not be placed upon either the presence or absence +of this sign. The diagnosis is only likely to be difficult in those +cases of typhus in which the delirium is active. In that form of +typhus in which the symptoms simulate those of delirium tremens some +difficulty may also be experienced in making a diagnosis, especially +if the patient be a drunkard. In delirium tremens it will be +remembered, however, that there is little or no elevation of +temperature, that the skin is bathed in perspiration, the tongue +moist, and the characteristic eruption absent. Typhoid pneumonia can +be distinguished from pneumonia complicating typhus fever by the +presence of the eruption in the latter. + +Other diseases which have occasionally been mistaken for typhus fever +are remittent fever, Bright's disease, giving rise to uraemia and +purpura. It does not seem likely that even the severest forms of +malarial fever should ever present such a resemblance to typhus fever +as to make the differential diagnosis a matter of difficulty; but it +would appear from the history of the latter disease given by Murchison +that such a mistake has occurred in some of the Spanish American +countries. The enlargement of the spleen and liver is much less marked +than in remittent fever, and the remissions of temperature are much +less decided. Uraemia may at times present a good deal of resemblance +to the condition often seen in typhus fever after the supervention of +coma or stupor, but the history of the case, the absence of fever and +of eruption in the former, will generally enable us to distinguish +between the two conditions. It should be remembered, however, that +Bright's disease may occur in the course of typhus fever. Purpura may +generally be recognized by the absence of fever and by the occurrence +of hemorrhages from the nose, gums, and bowels. + +PROGNOSIS.--The age, habits of life, and previous condition of health, +as well as the character of the prevailing epidemic, must all be fully +considered before making a prognosis in any special case. The disease +usually runs a much milder course in children and young people than in +adults past thirty years of age. After this age the mortality +progressively increases, and in advanced life it becomes very high, +being often as much as 50 per cent. or over. Sex does not of itself +exercise much influence upon the course of typhus fever, for, although +a few more men than women die of it, this appears to be attributable +to the greater prevalence of drinking among the former. Previous +intemperance acts unfavorably by producing a degeneration of the +tissues of the body, thus rendering the patient less able to withstand +the effects of the disease. Drunkards have therefore always furnished +a large proportion of the fatal cases. The mortality among patients +who are unfortunate enough to take typhus fever as they are +convalescing from other diseases is usually also very great. This has +often been observed in general hospitals in which cases of fever as +well as those of other forms of disease are admitted. Fat, lymphatic, +or muscular people more frequently die of it than those of a different +conformation. Gerhard found it especially {360} fatal among negroes in +the epidemic of 1836, and Buchanan seems to have had a similar +experience at the London Fever Hospital. It is a fact noticed by +English writers that people of the better class, although seldom +attacked by typhus, often suffer severely from it. The mortality is +always high among those patients who previously to contracting the +disease have been for some time deprived of sufficient food, or have +been overworked, or who have been the subjects of mental anxiety, +worry, or any other depressing emotion. It is high also among those +who in the beginning of the disease have exhausted their strength in +the vain effort to resist the disposition to go to bed. The chances of +recovery are, on the other hand, very much improved by the removal of +patients from crowded, ill-ventilated houses to the wards of a +spacious, airy hospital. + +Unfavorable symptoms are a profuse dark-colored eruption associated +with purpura spots and vibices, general lividity of the surface, great +injection of the pupils, and a dusky hue of the countenance; extreme +prostration; an excessively frequent and feeble pulse, especially if +it is at the same time irregular or intermittent; absence of the +cardiac impulse and of the systolic sound; hurried and spasmodic or +abnormally slow respiration; great dryness and retraction of the +tongue; excessive prominence of the nervous symptoms, such as +headache, delirium, whether active or muttering; unequal or pin-hole +contraction of the pupils; strabismus or other local paralysis; +sleeplessness; muscular tremblings; subsultus tendinum; carphology; +protracted hiccough; retention of the urine; relaxation of the +sphincters of the bladder and rectum; coma and especially coma vigil, +and convulsions; continued high temperature, rising instead of falling +after the tenth day, especially if it is associated with coldness of +the extremities and of the breath; a profuse perspiration without a +general improvement in the symptoms; diminution in the quantity of the +urine, or the presence in it of albumen, blood, or casts; vomiting; +and diarrhoea. Hope, however, should never be abandoned even in the +most unfavorable cases, as recovery has sometimes occurred when the +patient seemed almost in articulo mortis. Convulsions are said to be +invariably followed by death, and Graves regarded the presence of the +pin-hole contraction of the pupils as of very grave import. + +Favorable symptoms are--reduction of the frequency of the pulse, a +fall of temperature, a diminution of the stupor or a resumption of +consciousness, and a return of appetite and of moisture to the tongue. +When the patient begins to improve he will often without assistance +turn upon his side after having lain for a long time upon his back, +and this change of position is sometimes the first indication of the +approach of convalescence. + +The mortality varies of course in different epidemics. The cases which +have come under my own care being too few in number to draw deductions +from on this point, I must rely upon the experience of those whose +field of observation has been more extended than my own. According to +Murchison, out of 18,268 cases of typhus fever admitted into the +London Fever Hospital during twenty-three years, 3457 proved fatal, +making a mortality of 18.92 per cent., or 1 in 5.28. Deducting 686 +cases fatal within forty-eight hours, the mortality falls to 15.76 per +cent., or 1 in 6.34. Included among the fatal cases is a large number +in which {361} the disease had run its course to a favorable +termination, and in which death was really due to sequelae, such as +pneumonia, erysipelas, etc. Moreover, the death-rate in the hospital +is greater than in the community, because children, who rarely die of +typhus fever, are seldom brought to it; while, on the other hand, it +receives a large number of the infirm and aged inmates of the +metropolitan workhouses. Making allowance for these sources of +fallacy, Murchison believes that the actual mortality of typhus is not +more than 10 per cent. In Gerhard's cases the proportion of deaths +amongst the black was much greater than amongst the white men; thus, +of the whites 1 died in 4-2/3, of the blacks 1 in 2-19/28. Amongst the +women the reverse was true; thus, 1 white woman died in 4-3/5, but +only 1 colored woman in 6-1/2, nearly. Da Costa lost 6 out of 39 +cases. In one of the fatal cases the diagnosis was doubtful; in +another there was a great deal of previous disease; in two others +death was due to complications--so that there were but two in which +the fatal result could fairly be attributed to the disease itself. + +TREATMENT.--Typhus fever is an eminently preventible disease. It is +therefore proper that the description of its curative treatment should +be preceded by a few words in regard to its prophylaxis. + +It is still an unsettled question whether or not typhus fever ever +occurs de novo, and although the recent discovery by Klebs and others +of bacillus peculiar to typhoid fever (the bacillus typhosus), and of +special bacilli in other analogous diseases, renders it highly +probable that typhus fever has also its own bacillus, and that +therefore it is not likely to arise except as the result of infection, +it must be admitted that it has often prevailed in localities into +which it has not been possible to trace its importation. Under these +circumstances it will be well to refer to those conditions which are +asserted by some authors to favor its spontaneous generation, +especially as these same conditions are certainly known to favor its +propagation. It will not be necessary to do this at any great length, +as they have all been fully described in discussing the etiology of +the disease. The most important of them is the overcrowding of human +beings, especially when combined with deficient ventilation, +destitution, and want of personal cleanliness. The knowledge of the +laws of hygiene is now so universally diffused that this combination +of conditions never occurs at the present time to anything like the +degree it often existed in the eighteenth century, and consequently +epidemics of this disease are not only less frequent, but are also +much milder in character, than formerly. Much work, however, still +remains for sanitarians in the improvement of the homes of the poor, +which even in this country are too often overcrowded and +ill-ventilated. + +The extension of the disease in a community will almost always be +prevented by the prompt isolation of the first few cases. This can +often be thoroughly done, if the patient is in easy circumstances, by +placing him in an upper room, which should be stripped of its carpets, +curtains, and other unnecessary furniture; by cutting off all +communication between him and his attendants and the rest of the +household; and by the free use of disinfectants. The room should be +airy, and to ensure good ventilation a window should be left partly +open. This may be done during the febrile stage, even in winter, +without the risk of any injury to the patient. Among the poorer +classes, however, {362} isolation can rarely be effectually carried +out, and it is therefore much better to remove the patient to a +hospital. Upon the admission of such a patient to an institution of +this character his clothes should be at once disinfected. This may be +done by washing the underclothing in a disinfecting fluid, and then +exposing them to a free current of air, and by subjecting the outer +clothing to a very high temperature in an oven or to the fumes of +burning sulphur. Murchison believes that a neglect of this precaution +has often been the cause of the extension of the disease to other +inmates of the hospital, especially when the patient resumes during +his convalescence the same clothing he wore upon admission. If the +hospital is a general one, he should be placed, whenever practicable, +in a well-ventilated ward by himself or with other patients suffering +from the same disease. As this is not always possible, the number of +the other occupants of the ward should be reduced and their beds +placed as far away as possible from his. As the infectiousness of +typhus fever is very much lessened by free ventilation, this +precaution is often alone sufficient to prevent its extension to them. +It is also well, however, to supplement it by the use of +disinfectants. The diffusion of a solution of carbolic acid in the +atmosphere of the ward by means of the steam atomizer has not only +rendered the odor emanating from the patient less perceptible, but has +also appeared to diminish decidedly the risk of infection. As a still +further precaution the patient may be sponged with a weak solution of +carbolic acid or some other disinfectant. His nurses should be +selected, whenever practicable, from among those who have had the +disease themselves. They should never sleep in the sick room, lounge +about the patient's bed, or inhale his breath. They should be allowed +a certain amount of time every day for rest and recreation in the +fresh air, and should have a full supply of nourishing food. On the +other hand, they should be warned against the danger of +over-stimulation, which is often resorted to in the hope of warding +off the disease, and should be relieved as far as possible from +attendance upon other patients. It may be well here to say that the +nursing of a case of typhus fever should never be undertaken by the +relatives or friends of the patient, except as a matter of necessity. +Not only do the anxiety and distress they naturally feel unnerve them +and render them unfit to carry out the directions of the physician, +but they can rarely execute the many offices required in the sick room +with half the skill of a trained nurse or with so little annoyance to +the patient. + +Before the patient is allowed to leave his ward he should have a warm +bath. If the disease has occurred in a private house, the room which +he has occupied should be thoroughly disinfected. This is best done by +replastering, repapering, and repainting it. In many cases, however, +it will be sufficient to fumigate it with burning sulphur, and then to +air it for several days. The bed and bedding should also be +disinfected, and, where this cannot be thoroughly done, the latter had +better be destroyed. + +Of primary importance in the treatment of typhus fever is the +regulation of the diet. Although there are no ulcers in the bowels in +this as in typhoid fever, and although, consequently, there is not the +same imperative necessity in this as in the latter disease to restrict +the patient to liquid articles of food, experience has shown that such +articles are much more readily digested and assimilated than solids. +The diet {363} should consist, therefore, of milk, beef-tea, and +chicken or mutton broth. Of all of these, milk is incomparably the +best, and it should form, unless the patient manifest an unconquerable +repugnance to its use, a large part of the nourishment in every case. +Farinaceous articles of food are generally not well borne in this +fever, because the diminution in the secretion of the salivary glands +which almost always exists prevents their proper digestion. After the +third or fourth day nourishment should be given in small quantities at +short intervals, as every two hours, every hour, or even every half +hour when the prostration is extreme. It should be the aim of the +physician to give an adult at least two quarts of milk or their +equivalent daily. + +It is sometimes necessary to put a delirious patient under some +restraint to prevent him from leaving his bed or doing some other act +of violence. Frequently a judicious nurse will be able to accomplish +this without the use of an undue amount of force, but at other times +it will be necessary to have recourse to mechanical means of +restraint. Usually, all that is necessary is to pass a folded sheet +across the patient's chest, the ends of which are fastened to the +sides of his bed. + +It is now a universally accepted axiom among physicians that typhus +fever is a self-limited disease, and that any attempts to cut it short +is worse than useless. Not only do remedies which are employed for +this purpose often produce alarming prostration, but there can be no +doubt that they have in some cases been the cause of a fatal +termination, which under another plan of treatment would have been +averted. During the last century it was not uncommon to bleed, and to +bleed largely, in the beginning of an attack of typhus fever, but even +then there were physicians--as, for instance, O'Connell, Rogers,[28] +Pringle,[29] and Rutty[30]--who raised a warning voice against the +practice. Sir John Pringle goes so far as to say that "many have +recovered without bleeding, but few who have lost much blood." A very +similar opinion was also expressed by Baron Larrey in the early part +of this century. Indeed, it is very evident that the same difference +of opinion existed as to the employment of venesection in the +treatment of acute affections when these authors wrote as prevailed in +England and this country until within the last thirty years, and that +the disastrous results which occasionally follow the abstraction of +large amounts of blood from patients affected with fevers and +inflammations were as fully recognized then as now by many physicians. +This would seem effectually to dispose of the +change-of-type-in-disease theory which was generally accepted in the +first half of this century as sufficient to explain the fact which +could no longer be overlooked that this class of patients did much +better under a supporting than a depleting plan of treatment. +Purgatives were also at one time freely given for the purpose of +arresting the disease, but the results obtained from their use were +scarcely less unfavorable, and they are now never employed with this +view. The use of quinia in large doses has also been advocated for the +same purpose, but experience, while it has shown that it is a valuable +remedy, has demonstrated also that it does not possess {364} this +power. Exactly the same thing may be said of the cold-water treatment +of typhus fever. There is no evidence that it has ever shortened the +duration of the disease. + +[Footnote 28: _An Essay on Epidemic Diseases_, p. 60, by Joseph +Rogers, M.D., Dublin, 1734.] + +[Footnote 29: _Loc. cit._] + +[Footnote 30: _A Chronological History of the Weather and Seasons, and +the Prevailing Diseases, in Dublin during the Space of Forty Years_, +by John Rutty, M.D., London, 1770.] + +If the physician is called to a case of typhus fever during the chill, +before reaction has taken place, he will of course have recourse to +diffusible stimulants and external warmth to aid in the establishment +of this process. More frequently he is not sent for until after the +chill has been succeeded by fever. His treatment will then, of course, +vary with the condition of the patient. If his stomach is loaded with +food, an emetic should be administered to him. If the bowels are +constipated, a mild cathartic will often be of service, but after the +bowels have been once well moved it is generally unnecessary to +disturb them further. During the first day or two, while the fever is +still moderate in degree, and during the uncertainty which then +usually exists as to the diagnosis, it will be sufficient to prescribe +the neutral mixture or the spirit of Mindererus in tablespoonful doses +every two or three hours. Upon the third day more active remedies will +generally be required to reduce the temperature. This is best done by +the cold-water treatment in some form or other, or by the internal +administration of antipyretic doses of quinia. The manner in which the +cold water is to be used and the cases to which it is applicable must +be left in a great measure to the judgment of the physician. In the +form of the cold affusion it is now rarely resorted to, although +Currie[31] obtained most excellent results with it. It is calculated, +however, to alarm a timid patient, and it is probably owing largely to +this fact that it has fallen into disuse. The cold bath, packing in a +cold wet sheet, and sponging with cold water are the more usual means +of employing cold in the treatment of typhus fever at the present day. +The cold bath is much used in Germany in the treatment of different +forms of fever, and even of inflammation. It is also resorted to in +this country, but it has never attained the same popularity here as +abroad. The best way of using it is as follows: The patient as soon as +his temperature rises above 103 degrees F. should be placed in a bath +having a temperature between 80 degrees and 90 degrees, and which, +whenever practicable, should be brought to his bedside, as when he has +to be carried to the bathroom he is sometimes not only alarmed and +rendered very nervous by the operation, but may exhaust himself in his +struggles to free himself from his attendants. After his immersion +cold water should be gradually added until the temperature of the bath +is between 60 degrees and 70 degrees F. The length of time he should +be allowed to remain in the bath will of course depend upon +circumstances. If shivering is produced by it, he should be at once +removed from it and thoroughly dried and put back to bed. If no such +symptoms are observed, he may be allowed to remain in it longer. As a +general rule, a half hour is as long as will be necessary or safe for +him to continue immersed at any one time. His temperature will usually +continue to fall for some time after his removal from the bath, but in +the course of a few hours it will be found to have risen again to 103 +degrees or over, when he should have another bath. In this way it may +be necessary to repeat the baths from eight to twelve times a day. +Some authors recommend that the patient should be placed at once in a +bath having a temperature of 50 degrees F., {365} but this method of +applying cold possesses no advantage over that above described, and +is, like the cold affusion, very apt to excite alarm in the patient. +The cold bath is not, however, well borne by all persons, and alarming +symptoms, and even fatal collapse, have followed its use in the old +and feeble. It is also contraindicated when the skin is covered with a +profuse sweat or when the disease is complicated by an internal +inflammation. When the means of giving a cold bath are not at hand, +the cold pack will often be found a very efficient substitute for it. +Sponging with cold water, although not so efficacious in reducing the +temperature, has advantages over either of these methods of applying +cold. In the first place, it is more agreeable to most patients and +less calculated to excite alarm in those who are timid. Again, it may +be more frequently repeated, and may be used in cases in which the +cold bath is contraindicated. Occasionally alcohol or vinegar may be +added with advantage to the water, with the view of increasing its +refrigerant effects. + +[Footnote 31: _Medical Reports on the Effects of Water, Cold and Warm, +as a Remedy in Fever and Febrile Diseases_, by James Currie, M.D., +F.R.S., London, 1805.] + +When quinia is given for the purpose of reducing the temperature in +the treatment of typhus fever, it must be used in large doses, as much +as ten or fifteen grains repeated once or twice in the course of +twenty-four hours being required for this purpose. When given in these +quantities it has the disadvantage of producing deafness and +occasionally of increasing the headache. I have therefore contented +myself in the cases which have fallen under my own care with giving it +in more moderate quantities, in combination with one of the mineral +acids, as, for instance, a couple of grains of quinia in solution with +from eight to ten drops of dilute muriatic acid, repeated from four to +six times a day. The mineral acids were originally recommended in the +treatment of typhus fever in the belief that they neutralized the +poison which caused the fever, and which was supposed to be ammonia or +some of its compounds. Although this theory is now no longer +entertained, there can be no doubt that the tendency in this disease +to the accumulation of ammonia in the blood is prevented by their +administration. Digitalis, aconite, or veratrum viride may also be +given in appropriate doses if with a high temperature there coexists +great frequency of the pulse. The first-named remedy is especially +indicated if there is at the same time diminution of the secretion of +urine. + +As the disease progresses other symptoms present themselves for +treatment. One of the most urgent of these is the prostration. This +not only appears early, but is often extreme, and if not met by +appropriate remedies will often of itself be sufficient to cause the +death of the patient. As soon as it makes itself manifest stimulants +must be prescribed. These are, however, not to be resorted to simply +because the patient has typhus fever. Many cases do perfectly well +without them. In the young and robust it is often unnecessary to have +recourse to them. On the other hand, in the old, the feeble, and the +intemperate they should be employed early. The rule laid down by +Stokes, that they should be administered as soon as the first sound of +the heart becomes indistinct and inaudible, may be adopted for our +guidance in this respect. At first they should be given tentatively. +If the delirium, headache, and other nervous symptoms are increased +after their administration, it is best to withhold them. They should +be continued, on the other hand, when under their use the delirium +ceases or grows milder, the other nervous {366} symptoms subside, and +the patient falls into a refreshing sleep. The amount required to +prevent fatal prostration will of course vary in each case. I have +rarely myself found it necessary to prescribe more than half an ounce +of whiskey or brandy every two hours, and frequently a very much +smaller quantity has been found sufficient. Cases are, however, +reported in which from twenty to twenty-four ounces daily have been +given with asserted advantage. + +Another symptom which often demands prompt relief is the headache. +When not severe, it may be relieved by the application of cold to the +head, either in the form of the ice-cap or by means of cloths +frequently wrung out of cold water, and by the administration of +moderate doses of potassium bromide; but when intense it requires more +active treatment for its removal, such as the application of cups to +the back of the neck or of leeches to the temples. General bleeding +will accomplish the same result, but the good which is done by it is +often more than counterbalanced by the prostration it induces. +Sleeplessness is also sometimes the cause of a good deal of distress +to the patient. When it occurs early in the disease and is caused by +the headache, it will generally subside under the use of the remedies +which are employed for the relief of the latter symptom; but when it +comes on at a later period, it will often require special treatment. +There is some doubt as to the propriety of giving opium under these +circumstances, but Murchison, Gerhard, and others assert that it may +be given not only without injury, but with positive advantage to the +patient. Graves was in the habit of combining it with a small quantity +of tartar emetic in the condition in which the sleeplessness is +associated with active delirium. If, on the other hand, the delirium +is of a low muttering character, it should be given with a diffusible +stimulant. + +In this condition I have often found a pill containing a small +quantity each of opium and camphor, frequently repeated, to answer an +admirable purpose, not only in procuring for the patient the needed +repose, but also in diminishing the restlessness, jactitation, and +subsultus tendinum. Opium should, however, not be used at all or used +very carefully in cases in which there is congestion of the lungs or +disease of the kidneys. The existence of the pin-hole pupil is also a +contraindication to its employment. In young and robust patients, if +the insomnia is attended by active delirium, chloral in twenty-grain +doses, repeated if necessary, may often be given with advantage, but +it should never be prescribed in cases in which the action of the +heart is feeble. Other remedies which have been recommended in the +treatment of this condition are belladonna, hyoscyamus, musk, +chloroform, and cannabis indica. Potassium bromide appears to have no +power to relieve it. No special modification of the above treatment is +needed when delirium occurs independently of sleeplessness and +headache. When the stupor is profound, efforts should be made to rouse +the patient by the use of counter-irritants to the shaven scalp or to +the nape of the neck. Murchison speaks well of the administration of +strong coffee under these circumstances. If there is at the same time +suppression or diminution of urine, diuretics should be administered +in the hope of stimulating the kidneys to increased secretion. +Retention of the urine is not an infrequent occurrence in this +condition, and the physician ought never, therefore, to accept the +assertions of the {367} nurse or friends of the patient that the +latter has passed water, but should satisfy himself by an examination +in regard to the condition of the bladder at every visit. He will +often find that the apparent passage of urine is nothing more than the +dribbling due to an over-distension of this organ. Neglect of this +precaution has occasionally been the cause of much subsequent distress +to the patient, as cystitis is sometimes set up as a consequence of +it. In one case which came under my observation, and in which this +precaution had been neglected, the patient suffered from incontinence +of urine for some time after his recovery from the fever. Thirst is a +symptom which is always present and complained of at the beginning of +the fever, and usually bears some proportion to the severity of this +process. Weak tea, an infusion of cascarilla-bark, and camphor-water +have all been recommended by different authors for its relief, but it +is probable that no one of them possesses any superiority over water. +If the stomach is irritable and water is not retained, small pieces of +ice should be allowed to dissolve in the patient's mouth. Later, when +the stage of stupor supervenes, it is very important to see that the +patient obtains a full supply of water. In this condition he will not +call for it, although it is even more urgently required than before. + +Vomiting may occur at any time in the course of typhus fever. If it is +observed at the very beginning of an attack, an emetic will often +arrest it, but when it supervenes at a later period, it is generally +of cerebral origin, and will usually subside under the use of the +remedies already referred to which are prescribed for the relief of +the nervous symptoms. In addition to these, sinapisms may be applied +to the epigastrium, and champagne, when the circumstances of the +patient will permit it, should be given in the place of whiskey or +brandy. When everything is rejected by the stomach, recourse must be +had to nutritious enemata. Constipation is to be overcome by gentle +purgatives, as the use of powerful cathartics is very apt to be +followed by troublesome diarrhoea. If this should come on, it is best +treated by small doses of opium in combination with a mineral or +vegetable astringent. When these fail, it may sometimes be relieved by +a prescription containing sulphuric acid and morphia, and at others by +enemata of from twenty to thirty drops of laudanum in warm water. When +glandular swelling occurs in the parotid region or in other parts of +the body, an effort should be made to promote resolution by painting +them with tincture of iodine. Blisters have also been recommended for +the same purpose, but they should be used carefully, as in low +conditions of the system they are sometimes followed by sloughing of +the integuments. If these remedies fail, poultices should be applied. +As soon as pus has formed it should be evacuated by one or more free +incisions. + +Very few attacks of typhus fever run their course without the +occurrence of some pulmonary complication. When this is slight it +demands no special modification of the previous treatment, and it is +sufficient to apply mustard poultices or stimulating liniments to the +chest. But in cases of greater gravity, it matters not whether the +complication is bronchitis, congestion of the lungs, or pneumonia, a +more active treatment is required. Under these circumstances the +ammonium carbonate in five-grain doses, given in mucilage of acacia, +frequently repeated, or from thirty minims to a teaspoonful of the +aromatic spirit of ammonia every {368} two hours, sufficiently +diluted, may be prescribed with great advantage. When gangrene +supervenes the prognosis is almost hopeless, but an effort should be +made to save the patient's life by the administration of potassium +chlorate and of an increased amount of stimulus. Murchison also speaks +well of the inhalation of tar vapor and of carbolic acid. + +As the other complications of typhus are at least of as common +occurrence in typhoid fever, it will avoid a good deal of useless +repetition to refer the reader to the article on the latter disease +for a description of the treatment which they render necessary. + +The patient should be kept in bed for some time after the subsidence +of fever. Although relapses are rare in this disease, recrudescences +of fever not infrequently occur as a consequence of undue exertion in +the early part of convalescence. Syncope is also not infrequently +produced by the patient's sitting up too soon. The diet should be +carefully regulated until the recovery is complete. It should at first +consist wholly of liquid or semi-liquid articles of food, but later +meat in some digestible form may be allowed. Stimulants are often as +urgently demanded at this time as during the fever itself. They should +be given as the strength returns in gradually diminishing quantities. +The length of time during which it is necessary to continue them will +depend in great measure upon the previous habits of the patient. As a +general rule, their use should not be abandoned until he is able to +leave his bed, and they may often be continued after this with benefit +to him. As convalescence progresses it will be well to substitute ale +or porter for the brandy or whiskey the patient had previously taken. +A return to health will also be promoted by the judicious use of +tonics, such as iron, quinia, Huxham's tincture, tincture of nux +vomica, the mineral acids, and even cod-liver oil in some cases. + + + + +{369} + +RELAPSING FEVER. + +BY WILLIAM PEPPER, M.D., LL.D. + + +SYNONYMS.--Febris recidiva, vel recurrens; Fievre a rechutes; Fievre +recurrente; Typhus icterodes, vel recurrens; Bilious Typhoid Fever; +Ruckfall's Typhus; Tifo recidivo; Famine Fever, Hunger-pest, +Armentyphus, Hunger-typhus, Spirillum Fever. + +DEFINITION.--Relapsing fever is an epidemic contagious disease, the +specific cause of which is not certainly known, although a peculiar +spirillum appears to be constantly present in the blood. It occurs +chiefly among the over-crowded and destitute, but may spread widely +when introduced among more favorably situated populations. Its +invasion is abrupt, and is marked by a distinct chill or rigor, +followed quickly by high fever (104 degrees to 106 degrees), with +severe headache and pains in the back and limbs. Delirium is +comparatively rare. The tongue is heavily coated, and there are +epigastric tenderness, vomiting, constipation, and enlargement of the +liver and spleen, with frequent jaundice. There is no characteristic +eruption. These symptoms cease abruptly from the fifth to the seventh +day, with copious sweating; but after an apyretic interval of about a +week's duration a relapse occurs similar to the first attack, but of +less duration (three to five days). Second, third, or even more +numerous relapses may subsequently occur at less regular intervals. +One attack does not protect against a second one to the same extent as +with other contagious diseases. The mortality is usually small. + +HISTORY AND GEOGRAPHICAL DISTRIBUTION.--It is not important to +consider here at any length the history of this disease. Allusions to +it were made by Strother, 1729, and by Huxham, 1752, but the first +reliable account on record is the description of an epidemic in the +year 1739 by John Rutty.[1] Relapsing fever undoubtedly occurred at +different times and at various places during the next hundred years, +although the records of it are scanty, and for the most part +imperfect, owing chiefly to the want of a clear recognition of its +essential difference from typhus and typhoid fevers. + +[Footnote 1: _A Chronological History of the Weather and Seasons_, +etc., London, 1770, pp. 75-90.] + +During the decade from 1842 to 1852 relapsing fever prevailed in a +very active and widespread form. Epidemics occurred in England, +Scotland, and Ireland, in various parts of Germany, and it was during +this time that it was first observed and described in America. In +June, 1844, an emigrant ship from Liverpool came to America with +eighteen cases on board, which were taken to the Philadelphia and +Pennsylvania {370} Hospitals. In 1848 a few cases were imported by +emigrants to New York, and in 1850 to Buffalo in the same way.[2] + +[Footnote 2: See _Fevers, their Diagnosis, Pathology, and Treatment_, +Meredith Clymer, Phila., 1846, p. 99; _Clinical Reports on Continued +Fever_, A. Flint, Phila., 1855, p. 364; Dubois 1848.] + +The next great outbreak of relapsing fever began in Odessa in 1863 and +lasted until 1872. It prevailed in various parts of Russia, in +Germany, France, and Great Britain, and for the first time occurred +extensively in the United States, especially in Philadelphia and New +York. The present article is based largely on a study of this epidemic +as it presented itself in Philadelphia during the years 1869-70, when +the writer, in conjunction with the late Edward Rhoads, had the +opportunity of observing about two hundred cases, in the wards of the +Philadelphia Hospital. An admirable article on the same epidemic +appeared from the pen of the late John S. Parry, in the _Amer. Jour. +Med. Sciences_, N.S., vol. lx., Oct., 1870, p. 336. + +Between the years 1877 and 1880 relapsing fever occurred quite +extensively at Bombay, and was there studied by Carter[3] and Lewis; +and during 1879-80 it prevailed in Konigsberg, an account of which +epidemic has been published by Meschede.[4] + +[Footnote 3: _Spirillum Fever_, by H. Vandyke Carter, M.D., London, +1882.] + +[Footnote 4: _Virchow's Archiv_, Bd. lxxxvii. p. 393.] + +The geographical distribution of relapsing fever is seen, therefore, +to have been very extensive; and not only has it occurred in the +above-mentioned localities, but there have also been less extensive +outbreaks in France, India, Egypt, Algeria, South America, and +elsewhere. + +CAUSES.--In all probability the essential cause of relapsing fever is +a specific poison, but we know nothing of its real nature nor of the +precise conditions under which it originates. Recent investigations +have shown that the spirillum discovered by Obermeier is constantly +present during the febrile stages of relapsing fever, but it cannot +yet be decided whether this minute organism is the actual cause or +only an invariable accompaniment of the disease. + +It appears that conditions of destitution, filth, and intemperance +amongst an overcrowded population favor the development of the virus, +and hence the epidemics have, as a rule, begun in towns, such as +Dublin, Glasgow, Odessa, St. Petersburg, Breslau, etc., where such +conditions prevail. Great importance has been attached, in particular, +to the scarcity of food and to destitution as powerful factors in +favoring the production of the disease. Some of its names +(hunger-pest, hunger-typhus, famine fever) have been given with +reference to this, and in the case of several outbreaks a careful +comparison has been made of the decrease of the food-supply and the +consequent advance in price of the staple commodities with the +development and progress of the disease. Although this is in all +probability true of those centres where relapsing fever originates, it +has but a partial application to the secondary centres where the +disease is imported and develops. + +The presence of destitution and filth, enfeebling the vitality of a +section of the community, would favor the spread of this as of any +other specific fever, but there is considerable evidence to favor the +view that the importance of starvation as a cause of the fever has +been exaggerated. This was strongly urged by Parry[5] as the result of +his study of the {371} Philadelphia epidemic of 1870, and our own more +extended observation showed that the vast majority of the patients +appeared to be well fed. On the other hand, the influence of +overcrowding as favoring the development and spread of relapsing fever +has been clearly established by the study of many epidemics, as in the +Breslau attack of 1868, reported by Wyss and Bock, where single +tenement-houses furnished as many as seventy-one cases; in the +Edinburgh epidemic of 1869 and 1870, where Muirhead found the +breathing-space allotted to each individual in the affected houses to +vary from 250 to 400 cubic feet; and in the Philadelphia epidemic, +where the observations of Parry and ourselves showed the presence of +an extreme degree of overcrowding in most of the houses where the +disease broke out. + +[Footnote 5: _Loc. cit._, p. 339.] + +No age is exempt, but neither can it be said that age exerts any +influence upon the occurrence or frequency of relapsing fever. Of 1164 +cases in the Philadelphia epidemic of 1869-70 in which the age was +noted, the result was as follows: + + Males. Females. + Under 20 149 76 + From 20 to 30 220 140 + From 30 to 40 143 101 + From 40 to 50 135 67 + From 50 to 60 60 34 + From 60 to 70 20 6 + From 70 to 90 6 7 + --- --- + Total 733 431 = 1164 + +The youngest cases were in children two or three years old; the oldest +patients were women over eighty-five years old. + +Sex exerts no influence, though, on account of the larger proportion +of males likely to be exposed to the specific cause, the results of +nearly all epidemics show a preponderance of male patients in the +proportion of 33 per cent., 66 per cent., or even 85 per cent. +(Meschede). + +Nationality does not act as a predisposing cause,[6] except in so far +as certain countries may present more frequently than others the +conditions favorable for the development of this disease. Of 1170 +cases in Philadelphia in which the nativity was noted, 219 were Irish, +61 English, 161 German, 729 American. Of the latter 729, about +one-half, or nearly 28 per cent. of the whole number, were negroes, +while the negro population of Philadelphia was only about 3.3 per +cent. of the total. This excessive proportion of cases among the +negroes was undoubtedly due in large part to the fact that in +Philadelphia overcrowding is notoriously more common and extreme among +them than in any other portion of the population, although it is also +likely that they present an excessive susceptibility to the virus of +this as of many other specific diseases. + +[Footnote 6: Hirsch's _Geog. and Hist. Pathology_, New Syd. Soc. ed., +1883, vol. i. p. 615.] + +Attempts have been made to show some connection between the period of +the year or the atmospheric conditions and the rise and spread of +epidemics of relapsing fever; but, as Murchison clearly showed, these +epidemics are wholly independent of such influences. In Philadelphia, +of 1176 cases in which the date of occurrence is known, there occurred +in September, 1869, 4 cases; December, 1869, 6 cases; January, 1870, 5 +cases; February, 1870, 13 cases; March, {372} 1870, 124 cases; April, +1870, 209 cases; May, 325 cases; June, 293 cases; July, 115 cases; +August, 19 cases; September, 28 cases; October, 15 cases; November, 1 +case; December, 2 cases; January, 1881, 2 cases; February, 1 case; +March, 2 cases; May, 7 cases; June, 2 cases; September, 2 cases; +October, 2 cases. + +Occupation exerts no predisposing influence, but in all epidemics the +great majority of cases occur among the vagrant classes, who lead a +precarious life and commonly sleep in foul, overcrowded lodgings. +Murchison noted that in the London epidemics a considerable proportion +of cases occurred among recent residents, but he attributed this, +correctly, not to any special local cause, but merely to the fact that +this floating population is largely of the vagrant type. In +Philadelphia a careful inquiry showed that recent residence produced +no special predisposing influence, and a study of other epidemics +confirms this view. + +Contagion is, however, the essential cause of the spread of relapsing +fever when the virus has once been developed. It seems clear from the +distinct periods and from the widely-separated localities in which +different outbreaks of relapsing fever have occurred that its special +poison is capable of being called into existence or activity by +favoring conditions. Murchison held the belief that it was very +intimately connected with, if not generated by, destitution, and, as +already stated, much evidence exists to show that the disease is most +apt to break out after periods of scarcity; but no just and convincing +proof exists that destitution, any more than over-crowding and other +depressing influences, can actually engender a specific contagium +capable of being transported to great distances and of originating +widespread outbreaks of the specific disease among differently +situated populations. It appears necessary to assume the existence of +some unknown special virus which finds its suitable nidus for +development in the conditions attendant on filth and overcrowding, and +which attacks with greatest facility the systems of those who are +enfeebled by want and depressed by vitiated air. When once this +specific poison has been called into active existence, however, there +can be no doubt as to the fact that it can be carried by fomites, and +that it is given off from the bodies of relapsing-fever patients so as +to affect any who may approach. Although a few observers have doubted +this contagiousness of relapsing fever, the evidence in its favor is +overwhelming. In many epidemics, as in Philadelphia in 1869, its +contagiousness is at least as intense as that of typhus fever. A +single case may, indeed, be admitted to a healthy family among the +better classes or into the wards of a well-ventilated hospital without +propagating the disease, although striking cases of contagion are on +record where a patient has communicated the disease to all the members +of a family favorably situated and living at a distance from any other +possible source of contagion. On the other hand, if admitted to an +overcrowded and filthy lodging the disease is apt to spread rapidly. +Wyss and Bock report seventy-one cases as having occurred in a single +lodging-house during the course of the Breslau epidemic of 1868, and +in Philadelphia single houses in several instances furnished more than +a score of cases, and several short streets more than one hundred +cases each. + +In the Philadelphia Hospital twenty-three persons lying sick in the +wards with other affections contracted relapsing fever from the +patients {373} admitted with that disease; two of the visiting staff, +five resident physicians, and nine nurses also suffered attacks of +varying severity. This corresponds with the general experience of +those connected with fever hospitals during the prevalence of +relapsing fever. + +As in the case of typhus and other contagious diseases, the distance +at which relapsing fever can be contracted by direct contagion through +the atmosphere is a very short one, not exceeding a few feet at most. + +The poison may be carried by fomites. Instances are on record where +persons having visited infected districts have conveyed the disease to +others at a distance without contracting it themselves. + +When rooms which have been occupied by relapsing-fever patients are +subsequently occupied by other persons, these are very liable to +acquire the disease. Parry relates two remarkable cases in which +relapsing fever was transported to a distance by infected clothes; and +it has been more than once observed that during epidemics of this +disease laundry-women engaged in washing the clothes of fever +patients, but without any means of more direct communication with the +sick, were frequently attacked (Cormack, Wyss and Bock). + +In connection with the etiology of relapsing fever it is necessary to +consider the role played by a minute organism which has been +frequently detected in the blood of patients suffering with this +disease. This spiro-bacterium was first observed in relapsing fever by +Obermeier[7] in 1873, and has since been identified as a spirillum or +spiroechete. The very numerous observations of Obermeier, Albrecht, H. +V. Carter, Motschutkoffsky, Koch, Cohen, Holsti, Enke, Meschede, and +others leave no doubt that this peculiar parasite does occur at least +very frequently in the blood of patients with this disease. The +failure to detect it, which has been reported by several good +observers, may readily have been due to the extreme delicacy of the +organism, or to the neglect of the proper method of preparing the +slides of blood for examination, or to delaying the examination of the +blood until after death, when it rapidly disappears. Thus no value can +be attached to the negative observations of Rhoads and myself, made +prior to Obermeier's discovery, since our method of examination was +not sufficiently exact. + +[Footnote 7: _Centralbl. f. die med. Wissensch._, 1873, No. 10.] + +The following description of the mode of examining the blood, and of +the spirillum, is condensed from H. V. Carter's account: It is +necessary to employ magnifying powers of not less than 500 diameters. +The fresh blood may be examined immediately after obtaining it by +pricking the washed finger of the patient. For preservation dried +specimens are needed: a very thin layer of fresh blood is evenly +spread with the needle over the glass cover, exposed to the weak fumes +of a solution of osmic acid, and allowed to dry under protection from +dust; the dried film of blood may then be treated with glacial acetic +acid or may be stained. + +[Illustration: FIG. 19. Spirillum from the blood in a case of +relapsing fever, X 700 (Koch).] + +The spirillum [See Fig. 19] is a colorless, slender, twisted filament, +which when quiescent has a length of 2.66 times the diameter of a +blood-disc (1/1500 to 1/500 inch = 0.012 to 0.043 millimetre). When +unfolded they become distinctly elongated. They are very narrow (not +more than 1/40000 inch), and present four to ten spiral turns; when +fresh they are in active movement and unfold in part, becoming wavy or +bent. They {374} resist the action of concentrated acetic acid, and +are readily stained by certain dyes. In number, five or ten may be +visible in a field or they may be too numerous to count. They have not +been detected either in the secretions or in the evacuations. Both +Koch and Carter have succeeded in cultivating this special form of +bacteria outside of the body. + +To judge from the observations thus far made on this difficult +question, the parasite is found first toward the close of the period +of inoculation or soon after the beginning of the fever, or it may be +detected throughout the febrile stage; but shortly before the +cessation of the fever it quickly disappears, to reappear at the time +of the relapse. There would seem, therefore, to be some close +connection between the febrile paroxysms and this organism, and it is +not remarkable that many observers have concluded that this spirillum +is the essential and specific cause of the fever, and that it is +impossible to have this disease present without the appearance of the +parasite in the blood; nor that the name spirillum fever has been +applied to the disease by Carter. + +Such conclusions appear to be premature, however, and we prefer to +regard the undoubted existence of the spirillum in the blood of +relapsing-fever patients as at present only an important aid in +diagnosis, and to await the occurrence of other epidemics and the +repetition of careful studies upon this organism, both within and +without the human system, before venturing to decide whether it is +merely one of the phenomena of the disease or whether it is its true +cause and specific contagious principle. + +It must be added that both Carter and Koch have succeeded in +inoculating monkeys with relapsing fever, and Motschutkoffsky[8] of +Odessa, who had the opportunity of inoculating a human being, asserts +that he succeeded in producing the disease, and found the incubation +period to be not less than five nor more than eight days. Carter also +gives an interesting table[9] of six instances of inoculation, four of +them by cuts while making autopsies, with consequent development of +relapsing fever in each instance. Some allowance must be made for the +fact that in all the instances of this series there had been exposure +to contagion by close communication with fever patients, though this +exposure had existed for several months previously without leading to +the development of relapsing fever. + +[Footnote 8: _Centralblatt f. d. med. Wissenschaften_, 1876, No. 11, +p. 194.] + +[Footnote 9: _Op. cit._, p. 403.] + +GENERAL CLINICAL DESCRIPTION.--After a period of not less than five or +six days from the reception of the contagion the disease begins {375} +abruptly with a chill of variable severity, accompanied by headache +and aching pains in the back and limbs. The patient feels weak and is +often giddy, but is not always obliged to go to bed the first day. +Nausea and vomiting are among the earliest symptoms, and distress at +the epigastrium, with tenderness, may attend or even precede the +chill. Fever quickly follows; the pulse runs up from 110 to 130 in a +few hours; the temperature reaches from 103.5 degrees to 106 degrees +by the end of twenty-four hours; the pains increase, and there are +insomnia and great restlessness; appetite fails; thirst is extreme; +the tongue is moist and furred, and the bowels quiet. During the +subsequent six days these symptoms persist. The temperature presents a +daily remission at some period of the twenty-four hours amounting to +one or two degrees, the maximum reached in fully-developed cases +varying from 104 degrees to 108 degrees. The pulse continues very +rapid, and not rarely exceeds 140; the respirations are hurried and +rapid, and cough attends many cases. Delirium is rare, but insomnia, +restlessness, headache, and rheumatic pains in the back and limbs may +prove constantly annoying. Appetite is variable, more frequently lost; +nausea and vomiting are common; thirst is very troublesome; and the +bowels are constipated or loose. No characteristic eruption appears, +but sudamina are frequently present, since in a large proportion of +cases there is more or less sweating, even during the continuance of +high fever. Abdominal pain, tenderness in the epigastrium and +hypochondria, and demonstrable enlargement of the liver and spleen are +almost invariable. The urine is concentrated and dark or bile-stained. +Jaundice is a common symptom, though its frequency varies greatly in +different epidemics. The same may be said of epistaxis. + +While these symptoms are at their height and the patient is suffering +severely the paroxysm suddenly ceases, and in a few hours he is +entirely relieved. This remarkable crisis occurs usually at the close +of the seventh day, but may occur as early as the third or as late as +the fifteenth day. It is attended with a critical discharge, copious +sweating being by far the most common, though diarrhoea, free +epistaxis, or hemorrhage from some other surface may replace it. The +patient feels weak and languid; the temperature and pulse have fallen +below the normal, and remain so for a day or two. Soon there is a +rapid improvement in the appetite and the appearance of the tongue, +and the patient regains strength day by day, and often feels so well +that it is difficult to persuade him that he must avoid exertion and +exposure. The enlargement of the spleen subsides rapidly, that of the +liver more gradually; epigastric tenderness subsides, but in many +cases some degree of it persists for several days. This interval or +apyretic period lasts about a week, when, again without warning or +provocation, the patient relapses, and is seized abruptly with the +same set of symptoms which attended the first attack. This relapse +does not usually last more than three days (one to five are the +limits), and is terminated by a similar crisis, after which a slow +convalescence is entered upon, or else after an apyretic interval of +some days' duration a second relapse ensues, and this may, in rare +cases, be in turn followed by a third, fourth, fifth, or even sixth +similar relapse. In addition, it must be noted that many serious +complications are liable to occur. The total duration of the disease +thus varies from eighteen to ninety days. Convalescence is often +tedious, and there are many troublesome sequelae. {376} The mortality, +however, is not great, averaging 5 or 6 per cent. Death may occur +suddenly from collapse at the close of the first paroxysm or from +heart-clot; it may be produced by exhaustion in protracted cases; or +be hastened by any serious complication; or the patient may sink into +a typhoid condition, with low delirium, coma, and suppression of urine +for several days before the fatal termination. + +DETAILED STUDY OF SPECIAL CONDITIONS.--It is usually difficult to +determine the period of incubation. In the unique case in which +Motschutkoffsky is said to have produced relapsing fever by +inoculation the initial symptoms occurred seven days after the +inoculation. Wyss and Bock had several good opportunities of +determining the minimum period of incubation, and found it to be six +days. We may assume that the ordinary period is six to eight days, but +that it varies, in accordance with the virulence of the virus or the +susceptibility of the system, from four to fourteen days. During this +time the patient feels as well as usual, or at most suffers for a day +or two from slight malaise, with vague rheumatoid pains, headache, +giddiness, and anorexia. In only 13 out of 181 of our cases in which +this point is noted was the invasion gradual. Examination of the blood +prior to the invasion does not discover any spirilla. + +The invasion is usually abrupt and during the daytime; the patient can +often fix the very hour of its occurrence, a severe chill attacking +him while at work or at meal-time. This is the most common initial +symptom (138 out of 168 our cases of sudden invasion); less commonly, +obstinate vomiting and nausea or sudden vertigo are the first symptoms +(each 8 times out of 168), or violent headache (14 times out of 168), +or sharp epigastric pain. Parry also observed that the occurrence of +obstinate and profuse vomiting as the initial symptom was especially +frequent in children. + +The physiognomy is carefully noted in one hundred and seventy of our +records. The countenance is often flushed, with watery eyes and +anxious, suffering expression. The flush is less dingy and dull than +in typhus; the eye is comparatively rarely injected; and the +expression is much less dull and stupid than in that disease. In cases +where grave nervous symptoms supervene and the typhoid condition is +developed the facies assumes all the characteristics of that state. + +The livid bronzing of the face, described by Cormack in 1843 and by +Carter (Bombay epidemic of 1877), was noticed in a moderate degree in +only nine of our cases, and seems to be of infrequent occurrence. When +we observed it it seemed due to an admixture of a faint jaundice tinge +with a deep flush. Jaundice, as already stated, is of common +occurrence, though its frequency varies greatly in different +epidemics. It was present in 25 per cent. of our cases, rather more +frequently in the negro patients than in whites, and in degree varied +from a slight tinge of the conjunctiva and skin to the deepest +staining of the entire body. The presence of jaundice in combination +with the general features of high fever imparts a most peculiar and +alarming appearance to such patients. + +With the occurrence of the crisis the flush rapidly subsides and the +face becomes pale, or, if the discharges have been profuse, it may +appear sunken, haggard, and almost choleraic. Parry described a +peculiar puffed, velvety look at this stage, as though the skin had +been much thickened and softened at the same time. + +{377} There is no characteristic eruption in relapsing fever. In 150 +out of 180 cases where the condition of the skin was carefully noted +there was no eruption of any kind; in 4 cases there were small +roseolar spots, with peculiar subcuticular mottling, which resembled +the early stages of typhus eruption, but soon faded away without +becoming petechial. A similar eruption was noticed by Murchison in 8 +out of 600 cases. It appears from the third to the seventh day of the +first paroxysm; it may or may not recur in the relapse, or it may +occur then only. Eruptions apparently similar to this have been +described by others as quite common in certain epidemics. Carter +describes minutely an eruption which was noted in at least 10 per +cent. of his Bombay cases, the spots of which were at first small, +slightly raised, and pinkish or rose-colored, and which either faded +away soon or changed into purplish, more persistent stains. In a +valuable report on the Konigsberg epidemic of 1879-80, Meschede[10] +remarks that roseola was observed in cases complicated by exanthematic +typhus, which prevailed simultaneously, but in no case of +uncomplicated relapsing fever. While, however, this suggestion may +apply to some few of the cases of eruption observed by others, it is +certainly inapplicable to the vast majority of them. We also noticed +an eruption of pale-reddish, slightly elevated papules in seven cases. +It must be borne in mind that persons of such a low class as are the +great majority of relapsing-fever patients would naturally be expected +to present a variety of cutaneous eruptions from filth or vermin, and +that in consequence some of the appearances above described may have +been of such origin. It is certain that the bites of either +mosquitoes, fleas, or bedbugs may in this disease be followed by +persistent reddish papules passing into petechiae. Apart from this, +however, true petechiae have been quite common in some epidemics, +while very rare in others. Parry saw "small spots of purpura" once +only, in a delicate girl; and we did not observe petechiae once in +several hundred cases, many of which had extensive internal +ecchymoses. On the other hand, they have been found in as much as 30 +per cent. of all cases (314 out of 1000 cases, Smith at Glasgow). They +do not appear on any fixed day, but are more common in the first +paroxysm than in the relapses; and although sometimes associated with +a tendency to hemorrhages from other surfaces, they have been so often +observed in cases of ordinary severity that scarce any unfavorable +prognostic value can be attached to them. + +[Footnote 10: _Virchow's Arch._, Bd. lxxxvii., p. 405.] + +Vibices and extensive ecchymoses of the surface are of much more grave +import, and in cases where fatal sinking is threatened they may appear +accompanying a purplish lividity of the countenance. + +Herpetic eruptions about the mouth or nostrils were observed in 20 out +of 181 of our cases in which this point is noted. They appeared +usually toward the close of the febrile stage, and their development +was found to have value in determining the approach of the crisis. +Barensprung mentions especially the occurrence of herpes labialis in +cases of irregular relapsing fever which bore considerable resemblance +to typhus. Sudamina are, as might be expected in a disease attended +with so much sweating, of quite common occurrence, though much more so +in some epidemics than in others, unless searched for with greater +care by the one set of observers. Desquamation was noted in 42 out of +181 of our cases, and {378} invariably at the close of the relapse. It +was usually confined to the hands and face, and occurred in the form +of comparatively small flakes. This is more frequent than has been the +case in most epidemics. Murchison quotes a case in which a piece of +epidermis ten inches square separated from the body of a lad +convalescent from relapsing fever. + +A peculiar odor exhaling from patients with relapsing fever has been +repeatedly noticed. A description of this unpleasant symptom, given by +Kelly, as quoted by Murchison,[11] accords closely with what was +frequently manifest in our own cases: "The smell was peculiar, not +fetid or heavy, but somewhat like burning straw with a musty odor." +Carter, in describing a similar odor in some of his cases, notes that +the skin was not in these instances in a particularly foul state. + +[Footnote 11: _Op. cit._, p. 346.] + +From what has already been said, it will be anticipated that the +variations of the temperature in relapsing fever constitute the most +peculiar and characteristic feature of that disease. A careful study +of the accompanying charts will convey a more accurate impression than +can be given by any description. The temperature begins to rise before +the chill is fully developed, and when there is no initial chill the +patient may be found within a few hours of the appearance of giddiness +and headache with a temperature of 102.5 degrees to 103.5 degrees. +Before twenty-four hours have passed it has risen to from 104 degrees +to 106 degrees. During the paroxysm the febrile movement is continued, +presenting merely a diurnal variation of one to two degrees, sometimes +attended with sweating and partial relief of distressing symptoms, the +minimum being observed at different hours in different cases, or even +in the same case, though more frequently it occurs in the morning. + +In a case reported by Parry a chill recurred at the same morning hour +on three successive days. Wyss and Bock report some unusual cases in +which a brief intermission occurred, with a fall of pulse and +temperature to the normal, most frequently on the day before the real +termination of the paroxysm. The highest temperature varies from 104.5 +degrees to 108.75 degrees; in our cases the highest observed was 107.5 +degrees. This occurs, as a rule, on the last day or the day before the +last of the initial paroxysm, and Obermeier has observed a sudden rise +of four degrees in half an hour just before the crisis. Meschede,[12] +however, found the highest temperature on the corresponding days of +the first relapse. + +[Footnote 12: _Loc. cit._] + +The duration of the primary paroxysm is usually six or seven days; but +this is subject to considerable variations, as will be seen from the +following table of 160 cases in which the duration was accurately +ascertained: Initial paroxysm lasted--2 days in 1 case; 3 days in 2 +cases; 4 days in 10 cases; 5 days in 19 cases; 6 days in 40 cases; 7 +days in 58 cases; 8 days in 18 cases; 9 days in 2 cases; 10 days in 5 +cases; 11 days in 2 cases; 14 days in 2 cases; 15 days in 1 case; and +Parry, observing the same epidemic, found the duration of the first +paroxysm to vary from 4 to 11 days. It is, however, rare for the +duration to exceed ten days unless some complication be present. + +{379} [Illustration: FIG. 20. Typical case of relapsing fever, with +three relapses, terminating in recovery. (From Motschutkoffsky)] + +With the beginning of the crisis there is a prodigious and sudden fall +of temperature, unequalled in any other condition of disease. Within a +few hours it may fall six or eight degrees (going down at the rate of +1.5 degrees or 2 degrees an hour); and falls of 12 degrees, 13 +degrees, or even 14.4 degrees (Murchison), in the course of twelve +hours have been noted. In our own cases the greatest {380} fall was +from 107.2 degrees to 95 degrees, or 12.2 degrees; and this is as low +a point as is usually reached, though temperatures of 94 degrees, 93 +degrees, or even 92 degrees, have repeatedly been observed. Murchison +refers to one case in which collapse supervened, where the rectal +temperature was 90.6 degrees. In nearly all of our cases a subnormal +temperature occurred at the crisis, and lasted for a day or two +subsequently, when it gradually rose and remained normal until the +relapse, unless some transient complication caused a temporary rise in +the interval. + +[Illustration: FIG. 21. Typical case of relapsing fever (Mary Collins, +aged 32), terminating in recovery. One relapse, with slight +post-critical rise of temperature.] + +Occasionally, there is no relapse whatever, but convalescence follows +{381} the initial paroxysm. This occurred in 10 out of 181 of our +cases, and Murchison found that of 2425 cases reported by various +authors no relapses occurred in about 30 per cent. Carter describes +these under the name of the abortive form, and found them to +constitute 23.8 per cent. of all his cases. It is probable, however, +that in many cases so regarded either a relapse of very transient +duration has been overlooked, or else that an attack of ephemeral +fever has been regarded as of specific nature. In ordinary cases the +duration of the intermission averages six or seven days, but here, +again, considerable variation occurs. In 139 of our cases where its +duration could be accurately determined it was as follows: + + 3 days in 4 cases. 7 days in 64 cases. 11 days in 1 case. + 4 " " 3 " 8 " " 22 " 12 " " 1 " + 5 " " 12 " 9 " " 9 " 13 " " 1 " + 6 " " 12 " 10 " " 9 " 20 " " 1 " + +Despite these variations in the duration of the initial paroxysm and +of the first intermission, the average date of the occurrence of the +relapse in any large series of cases is about the twelfth day from the +primary chill. + +The relapse is ushered in with the same striking abruptness as the +initial attack. The temperature again rises rapidly to 104 degrees or +106 degrees, and then pursues a continuous course resembling +ordinarily that of the primary paroxysm. The difference between the +maximum of the two paroxysms is rarely more than 1.5 degrees or 2 +degrees, though either may be much milder than the other; as a rule, +the highest temperature is attained on the last or penultimate day of +the first attack. The duration of the relapse averages three or four +days, though it may last but a few hours or a single day, and yet +exhibit a rise of 5 degrees, 6 degrees, or 7 degrees; or, on the other +hand, it may be prolonged to six, seven, or even more days. Lyons, +observing the disease in the Crimea, reports some relapses as having +lasted twenty-one days, though it is improbable that a greater +duration than seven days occurs without the presence of some +complication. The relapse usually terminates by crisis, with an abrupt +fall to an abnormally low temperature; though we observed at this +time, much more frequently than at the close of the first paroxysm, a +gradual subsidence of fever, or lysis. Again the patient regains +strength and appetite, but in a considerable proportion of cases +subsequent relapses ensue. As a rule, the second, third, and later +relapses are attended with a febrile movement of shorter duration and +of less severity than the first two paroxysms, and are also separated +by intermissions of increasing length. Meschede[13] found from a study +of 360 cases that the average duration was for the first paroxysm six +or seven days; second paroxysm, four or five days; third paroxysm, +three or four days; fourth paroxysm, one or two days; fifth paroxysm, +one day. + +[Footnote 13: _Loc. cit._] + +In a remarkable case given in full at page 394, the duration of the +paroxysms and intermissions were as follows: + + First paroxysm, 8 days; first intermission, 9 days. + Second " 5 " second " 1 " + Third " 1 " third " 6 " + Fourth " 6 " fourth " 8 " + Fifth " 5 " fifth " 9 " + Sixth " 4 " sixth " 10 " + Seventh " 3 " seventh " 11 " + Eighth " 3 " followed by convalescence. + +{382} The proportion of cases in which more than a single relapse +occurs appears to vary in different epidemics. Murchison found that in +1500 cases reported by various authors a second relapse occurred 109 +times (1 out of 14); a third relapse, 9 times (1 out of 166); and a +fourth relapse, once. Of 182 cases noted carefully by ourselves, a +second relapse occurred 24 times (1 out of 7-1/2); a third relapse, 5 +times (1 out of 36); a fourth relapse, once; and in the +above-mentioned case six or seven relapses. + +It follows that the total duration of the morbid process varies from +the average of about eighteen or twenty days, in cases with a single +relapse, to forty, sixty, or even ninety days. Of course the +occurrence of complications may lead to very great modifications of +the febrile movement and of the total duration of the disease. + +There are several additional points about the febrile process +requiring mention. In all the paroxysms there is a greater tendency to +local or general perspirations than is met with in other continued +fevers, and occasionally there are rigors or slight chills about the +same hour on several days after the invasion or on the day preceding +the crisis. It has been noted also that, even when the temperature is +very high, the quality of the heat, as judged by the feeling of the +skin, is different from that in typhus fever, and that the peculiar +pungent irritating sensation known as calor mordax is rarely marked. +But a more important peculiarity is the fact that the extreme +temperatures (106 degrees, 107 degrees, or 108 degrees) that are +frequently observed in relapsing fever for several days in succession +do not appear to involve any great increase of danger, and in +particular are not attended with the production of the grave nervous +symptoms so often met with in connection with hyperpyrexia in typhus +and typhoid, and often regarded as the direct result of the exalted +temperature itself. This striking fact is of much interest in its +bearing on the theory of hyperpyrexia, and may possibly be explained +by some marked difference in the conditions of heat-dispersion in +these different diseases. + +The pulse in relapsing fever is very rapid, and on the whole the rate +corresponds with the movement of the temperature. It usually rises +above 110, the limits being 90 and 140, the lower rate being noticed +in the milder and uncomplicated cases and in subjects of phlegmatic +constitution. The pulse rises rapidly at the invasion, and may reach +120 in the course of a few hours. Its maximum is usually noticed when +the temperature is highest, shortly before the crisis; and when this +actually begins the pulse may fall with a rapidity as remarkable as +that of the decline of the temperature. Thus, within twenty-four hours +it may fall from 152 to 80, or in even a shorter time from 140 to 54, +or even as low as 48 (Obermeier) or 44 (Muirheid), or even 30 +(Stille). While this great fall is often noted, it is by no means +constant. In our own cases it was frequently observed that the +critical fall in temperature was not accompanied by a commensurate +fall in pulse. Thus, at the close of a very severe initial paroxysm +lasting nine days the temperature was 107 degrees, and fell in the +course of twenty-four hours to 99 degrees, and in twenty-four hours +more to 96 degrees; during the first day of this fall the pulse was +from 96 to 100, and during the second it fell to 76. + +This want of correspondence was more marked at the close of the {383} +relapse than of the primary attack; thus, in a well-marked case, where +the maximum temperature (105.4 degrees) occurred eighteen hours before +the crisis of relapse, the temperature fell in four hours from 104.4 +degrees to 96.2 degrees, while the pulse, which was 130, fell in +twelve hours to 108, and in twelve more to 92. In another case, in a +man aged twenty, the temperature at the close of the second relapse +was 106.4 degrees, with a pulse of only 100; after the crisis, as the +temperature fell, the pulse rose to 120, and did not descend until the +end of twenty-four hours; and later, at the close of thirty-six hours, +the temperature was 98 degrees and the pulse 72, lower than which it +did not go. Carter[14] states that in the Bombay epidemic it was +invariably the case that the pulse did not decline to an extent +corresponding with the temperature. + +[Footnote 14: _Op. cit._, p. 140.] + +During the remainder of the intermission the pulse may be normal, or +it may continue accelerated in consequence of some irritative +condition; as the time for the relapse approaches it frequently again +becomes abnormally slow. In either event it is found that any muscular +exertion causes marked acceleration of the pulse. + +During the paroxysm the character of the pulse is full and bounding, +and there is considerable arterial tension. This is well shown in some +of the sphygmographic tracings by Carter;[15] while in one of our +tracings from the right radial of a man aet. 32, taken on the fourth +day of a severe initial paroxysm, the line of ascent is steep and the +summit sharp. During the crisis, and for a day or two thereafter, the +pulse may be weak, compressible, and dicrotic, and occasionally +irregular. + +[Footnote 15: _Op. cit._, p. 103.] + +The sounds of the heart and its impulse are weakened, except possibly +during the first few days of the primary paroxysm. Blood-murmurs over +the base of the heart and along the great vessels in relapsing fever +were first noticed by Stokes, and have been frequently observed in +subsequent epidemics. They were found in a large proportion of our +cases, not rarely in both paroxysms, and during the early stage of +convalescence when anaemia was marked; but during the intermissions +they are rarely audible, and when the action of the heart was slow +they were replaced by prolongation of the first sound. + +It must be further noted that the pulse-rate is not a reliable +indication of the danger in this disease, since, just as is the case +with the hyperpyrexia, extreme rapidity of pulse may be present when +the general symptoms denote no unusual danger, and when the patient +ultimately recovers most satisfactorily. + +There is a remarkable disproportion and dissimilarity between the +cerebral and peripheral nervous phenomena in relapsing fever and those +familiar to us in typhus and typhoid fevers. We have seen that +patients almost invariably complain of headache. When prodromes are +present it is commonly among them, and it may be the initial symptom +to usher in each paroxysm. When the attack is fully developed headache +is usually very severe, and no symptom is more bitterly complained of. +It varies in seat and character. More commonly it is frontal or +general; occasionally we found it occipital, and still more rarely it +was unilateral, constituting hemicrania. It rarely continues during +the relapse. Headache of an equally acute and violent character may be +present in typhoid, but the headache of typhus is much more dull and +contusive. + +{384} The mental condition is only exceptionally affected, a +circumstance which greatly increases the patient's perception of his +sufferings. Delirium is not present in ordinary cases, even though +very severe and attended with hyperpyrexia; or if present is limited +to the period immediately preceding the crisis, when there may be +violent and noisy delirium of transient character. In some of our +cases forcible restraint was necessary under these circumstances. + +There are numerous instances on record showing the abruptness with +which noisy, demonstrative, or even destructive delirium may appear, +and the equal suddenness with which in the course of a few hours, or +even of fifteen minutes, the patient may become rational and composed. +Such attacks resemble hysteroidal spells, and probably occur more +readily in patients of a nervous or hysterical temperament. They were +certainly more common when the patients had been of intemperate +habits; and, further, we had opportunities of noting that the +occurrence of relapses in habitual drunkards who had previously +suffered with delirium tremens was apt to develop a form of delirium +which was to all appearance of that nature. + +Delirium of a different and much more grave type may appear in +connection with the symptoms of the typhoid state. In some cases this +results from the presence of serious complications which induce a +state of great prostration, while in others it is associated with +great diminution or entire suppression of urine. The delirium under +these circumstances is apt to be low and muttering, with a tendency to +pass into stupor or profound coma. + +Vertigo is present more frequently and in a more persistent form than +in any other febrile disease. It was noticed as among the occasional +prodromes, and was especially severe for the first few days of the +initial paroxysm, though it often continued throughout this stage and +recurred with the relapse. Occasionally it was complained of in the +recumbent position, but usually it was excited only by a change of +position. + +Wakefulness was one of the most distressing symptoms in all cases, and +appears to have been noted in all epidemics. Although the severity of +the pain in various parts of the body and the absence of blunting of +the perceptions would naturally cause much loss of sleep, the degree +of the insomnia and the obstinate resistance it offers to the action +of anodynes are apparently far in excess of what could thus be +accounted for. Parry found that several of his patients could take as +much as three grains of opium every second hour throughout the +afternoon and night without either inducing sleep or causing +contraction of the pupils. + +Convulsions are rare and of very grave import. They may occur at the +period just preceding crisis, when the nervous irritation is most +intense, and are then somewhat less indicative of a fatal result than +if occurring in the course of the paroxysm, when they are apt to be +associated with extreme prostration of the nervous centres, with a +tendency to subsequent fatal coma. No connection has been observed +between their occurrence and the presence of albumen in the urine. + +General tremor is rare, and was observed only in those of our cases +where there had been habitual intemperance, with presumably a tendency +to delirium tremens. Muscular rigidity was noticed occasionally, but +may have been only apparent, being induced by the hyperaesthesia and +{385} soreness which were marked in some cases. The hyperaesthesia +which was observed was both cutaneous and muscular, and was attended +with tenderness of the body of the muscle, and also of the nerve-trunk +supplying it. Meschede speaks of opisthotonos as a rare complication +in his cases. + +Motor paralysis involving single muscles or groups of muscles is +occasionally noticed, as of the deltoid or of one arm (Meschede). +Parry observed transient loss of power of the extremities in several +cases, chiefly during the intermission or the period of convalescence. +In one of our cases temporary hemiplegia occurred, with partial loss +of sensation on the affected side. + +The bladder and rectum are rarely affected, except in cases where the +typhoid state with tendency to coma is present. Disorders of sensation +are, however, much more common. When motor palsy occurs the affected +part may also be the seat of impaired sensibility, while in a large +proportion of all cases numbness of the extremities, with or without a +sense of tingling, is complained of; out of 182 cases we noted this +symptom in 94, affecting the fingers alone in 62, the feet alone in 6, +and all the extremities in 25 cases. Cutaneous hyperaesthesia or +partial anaesthesia are also occasionally observed. But the most +noteworthy and constant symptom of this class are the pains in the +muscles and joints which are bitterly complained of by nearly all +patients with relapsing fever. They constitute, indeed, one of the +highly characteristic features of the disease, and possess a +diagnostic value. They may occur among the rarely present prodromes, +but usually they appear with the chill and increase in intensity +during the paroxysm; they may persist with even greater severity +during the intermission, or, if they have then subsided, recur with +the relapse, and may constitute one of the most troublesome hindrances +to convalescence. It will thus be seen that in frequency, severity, +and persistency they differ widely from the aching pains in the +extremities complained of in typhus and other specific fevers. They +are one of the most potent causes of the extreme insomnia, and are apt +to dwell in the mind of the patient so vividly that he dreads each +relapse on this account, and consequently looks back upon his attack +of relapsing fever as a terribly painful experience. These pains are +usually described as rheumatic in character, and several times +patients presenting themselves at the hospital on the second or third +day of the initial paroxysm stated that they had inflammatory +rheumatism. As a fact, we observed the utmost intensity of these pains +in a few cases where the patients were of marked rheumatic diathesis. +The nape of the neck, the muscles of the trunk or extremities, or the +large or small joints, or lower parts of the spinal region, may be the +seat. At times they extend along the course of nerve-trunks. In +character they are described as a deep intense aching, with occasional +severe or excruciating, sharp, lancinating pains. Pressure or movement +increases them. The joints are not red or swollen (though swelling may +appear as a sequel), and the pains seemed to us rather to be referred +to the joints than to be caused by any local irritation therein. As +already stated, there is often tenderness of the body of the muscles, +and this was especially marked in many of our cases on pressure along +the course of the nerve-trunk. + +Murchison suggests that they are due to the circulation in the blood +of an {386} abnormal substance, such as uric, lactic, or phosphoric +acid; but it appears to us altogether probable that they are rather to +be connected with states of congestive irritation of the sheaths of +the nerve-trunks (early stage of perineuritis), or possibly in some +cases of the spinal membranes also. It is true that they are sometimes +shifting in their seat and fluctuating in their severity, but this is +not inconsistent with the above suggestion, while the widespread +irritative processes found in this remarkable disease, the resemblance +of these pains and the frequently attendant numbness and tingling to +the sensations caused by other forms of perineuritis, and the +occasional development of local palsies of a single muscle or group of +muscles, all are in its support. + +The special senses are acute, sometimes painfully so. The eyes are +watery and occasionally injected, but this latter condition is rare +and slight in relapsing as compared with typhus fever. At the crisis +and for a few days subsequently wide dilatation of the pupils is not +infrequently observed. Dulness of hearing was present during the +paroxysm in 14 of our cases, and a few patients complained of +tinnitus; but these symptoms are not at all common in the disease, +although it will be seen hereafter that affections of the middle ear +are among its sequelae. + +Debility is not such a prominent symptom as in typhus and typhoid +fevers. Patients manage to drag themselves about for several days +during the initial paroxysm with all the symptoms fully developed, and +after admission to the hospital will often be able to help themselves, +or even to rise from bed, unless prevented by the severe pains or the +vertigo. Still, there are many cases, not necessarily of very grave +type, in which there is a marked sense of weariness and exhaustion, +and of course in all cases of typhoid character the prostration is +great. It must constantly be borne in mind that even when the patient +feels or seems able to sit up he must on no account be permitted to do +so, since the occurrence of sudden and fatal syncope is one of the +accidents constantly to be apprehended. It is not only during the +pyrexia that this precaution must be enforced; we meet with extreme +debility during the intermission in some cases, and syncope has +followed exertions made at that period as well as at others. + +During the paroxysms the respirations are much accelerated, at times +to a greater degree than would correspond with the pulse-rate, while +at others extreme rapidity of pulse may be associated with moderate +elevation of the rate of respirations. + +As examples of the relation between temperature, pulse, and +respirations we quote the following from our records of adult cases: + +(_a_) Temperature, 108 degrees; pulse, 124; respiration, 40. In the +relapse; no chest trouble. + +(_b_) Temperature, 107.5 degrees; pulse, 120; respiration, 28; falling +to temperature, 96 degrees; pulse, 68; respiration, 18, within twelve +hours, during which crisis occurred. + +(_c_) Temperature, 107 degrees; pulse, 144; respiration, 31. In the +relapse. + +(_d_) Temperature, 107 degrees; pulse, 108; respiration, 44. Initial +paroxysm; no pulmonary congestion. + +Temperature, 106 degrees; pulse, 116; respiration, 28. Relapse; no +pulmonary congestion. + +Temperature, 97 degrees; pulse, 76; respiration, 24. Critical fall; +cough, {387} congestion of lungs posteriorly, and left one relatively +dull on percussion, but pneumonia did not develop. + +In many epidemics bronchitis, hypostatic congestion, and pneumonia are +of rare occurrence, while in others, as in Philadelphia in 1870, they +are comparatively frequent and lead to serious respiratory symptoms. +While the pyrexia was high there was very frequently an irritative dry +cough, with the fine crepitant and subcrepitant rales attending +congestion and imperfect expansion of the lungs heard at the middle +and lower portions of the chest posteriorly. In numerous instances the +rales would disappear entirely after a few full inspirations in the +sitting posture, just as in the corresponding condition in typhoid +fever. But in a considerable proportion of all the cases (fully 35 per +cent.) there was more troublesome bronchial cough, associated with +sonorous, sibilant and subcrepitant rales, with mucous or +muco-purulent expectoration. + +Bronchitis of this character was a source of serious annoyance to many +patients. In several cases there was impaired resonance at the lower +margins of the lungs posteriorly, with imperfect bronchial +respiration, but without the symptoms of fully-developed pneumonia. +Such conditions were regarded as due to hypostatic congestion, and +proved amenable to treatment. Pneumonia occurred in eleven cases out +of 200 recorded with reference to this complication. It will be more +fully discussed under the head of Complications. It was attended with +the usual physical signs, and gave rise to extremely rapid and labored +breathing, especially when associated with painful enlargement of the +liver and spleen. In a case of double pneumonia, with enlarged and +ruptured spleen, the respirations were from 80 to 90 for two days, the +pulse being 130 to 136. It was a very fatal complication, death +resulting in all but two instances. + +Leyden[16] has shown that though the percentage of carbonic acid in +the air expired during the pyrexia is diminished, the total quantity +exhaled is increased, the proportion being as 1.5 to 1 in the +non-febrile state. + +[Footnote 16: "U. d. Resp. in Fieber," _Deutsch. Arch. f. klin. Med._, +1870, 536, quoted by Murchison.] + +Elaborate investigations have been made of the condition of the urine +in relapsing fever by numerous observers, and in the Philadelphia +epidemic of 1870 we had the great advantage of being assisted by the +distinguished chemist, the late Horace B. Hare, who conducted an +extensive series of analyses in our cases. In a number of cases +quantitative analyses were continued daily throughout the entire +course of the disease. + +As a rule, the quantity of the urine is comparatively free during the +febrile periods, very scanty at the time of crisis, except in the +cases where critical discharges of urine occur, and excessive for some +days after the crisis. + +Still, there were not rare exceptions, especially to the first of +these statements. Thus on four successive days of the relapse of a +severe case with delirium, but without albumen, and which ultimately +recovered, the analysis gave-- + + Temperature. Amount in ccm. Sp. gr. Urea in Grm. Na. Cl. + 103 400 1024 23.8 2.64 + 105 300 1025 15.27 1.95 + 106 500 1024 24.7 4.3 + 106 to 97 850 1021 24.735 5.525 + +{388} And in another severe case, also resulting in recovery, the +analysis was, for two days preceding the crisis of the initial +paroxysm-- + + Amount. Sp. gr. Urea. Na. Cl. + 500 1014 12.9 Traces of albumen. + 650 1014 15.85 1.365 + +After the crisis: + + 2250 1004 18.9 15.75 No albumen. + +And again, in another case at the height of the initial paroxysm, +within twenty-four hours of the crisis, no vomiting, purging, or +epistaxis being present; temperature 105 degrees; only 500 ccm. was +passed of dark reddish colored urine, non-albuminous, and with sp. gr. +1011. + +In a fatal case there was total suppression of urine for three days, +the catheter drawing off only a few drops of almost pure liquid blood. + +When crisis occurs by copious urination the discharges are frequent, +large, and of light color and low specific gravity. + +The urine of the intermissions is of similar character, and for +several days after crisis it is not rare to have 2000 to 2500 ccm. +passed. The largest amounts we noted were in a man who recovered, and +who passed at the crisis of the relapse and during the following days +the amounts here given. + + Amount. Sp. gr. Urea. Na. Cl. + 1000 ccm. 1010 14.9 2.6 + 2000 " 1003 20.2 42.8 + 3550 " 1002 26.625 130.995 + 2600 " 1002 19.24 27.30 + 2800 " 1005 24.96 22.66 + 2500 " 1013 47.25 11.25 + 2700 " 1014 59.13 7.29 + +Carter reports a case where the patient continued for two weeks after +the relapse to pass 130 oz. of sp. gr. 1002.6. + +The amount of urea varies considerably, and is evidently under the +influence of complicated conditions. The rule appears to be that it +increases during the paroxysms, diminishes during the crisis, +increases during the few days following crisis, and then falls off +again. These results are stated upon the authority of Murchison, +quoting from Pribram and Robitschek, Wyss and Bock, and others. Our +own observations, however, while agreeing in the main with these, show +that there are numerous and important exceptions, especially to the +occurrence of the post-febrile increase in the elimination of urea. + +The largest amount of urea excreted in twenty-four hours by any of our +patients was 59.13 grammes, or 912 grains, on the sixth day after the +end of the relapse, but as much as 74 grammes (1142 grains) have been +found. + +Deposits of urates were very common in the urine of the paroxysms and +of the crisis. The uric acid has been found increased, and so also +have the phosphates, crystals of which are frequently found mixed with +the urates. + +The chlorides diminish during the paroxysms, until just before the +crisis their amount is very small, or they may even have disappeared. +Immediately after the crisis they reappear slowly or quickly, and even +{389} very large amounts may be discharged, as seen in the figures +given by Hare's analyses: 2.6 grm. on day of crisis, 42.8 grm. the +following day, and the enormous amount of 130.995 grm. on the next +day. A copious flow of urine corresponds with great augmentation in +the amount of the chlorides. + +Bile-pigment was constantly present in jaundiced cases, the amount +being proportioned to the depth of the jaundice and the quantity of +the urine. Bile-acids have been detected (Carter and Schmidt), and +also leucin and tyrosin (Pribram and Robitschek). + +Albumen, with or without tube-casts, is not uncommonly found, and +traces of sugar have been detected in a few cases. More careful +consideration will be given to these under the head of Complications. + +The following appearance of the tongue has been repeatedly described, +and when present may be regarded as possessing some diagnostic value: +The body of the tongue slightly swollen, so as to show the impressions +of the teeth, and by the second day the central part of the dorsum +covered with a peculiarly white fur, while the edges and a small +triangular space at the tip are clean and red. Such a tongue was seen +in many cases at the beginning of the Philadelphia epidemic, but later +it was present in but a small proportion. We find it specially +mentioned in 97 of our recorded cases, or about 50 per cent., the +general description being given that it was moist, rather large, with +pink, clear edges, and a triangular clear space at the tip, and with +heavy white fur in the centre. + +Some accurate observers, as Wyss and Bock, did not notice anything +peculiar about the tongue, but merely described it as moist and coated +with a thick white fur. The tongue often remains moist throughout the +case, the coat becoming yellowish, and later brownish. Of course if +there is nasal obstruction from epistaxis or catarrh, and the patient +breathes through the mouth, the tongue will soon become dry and brown; +but in addition, this state of the tongue with sordes on the teeth and +lips, appears in a small proportion of cases (3 per cent., Zuelzer; 12 +per cent. of our own patients) in conjunction with grave typhoid +symptoms. + +During the intermissions the tongue clears off quite rapidly, unless +marked gastric disturbance persists, but regains its former state as +soon as the relapse occurs. + +In rare cases the tongue is red and glazed, and Parry and ourselves +observed peculiar painful cracks continuing obstinately after the +relapse. It is apparent, therefore, that the tongue presents evidences +of vitiated secretions, of local catarrh of the buccal mucous +membranes, and of the high grade of gastric irritation so constantly +attendant on this disease. + +As a rule, there is complete anorexia during all of the febrile +paroxysm, while in the intermission the appetite soon returns, and is +sometimes truly ravenous. We did not, however, observe in any case a +voracious appetite during the febrile paroxysms, such as was very +often present during the London epidemic of 1843 and the Irish +epidemic of 1847, and is particularly mentioned by Murchison.[17] + +[Footnote 17: _Op. cit._, p. 360.] + +Thirst is constant and intense, and is excited not only by the high +temperature, but by the irritation of the stomach; it may continue +through {390} the intermission, when natural appetite and the power of +digesting solid food have returned. + +Nausea and vomiting are always prominent symptoms, and most especially +so in children. In some cases nausea occurs among the prodromes; and +occasionally the attack is ushered in by profuse and uncontrollable +vomiting instead of by a chill, and the stomach continues entirely +non-retentive throughout the paroxysm. Vomiting is not usually so +obstinate and severe, however, and with extreme care in feeding and +medication it will often be allayed after two or three days. It +occasionally recurs profusely immediately before the crisis, as in the +case given in full at page 394, where after a violent attack of +vomiting the patient fell asleep, and awakened in a profuse sweat. + +This symptom was present in 146 out of 182 of our cases, was usually +confined to the febrile stages, and was, as a rule, worse in the +initial paroxysm. + +The matters vomited consist of the ingesta colored with bile, of +glairy mucus tinged with bile, or of green bile, sometimes in +considerable quantity. Small particles of blood may occasionally be +noticed in the matters vomited, and in rare instances true hematemesis +occurs. Judging from the frequency with which in fatal cases we find +ecchymoses of the gastric mucous membranes with blood-stained mucus in +the cavity of the stomach, we should expect black vomit to be more +often observed than is the case. Murchison (p. 361) states that it was +not noted in any British epidemic except that of 1843, and then it +occurred in only a few cases, although it seems to have varied in +frequency at different places. Arrott at that time described the +symptoms as "quite common" in the fever at Dundee; and W. Reid of +Glasgow recorded the case of a girl in the same epidemic who vomited +large quantities of clotted blood, and who also had hemorrhages from +the bowels and from the ears. It has occasionally been observed in the +continental epidemics. It was observed in four of our cases. By all +who have observed blood-vomiting in relapsing fever it is recognized +as a symptom of almost invariably fatal import. Three of the four +cases in which we observed it proved fatal, but one patient, who had +copious hematemesis, both at the close of the first relapse and during +the second relapse, recovered after a desperate and protracted +struggle. + +The bowels are not so often constipated as in typhus, and it is not +rare for diarrhoea and constipation to alternate, or for the bowels to +be loose throughout the paroxysms. They are noted in 181 of our cases +as regular in 32, loose in 61, and constipated in 88 instances. +Meschede states that diarrhoea was present in nearly one-half the +cases of the Konigsberg epidemic of 1879, though usually as a late +symptom, the early stage being marked by constipation, which in a few +cases persisted throughout. The stools may be consistent and dark or +thin and bilious, or occasionally, when gastric or intestinal +hemorrhage has occurred, they contain black coffee-ground matter. +Occasionally, the diarrhoea has a critical character, and occurs at +the close either of the initial paroxysm or of the relapse, though it +may not entirely substitute sweating. This mode of crisis occurred in +two of our cases, but Douglas observed it in 6 out of 33 cases. + +The abdomen may appear enlarged, but this is as much the result of the +{391} enlargement of the liver and spleen as of gaseous distension, +which is rarely present in a high degree. Abdominal pain is almost +constant, and may be very severe. It is especially mentioned as having +been present in 148 out of 182 of our cases. It commonly extends +throughout the epigastrium and both hypochondria, but may be present +on one or the other side, while, on the other hand, there may be +general abdominal soreness. It is associated with tenderness on +pressure, which may be so great as to hinder the movements of the +trunk and to render the descent of the diaphragm in breathing painful. +This may be the first symptom to usher in the attack, and it occurs at +an early stage in most cases. Many of our patients when admitted to +the hospital had already been cupped or blistered over the region of +the liver or spleen. This distress was greatest in cases attended with +jaundice and marked gastric irritation; and Parry reports that in his +cases (occurring in the early part of the epidemic which we studied) +jaundice was rare (4 out of 37), and abdominal tenderness was not +present. It is not difficult to explain its almost universal presence +in view of the severe lesions of the substance of the liver and +spleen, the distension of their capsules from the acute swelling of +the organs, and the implication of the coats of the stomach. + +Enlargement of the liver and spleen probably exists to a greater or +less degree in every case of relapsing fever without exception. This +statement is based on the concurrent testimony of accurate observers +in all epidemics and upon the evidence of post-mortem examinations. + +The enlargement of the liver can be demonstrated in nearly all +instances by careful percussion. It varies greatly in its degree, +however; in mild cases it may be slight, while in severe ones the +liver may be found extending at least three inches below the margin of +the ribs within three or four days from the initial symptom. In our +own fatal cases the weight of the liver averaged between four and four +and a half pounds. + +The spleen enlarges even more rapidly and to a greater degree than the +liver. In fact, its enlargement in relapsing fever is greater than in +any other acute disease. It may be detected by percussion by the first +or second day, and may then continue to rapidly increase until by the +fifth or sixth day a large painful mass is readily recognized by +palpation and percussion, or even by inspection. The organ often +weighs twelve or sixteen ounces, not rarely twenty to twenty-five, +and, as an instance of the extreme limit that may be reached, Kuttner +reports sixty-eight ounces in one case. This enlargement is greatest +toward the close of the first or second paroxysm, and subsides quite +rapidly in most cases during the intermissions and as convalescence +progresses; we have, however, known a moderate degree of enlargement +of the spleen to persist for some weeks after the crisis of the last +paroxysm. + +The occurrence of jaundice in a considerable proportion of cases of +relapsing fever is a clinical fact of much interest. Its frequency +varies greatly in different epidemics, and even at different stages of +the same epidemic. At times it is rarely met with (1 out of 14, 20, or +35 cases), while in other epidemics it is present in 1 out of every 6, +5, or even 4 cases. Of 182 of our own cases jaundice is recorded in +45, or exactly in 1 out of 4. According to our observation, it +occurred in a larger proportion of cases among negroes (14 out of 32) +than in whites, and {392} Stille states that it occurred in nearly +every such case that came under his observation. When present it +usually occurs during the first paroxysm, and may be limited to that +stage; or, again, it may be present in each of three or four +successive paroxysms in the same case; or, finally, it may first +appear in the relapse. As a rule, it subsides speedily after the +crisis, though Carter states that in two or three cases the symptom +made its first appearance just after the crisis. It varied from the +slightest yellow tinge of the conjunctiva to the deepest staining of +the whole surface. The urine is discolored in proportion to the +intensity of the jaundice, and the serum of a blister will be deeply +tinged. It must be carefully noted, however, that the feces are not +decolorized, but, as already described, contain fully a normal amount +of biliary coloring matter. This fact has been relied on by Murchison +and others to prove that the jaundice in relapsing fever is purely +dependent on the morbid state of the blood, and is not due to +obstruction of the biliary passages; and we are prepared to admit that +the element of blood-dyscrasia may play a part in the production of +the jaundice. The anatomical evidence, however, given on page 414, +renders it probable that in many cases at least the essential cause is +to be sought in an obstructed state of the minute gall-ducts of +certain areas of the liver. If the main hepatic duct or the common +duct were obstructed, there would of course be paleness of the feces, +as the bile would be prevented from entering the duodenum. But when a +large amount of highly-colored bile is being secreted, as in relapsing +fever, it seems clear that the obstruction of a certain number of +minute ducts would cause sufficient resorption of the bile to induce +jaundice of varying degrees of intensity, while at the same time +allowing a flow of bile through the patulous ducts. + +Jaundice must be regarded as an unfavorable or even a grave symptom in +relapsing fever, but not to the extent that would be the case were it +directly connected with the intensity of the blood-dyscrasia. Many of +the most violent cases in all epidemics have been unattended with +jaundice, while, on the other hand, many cases in which jaundice has +been marked "have had not a single symptom that made them differ from +ordinary cases excepting the yellowness" (Henderson). It follows, +therefore, that the gravity of a certain proportion of the jaundiced +cases does not follow directly from the presence of bile in the blood +and tissues, but from the lesions of the liver of which the jaundice +is a symptom, or from the existence of widespread irritation of many +parts of the body. Thus jaundice is present in an unusually large +proportion of the cases attended with marked enlargement and +tenderness of the liver and spleen, whether vomiting is also present +in extreme degree or not. It was noteworthy that it was +disproportionately frequent in negroes, and that in these patients the +lesions of the liver and spleen were also unusually pronounced. Again, +jaundice is present in an unusually large proportion of the cases +attended with low delirium, extreme prostration, defective secretion +of urine, and the other features of the typhoid state--so much so that +such cases have been described by various writers under the name of +bilious typhoid fever. + +But, as already stated, it is not legitimate to consider the gravity +of these cases as the result of the jaundice, but rather that the +jaundice is merely a symptom of the widespread irritative lesions, +which in such {393} cases not only involve the liver and spleen, but +the kidneys, the lungs, the marrow of the bones, the muscle of the +heart, and occasionally the membranes or substance of the brain and +cord. + +The true prognostic value of jaundice in relapsing fever would then +seem to be, that of itself it indicates merely an obstructed state of +a certain number of minute bile-ducts, but that its presence justifies +the apprehension that the local lesions of the liver may become +excessively developed, or that there is a tendency to widespread +tissue-changes which at a later stage of the disease may lead to the +appearance of grave constitutional disturbance of a typhoid type. + +Hemorrhage in relapsing fever is not uncommon, and may occur from +various surfaces. Epistaxis is, however, the only form which is +frequent enough to justify being regarded as a symptom. It usually +occurs in from 5 to 15 per cent. of cases of relapsing fever, but in +the Philadelphia epidemic it was much more frequent than this, +occurring in not less than 83 out of 182 of our cases. It was not more +frequent or profuse in grave cases than in those of ordinary severity, +and consequently could not be regarded as a reliable indication of the +intensity of the blood-dyscrasia. Although ordinarily moderate in +amount, it was occasionally so copious and persistent as to require +prolonged plugging of the nostrils, and in at least one case +contributed chiefly to cause an intense anaemia, which long delayed +convalescence. It occurs at all periods of the paroxysms, but more +commonly toward the close. In fifteen of our cases extraordinarily +profuse epistaxis attended the crisis, and evidently replaced in part +the copious sweating by which the paroxysm more commonly terminates. + +SYMPTOMS ATTENDING THE CRISIS.--We have already described the +aggravation of all the symptoms which immediately precedes the crisis +in typical cases of relapsing fever, and the abrupt fall of +temperature, and usually of the pulse, that follows. But this +extraordinary change is nearly always attended with some profuse +critical discharge, of which sweating is by far the most common, +though copious epistaxis, metrorrhagia, diarrhoea, or vomiting may +also occur, and to a greater or less degree, but seldom entirely, +replace the sweating. In 182 cases in which we carefully noted the +mode of termination of the paroxysm there was no definite crisis +(termination by lysis or gradual and irregular defervescence) in 76; +profuse sweating, 89; profuse epistaxis, 15; profuse diarrhoea, 2. + +In most epidemics the proportion of true crises is greater than in the +above table--a fact dependent upon the unusually severe and +complicated form of the disease which we were studying. The beginning +of the sweat may be preceded by chilliness or rigors, by extreme and +dangerous prostration, or by violent nervous disturbances; or there +may be an attack of profuse vomiting, followed by sleep, during which +sweating begins. The sweat may be moderate in amount, but is often +extraordinarily copious; the patient is literally bathed in it, the +bed- and body-clothing is saturated, and we have seen the mattress +saturated. It has an acid reaction, but we do not know of any accurate +analyses of it. Some writers have attributed to it a characteristic +disagreeable odor, but we did not notice any in our cases that could +be considered peculiar to this disease. + +CONVALESCENCE.--We have already stated the average duration of {394} +relapsing fever to be eighteen or twenty days, while the extreme +limits are from eighteen to ninety days. Despite the fact, however, +that the mortality is in most epidemics only about 5 or 7 per +cent.--greatly less, therefore, than in typhus fever--the +convalescence from relapsing fever is frequently slow and protracted. +The obvious cause is, just as in the case of typhoid fever, the +existence of numerous and serious lesions of the solids and the +tendency to many troublesome complications and sequelae. We have, +however, seen many instances of rapid recovery of strength and health, +even after prolonged attacks with several successive relapses. + +The following case is quoted partly on account of the numerous +relapses, and the long duration of the sickness: + +B. B. Y., medical student, was much exposed to the contagion of +relapsing fever in the wards of the Philadelphia Hospital during the +spring of 1870, and in May had an attack apparently of this disease, +which, however, subsided in four or five days and was followed by no +immediate relapse. He continued his attendance at the hospital during +the remainder of May and the whole of June; in July took a trip to the +South, where there was no relapsing fever prevailing, and after +exerting himself for several days during intensely hot weather, he +became sleepless and much prostrated. He returned home, and after +recovering from the fatigue felt quite well for about a week, until 3 +A.M., August 1st, when he was attacked with a severe chill, followed +by great insomnia, obstinate vomiting, intense headache, especially in +the back of the neck, occasional sweating, violent fever, recurrence +of very severe chill the following day at 11 A.M., epigastric and +hypochondriac tenderness, decided jaundice, costive bowels, and +scanty, high-colored urine. This paroxysm lasted till the morning of +August 9th, when severe vomiting took place, followed by sleep, during +which crisis occurred by drenching sweat lasting several hours. +Appetite and strength soon began to return, though some jaundice +persisted, and by August 17th he felt able to drive out a short +distance, and retired feeling somewhat fatigued. He awoke with pain in +the back of the neck, which continued increasing till 11 A.M., August +18th (second paroxysm), when a severe chill occurred, lasting three +hours and followed by the same train of symptoms, including jaundice, +which persisted five days, till Aug. 23d, when crisis again occurred +by sweating. On the 24th he felt well enough to use slight exercise, +which was followed by prostration and by a return of chill (third +paroxysm) the next day at 11 A.M., with subsequent headache, fever, +irregular sweats, etc., lasting but one day. Again felt well until +Aug. 30th, when he was attacked (fourth paroxysm) at 11 A.M. with +severe chill, lasting three hours, followed by severe paroxysm, +lasting six days, till Sept. 5th, when crisis again occurred by +sweating. Again felt well for eight days, until Sept. 13th, when the +fifth paroxysm occurred, lasting five days, ending Sept. 18th by +critical sweating. This was followed by an intermission of nine days, +until Sept. 27th, at 11 A.M., when the sixth paroxysm occurred, +lasting four days, and less severe than the preceding ones. This was +followed by an intermission of ten days, till Oct. 11th, when the +seventh paroxysm occurred at the same hour of the day, and lasted +three days. He then went sixty miles from home to a fine, pine-bearing +district, and enjoyed an intermission of eleven days, when the eighth +and {395} last paroxysm occurred at the same hour, and lasted three +days, until Oct. 25th. His convalescence was very satisfactory, and he +was enabled to resume his studies by the middle of November. No +sequelae occurred. In 1878 Dr. Y., who had been working very steadily +with a rapidly-growing practice, was attacked with severe typhoid +fever, with grave nervous symptoms and with albumen and tube-casts in +the urine, and died on the twelfth day. + +It will thus be seen that in this unusually protracted case there were +seven distinct relapses, one of which was brief and interrupted one of +the regular intermissions, while the rest were all severe. + + Duration of + 1st paroxysm, violent, 8 days. 1st intermission, 9 days. + 2d " violent, 5 " 2d " 1 day. + 3d " less violent, 1 day. 3d " 6 days. + 4th " severe, 6 days. 4th " 8 " + 5th " severe, 5 " 5th " 9 " + 6th " less severe, 4 " 6th " 10 " + 7th " less severe, 3 " 7th " 11 days, + 8th " mild, 3 " followed by convalescence. + +The total duration of the case, which was entirely free from +complications, was therefore ninety days. + +VARIETIES.--The foregoing clinical description prepares us to +appreciate the varieties of relapsing fever that may be said to exist. +They consist of-- + +The abortive form, in which a single paroxysm of variable length and +severity occurs, terminating in a critical fall of temperature and +usually with some critical discharge, but not followed by any relapse. +There can be no doubt of the existence of such cases, although they +are not common; and at times the paroxysm is so slight that were it +not for the known exposure of the individual to the prevalent epidemic +influence, in the absence of any other adequate cause, the case might +readily be regarded as one of non-specific febricula. The caution +must, however, be borne in mind as to the occurrence of relapses of +such extreme shortness of duration (less even than twenty-four hours) +as to readily escape notice unless a careful watch be kept for their +detection. + +The ordinary or typical form, including the cases with one or two +relapses, presenting the usual variations in the severity of the +symptoms and in the duration of the paroxysms and of the +intermissions. + +The multiple or protracted form, if it be thought desirable to thus +particularize cases presenting an excessive and unusual number of +relapses, as three, four, five, six, or even seven. + +The grave or subintrant form, which is designed to include the highly +congestive form of Cormack and the bilious typhoid of Griesinger and +Lebert. + +Under another heading (see relations to other diseases, p. 420) we +shall give reasons for regarding the bilious typhoid fever of +Griesinger and Lebert as merely a form of relapsing fever, with which +a certain proportion of cases of true typhoid fever complicated with +hepatic catarrh may have been included. + +The characteristics of this grave subintrant form are as follows: +Jaundice, occasionally absent, but usually present in an intense +degree; marked enlargement of the liver and spleen; a tendency to +hemorrhage from various mucous surfaces; extreme prostration; +defective or suppressed {396} secretion of urine; hypostatic +congestion or inflammation of the lungs in a large proportion of +cases; dry brownish tongue; low muttering delirium, often passing into +stupor or coma; hiccough; imperfect crisis; and a continuance of some +morbid phenomena, so that merely a remission occurs to separate the +paroxysms; and a high percentage of mortality. The great modification +of the intermission which is so highly characteristic of typhoid +relapsing fever is doubtless due in chief part to the serious local +lesions developed, and seems to justify the name of subintrant as +above suggested. The course of such fever is well illustrated by the +following case, in which the characters of typhoid relapsing fever +were present in the highest degree, death occurring on the fifteenth +day: + +Charles Hood, colored, aet. 28, of temperate habits, was taken ill on +April 5, 1870, after malaise lasting thirty-six hours, with fever, +nausea and vomiting, headache, and general aching throughout body; and +was admitted to the hospital April 6th. There was already marked +jaundice, and epistaxis had occurred; there were also insomnia; +wandering delirium; extreme tenderness over the liver and spleen, both +of which were enlarged; dryness of tongue, vomiting, and distension of +the abdomen. These symptoms continued, his condition becoming daily +more aggravated. Restless delirium alternated with heavy sopor. The +jaundice grew deeper. Marked digital formication existed, but the +arthritic pains were not so severe as in ordinary cases. The tongue +was dry and of a red orange color. Profuse epistaxis occurred on the +seventh day of the disease, requiring plugging of both anterior and +posterior nares, and followed by great prostration. A gradual fall in +the temperature occurred during the sixth, seventh, and eighth days, +reaching 99 degrees on the latter day. During this decline the +delirium ceased and the mind remained merely dull; the jaundice +decreased, as did also the tenderness of the hypochondriac zone. The +pulse and respirations improved, and diarrhoea ceased. The improvement +was but brief; for about eighteen hours he lay apyretic, with cool +hands and feet, and with eyes closed and mind dull but free from +delirium. Fever then reappeared and with the ascent of the temperature +the unfavorable symptoms recurred. The relapse lasted but two days, +and was followed by irregular decline of fever till death occurred on +the fifteenth day of the disease. Obstinate hiccough appeared on the +eleventh day, and continued, accompanied with occasional vomiting on +the fourteenth day. Delirium alternating with sopor reappeared. +Jaundice again became marked, and again there was extreme tenderness +over the liver and spleen. The pulse grew small and feeble, the +respirations shallow and labored, with an expiratory moan. Cough began +on the twelfth day, and was soon followed by the physical signs of +pneumonia of the lower lobe of both lungs. The urine continued free +from albumen. The patient sank into deeper coma, and died on the +fifteenth day. Post-mortem examination showed highly-developed +characteristic lesions of the spleen and liver, with red hepatization +of lower lobe of both lungs. There was no affection of the glands of +Peyer. The course of the fever is shown in the following tracing (see +Fig. 22). + +[Illustration: FIG. 22. From a case of the bilious typhoid or grave +subintrant form of relapsing fever.] + +COMPLICATIONS AND SEQUELAE.--As would be anticipated from what has +been said of the wide range of the symptoms and of the remarkable +course of the temperature in relapsing fever, there are many +complications and sequelae liable to occur, and which require special +consideration. {397} They may be classified according as they affect +the febrile movement, the state of the blood, or one or other of the +groups of organs. + +We have already described the various irregularities presented by the +febrile paroxysms and the intermissions, and no further allusion need +be made to mere variations in length, severity, or number of the +former. In rare cases, however, a peculiarity is presented, usually in +the first intermission, which is difficult of explanation. About +twenty-four hours after an apparently complete crisis, with a fall of +temperature to a subnormal point, there may be a sudden and rapid rise +or rebound of temperature to 104 degrees or 105 degrees, attended with +distressing symptoms of high fever, but lasting only twenty-four or +forty-eight hours. A good example of this is given in the case +described on page 394; and Carter[18] cites several examples of it +terminating either in recovery or in rapid death. He asserts that +examinations of the blood during such post-critical febrile rebounds +invariably showed an absence of spirilla, so that in his opinion such +fever must be considered non-specific. Their explanation seems +difficult, since the pyrexia is too brief to be associated with any +local inflammatory complication. + +[Footnote 18: _Op. cit._, p. 172.] + +More frequent and serious is the protracted post-critical pyrexia +which we have already described as modifying the interval, so as to +produce a subintrant type by maintaining continuous though irregular +fever until the accession of the relapse, unless cut short by death. +This post-critical fever is non-specific, is unattended with spirilla +in the blood, and is to be associated with the extensive irritative +processes in the liver, spleen, kidneys, lungs, and other parts that +are present in these grave and {398} complicated cases. It is to be +noted that the course of those paroxysms which terminate in lysis +indicates that they may represent a milder type of the above process. + +The peculiarities of the delirium, amounting sometimes to maniacal +excitement, which attends some cases of relapsing fever, has been +fully described. + +Less common are the following: mental hebetude, lasting some days or +even weeks after the close of the last paroxysm, or, as in a case of +Carter's, gradually increasing mental feebleness, terminating in +imbecility. In such cases suspicion must arise of the occurrence of +some local lesion of the membranes or substance of the brain. + +Partial palsy is mentioned by numerous authors as occurring during or +shortly after attacks of relapsing fever. Paralysis of one or both +deltoids has been noted, the latter by Cormack, who saw it continue +ten days after the patient was well in all other respects. Temporary +paralysis of the forearm (Douglas) or of the whole arm (Parry, +Meschede) has been observed; and Parry also describes loss of power in +the legs lasting for one week. In one of our cases temporary loss of +power of the left arm and leg occurred, attended with such impairment +of sensibility that the woman had to feel for the fingers of the left +hand to assure herself of their existence. This loss of power occurred +during the initial paroxysm, and gradually passed away, but she was +unable to stand alone on the thirty-first day of the disease. In a +case reported by Tennent[19] facial palsy was developed six days after +the second crisis. + +[Footnote 19: _Glasgow Med. Jour._, May, 1871, p. 379.] + +Various explanations have been offered for these local palsies, but, +as already stated (see page 386), it seems probable that they are +referable to morbid conditions of the nerve-trunks, or, less commonly, +of the spinal cord. It must be noted, however, that in a certain +number of autopsies serious intracranial lesions are found, which are +evidently the results of the attack of relapsing fever. These consist +of abscess of the brain, meningitis, and specially cerebral +hemorrhage. This was present in one of our cases, but Carter found +copious hemorrhage in no less than 8 out of 54 autopsies, and in 5 +others there were minute capillary cerebral hemorrhages. Still, in +nearly all the cases of large hemorrhage we have found recorded the +effusion was upon the surface of the brain, and this, combined with +the absence of true hemiplegia from the forms of paralysis noted in +relapsing fever, and the transient character of these palsies, makes +it clear that they are not to be explained by any considerable +cerebral hemorrhage. On the other hand, however, it must be admitted +that an additional possible cause of them is to be found in minute +hemorrhage into small areas known to govern the movements of certain +groups of muscles. Again, we have had occasion to note the occurrence +of both thrombosis and embolism among the lesions of relapsing fever, +and it is evident that either of these accidents, if involving a +comparatively small branch of a cerebral vessel in certain motor +areas, might cause transient paralysis, such as has been described. +Nor can we fail to see that, while such symptoms as the delirium, +mania, coma, or subsequent mental impairment may receive other +explanations, it is possible that they may arise from similar +processes of minute hemorrhage, thrombosis, or embolism involving +other parts of the brain. + +{399} The frequent occurrence of severe rheumatic pains in the muscles +and joints during the course of the disease has been dwelt upon (p. +385); but in some cases they persisted during the intermissions and +for a considerable time after all other symptoms of disease had passed +away. Occasionally they greatly retarded convalescence by interfering +with exercise and sleep. These pains were mostly in the legs, and were +increased by exercise, and also seemed to be influenced by changes of +weather. Patients who suffered thus were also liable, after exposure +or in consequence of severe atmospheric changes, to sharp attacks of +similar pains elsewhere, and especially in the course of the +intercostal nerves. Occasionally violent and persistent headache +follows the disease, not improbably associated with changes in the +membranes of the brain, although in other cases severe neuralgia +occurs in consequence of the anaemia which may remain in an intense +degree after the fever. Troublesome numbness and soreness of the soles +of the feet and of the palms of the hands, increased by pressure, has +been noted as a sequel persisting for several days or weeks. + +Affections of the special senses are not rare. The most remarkable +among these is the affection of the eyes, which is apt to occur far +more frequently in connection with relapsing fever than with typhus or +typhoid. The proportion of cases in which this sequel appears varies +greatly in different epidemics. In the British epidemics of 1826 and +1843, when this form of post-febrile ophthalmia was first accurately +described by Mackenzie of Glasgow, it was very frequent; and it was +equally so in Finland in 1867-68, when Estlander[20] again carefully +studied it. + +[Footnote 20: "U. Choroiditis nach Febris Recurrens," _Arch. f. +Ophth._, 1869, Bd. xv., Abth. ii., 108.] + +On the other hand, so far as can be stated in regard to a sequel which +may appear after convalescence is far advanced and the patient +discharged from medical care, it was very uncommon in the Philadelphia +epidemic of 1869-70. This ophthalmia may occur during the course of +the fever, but more frequently it begins during convalescence, and +even some months after convalescence has been established. It occurs +in patients of both sexes and at all ages. Usually it affects but one +eye, but both may be attacked simultaneously or consecutively. +Patients who were very ill-nourished and debilitated were most apt to +present this sequel, and Murchison regards previous starvation as one +of its main causes. The exciting cause and true pathology appear +obscure as yet, however, and the existence of a neural origin is not +improbable. In some cases the ophthalmia has seemed to result directly +from exposure to cold. Among our own patients, as already stated, eye +symptoms were less common and severe. A careful record of 184 cases +was kept in reference to this question. Several patients complained of +diplopia during the febrile stage, and one asserted that every object +appeared fourfold to him. Conjunctivitis of moderate severity, usually +associated with otorrhoea, occurred in about 5 per cent. of our cases; +it generally affected only one eye, and occurred in a few instances as +late as the third week after the relapse. In a few cases (four) also +there was dulness of vision in one eye, noted during the course of the +disease and persisting for some time after convalescence began. In +only one instance, however, did permanent impairment of vision ensue, +and this man had passed through a violent attack of the fever with +unusually grave nervous symptoms. {400} It left him with optic +neuritis on the right side, which induced partial atrophy of the nerve +and great limitation of the field of vision. Meschede reports +intraocular affections in 6 cases out of 180 specially examined, +though it is not certain that such affections were directly connected +with the febrile process. Ocular ecchymosis occurs in a small +proportion of cases, especially of the graver types. + +Dulness of hearing is not so common in relapsing fever as it is in +typhoid. It was present in 14 out of 184 of our cases during the +course of the disease, and in a few instances partial or almost +complete deafness in one ear persisted after convalescence, owing +doubtless to a slight affection of the middle ear. In one case marked +deafness appeared suddenly on the day after the termination of the +relapse by crisis. Meschede[21] found disease of the middle ear in no +less than 8 per cent. of his cases. + +[Footnote 21: _Loc. cit._] + +Purulent otorrhoea from one or both ears is of more frequent +occurrence, and without any special exciting cause may present itself +at any time during the course of the disease or more commonly after +the relapse. In the same manner purulent coryza may occur. + +The eruptions occasionally present during the fever have been +described. Bed-sores from pressure are much less common than in +typhus, but are met with in a small proportion of cases. As a rule, +they are of moderate size and heal quickly. Superficial gangrene of +the lips, nose, and ears has also been noted in rare cases (Zuelzer) +in connection with gangrene of the extremities, probably from +embolism. The occasional occurrence of painful boils, of abscesses in +the cellular tissues (Wyss and Bock), and the more rare occurrence of +erysipelas may be mentioned among the sequelae. + +As already stated, the severe pains in the joints and members which so +frequently occur during relapsing fever are, as a rule, unattended by +any redness or swelling of the joints. In rare cases, however, there +is effusion into the joints during the fever, or more commonly there +are attacks during convalescence which simulate subacute rheumatic +arthritis. Such attacks may last but a few days, but in several of our +cases there was painful swelling of the knees, wrists, and fingers +which persisted for several weeks after the fever, being attended with +slight crepitation on motion, and altogether behaving like subacute +rheumatism. + +As would be expected from the severity of the fever, the marked +disorder of digestion, and the lesions of the spleen and liver in +relapsing fever, anaemia is a common sequel. In cases where there has +also been free hemorrhage, usually in the form of epistaxis, the +anaemia may indeed reach an intense degree. + +The cardiac murmurs which have been described as present in a certain +proportion of cases are dependent upon the blood-changes, and when the +anaemia is extreme these murmurs are also audible over the large veins +and the pulmonary artery, and persist after convalescence is fully +established. + +Oedema of the lower extremities occurs in a considerable number of +cases. It is clearly due in part to the anaemia, but the cardiac +debility which follows the fever is also largely concerned in its +production. It was, indeed, marked in some of our cases where no +anaemic murmurs existed, but where there was great nervous and +muscular debility. {401} Usually limited to the feet and ankles, it +occasionally extended above the knees, and in one case, where great +anaemia and debility from fever and over-exertion coexisted, there was +oedema of the hands and wrists, with great distension of the legs up +to the hips. It is not associated with albuminuria as a rule, and +yields readily to treatment and rest, in the course of a few weeks. + +Hemorrhages from various surfaces have already been mentioned, and a +full account given of epistaxis, which is by far the most common form. +Bloody vomiting has been noticed in a small proportion of cases in +various epidemics. It varies in amount, but is always attended with +great gravity of the attack, and usually is followed by fatal results. +It occurred in four of our cases, two of which presented also black +stools containing altered blood, and suppression of urine; while in +another it occurred at the close of the first relapse, and during the +second relapse was copious and repeated. In this case it was attended +with alarming symptoms of collapse, from which the patient rallied, +and after a desperate struggle recovered. + +Blood may also be discharged from the bowels in such large amount as +to constitute actual hemorrhage--a symptom of great gravity; or in +small quantity and completely altered, so as to impart an inky black +color to the stools--a condition not necessarily attended with urgent +danger; or, finally, there may be frequent bloody dysenteric stools. + +Hemorrhage has also been observed from the uterus, from the kidneys, +from the ears, and from the old cicatrix of a syphilitic chancre. +Hemorrhage occurred in 87 out of 183 of our cases, or in nearly 50 per +cent. It was from the nostrils in 82 cases, from the uterus in 1 case, +from the stomach in 4 cases, and from the cicatrix of a chancre in 1 +case. + +Sudden collapse occurs with such comparative frequency in relapsing +fever as to require special attention as one of its complications. It +may occur at any period of the disease, but it is most common at the +crisis of the first paroxysm or of the relapse. The symptoms are +usually those of cardiac failure, with rapid, small, and feeble pulse; +shallow and hurried, or slow, labored, and imperfect respiration; +coldness of the extremities, while the central temperature may remain +elevated; muttering delirium, rapidly passing into unconsciousness. +Occasionally almost instantaneous death occurs from syncope induced by +some muscular exertion, as standing up or even rising in bed. In other +cases the symptoms indicate the development of cardiac thrombosis, and +subsequent examination has verified this opinion. In still other cases +the symptoms resemble those which occur in extreme hyperpyrexia +dependent upon overwhelming and paralysis of the nervous centres. +Copious hemorrhage from the stomach and nose may also induce syncope +of alarming and even fatal severity. When from the latter cause, +reaction may be induced and the patient may ultimately recover, as we +saw in a case where after repeated hematemesis the patient sank into +profound collapse. In all of its forms, however, this complication is +of extreme and imminent danger, and death follows, as a rule, in a few +hours. The cases in which it occurs are usually of severe type, +occurring in persons who have previously been in poor health or +intemperate, or who have been subjected to privation and improper +exposure previous to and during the early stages of their attack. +Still, collapse may occur in mild cases {402} also, and whatever the +type of the disease there may be no special indication of approaching +trouble, when the patient rapidly passes into collapse, to be followed +by death in a few hours. It occurred in nine of about two hundred +cases under our observation. In one it was the result of hemorrhage +from the stomach, and ended in recovery; in one, at the close of the +initial paroxysm the patient, who was stupid, with muttering delirium, +sank into collapse as the temperature rapidly fell from 105 degrees to +97 degrees, and died in a few hours; in one, on the fourth day of the +relapse the temperature suddenly fell from 102 degrees to 96 degrees, +with free sweating, but suddenly rebounded to 102 degrees, with very +rapid, feeble pulse, distinct basic cardiac murmur, constriction of +chest, restlessness and delirium, slight convulsions, and death in +eight hours; in one, a man at the end of the initial paroxysm, +immediately after his admission to the hospital in apparently fair +condition, became violently delirious, with bounding pulse, soon grew +comatose, and died in one hour; in one, a man who was in feeble +condition, on the nineteenth day, with irregular persistent fever (he +had splenic abscess), sat up on the edge of the bed, sank back in +syncope, and died in less than an hour; in one, a man who did well +until the second day of the relapse, when pleuro-pneumonia and +pericarditis were developed, died suddenly four days later: there was +considerable pericardial effusion; in one, sudden death from syncope +or cardiac thrombosis occurred on the twelfth day in a man who had +suppurative parotitis and metastatic abscesses of the lungs; in one, +sudden collapse and death occurred in one and a half hours at the end +of the initial paroxysm; in one, a drunkard with large fatty liver had +pyrexia continuing after the initial paroxysm, and on the ninth day, +while in a state of hebetude, with mild delirium and a pulse of 112, +coma suddenly occurred, and death followed in two hours. + +Pericarditis is a rare complication, and is apt to coexist with +pleuro-pneumonia. This combination occurred in one of our cases where +pleuro-pneumonia and pericarditis were developed on the second day of +relapse, and proved fatal by sudden collapse on the fifth day, with +the pericardial sac distended with serum and its layers coated with +plastic lymph. + +Thrombosis of veins, as in phlegmasia alba dolens, occurs much more +rarely than after typhoid fever. Arterial embolism, on the other hand, +is not uncommon. Murchison[22] reports a case in which gangrene of the +left foot from obstruction of the left femoral artery, together with +cerebral softening from obstruction of the left middle cerebral +artery, occurred in connection with cardiac thrombosis. Zuelzer +alludes to similar cases in the St. Petersburg epidemic of 1865-66, +where, in addition to the extremities, the nose, ears, and lips became +gangrenous. Other examples of embolism are found in lesions of the +spleen and kidneys, where infarctions are of frequent occurrence. + +[Footnote 22: _Op. cit._, p 384.] + +Heart-clot, or cardiac thrombosis, appears to occur more frequently +than in any other acute zymotic disease, with the exception of +diphtheria. Even when the occurrence of passive hemorrhages and of +ecchymoses of various tissues indicates marked dyscrasia of the blood, +there will not rarely be found firm white clots in one or other of the +cavities of the heart. These frequently present unmistakable evidences +{403} of ante-mortem formation, and, as already stated, there is a +certain proportion of the cases of rapid and unexpected death where +the fatal result is directly due to cardiac thrombosis, attended with +the usual symptoms. + +The constant affection of the spleen has been fully described; it is +not therefore surprising that both complications and sequelae arise in +connection with it. At times, in cases which ultimately recover, the +pain in the splenic region is so violent and continuous, and is +attended with so much tenderness over the enlarged organ, that +localized peritonitis is undoubtedly present. Occasionally this +perisplenitis persists, and in conjunction with the inflammatory +changes in the substance of the spleen maintains an irregular fever +after the specific pyrexia has run its course. This was noticed in +several of our cases, but especially so in a case where, after the +initial paroxysm, an irregular fever was kept up, obscuring the +relapse, until the nineteenth day, when death occurred suddenly from +syncope on rising on the edge of the bed, and where examination showed +splenic peritonitis, with a splenic abscess as large as a pigeon's +egg. + +The enlargement of the spleen usually subsides during the +intermission, and disappears speedily or in the course of a few weeks +after convalescence is established. Occasionally, however, it +persists, and is attended with marked anaemia. In one case, where +death occurred from pneumonia, the sequel of relapsing fever, at about +the thirtieth day, the spleen weighed twenty-nine ounces; and in +another case, where death occurred from gangrenous pleuro-pneumonia, +at the fortieth day, the spleen was still enlarged and presented +characteristic changes in its pulp. On the other hand, in a case where +death occurred on the twelfth day of typhus, occurring forty-four days +after recovery from a very bad case of relapsing fever, making it +altogether the one hundredth day, none of the lesions of the first +disease were discoverable. + +Rupture of the spleen occurs occasionally, and is usually attended +with sudden pain, collapse, and speedy death. Murchison refers to two +examples recorded by Zuelzer and one by Hudson; Petersen reports +fifteen cases, in seven of which sudden rupture occurred with speedy +death, while in the other eight the rupture followed local softening +from infarction, and resulted in death in a few days from purulent +peritonitis. + +In one of our cases, where death occurred on the sixteenth day, +apparently from double pneumonia and heart-clot, it was found that +there was a rupture in the enlarged spleen near its upper end, recent +plastic peritonitis in the region of the spleen, and a moderate amount +of bloody pulpy fluid throughout the peritoneal cavity. + +As we have seen, disturbances within the respiratory tract occur with +very different frequency in different epidemics. In many they are +rare, while in 1870 we noticed cough and other evidences of +respiratory trouble in no less than 90 out of 200 cases. + +Severe catarrhal laryngitis is a rare and dangerous complication. It +did not occur in our cases, but both Begbie and Paterson report cases +of it which required tracheotomy, and Wyss and Bock met with +ulcerative laryngitis with perichondritis. + +Bronchitis of moderate severity, although rare in many epidemics, +{404} occurs so frequently in others, as in Philadelphia in 1870, as +to rank as a symptom of the disease. + +Pneumonia is one of the most fatal complications. The results of our +own observations agree with the statements of Jenner and of Carter, +that it is the next most common lesion after enlargement of the liver +and spleen. On the other hand, Murchison noted it only in 4 or 5 out +of 600 cases. It occurred in at least 11 of our cases, 8 of which were +fatal; and unquestionably less extensive inflammation was present in +other cases which recovered, in view of the marked respiratory +disturbances frequently present. Both lungs were involved in 4 cases; +of the remainder, the right and left were about equally divided. Out +of 23 autopsies, the lesions of pneumonia were found 8 times. The +lower lobes were affected in every case. The form of this disease was +croupous in 9 cases; in 1 it was that of metastatic suppuration, and +in 1 it was more properly described as splenification. The amount of +plastic pleurisy associated with it was usually great, and in one case +there was also severe pericarditis. In another case the disease +advanced to the stage of gangrene of a circumscribed area of the +pleura and of the superficial layer of the lung. In only one instance +was albuminuria present. In two cases the pneumonia occurred so late +in the course of the disease that it might be regarded as a sequel. +Death occurred in one of these on the thirtieth day, and in the other +(that in which gangrene ensued) it ran a subacute course, and death +did not take place until the fortieth day. In the other cases the +disease began at the close of the initial paroxysm, during the +intermission, or early in the relapse. As would be expected, the +sympathetic fever due to this complication modified and obscured the +characteristic course of the specific pyrexia. + +This rare termination in gangrene has been noted by other observers; +in all five or six times. Parry met with a truly remarkable case of +double pneumonia, followed by gangrene, and yet resulting in recovery. +Jaundice is apt to attend cases of relapsing fever which are +complicated with pneumonia. + +Pleurisy is an almost constant accompaniment of pneumonia, and +frequently occurs in marked degree. It may also be present in cases of +severe splenic inflammation. In all probability, localized plastic +pleurisy is not infrequent, and may cause some of the severe thoracic +pains so frequently present. + +Metastatic abscesses of the lung occur occasionally as a result of the +profound toxaemia, and are apparently preceded by patches of +infarction, which soften in the centre, as in the usual development of +pyaemic abscesses. This condition was found in one of our cases in +conjunction with suppurative parotitis. It has been included among the +instances of pneumonia. + +Acute miliary tuberculosis, involving chiefly the lungs and intestinal +canal, occurred as a sequel in one case under our observation, and +phthisis has been found to follow by other observers (Carter). It is +to be expected that if the patient did not so quickly pass from under +observation it would be found that an affection so gravely +complicating nutrition as does relapsing fever is frequently followed +by serious organic disease. + +Parotitis is mentioned by so few authors as to show that it is a {405} +rare complication in most epidemics, varying from 1 in 600 to 1 in 50 +cases. One gland only is affected at a time as a rule, though both may +be involved successively. The inflammation begins either during the +intermission or the relapse, and may terminate by resolution or by +suppuration. Although a painful and severe complication, it is +followed by recovery in a considerable proportion of cases. Carter[23] +states "that in some degree it was noted in 2 or 3 per cent. of all +cases, and nearly as often amongst survivors as in the casualties." It +occurred in three of our cases (185); once it underwent resolution; +once suppuration occurred in the parotid and in the masseter muscle, +with metastatic abscesses in the lungs, and death; and once the +patient, who had previously existing amyloid degeneration of liver and +spleen without albuminuria, had severe relapsing fever with two +relapses, in the first of which parotitis occurred in both glands, +successively terminating in suppuration, after which he did well +through an apyretic period of six weeks, when sudden high fever +appeared, followed by speedy death. + +[Footnote 23: _Op. cit._, p. 210.] + +Pharyngitis and tonsillitis of mild grade occur in from 3 to 25 per +cent. of the cases in different epidemics. + +Hiccough deserves to be ranked among the complications, because it is +of frequent occurrence, obstinate and annoying. It occurred in a +considerable proportion of our cases, and much more frequently in +those who had jaundice. It was often present both in the initial +paroxysm and in the relapse, but disappeared soon after the end of the +pyrexia. It bore no constant relation to the severity of the vomiting. +Not rarely it lasted several days and nights, causing exhaustion and +interference with sleep and proving rebellious to treatment. +Hypodermic injections of morphia and atropia, chloroform internally, +and extremely careful alimentation proved most serviceable. + +Hemorrhage from the stomach has already been spoken of (see p. 390). + +Diarrhoea, as already stated (see p. 390), occurs much more frequently +than in typhus fever, varying from 1 per cent. (Murchison) to 15 per +cent. (Scotch epidemics) or 33 per cent. (Philadelphia), or even 50 +per cent. (Konigsberg). It is usually of moderate severity, but +occasionally is so profuse and intractable as to constitute the main +cause of death. In some epidemics the attacks of looseness occur +almost exclusively after the relapse, but in others the bowels are +frequently loose during the febrile stages. In our cases there were +not infrequently from three to eight thin, dark, bilious or light +yellowish stools daily after the second or third day of the initial +paroxysm, and then the looseness would stop during the intermission, +probably to recur in the relapse. Occasionally diarrhoea with very +frequent liquid stools occurs at the close of one or both of the +febrile stages, assuming a critical character, and substituting more +or less of the sweating which is the common mode of crisis, although +in several such cases quoted by Murchison from Douglas the sweating, +despite the critical diarrhoea, was usually profuse. It can scarcely +be said that there is any relationship between diarrhoea and vomiting; +both are frequently present, and may even be severe and persistent in +the same case, though either may be marked while the other is moderate +or slight. Abdominal pain and tenderness in the epigastrium and +hypochondria are constant symptoms, but when diarrhoea is marked there +are apt also to be griping {406} pains and tenderness in the lower +segment of the abdomen. When diarrhoea occurs as a sequel, either +beginning after the close of the relapse or continuing in cases where +the bowels have been loose during pyrexia, it is apt to prove +obstinate and intractable, or even to lead to a fatal result. + +The character of the stools varies much; usually thin and dark, they +may be light yellowish or even whitish. Thus, in a severe case with +deep jaundice we observed seven liquid and decidedly whitish stools in +twenty-four hours. In such instances there is undoubtedly more or less +complete closure of the biliary ducts by plugs of mucus or by swelling +of the mucous membrane. On the other hand, the stools may be inky +black from admixture with altered blood, or, lastly, they may consist +of mucus and blood, in which event the complication assumes the form +of actual dysentery and is attended with increased abdominal pain and +with tenesmus. Dysentery was, as would be expected, quite frequent in +the Indian epidemics studied by Carter.[24] It is usually of moderate +severity, but occasionally it runs into gangrenous inflammation, is +attended with perforation of the bowel, or is followed by hepatic +abscess. In one instance we noticed a peculiarly fetid puriform +discharge from the anus, which occurred during the relapse and +persisted for several weeks, gradually subsiding, as though from some +unhealthy ulceration which slowly healed. + +[Footnote 24: _Op. cit._, p. 218.] + +Jaundice is of frequent occurrence, but has been sufficiently +discussed at page 391. + +Peritonitis is not rare in its circumscribed form. This statement is +based on the comparative frequency with which localized splenic +peritonitis, of varying degrees of severity, is found after death in +relapsing fever from various causes, and from the great frequency of +severe pain and tenderness in the region of the enlarged spleen in +favorable cases. In its lesser degrees it may not add materially to +the danger of the patient, but in more severe forms, associated with +serious splenic lesions, it may run a protracted subacute course and +maintain irregular fever. + +General peritonitis is, on the other hand, a rare complication, +occurring not more than once in several hundred cases. It results from +dysenteric perforation of the bowel, from rupture of a splenic +abscess, or from rupture of the spleen itself. An example of this +latter accident which occurred under our observation has already been +given. Speedy death invariably follows, though in the case just +referred to the symptoms of peritonitis were totally masked by those +of the coexisting double pneumonia, which seemed to be the immediate +cause of death. + +Suppuration of the mesenteric glands is a rare complication, mentioned +especially by Wyss and Bock. As these glands are not usually found +enlarged, there being no irritative lesion of the intestines of common +occurrence in relapsing fever, it is probable that the collections of +pus which have been found were metastatic in origin. + +Dyspepsia is not an infrequent sequel, as would necessarily be the +case after a disease characterized by so much gastric irritation and +by such serious lesions of the liver and spleen. As a consequence, +care in diet is often required for a considerable period after the +course of the disease has ended; dyspeptic symptoms are frequently +complained of, and marked emaciation and anaemia often protract +convalescence. + +{407} It may be observed that a striking appearance of emaciation is +often developed shortly after the crisis of the first paroxysm, or, +more particularly, of the relapse. It is partly due to the actual loss +of weight during the high pyrexia, but even more to the abrupt +transition from a state of extreme febrile turgescence to one of +equally extreme relaxation and maceration of the surface. + +The amount of urine has been seen (p. 387) to vary greatly in cases +distinguished by no special disorder of the kidneys; the extremes in +ordinary cases being from twelve or fifteen ounces just before the +crisis to from eighty to one hundred and twenty within forty-eight +hours after the crisis. Suppression is, however, sometimes noted, and +is always a grave symptom, though Parry[25] reports more than one case +in which on several successive days there was not more in twenty-four +hours than one fluidounce of non-albuminous urine, and in which no +symptoms of uraemia occurred, and the sweat had no urinous odor. In +one of our fatal cases, with intense jaundice, hematemesis, inky black +stools, and oedema of the feet and of the lungs, there was not a drop +of urine secreted during the last four days of the initial paroxysm; +death occurred on the eighth day, and the kidneys were found intensely +engorged, of a deep blackish-blue color, with numerous ecchymoses in +the cortex, due to impaction of the convoluted tubules with blood, +while the renal epithelium was granular and swollen, and many tubules +were filled with epithelial cells and granular matter. At the autopsy +the urinary bladder was firmly contracted and contained a very small +amount of bloody liquid. + +[Footnote 25: _Op. cit._] + +More frequently, incontinence of urine, with or without retention, +occurs during the febrile stages--according to our observation, most +commonly in cases attended with mental disturbance and tending to a +typhoid condition. The symptom was not of very grave significance, +however, and after the use of the catheter for a few days the bladder +regained its tone. + +Albumen is quite frequently present in small amounts during the +pyrexia of relapsing fever. Thus, in 18 cases of ordinary severity, +which all recovered, and in which the urine was carefully examined +daily, a trace of albumen was found in 5; in 2 cases it appeared both +in the initial paroxysm and in the relapse, but in all instances its +presence was of brief duration. In one of these five cases the albumen +appeared at both critical periods, when the amounts of urine in +twenty-four hours were respectively 150 ccm. and 250 ccm.; but in the +other cases the transient albuminuria coincided with free secretion of +urine (1250 ccm., 1850 ccm.). It is probable that were the same +careful search to be made in all cases the presence of albumen would +be detected in fully 20 to 25 per cent. On the other hand, in fatal +cases the occurrence of albuminuria is by no means constant, although +undoubtedly it is present in a larger proportion of such cases than of +those of ordinary severity. + +Our experience does not confirm that of Murchison, who states that he +never met with typhoid symptoms in relapsing fever without albuminuria +or some other evidence of retarded elimination by the kidneys. In +several of our cases where the typhoid state was developed in the +highest degree repeated examination of the urine failed to discover +albumen. + +{408} Most observers have been struck with the comparative immunity of +the kidneys from serious disturbance in a disease presenting such +complicated morbid processes and widespread lesions as relapsing +fever. To show, however, that these organs suffer specially in certain +epidemics, it may be mentioned that Obermeier[26] reports having found +albumen with tube-casts of various kinds in 32 out of 40 cases of +relapsing fever, thus showing that, in the particular epidemic he was +studying, catarrhal nephritis was of almost uniform occurrence. It is +true that serious interference with the elimination of urea and other +nitrogenous matters may occur without the coexistence of albuminuria, +so that it is impossible to deny that severe nervous symptoms may +result from impaired renal activity even when the urine contains no +albumen. + +[Footnote 26: "U. d. wiederkehrende Fieber," _Arch. f. path. Anat. u. +klin. Med._, Bd. xlvii. p. 170.] + +Attention has already been called to the variations presented in the +amounts of urea, but more extended observations are required to show +the precise relations of these variations to the graver nervous +phenomena. It will be found, we venture to opine, that, while in one +group of relapsing-fever cases of grave type, cerebral symptoms are +dependent upon the retention and accumulation in the system of urea +and other effete nitrogenous products, owing to interference with +renal activity from pre-existing organic disease of the kidneys or +from an exceptional degree of congestion of those organs, there are +other groups where similar typhoid cerebral symptoms are more directly +dependent upon the specific toxaemia, upon the hyperpyrexia, upon +exhaustion of the nerve-centres by intense peripheral irritation, or +upon congestion or other morbid conditions of the nerve-centres +themselves. + +In all cases where cerebral symptoms manifest themselves in relapsing +fever the daily examination of the urine--which here, as in other +zymotic diseases, is a duty in all cases--becomes of extreme +importance. Three conditions should be borne in mind in such +examinations. In the first place, the attack of fever may have +occurred in one already the subject of organic kidney disease, and, +considering the classes from which the majority of the cases of +relapsing fever are drawn, this possibility cannot be of rare +occurrence. Out of eighteen post-mortem examinations in which the +kidneys were studied with especial care we found positive evidence of +pre-existing organic disease four times. In these cases the +albuminuria was marked and persistent, though tube-casts were rarely +found, and severe cerebral symptoms of typhoid type were prominently +present. In another highly interesting case the patient, who had +amyloid disease of the liver, spleen, and kidneys, contracted severe +relapsing fever; he had increased albuminuria during both febrile +stages, suppurative parotitis, but no grave cerebral symptoms, and +apparently recovered. After an apyretic period of six weeks, during +which the symptoms of the amyloid visceral disease persisted, a sudden +and rapidly fatal pyrexia occurred. Unfortunately, the existence of +spirillar infection of the blood was not known at the time. + +In the second place, the attack of fever may become complicated with +acute nephritis from special localization of the poison, as in +Obermeier's cases, or from vulnerability of the kidneys. In such cases +careful study of the urine should indicate the event, and the +prognosis, though grave, is not so hopeless as in the first instance. +An interesting example of {409} this occurred under our observation, +where the patient, who had apparently an ordinary attack, was seized +with acute catarrhal nephritis, with temporary uraemia, during the +relapse, but after a dangerous illness recovered without any organic +renal disease as a sequel. + +In the third place, may be found the more usual and more +readily-determined condition of slight and transient albuminuria (with +variations in urea excretion) which has already been discussed, and +which has no serious prognostic significance. + +The following very interesting case deserves special mention: The +patient, a man aged thirty-six, was admitted on the fifteenth day of +an attack of acute catarrhal nephritis, with slight ascites, marked +oedema of the feet and legs, and highly albuminous urine. In the +course of ten days the oedema and albuminuria were much diminished, +when on the thirteenth day after admission he was attacked with +relapsing fever, the ward in which he lay containing a number of +persons ill with that disease. The initial paroxysm was severe, but +without any grave cerebral symptoms; the urine grew scanty, dark, and +bloody, and the oedema increased and invaded the pelvis. Crisis +occurred on the fifth day, temperature falling 9 degrees, sweating +copious, urine 473 ccm. in twenty-four hours, color of porter, highly +albuminous, and depositing blood, renal epithelium, hyaline, granular +and epithelial casts, all stained reddish. Two days later, urine 1600 +ccm., light colored, with only a small amount of albumen. + +A slight and brief relapse (101 degrees for two days) occurred after +an interval of four days; a second imperfect relapse (100.5 degrees +for three days) after a further interval of six days; and finally, +after a further interval of only two days, a violent relapse +(temperature rising rapidly to 106 degrees) with crisis (fall of 8 +degrees in twelve hours) at close of fifth day. The oedema gradually +diminished from the time of the first crisis, did not increase in the +relapses, and disappeared completely and finally about ten days after +the last relapse. The urine was very free after the first paroxysm, +averaging from 2000 to 2300 ccm. During the subsequent febrile periods +it did not decrease, and indeed on the second day of the last relapse, +with the temperature at 105 degrees, the amount in twenty-four hours +was 3200 ccm. Four days subsequently, during crisis, the amount was +only 350 ccm. + +The albumen disappeared entirely from the urine in two weeks from the +close of the last relapse; there had then been no tube-casts for some +days, and the patient was discharged entirely well a short time +afterward. The treatment consisted of hot vapor-baths, repeated dry +cupping over the kidneys, infusion of digitalis with acetate of potash +during pyrexia, and Basham's iron mixture in the intermissions. It +seemed that the occurrence of the relapsing fever interfered +wonderfully little with the recovery from nephritis. + +Hematuria is a comparatively rare and very grave complication. It may +occur as an additional evidence of the dyscrasia of the blood in +connection with hemorrhages from other surfaces, or as in the case we +have before referred to or in that reported by Murchison,[27] it +results from intense engorgement of the kidneys. In Murchison's case +hematuria, with much albumen and tube-casts, occurred in both +paroxysms {410} without any uraemic or typhoid symptoms, and was +followed by satisfactory recovery. + +[Footnote 27: _Op. cit._, p. 370.] + +Sugar is sometimes present in small quantity as a transient symptom; +and diabetes has been observed as a sequel.[28] + +[Footnote 28: Tyson, _Phila. Med. Times_, 1871, i. 418.] + +Metastatic inflammation of the kidneys, with centres of suppuration, +was observed by Wyss and Bock. + +When menstruation occurs during relapsing fever, as it may do at any +time, it is apt to be excessive, and may amount to severe hemorrhage. +Crisis has been known to occur in this manner. + +The numerous cases reported by various observers of relapsing fever +occurring in pregnant women establish the rule that abortion almost +invariably occurs, whatever may be the stage of the pregnancy. In a +large majority of cases the mother recovers, but the child, if viable, +is stillborn or dies in a few hours. Only two of our patients were +pregnant women, and the result in each was unusual. In one, the +patient, already the mother of several children, was in the fifth +month of gestation; the initial paroxysm was severe, with delirium, +but no symptoms of abortion occurred; the intermission lasted six +days, during which she felt very well; the relapse was also severe, +and crisis occurred on the fifth day, the temperature falling below +normal, and the case promising to do well; but on the following day +there was a sudden rebound of temperature, pulse 140, severe +praecordial pain, and death occurred in twenty-four hours, the +contents of the uterus being partially expelled during the act of +dying. In the other case, a girl of eighteen years, who had aborted at +the third month of gestation eight months previously, and who was +again three months advanced in pregnancy when attacked with relapsing +fever, went safely through a bad attack and carried her baby +successfully to full term. + +MORBID ANATOMY.--The surface of the body often presents patches of +livid discoloration, and jaundice persists in cases where it has been +present during life. There is but little appearance of emaciation, +except in cases where it has been present before the attack. + +When death occurs while the temperature is high the body remains warm +an unusual length of time. Thus, in one case where death occurred at +11.30 P.M., the temperature at 12 was 103 degrees, and at 1 A.M. it +was 101-3/5 degrees, that of the room being 73 degrees; at 6 A.M. it +remained at 93 degrees, the room being at 73 degrees; between 9 A.M. +and 2 P.M. the room was kept at 55 degrees, but the body was still at +82 degrees at the latter hour. + +The voluntary muscles are often jaundiced, and in prolonged cases they +may be found flabby and having undergone marked granular degeneration. +In many cases, however, they remain quite dark and firm. Ecchymoses of +the muscular substance are met with occasionally. + +In one case, where during life there had been painful swelling of the +left parotid region, with fistulous openings on the cheek, and where +death occurred on the twelfth day of the disease, the masseter muscle +was swollen, with patches of dark, almost black, discoloration from +ecchymosis, and was studded throughout with small collections in its +substance. The fluid from these contained very numerous cells +indistinguishable from leucocytes. The muscular fibrils were friable +and granular, and there was multiplication of the nuclei of the +sarcolemma. {411} These unusual lesions seemed to have originated in +interstitial disintegrating thrombi, with consequent inflammation of +the muscle. + +The muscle of the heart is more frequently affected, and in the fatal +cases our attention was particularly drawn to those lesions. +Ponfick[29] has also described them minutely. The degree of change +varies from a partial loss of transverse striation, with slight +granular appearance, up to a very high degree of granulo-fatty +degeneration. The organ is then flabby, its substance pale gray or +brownish, either wholly or in streaks, and microscopic examination +shows an extreme degree of fatty granular change. It must not be +forgotten, however, that many of the subjects of relapsing fever have +been leading irregular and dissipated lives, and that in some +instances the lesions of fatty degeneration detected in their organs +may have been the result of their previous habits. + +[Footnote 29: _Virchow's Archiv. f. path. Anat._, Bd. lx. Hft. 2, p. +162.] + +Lesions of the cardiac muscle were most marked in those of our +patients who had been intemperate, and in whom fatty degeneration of +the viscera (chiefly liver and kidneys) was also found. They were most +fully developed in cases where death occurred at a comparatively late +period, while in some very severe cases, in which death occurred as +early as the fifth day, the cardiac fibre presented merely faintness +of striation without actual granular degeneration. + +Ponfick in particular notes that the great majority of the bodies he +examined were of persons who had been habitual drunkards. + +Pericarditis is occasionally present, and is marked by the usual +lesions. In a very severe case in which it contributed largely to the +production of the fatal result it was associated with pneumonia. In +addition to this, effusions of blood beneath the endocardium and +pericardium are not rare; and we have seen them quite large and +numerous in cases where the muscular fibre was firmly contracted and +the cavities contained quite firm decolorized clots. + +Thus in our case No. 62, Series C., "the heart was normal in size, +with no appearances of previous disease. There were numerous +ecchymoses of both layers of the pericardium. The right cavities +contained large, firm, yellowish, fibrous clots, forming a cast of the +upper part of the ventricle and of the auricle, and extending both +into the pulmonary artery and back into the veins, and so firm that by +gentle traction a complete cast of these vessels was drawn out. The +clot in the pulmonary artery was throughout firm, fibrous, and +yellowish. There were numerous ecchymoses of the pleura and of the +mucous membranes of the stomach and urinary bladder, hemorrhagic +infarctions in the kidneys and lungs, and granulo-fatty degeneration +of the cardiac muscle." Death had occurred in this case about the +close of the third week, and was preceded by hematemesis and +suppression of urine. We must note in this connection the tendency to +embolism that exists in this disease. + +Especial interest attaches to the condition of the blood in relapsing +fever. Usually it presents no abnormal appearance if drawn during +life, though in grave cases it may coagulate imperfectly. We have no +knowledge of its minute chemical characters, save that in several +cases where there was great diminution in the amount of urine, with +uraemic symptoms, urea has been found in considerable amount in the +blood (Murchison, p. 368). The red globules present no definite or +{412} characteristic changes. In some of our examinations they +appeared of light color and became crenated very quickly on exposure. +On the other hand, the white corpuscles have repeatedly been observed +to be increased in number, at times considerably so (Cormack, +Thompson, Zuelzer, Carter, Boeckmann, and ourselves), though this +change is not regarded as constant or essential. It has, however, a +very great interest in connection with the characteristic lesions of +the spleen which will be described hereafter. In several cases we +observed that many white corpuscles were small and apparently +imperfectly developed. Boeckmann[30] concludes that they increase in +number during the febrile paroxysm, reaching their highest number at +the crisis, and then diminishing gradually to the normal. The red +globules are much decreased during the fever, and return to the normal +slowly during convalescence. + +[Footnote 30: _Deutsch. Arch. f. klin. Med._, Sept. 1881, p. 513.] + +In addition to these changes, various abnormal elements have been +observed more or less constantly. By far the most important of these +is the spirillum or spirochete of Obermeier, which has been already +carefully described. In proportion as this organism has been carefully +looked for it has been found constantly, so that the evidence has +become very strong in favor of its uniform presence in the blood of +relapsing-fever patients during the febrile stage of the disease. + +Ponfick in 1874[31] called attention to the occurrence of large +granule-cells in the blood in this disease. They are found during life +as well as after death, when they exist in largest proportion in the +blood of the splenic, hepatic, and portal veins. Their shape is +spherical, ovoid, or elongated; the basis of the cells is a delicate, +translucent, albuminous substance; and the granules are of a fatty +nature, as shown by the action of reagents. These cells have been +found by other observers, and the view is generally received that they +are derived from the lymphoid elements of the spleen, and perhaps of +other portions of the lymphatic system; and Carter, who has studied +them carefully, is inclined to think there is some connection between +them and the development of the spirillum. + +[Footnote 31: _Centralbl. f. d. med. Wissensch._, 1874, p. 25.] + +Ponfick also first described[32] certain other large, +irregularly-shaped, pale, granular, nucleated cells, which occur in +smaller number in the blood in relapsing fever, and which he regarded +as altered endothelium, derived from the lining of the blood-vessels, +of the lymphatics, or of the lacunar spaces of the spleen. +Occasionally these cells are found with such highly granular contents +as to make them closely simulate the large granule-cells described +above. These results of Ponfick have been confirmed by other +observers. + +[Footnote 32: _Loc. cit._] + +In several of our reports of examinations of blood there is mention +made of quite abundant, free granular matter--an appearance also +observed by Carter. Finally, the latter describes the occurrence of +thread-like filaments and of short, rod-like bodies. + +There are no characteristic lesions connected with the +gastro-intestinal canal. The mucous membrane of the stomach may be +normal or merely injected, though where there has been much vomiting, +and especially bloody vomiting, there is marked injection, and not +rarely ecchymosis and submucous extravasations of blood, with +softening of the membrane. {413} These extravasations are usually +small, but Cormack reports a case where one-third of the mucous +membrane of the stomach was the seat of ecchymosis and extravasation. +In one of our own cases the extravasations occupied an area of four +inches square. + +The small intestines exhibit patches of congestion or ecchymosis less +frequently than the stomach, though it is usual to find injection of +the mucous membrane, especially of the lower portion, in cases where +there has been diarrhoea. Carter, observing the disease in India, +found in one-half of all autopsies some amount of congestion, +hemorrhage, or inflammation of the ileum. In two instances he found a +layer of diphtheritic deposit over the mucous membrane of the lower +part of the ileum. + +There are no special alterations of the solitary or agminated glands, +and ulceration never occurs. Even in cases where the constitutional +infection is severe, whether diarrhoea has been present or not, it is +noteworthy that there is rarely any swelling of the solitary glands or +Peyer's patches, such as is met with in many other acute specific +diseases. It was not present in any of our autopsies. + +The large intestine in like manner exhibits no characteristic lesions. +Patches of congestion and occasionally submucous ecchymoses may be +observed, and croupous exudation occurs here somewhat more frequently +than in the small intestine. + +Wyss and Bock[33] speak of enlargement of the mesenteric and +retroperitoneal glands as of frequent occurrence, but we did not +observe it, and Murchison states that these glands present no abnormal +appearance. + +[Footnote 33: _Op. cit._, p. 223.] + +Alterations of vascularity of the brain or its membranes are met with, +but they are variable and bear no definite relation to the precedent +symptoms. Ecchymoses of the membranes are occasionally observed, and +in one of our cases extensive meningeal hemorrhage was found. +Murchison reported a case in which embolism of the left femoral artery +occurred, and subsequently of the left middle cerebral artery, +inducing death. The suggestion may be hazarded that in some of the +cases where there is severe delirium ending in stupor and death there +has been multiple capillary embolism of the cerebral vessels. + +There is occasionally the evidence of catarrhal inflammation of the +upper air-passages, and in some epidemics diphtheritic exudation in +the pharynx and larynx has been noted (Wyss and Bock); and Ponfick +found acute oedema of the glottis in a considerable proportion of the +fatal cases at Berlin. The lesions of pleurisy are met with in a small +proportion of cases; in our own autopsies this complication was more +frequent than in most epidemics. + +The lungs may be normal, and Murchison concludes that they are more +frequently so than in typhus. Still, they often present congestion or +oedema, and subpleural ecchymoses, hemorrhagic infarctions, and +pneumonic consolidation are not rare. Lobar pneumonia was present in +33 per cent. of our own autopsies, in 28 per cent. of Carter's, and in +20 per cent. of those conducted by Ponfick. The inflammation usually +presents the regular stages, and is associated with a moderate degree +of plastic pleurisy; but occasionally, as in one of our cases, it +terminates in gangrene. In the instance referred to there was an area +of gangrene about three inches square and one inch in depth, involving +the pleura and a {414} superficial layer of lung on the antero-lateral +aspect of the left lower lobe. In another remarkable instance, already +referred to on account of the suppurative inflammation of one masseter +muscle, the lungs, which were stained yellow throughout, presented +numerous deep purplish patches, which on section altogether resembled +the secondary metastatic deposits of pyaemia, with yellowish softening +or even puriform centres surrounded by a rim of purplish livid +discoloration. Very numerous similar patches, varying from the size of +a pea to that of a hazel-nut, and presenting every stage of +development, were found throughout both lungs. In a few instances we +found the lesions of chronic phthisis, which had, of course, existed +before the attack of relapsing fever. The bronchial glands were found +swollen and infiltrated in cases where inflammatory processes in the +lungs have existed. + +Much interest attaches to the state of the genito-urinary organs in +relapsing fever, but caution is required to distinguish lesions that +have existed prior to the attack from those properly referable to it. + +Owing to the intemperate and exposed lives of many of the patients, +renal lesions might reasonably be expected in no small proportion. The +comparative rarity of albuminuria (see p. 407), even in severe cases, +is suggestive of the view that when it is present it may at least +sometimes be due to pre-existing lesions aggravated by the acute +infectious process, and further that the extreme gravity generally +presented by such cases may be in part due to the impaired condition +of the kidneys. + +The morbid changes most frequently referable to the fever are moderate +enlargement and congestion, occasionally very intense so that we find +it described in our notes as deep blackish-purple or blue; ecchymoses +of the capsule or of the mucous membrane of the pelvis; small +hemorrhagic infarctions, usually in the cortex; and cloudy swelling of +the glandular cells. Less commonly are found hemorrhagic infarctions, +or small embolic patches advanced to various stages of disintegration, +even to the formation of small puriform collections. In quite rare +cases the lesions of acute nephritis are present, while caution must +be used in interpreting other changes occasionally met with, such as +pallor with granulo-fatty degeneration or other advanced alterations +of the glandular cells, or hyperplasia of the intertubular connective +tissue, with or without contraction of the kidneys. + +The mucous membrane of the bladder, as already mentioned, may present +ecchymoses, or, more rarely, croupous exudation (Wyss and Bock). The +urine contained may be bloody, or, as in one of our cases where there +had been total suppression of urine for over seventy-two hours before +death, there may be but a small amount of almost pure blood, +containing a few phosphate crystals, but no tube-casts. In this case +there were also ecchymoses of the bladder and of the pelvis of the +kidneys, with intense congestion and numerous small hemorrhagic +infarctions of the kidneys. + +The liver is constantly though variously affected. It is found +enlarged in the great majority of cases, especially if death has +occurred during the febrile stage. The ordinary degree of enlargement +in our cases was from four to four and a half pounds, but in a few +instances the liver weighed one hundred or one hundred and two ounces, +though in most of these extreme cases the patients had been drunkards, +and there was such advanced fatty alteration of the liver as to make +it probable that the {415} organ had been diseased previously. These +figures correspond with the results of other observers. + +In many cases, especially when death occurs early and during the +febrile stage, the capsule and substance of the liver are congested, +at times intensely so; and when ecchymoses are found elsewhere they +are apt to be present here also, appearing as purplish patches dotted +over the capsule and extending into the superficial layer of hepatic +tissue. Not rarely, however, the liver substance is paler than normal, +and presents a yellowish tinge, apart from the decided yellowish +staining present in cases attended with jaundice. Carter describes a +partial mottled paleness of the liver as having been frequently +observed in his cases, the circumscribed pale areas presenting a +corresponding localized degeneration of the cells, as though from some +local interruption of circulation. + +Cloudy swelling and fatty degeneration of the liver-cells are indeed +very often present, and in some epidemics with preponderance of +bilious symptoms are constantly found (Ponfick). The degree of the +cell-alteration varies from a slight granulo-fatty change to an +advanced fatty degeneration, even with a marked tendency, in rare +cases, to disintegration of the cells, so as to produce lesions +analogous to those of acute yellow atrophy (St. Petersburg epidemic). + +The whitish deposits described by Kuttner as due to albuminous or +fibrinous infiltration are probably referable to transformed +hemorrhagic infarctions, and the minute puriform collections that have +been observed at the centre of the acini (Wyss and Bock) may have been +metastatic in origin, or attributable to the disintegration of minute +thrombi associated with irritative hyperplasia of the adjacent +lymphoid elements. The consistence of the liver varies: when death +occurs early and bilious symptoms have not been marked, it may be even +firmer than normal, but more frequently it is softer, and it may be +relaxed, flabby, and friable. + +The condition of the bile-ducts is of great interest in view of the +frequency of jaundice as a symptom in relapsing fever, and most +authorities unite in saying that they present no lesions capable of +explaining it. + +The gall-bladder is usually found full of dark bile, but there is no +such degree of inspissation, except in rare instances, as could +interfere with its passage through the ducts. Murchison quotes the +statement of Peacock that in some instances the bile was thick and +viscid, so as apparently to cause obstruction, but all observations +agree in showing that this is exceptional. The mucous membranes of the +larger ducts may present evidences of slight catarrhal inflammation, +but in nearly all cases where they have been carefully examined, even +when jaundice had been marked, they have been found patulous and free, +so that the jaundice cannot be regarded as due to obstruction of the +larger ducts save in rare instances (Pastau). In further confirmation +of this may be stated the fact that there is no want of bile in the +duodenum and feces. + +On the other hand, a careful consideration of the lesions of the +substance of the liver will show that it would be most improbable that +the minute biliary ducts in the areas most affected should escape +implication. Munch, who investigated this subject carefully, found +that there was a catarrhal state of the fine bile-ducts in every case +of relapsing fever with jaundice; and Litten found the smallest ducts +plugged with bile-stained pellets of mucus. It would appear, +therefore, that in many cases at least {416} the jaundice is really +obstructive in its origin, the seat of the obstruction being in the +too-rarely examined minute bile-ducts, though further investigation of +this interesting question is required. + +The clinical bearing of these conditions has been fully discussed in +the appropriate section. + +The changes in the spleen are constant, and even more remarkable than +those in the liver. It is enlarged with rare exceptions, and +especially so if death has occurred during the febrile stage. Upon the +subsidence of the fever the spleen probably returns to its normal size +more rapidly than the liver. The more common extent of the enlargement +in our own cases was from ten to eighteen ounces, though we found the +spleen in one case weighing twenty-nine and a half ounces and in +another forty-four and a half ounces. In neither of the latter +instances was there any reason to suspect malarial complication. The +most extensive enlargement we have found recorded is sixty-eight +ounces in a case reported by Kuttner.[34] + +[Footnote 34: _Schmidt's Jahrb._, 1865, vol. cxxvi.] + +There is usually a correspondence between the stage and extent of the +splenic and hepatic lesions, but this is not invariable, and one or +the other organ may present a far higher degree of enlargement or much +more intense interstitial changes. It may be mentioned, moreover, that +in some unusual cases the lesions of the lungs, such as ecchymoses and +hemorrhagic infarctions, may be disproportionately marked as compared +with those of either the liver or spleen. + +The capsule of the spleen often presents a mottled look, with at times +large purplish ecchymoses; it is apt to be more or less opaque, and +local peritonitis, with thin layers of plastic exudation often forming +friable adhesions with the abdominal wall, may exist. + +In one of our cases the capsule presented a small perforation or +rupture, with an exudation of plastic lymph over an area of four by +six inches, and diffuse peritonitis, with effusion of bloody liquid +with shreds of lymph throughout the abdominal cavity. This fatal +termination is fortunately rare, but there are several other instances +on record. The splenic pulp may retain its consistency and firmness, +even in cases that have run a long course; but more frequently it is +softened, and may be almost diffluent. The pulp is often swollen, so +that when cut it projects above the section. The color is darker than +normal, and often is of a deep maroon color. This swelling is due to +enlargement of the blood-vessels, associated with great increase of +the cellular elements of the pulp and with enlargement of the +Malpighian corpuscles. + +When death occurred early in the disease we found these bodies grayish +or grayish-yellow in color and of the size of hempseed, so that the +section very thickly studded with them closely resembled shad-roe, and +this stage of the lesion is frequently described in our notes as the +shad-roe spleen. Subsequently, the Malpighian bodies enlarge still +more, and stand out above the section a line or more in diameter, and +of a lighter color; not rarely, several of them come in contact, and +thus form a considerable mass of irregular shape, resembling the +infarctions described below.[35] It is probable that central softening +may occur later in the {417} Malpighian bodies, though we are inclined +to regard the puriform collections frequently found as chiefly due to +the disintegration of hemorrhagic infarctions or of embolic patches. +Of these, hemorrhagic infarctions are by far the most common and +present the familiar appearances. They may be quite numerous, +superficial, or deep-seated, and of variable shape and size. At first +dark reddish, firm, and sharply separated from the surrounding pulp, +they grew reddish-yellow or yellowish later, softened in the centre, +and eventually were transformed into puriform collections. Doubtless, +in a large proportion of cases that recover such infarctions exist and +are slowly absorbed. Ponfick has shown that these are venous +infarctions, the arterioles leading to them being patulous. True +arterial embolism does, however, occur, though much more rarely +(Ponfick, Murchison), giving rise to firm, wedge-shaped infarctions at +the periphery of the spleen, which may undergo degenerative changes +similar to those above described. The resulting abscesses may burst +into the peritoneum, pleura, lung, or bowel. The microscopic +appearances have been most fully described by Ponfick, our own +comparatively meagre observations having accorded entirely with his +subsequent accurate description. The cells of the swollen pulp contain +red blood-discs and pigment, and some present collections of bright +granules. The lymphoid cells of the Malpighian corpuscles are at first +in a state of cloudy swelling with multiplication of their nuclei, and +later show marked granular fatty degeneration. + +[Footnote 35: Thus, Wyss and Bock describe "multitudes of minute +abscesses as large as poppy or hempseed, and containing a single drop +of pus."] + +The lymphatic glands present no lesions, and the pancreas is normal. + +The peritoneum is not affected as frequently as other serous membranes +in this disease. Superficial ecchymoses are, however, quite common, +especially so over the solid viscera; and more rarely effusions of +blood have been found in the subperitoneal connective tissue, +involving the muscular or glandular tissues beneath. We have already +mentioned (p. 406) the occasional occurrence of local peritonitis, +most frequently of the splenic capsule, and also the rare accident of +diffuse inflammation from rupture of the spleen. + +The marrow of the bones was carefully examined by Ponfick, who first +called attention to the presence of important changes in relapsing +fever, which have since been confirmed by other observers. These +changes consist in proliferation and subsequent degeneration of the +lymphoid cells of the marrow, with multiplication of the nuclei in the +walls of the minute vessels and fatty degeneration of their coats. As +a result of these changes, spots of puriform softening may form, +chiefly in the cancellous tissue of the extremities of the long bones, +with the production of localized necrosis, and possibly with extension +of inflammation to the neighboring articular cavity. + +Considerable space has been devoted to the detailed consideration of +the pathological changes in relapsing fever, partly because we believe +the fact has not been sufficiently recognized that the disease is +constantly attended with important and characteristic lesions. These +consist, in brief, of remarkable changes in the blood; of widespread +ecchymoses and infarctions, which not rarely undergo puriform +disintegration; of hyperplasia and subsequent degeneration of the +Malpighian corpuscles of the spleen, with changes in the cellular +elements of the splenic pulp; of cloudy swelling of the gland-cells of +the liver and kidneys, with a {418} marked tendency to fatty +degeneration; of changes in the marrow of the long bones; and, +finally, of granulo-fatty degeneration of the muscles, and especially +of the heart. + +DIAGNOSIS AND RELATION TO OTHER DISEASES.--The entire question of the +diagnosis of relapsing fever is dominated by that of spirillar +infection. Before Obermeier's discovery the differential diagnosis of +the initial paroxysm, and to a less extent that of the subsequent +events of a case of relapsing fever, was attended with considerable +difficulty. But if, as now seems established, immediately before and +throughout the initial paroxysm and subsequent relapses a +characteristic spirillum is to be detected in the blood upon proper +examination, while it rapidly disappears after the crisis, it is +evident that as soon as a suspicion is aroused as to the possible +presence of relapsing fever the question may be settled conclusively +by the microscope. + +None the less is it important to consider carefully, but briefly, the +symptoms by which relapsing fever is to be distinguished from various +affections which may simulate it, because even the most experienced +observers admit that the spirillum cannot be invariably detected; +because it is not yet known that a similar organism may not be found +in some other affections; and, finally, because on the outbreak of an +epidemic of relapsing fever, especially in America, where its +occurrence has hitherto been so rare, there is strong probability that +the nature of the early cases will not be even suspected until the +relapse occurs. + +Typhus fever often prevails in an epidemic form simultaneously with +relapsing fever, so that it was inevitable they should have been for a +time confused. Their essential non-identity is, however, now too well +recognized to require any lengthy demonstration. The following +statement of the heads of the argument may therefore suffice. + +In typhus there is no characteristic spirillum, and the lesions which +are truly characteristic of relapsing fever are totally wanting. There +are convincing differences in the symptoms, course, and results of the +two diseases. There is no evidence to show that when fever has been +imported into a locality by a single case, typhus fever has ever +produced other than typhus, or relapsing other than relapsing fever. +The two diseases often prevail together, and may coexist in the same +house, each preserving its own distinct characteristics; and persons +exposed to the double contagion may contract one or the other, or +first one and then the other at a shorter or longer interval, so that +an attack of either exerts no protective power against the other. It +must be noted, however, that in a large majority of such cases of +successive contagion it is relapsing fever which has been followed by +typhus, while the reverse has been observed much more rarely. + +In 1869-70 the two diseases were prevalent in Philadelphia, and the +wards of the municipal hospitals constantly contained a considerable +number of cases of both. Three instances came under our care in which +after recovery from relapsing fever the patient contracted typhus. All +of these patients were employed as assistant nurses, and were +continuously under observation from the early part of their attack of +relapsing fever to the end of the attack of typhus. In one case the +interval of health between the close of the relapse and the onset of +typhus was forty-four days; in the second it was thirteen days. In +both cases the original disease was {419} thoroughly characteristic +and the subsequent attack of typhus was typical. In both death +followed, and the post-mortem examination verified the above +statement. The third patient had severe relapsing fever, from which he +recovered and returned to work, though with pains in the legs, +shoulders, and forehead. After an interval of apparent health of +eleven days he developed a well-marked attack of typhus, which +terminated on the twelfth day in recovery. It may be added that +although typhus is not of frequent occurrence in any portion of North +America, there have been a number of epidemics unattended with a +single case presenting the features of relapsing fever. + +Between well-marked cases of the two diseases there should be no +difficulty in making a prompt diagnosis. Relapsing fever is +distinguished from typhus clinically by the severity of the initial +chill; the rapid elevation of the pulse and temperature; the +comparative infrequency and mildness of cerebral symptoms, despite the +intense fever; the severity of the gastric symptoms, nausea and +vomiting; the enlargement of the liver and spleen, with marked +abdominal pain and soreness; the frequency of jaundice, of epistaxis, +and of other hemorrhages, and of anaemic murmurs over the heart and +large vessels; obstinate insomnia; vertigo; peculiar rheumatoid pains +and perversions of sensation; the frequency of sweating during the +high pyrexia; by the occurrence of crisis, subnormal temperature, +apyretic interval, and relapse; the rarity of measly eruption and of +bed-sores; the frequency of pneumonia, diarrhoea, ophthalmia, oedema, +and desquamation as complications and sequelae; the usual occurrence +of abortion in pregnant females; the protracted course of the disease, +and its remarkably low mortality despite the severity of the symptoms, +except in cases of complicated or typhoid type; and, finally, by the +modes in which death occurs. Of course to this must be added the +specific result of examination of the blood in relapsing fever. + +Doubt will arise only in very rare cases where a measly eruption +appears on or before the fifth day of relapsing fever, with headache +and mild delirium, but without severe gastric symptoms, epistaxis, or +jaundice. If no relapsing fever were prevalent at the time, such a +case might well be regarded as one of mild typhus until the crisis and +the relapse disclosed its real nature. But if the two diseases were +known to be prevalent in the community, examination of the blood would +properly be made at once and the diagnosis be established. + +The diagnosis between ordinary cases of relapsing fever and typhoid is +readily made by the gradual onset and peculiar course of the pyrexia +in the latter disease, as well as by the frequency of delirium, of +abdominal distension, and of diarrhoea, and by the characteristic +eruption. The occurrence of epistaxis, bronchial irritation, and +splenic enlargement is common to both, and an eruption of small +rose-pink spots has been noted by some observers (Carter, pp. 194, +317). But jaundice, enlargement of the liver, hypochondriac pain and +soreness, excessive nausea and vomiting, severe rheumatoid pains, and +numbness and tingling of the extremities, are very significant +symptoms of relapsing fever. Attention has already been called to the +grave type of relapsing fever in which the typhoid state is fully +developed, and to the fact that in such cases the pyrexia is often +modified, the onset less abrupt, the crisis imperfect, and the +interval occupied by an irregular post-critical {420} symptomatic +fever. It is altogether probable that such cases have not rarely been +regarded as of true typhoid character; and indeed the attempt has been +made by Griesinger to establish as a separate and independent +affection, under the name of bilious typhoid fever, a group of cases +which close examination seems to show to be chiefly composed of grave +complicated relapsing fever with a certain proportion of true typhoid +fever, complicated with jaundice. + +The recognition of the bilious typhoid type of relapsing fever is +based upon the history of the case; the mode of onset; the greater +severity of the pains, arthritic and abdominal; the early appearance +and intensity of the jaundice; the more marked enlargement of the +liver and spleen; the marked tendency to hemorrhages from various +surfaces; the peculiarities which careful study of the temperature +curve will show, especially about the time of crisis; the rarity of +eruption; the characteristic spirillum;[36] and the totally different +anatomical lesions, which are, unfortunately, often demonstrable, as +this form of relapsing fever is fatal in from 33 to 50 per cent. of +cases. + +[Footnote 36: As first demonstrated by Motschutkoffsky.] + +Since the discovery of the spirillar test for relapsing fever it may +be said that Griesinger's bilious typhoid must be stricken from +medical nosology as an independent affection. + +The case of Charles Hood, on page 396, is a good example of the +bilious typhoid form which occurred not rarely in the Philadelphia +epidemic. + +Murchison points out that, owing to the frequent occurrence of +jaundice in relapsing fever, this disease has been mistaken for yellow +fever by such good observers as Graves, Stokes, and Cormack. +Difficulty in diagnosis would be likely to arise only in regard to the +bilious typhoid type of relapsing fever, and since its clinical +history has become so well known, a mistake is not likely to occur. +The geographical distribution of the diseases is widely different. +Yellow fever is influenced powerfully by season and temperature, while +relapsing fever is independent of both. Negroes are but slightly +liable to yellow fever, while relapsing fever attacks them with +special violence. Yellow fever is not contagious, but infectious, and +second attacks are extremely rare; relapsing fever is one of the most +contagious of the zymotic diseases, but one attack does not protect +against a subsequent one. The mortality, the anatomical lesions, the +course of the pyrexia, the leading clinical symptoms, are all widely +distinct in the two affections; and, finally, no spirillum has been +found in the blood in yellow fever. Yellow fever is an extremely fatal +disease; the ordinary form of relapsing fever has a mortality of 2 to +10 per cent.; the bilious typhoid form, one of 33 to 50 per cent. In +yellow fever the spleen is but slightly enlarged, and the liver is +pale and softened; in relapsing fever the liver and spleen are greatly +enlarged, and there is great tenderness over the hypochondriac region. +In yellow fever albuminuria is much more common, and the urine more +frequently suppressed, than in relapsing fever. + +The sudden onset, the severe headache and pains in the limbs, the +vomiting, jaundice, epigastric tenderness, enlargement of the liver +and spleen, occasional epistaxis, hematemesis, or hematuria, absence +of characteristic eruption, liability to herpes facialis, pneumonia, +and diarrhoea; the occasional occurrence of remissions in the pyrexia, +and even of more or less fully-developed chills for several successive +days during the initial paroxysm or {421} the relapse, suffice to +explain the difficulty which may arise in distinguishing the bilious +form of relapsing fever from bilious remittent fever. But the latter +disease arises exclusively from malaria, and is therefore powerfully +influenced by season and locality; is not contagious; does not present +anything approaching to the crisis, the apyretic interval, or the +abrupt relapse of relapsing fever; presents pigmentary changes in the +blood, instead of the spirillum; and lesions of the spleen and liver +totally unlike those characteristic of relapsing fever; can be +promptly controlled by antiperiodic doses of quinine, and therefore +should have a mortality far less than that of the grave form of +relapsing fever. It is not necessary to pursue this subject further, +but a reference to the temperature charts of Carter[37] or of +Litten[38] will show that in some epidemics single paroxysms +resembling those of quotidian ague might occur during the interval +between the initial paroxysm and the relapse, or a series of two, +three, or more such paroxysms of quotidian or tertian type might +represent an entire relapse. Such phenomena are wholly uncontrollable +by quinia, and are presumably dependent upon irregularities in the +specific infection, instead of upon a blending of malaria with the +poison of relapsing fever. There is some ground for believing, +however, that those who have recently passed through an attack of the +latter are highly, perhaps unusually, susceptible to malarial +infection, as we have already seen they are liable to contract typhus. + +[Footnote 37: _Op. cit._] + +[Footnote 38: _Deut. Arch. f. klin. Med._, xlii. 1874.] + +The chill, the sudden and high fever, the acid sweat, the high-colored +urine, the intense pains and soreness, and the occasional murmur over +the heart, will in some cases of relapsing fever suggest the idea of +severe rheumatic fever, with illy-developed articular inflammation and +with a tendency to hyperpyrexia. The urgent danger presented by the +latter condition and the necessity for immediate recourse to cold +baths and large doses of quinine or of the salicylates, render it +highly important that no such error of diagnosis should be made. It +will usually be avoided readily by observing that in relapsing fever +there are great nausea, repeated vomiting, insomnia, peculiar +formication of the extremities, jaundice, early enlargement of the +liver and spleen, with abdominal pain and soreness, and a tendency to +epistaxis; and, further, that despite the high temperature, cerebral +symptoms such as result from rheumatic hyperpyrexia are not +threatened, except in grave typhoid cases or just preceding the +crisis. + +The onset of relapsing fever may suggest forcibly the invasion period +of small-pox, with its marked rigors, high fever, lumbar pain, aching +in the head and limbs, nausea and vomiting, and if the patient is +known to have been exposed to the contagion of both diseases a +diagnosis would be impossible until the third day. But such a dilemma +can rarely occur, and under ordinary circumstances the patient's +antecedents will enable a correct opinion to be formed. + +Severe cases of simple febricula with marked gastric disturbance may, +as remarked by Jenner, closely simulate relapsing fever; and the same +is true of attacks of acute gastro-hepatic catarrh, with severe +headache, sharp fever, cholaemic eye, epigastric tenderness, and +frequent vomiting. Of course there is no danger under ordinary +circumstances of these simple conditions being regarded as relapsing +fever, but when the latter is prevalent in epidemic form it is +probable that the mistake is frequently made. {422} Although an +immediate diagnosis might be possible only by microscopic examination +of the blood, the peculiar clinical symptoms of relapsing fever would +soon be found wanting, and suitable treatment would bring the simpler +affection under control. + +Acute yellow atrophy of the liver occurs chiefly in pregnant women, +though it is also met with in men and children; but it is so rare that +should a case of it come under observation during the prevalence of +relapsing fever there is considerable danger that its nature would be +overlooked. It resembles relapsing fever in the occurrence of jaundice +and other signs of hepatic disorder, of delirium, and of a tendency to +hemorrhage from various surfaces. The temperature, however, is more +moderate, and does not exhibit the sudden remission of relapsing +fever; the liver is usually demonstrably diminished in size; severe +nervous disturbances, such as convulsions followed by stupor and then +by coma, are more constant; while the occurrence of spirilla in the +blood of relapsing fever and of leucin and tyrosin in the urine of +acute yellow atrophy serves to distinguish completely the two +diseases. Acute yellow atrophy is, moreover, invariably fatal. + +With ordinary care there is but little danger that any of the local +complications of relapsing fever will so absorb attention as to lead +to a neglect of the specific general disease, so that the cerebral +symptoms should be readily distinguished from the onset of any acute +intracranial affection; the parotitis which occasionally appears early +in the disease should not be confounded with idiopathic mumps; and so +for other complications. There is far more danger, indeed, lest some +of the complications may be overlooked; and this is especially true of +pneumonia, one of the most frequent and most important of them all. +Its occurrence is the cause of the supervention of grave typhoid +symptoms or of the modification of the normal course of the pyrexia in +so many cases that nothing but a systematic daily examination of the +lungs will avert serious oversights. + +MORTALITY AND PROGNOSIS.--The rate of mortality has varied in +different epidemics from 2 or 3 to 24 per cent. Murchison shows that +out of 2115 cases admitted to the London Fever Hospital during a +period of twenty-two years, and embracing two distinct outbreaks, only +39 proved fatal, making 1.84 per cent. mortality. Adding to these the +results of Scotch and Irish epidemics, a total of 18,859 cases, with +761 deaths, is reached, giving the rate of mortality for Great Britain +as 4.03 per cent. The great Indian epidemics studied by Carter gave +111 deaths out of 616 cases, equal to 18.02 per cent. Recent German +epidemics have given from 5 to 10 per cent. The above rates are +obtained where all the cases observed during an epidemic are included. +If, however, the mortality of the ordinary form of relapsing fever is +computed separately from that of the bilious typhoid form, it does not +exceed 2 to 5 per cent., whilst the mortality of the latter form rises +to from 33 to 50 per cent., or even higher. + +In the Philadelphia epidemic, out of a total of 1174 cases there were, +as nearly as can be ascertained, 169 deaths, giving a rate of +mortality of 14.4 per cent. Taking all the cases admitted to the +hospital under our observation, many of which entered at a late period +of the disease and not a few when moribund, the mortality was not less +than 13 per cent. {423} The mortality among the negroes who were +attacked with the disease was considerably greater than among the +whites. Finally, if the mortality of the bilious typhus form be +considered separately--although from the frequency of jaundice in this +epidemic and the numerous gradations of severity presented it is +difficult to form a sharply defined group of this character--it was +certainly not less than 50 per cent. + +The date of death varies with the epidemic, the form of the disease, +and the previous condition of vitality of those attacked. Ordinarily, +by far the larger proportion of deaths occur during the first relapse +or the second interval, but in bilious typhoid cases, presenting grave +complications, especially pneumonia or severe hemorrhages at an early +date, or in cases occurring in intemperate subjects, or in those +previously in impaired health, the mortality is much heavier in the +initial paroxysm or the first interval than at later periods. + +Youth exerts the same favorable influences upon the result of +relapsing fever as it does in the case of typhus and typhoid. +Murchison states that of 717 male patients under twenty-five years of +age admitted into the London Fever Hospital, not one died, and in most +epidemics similar, though not equally marked, results have been noted. +In some epidemics the mortality among young children has been +considerable. As a rule, the percentage of deaths increases with each +decade after thirty years. + +Sex does not exert any definite or constant influence upon the +mortality. The number of males affected is far greater; they are +liable to be exposed to the contagion in its most concentrated form; a +larger proportion of them are probably the subjects of intemperance +than in the case of females; and thus most statistics agree in making +the mortality somewhat greater in the male sex; but, all things being +equal, there is no good reason for holding that sex itself has any +value in determining the result. + +As in other zymotic diseases, the mortality from relapsing fever is +highest during the early period of an epidemic, and the type of the +disease grows milder as the epidemic declines. Cases of the bilious +typhoid form have become notably less frequent during the later stages +of some epidemics than at an earlier period. + +Marked difference has been observed also as to the action of remedies +at different stages of epidemics, the early cases exhibiting an +extraordinary resistance to remedies, and especially to anodynes, +which passes away later. When typhus and relapsing fevers have +prevailed together, and a clear discrimination between the two sets of +cases has not been made, it has appeared that the mortality increased +as the epidemic advanced, but this apparent exception has been due to +the fact that at first the cases of relapsing fever were in the +majority, while later those of typhus, the much more fatal disease, +preponderated. + +Epidemics of relapsing fever prevail at all seasons, but more commonly +they are at their height during the colder months of the year. The +total mortality will of course correspond, but the actual percentage +is not constantly greater during any one season, although it is +probable that the greater liability to chest complications during the +colder months will render the disease more fatal then. + +The gravity of relapsing fever has varied so greatly in different +epidemics that it is very difficult to determine what influence upon +the mortality {424} has been exerted by mere difference of race. A +further source of difficulty is found in estimating the differences in +the physical conditions of the poorer classes in the various +communities affected. The mortality has been exceptionally high in the +Russian and Indian epidemics and in some of the German ones, while in +the British epidemics it has uniformly been light. It is interesting +to note that in the Philadelphia epidemic, where the great majority of +patients were Irish or negroes, the mortality was high, over 14 per +cent. The previous condition of the Irish patients must certainly have +contrasted favorably with that of the individuals attacked in the +Dublin and Belfast epidemics, so that the difference in result seems +attributable only to a greater virulence of the disease. As an ample +opportunity was here afforded to judge of the relative severity of +relapsing fever in the negro and white races when the cases occurred +at the same season, at the same stage of the epidemic, and in +individuals living under nearly similar conditions, it may be stated +that the conclusion of all who studied the question closely was that +the disease was much more severe among negroes, and in particular that +they displayed a greater tendency to serious complications and to the +bilious typhoid form. + +Although the degree and virulence of the infection undoubtedly +constitute the most important elements in determining the mortality, +the previous health and habits of those attacked with relapsing fever +exert an influence upon the result. This is especially true of +habitual intemperance, which, by disposing to disease of the liver and +kidneys, greatly increases the liability to a fatal result. It has +been seen (page 409), however, that even when acute catarrhal +nephritis existed at the time of the attack severe relapsing fever +might terminate favorably. Another observation which we made +frequently, and which coincides with what is well known in regard to +typhoid and typhus, is that improper exertion and exposure during the +stage of incubation and immediately after the invasion produced a +highly unfavorable effect on the subsequent course of the disease, and +seemed in particular to dispose to dangerous or fatal collapse at the +critical periods. + +Apart from these general considerations, there are many special points +to be considered in regard to the prognosis of relapsing fever: + +If after the crisis of the invasion there is not rapid and decided +improvement, complications should be suspected. + +A sharp rebound of temperature quickly following crisis may be +followed by speedy death. + +Mere elevation of temperature during the invasion and the relapse, +even though to an extreme height, is not attended with the danger +which even a somewhat lower degree would indicate in other zymotic +diseases. + +Increased elevation toward the expected time of crisis should arouse +anxiety, as sudden and dangerous cerebral symptoms may occur. + +Prolonged duration of the pyrexia, or the substitution of irregular +gradual defervescence (lysis) for the characteristic crisis often +associated with typhoid symptoms as are these conditions, is +significant of complications and of danger. + +Wild delirium during the pyrexia, or transient active delirium about +the time of crisis, is not necessarily unfavorable, but continuous low +delirium, with disposition to stupor, is associated with a typhoid +tendency and is frequently followed by death. Excessive muscular {425} +tremor or convulsions are highly unfavorable, but not necessarily +fatal, symptoms. + +Cardiac murmurs are not of serious import. The pulse is not usually as +rapid in proportion to the temperature as in typhus or typhoid, and an +excessively rapid pulse toward the expected time of crisis, especially +if associated with feebleness of the heart's action, points to the +danger of sudden collapse at or soon after that time. Previous cardiac +disease, especially fatty degeneration in habitually intemperate +persons, increases this danger. Continued frequency of pulse after the +crisis indicates some complication or the danger of some accident. + +Cough of a bronchial origin is not a specially unfavorable symptom, +but if associated with the physical signs of pneumonia and with marked +disturbance of respiration it indicates extreme danger. + +Epistaxis, even when copious, often occurs in favorable cases, but +hemorrhage from the stomach or the kidneys is usually, though not +invariably, followed by death. + +An eruption, measly or of pink spots, with or without minute +petechiae, is rare, and usually occurs in severe cases, but is not of +specially unfavorable significance unless associated with the typhoid +state or with patches of purpura. + +Hiccough is a much less unfavorable symptom in relapsing fever than in +typhoid or typhus, and vomiting, even frequent and persistent, may +occur in cases of ordinary severity. + +Enlargement of the liver and spleen indicates special risk only when +persistent for some time after the relapse, in connection with +persistent irregular fever. Jaundice has no necessarily unfavorable +signification, is frequent in ordinary cases in some epidemics, but +when it is associated with the other features of the bilious typhoid +form the danger is extreme, at least 33 per cent. of such cases +proving fatal. + +Slight transient albuminuria may exist without special danger, but if +associated with evidences of catarrhal nephritis, or if extreme +diminution of urine, with or without albuminuria, exists, cerebral +symptoms are apt to ensue, with a high degree of danger. + +All serious complications--parotitis, erysipelas, dysentery, abortion, +pneumonia, and, above all, peritonitis--greatly increase the risk. + +It is not possible to determine in what cases the relapse will fail to +occur. Motschutkoffsky's statement, that when a slight post-critical +rise occurs a relapse will follow, must be applicable only to a +limited number of cases. + +In all cases at least one relapse must be expected; the patient in the +interval must be regarded as still sick, and after the close of the +relapse he must still be treated with rigid care until convalescence +is permanently established. It must be remembered in hospital practice +that many patients enter toward or after the crisis of the first +paroxysm, so that caution is needed in estimating the effect of +remedies and the period of the disease. + +The undue prominence of certain conditions during the course of the +disease is apt to be followed by corresponding sequelae, and +emaciation, anaemia, dyspepsia, diarrhoea, dysentery, enlargement of +the spleen and rheumatoid pains may then be anticipated. The liability +to ophthalmia and affections of the middle ear is not to be forgotten. + +{426} CAUSES OF DEATH.--In fatal cases death occurs from exhaustion +dependent on the protracted and severe sufferings of the patient; from +cerebral symptoms; from hyperpyrexia; from the virulence of the +toxaemia; from uraemic poisoning; from sudden collapse; or from some +complication, such as hemorrhagic meningitis, hemorrhages, pneumonia, +dysentery, rupture of the spleen, peritonitis, or abortion. + +TREATMENT.--The indications for treatment presented by regular cases +of relapsing fever seem to be--to moderate the pyrexia; to relieve +distressing symptoms, especially pain, insomnia, and gastric +irritability; to sustain the strength of the system; to prevent or +modify the relapses; and to avoid complications and sequelae. + +It is needless to observe that until the nature of the specific cause +of relapsing fever is fully determined, whether the spirillum occupy +that relation or not, it is impossible to direct our efforts +rationally toward its neutralization or elimination. The various +remedies which have been employed for these special purposes have no +clinical support to recommend them. And while experiment has shown +that the activity of the spirillum is readily destroyed by the direct +action of various weak solutions, as of quinine, carbolic acid, +iodine, and mineral acids, no special curative effect follows the +internal administration of these remedies, even in the largest doses +consistent with safety. In fact, there can scarcely be any disease in +which treatment is less satisfactory or its results more difficult to +estimate. The marked difference between various epidemics, and the +wide variation presented by the development of individual symptoms in +different cases of the same epidemic, fully account for this. + +Quinine, as might be expected, has been largely used, in the hope that +it might control the pyrexia or prevent the relapse. Murchison[39] +quotes a considerable amount of evidence from various sources to show +that it does not possess either of these powers. It was administered +to a considerable number of our cases, either in small and frequently +repeated doses during the pyrexia or the intermission, or else in +large doses repeated several times in immediate anticipation of the +expected time of the relapse. Thus in some cases three grains of +sulphate of quinia were given every two or three hours until tinnitus +was produced, and then this was maintained during the remainder of the +pyrexia and of the intermission. The amount given daily was from +thirty to forty-two grains. It seemed to rather increase the +discomfort in the head, and in some cases it aggravated the +irritability of the stomach. The pyrexia was certainly not controlled +by it. Given in the same manner during the intermission, it was +usually well borne, but was not effectual in preventing the relapse. +It is true that in some cases the subsequent relapse seemed to be +somewhat modified. + +[Footnote 39: _Op. cit._, p. 408.] + +Thus in one case 30 grains were given on the 6th of April; 39 grains +on the 7th; 39 grains on the 8th; 42 grains on the 9th; and 60 grains +on the 10th; the critical fall had occurred during the night of the +7th, and the relapse began on the evening of the 9th, but the rise in +temperature was less abrupt than usual, and the relapse lasted less +than five days. It was quite severe, however, so that it is doubtful +whether the apparent modification was anything more than is frequently +observed in cases where no quinine has been administered. + +In another case the fall in temperature at the end of the first +paroxysm {427} was from 105.5 degrees to 97 degrees on March 26th: 35 +to 40 grains of sulphate of quinine were given daily on April 4th, +5th, 6th, 7th, and 8th; the temperature began to rise on the 3d, but +the severe pyrexia and the usual symptoms of the relapse were limited +to a period of less than thirty-six hours. This is a less common +irregularity, and yet does not afford sufficient evidence of the +efficiency of quinine. In other cases, however, as already stated, no +appreciable effect followed its administration in this manner. + +To illustrate the other method of giving quinia, a case may be quoted +in which 20-grain doses every three or four hours were given from +April 25th to April 29th, so that in four days 575 grains were taken. +The initial paroxysm was of average severity, and terminated at the +end of the seventh day, April 20th. The quinine did not postpone the +relapse, which occurred on April 28th, but was of much less than the +usual duration. + +In no other case in which these large doses were given was there even +as much reason as in the above instance to attribute to quinine any +positive influence upon the course of the disease. + +In order to demonstrate that the failure of quinine was not dependent +upon a want of absorption, Muirhead injected large amounts +subcutaneously with no better results. + +In conclusion, it may be said that the evidence shows positively that +quinine possesses no specific influence whatever upon relapsing fever; +that in only occasional cases, if at all, will even enormous doses +given during the intermission postpone or modify the subsequent +relapse; and that it is not effective in reducing the temperature. In +view, therefore, of the usual gastric irritability and tendency to +vertigo and headache, which seem to be increased by large doses of +quinine, and, further, in view of the small mortality, and of the fact +that when death occurs it usually comes from causes over which large +doses of quinine could exert no influence, it seems clear that this +drug should be prescribed only in tonic doses and only in cases where +it is well tolerated by the stomach. + +Arsenic was used in a considerable number of our cases with the view +of determining if it possessed any power of relieving the severe pains +or of influencing the relapse. It was administered in the form of +Fowler's solution (Liq. potassii arsenitis), and was given exclusively +by the mouth. If given during the intermission, it was well borne in +doses of five to ten drops every four or even every three hours, given +freely diluted with water and immediately after food. In several cases +it quickly induced puffiness about the eyes, but no effect whatever +was produced on the pains or on the succeeding relapse. In more than +one such case there was an unusually profuse crop of sudamina during +the relapse, many of the vesicles breaking and being followed by +brownish stains. When given during the pyrexia it aggravated the +nausea and vomiting, so that it had to be suspended. In one +unfortunate case, indeed, although promptly suspended, the arsenical +solution seemed to have assisted in the establishment of vomiting and +purging, which proved uncontrollable and contributed greatly to the +fatal result. Hypodermic injections of arsenic have been used +considerably with no better results. There seems, therefore, to be no +reason whatever for any further use of this drug in relapsing fever. + +{428} The high pyrexia and the severe rheumatoid pains have naturally +suggested the use of salicylic acid and the salicylate of soda. We +were not sufficiently aware of their antipyretic properties in 1869-70 +to have recourse to them, but in more recent epidemics Unterburger[40] +and Riess[41] have found that large doses of the latter substance (one +hundred grains or more daily) will reduce the temperature either in +the initial paroxysm or in the relapse, but that the disease is not +cut short nor are the lesions of the blood or solids prevented. + +[Footnote 40: _Jahrb. f. Kinderheilk._, v. x., 1876.] + +[Footnote 41: _Deutsch. Med. Wochnsch._, Dec., 1879.] + +It must be borne in mind here, as in connection with the action of +quinine, that apparent modifications of the relapse are to be viewed +with great distrust, since such great irregularities therein naturally +present themselves. Care must further be taken lest such attempts to +reduce the temperature aggravate the irritation of the stomach, and by +lessening the power of taking food induce more serious exhaustion than +would have resulted from the unchecked pyrexia. The evidence in our +possession is not sufficient to justify a positive decision as to the +therapeutic value of the salicylates in relapsing fever, but, +apparently, they are applicable to only a portion of the cases, and in +these are of but limited utility. + +The same failure which has followed the use of quinine, of arsenic, +and of salicin and the salicylates has attended the effort to prevent +the relapse by berberine, benzoate of soda, tincture of eucalyptus, +and other reputed antiperiodics. + +Digitalis, veratrum viride, and aconite were used by us quite freely +as antipyretics. The first two of these were often suspended on +account of the irritability of the stomach, and no valuable results +followed their use when well tolerated. Aconite in small doses, +frequently repeated, as one drop every two hours, seemed to aid in +allaying nausea and to exert some slight influence upon the fever. In +cases where there was a distinct tendency to heart-failure, digitalis +was given freely with advantage. + +Cold baths were not used to reduce the temperature in any of the cases +under our observation. They have been employed in other epidemics, +but, as far as we know, with no other effect than to cause merely +temporary lowering of temperature, without any decided relief to the +other symptoms and without any apparent influence upon the course of +the disease. Frequent spongings with cool water and the application of +ice to the head gave only slight and temporary relief. + +Simple febrifuge remedies, such as effervescing draught or spirit of +nitrous ether with solution of acetate of ammonium, were well received +by the stomach, and appeared to promote perspiration and the more free +secretion of urine. + +Finding all our efforts to control the pyrexia so unsuccessful, +recourse was had in a large proportion of our cases to the +hyposulphite of soda, given, dissolved in two ounces of water, in +doses of twenty grains every two or three hours. In two cases it +seemed to increase nausea, and at times it caused some purging, but +otherwise it was well borne by the stomach, and, indeed, frequently +appeared to aid in controlling vomiting. The records show that this +drug was given in only two or three of the fatal cases, so that +although the patients who took it regularly presented every grade of +severity of the disease, they did well uniformly. It is certain, +however, that the hyposulphite of soda exerted no specific effect +{429} upon the disease; it did not reduce temperature, it did not +prevent or modify the relapses nor relieve the severe pains; it may +have promoted more free and healthy secretions, and, by tending to +prevent vomiting, may have aided in maintaining nutrition; but, on the +whole, it may fairly be doubted whether this remedy merits any more +extended trial. + +One chief reason of the failure of antipyretics in relapsing fever is +to be found in the existence of widespread irritative lesions of the +glandular and mucous tissues, which combine with the specific +blood-changes in causing and maintaining the high temperature. It is +not surprising, therefore, that the remedies which afford the greatest +relief in this disease are opiates and sedatives to the +gastro-intestinal mucous membrane. Opium, or morphia, must indeed be +regarded as the basis of the rational treatment of relapsing fever. It +is called for by the insomnia, the severe headache and the pains in +various parts of the body, the nausea and vomiting, and the pyrexia. +It does not appear to have been as prominent a feature in the +treatment of other epidemics as we found it necessary to make it in +Philadelphia. Parry[42] used it very freely, chiefly in the form of +opium, by the mouth, and found a singular tolerance exhibited by his +patients, several of whom took as large a dose as three grains every +two hours during the afternoon and night without producing any sleep +or even any contraction of the pupils. This resistance to the action +of opium was observed chiefly in the early part of the epidemic, and +we may add that it was exhibited chiefly when opium was given by the +mouth. When morphia was used hypodermically we found that one-fourth +of a grain, given at intervals of six to twelve hours, afforded very +great relief to the pains, aided and relieved vomiting, and often +induced quiet, refreshing sleep. Its use was not contraindicated by +jaundice, by cough or pulmonary congestion, or by moderate contraction +of the pupils. It was frequently given so as to maintain decided +drowsiness throughout the pyrexia. When the pains persisted during the +intermission the morphia was continued in smaller doses or at longer +intervals. It occasionally happened that when patients were thus kept +continuously under opium influence no relapse occurred; but here, as +in regard to the action of quinine, it may safely be asserted either +that what was regarded as the initial paroxysm was in reality the +relapse, or else that the absence of a relapse was a mere +irregularity, and in no way to be attributed to the action of the +opium. On the other hand, in cases presenting a tendency to the +typhoid state, with a disposition to stupor, or where the urine was +scanty and albuminous, no opiate was administered. + +[Footnote 42: _Loc. cit._] + +We have already stated that in our cases quinine in acid solution was +frequently ordered, and it answered very well to add to each dose of +this a suitable amount of morphia. + +Atropia, in the dose of gr. 1/60 to gr. 1/40, was usually associated +with the hypodermic injections of morphia. This was done particularly +in cases where the pains were very severe, when the pupils were +disposed to be contracted, or when there was continued profuse +sweating. In addition to this, atropia was continued without morphia +during the intermission in a few cases. The patients proved +susceptible to its influence, and dryness of the mouth with dilatation +of the pupils was readily {430} produced by gr. 1/60 every six hours. +In one case gr. 1/40 every four hours for two days caused delirium, +with the usual symptoms of belladonna action, all of which passed away +quickly after withdrawal of the drug. But in none of these cases was +the relapse influenced in the least. + +Other remedies may be used for the relief of the insomnia, which is +always one of the most distressing symptoms. Chloral and bromide of +potassium have been found serviceable in various epidemics, and some +observers have preferred them to opium for the relief of headache and +insomnia. They did not prove reliable in the Philadelphia epidemic of +1869-70. Bromide of potassium, even in large doses, produced scarcely +any effect, and, while in a few cases chloral in doses of gr. xx. gave +positive relief, in the majority of instances 40 grains failed to +cause sleep or relieve suffering. It must not be forgotten also that, +as there is a special tendency to cardiac failure in this affection, +the action of chloral must be closely watched. + +In a small series of our cases where muscular pains, hyperaesthesia, +and twitching were marked succus conii was given quite freely, but +without any apparent benefit. + +The condition of the stomach required attention in almost every case. +Nausea, vomiting, and epigastric and hypochondriac soreness were the +prominent symptoms. Anorexia was usually complete during pyrexia, and +not rarely patients were admitted to the hospital who asserted that +for one or more days they had not taken any nourishment whatever. +Under such circumstances, and in a disease where the tendency to +prostration and cardiac failure calls for stimulants and food, it is +evident that strict care must be given to the diet. In many cases +skimmed milk with lime-water, meat broths, arrowroot, or gruel, could +be taken in small amounts at short intervals, and retained. But +whenever these are rejected, no attempt should be made to persist in +their use, but koumiss, whey, or chicken-water should be substituted, +and continued until the stomach grows retentive. Equal care must be +paid to the selection of a suitable form of stimulus. It may be proper +to employ a mild and relaxing emetic if the patient be seen at the +onset of the disease and if there is reason to suspect the presence of +indigested food in the stomach, but under any other circumstances +there seems no reason for its use in a disease where vomiting is so +common and gastric irritability one of the most troublesome symptoms. +Nor should purgatives be given save when very positive indications +exist for their use. + +Constipation is rarely obstinate; the amount of nourishment taken is +very small; in a considerable proportion of cases there is diarrhoea, +or at least a sensitive state of the bowels; and as a consequence it +is preferable in nearly every case to dispense with laxatives +entirely, and, if the bowels must be opened by assistance, to +administer a simple enema. + +When irritability of the stomach is marked, benefit may be derived +from very small doses of calomel frequently repeated, as, for example, +gr. 1/8 or 1/4 every one or two hours. Subnitrate of bismuth may be +used in combination with this or as a substitute for it. In several +instances more prompt relief was obtained from nitrate of silver given +in the dose of gr. 1/12 every three or four hours, dissolved in thin +mucilage of acacia. + +Stimulants were remarkably well borne, and their administration in +such form as was acceptable to the stomach was clearly of service, +{431} even from an early period of the disease. As a rule, whiskey was +employed, given in the form of milk punch. By carefully graduating the +amount of alcohol, and when necessary diluting the milk freely with +lime-water, the stomach usually received it well. If circumstances +favored, dry champagne, or brandy or sherry in carbonated water would +often prove preferable. The exhausting nature of the disease, the +marked tendency to cardiac failure, and the inability to digest an +adequate amount of nourishment, all indicate the early use of +stimulants. In cases where a tendency to the development of the +typhoid state existed alcohol was freely given, even to the extent of +sixteen ounces of whiskey in twenty-four hours. Other stimulants were +usually given in these cases, such as carbonate of ammonium, +especially if pulmonary congestion existed; turpentine, especially if +tympany was marked; or Hoffmann's anodyne or spirit of chloroform, if +muscular twitchings, hiccough, or insomnia with wandering delirium +were prominent symptoms. In all cases of severity the use of tonics +and stimulants should be maintained in reduced doses during the +intermission and for some days after the final fall of temperature. + +It remains to allude briefly to certain special remedies and to +certain symptoms requiring special treatment. Formerly, much diversity +of opinion existed as to the propriety of venesection or local +depletion in relapsing fever, but Murchison concluded, after a careful +examination of the evidence, that it had not been shown to be of +service; and certainly the disease as it occurred in Philadelphia in +1869-70 presented no indication whatever for even the mildest +depletory measures. This corresponds with the recognized plan of +treatment in all the specific fevers. + +Blisters are not so objectionable in relapsing fever as in either +typhus or typhoid, and there are several conditions in which they have +been found decidedly useful. In cases where the headache has +obstinately resisted cold applications, bromide of potassium, and +opiates, a blister to the back of the neck has afforded marked relief, +with no unfavorable result. Again, in cases where the vomiting and +epigastric distress were severe and obstinate the application of a +blister three inches square to the epigastrium is to be recommended. + +Chloroform has proved of value for the relief of various symptoms in +relapsing fever. As already stated, it was found the most useful +remedy for the hiccough which was so troublesome in a number of our +cases, and especially in those where jaundice was pronounced. It also +seemed serviceable in controlling the peculiar chills which in varying +degrees of severity were present in a few cases, recurring at about +the same hour on successive days. These rigors or chills were +uninfluenced by very large doses of quinine or other antiperiodics, +but were apparently controlled by full doses of chloroform given in +advance of the expected hour of recurrence. + +Jaundice, which, as has been stated, is partly of haemic origin, but +is probably also due in part to obstruction from catarrhal swelling of +the mucous membrane of the bile-ducts, is not influenced by mineral +acids, and still less should mercurials or purgatives be administered +for its relief. It would seem proper, in cases where this symptom is +marked, to observe special care in diet and the use of stimulants, and +to employ local sedative {432} astringents, such as small doses of +nitrate of silver combined with opium and belladonna. + +Muscular soreness, pains, and tremor may call for special treatment on +account of their severity. The only remedy which has proved useful in +relieving the first two of these symptoms is opium, conjoined with the +external use of anodynes. Iodide of potassium fails even in doses as +large as can be borne, and the same is true of muriate of ammonium and +cimicifuga, which we used thoroughly without any effect. In the +muscular pains, however, which torment the patient during +convalescence, the ammoniated tincture of guaiacum was found of +service. Atropia hypodermically and chloroform internally have been +found useful for the relief of severe muscular twitchings. + +Upon the whole, therefore, it will be seen that in ordinary cases a +supporting and expectant plan of treatment is all that is required. +Abandoning the idea of forcibly controlling the fever or of preventing +the relapse, care should be given in the first place to the diet and +to judicious stimulation. + +Opium or morphia should be used to control pain, excitement, and +insomnia, aided, as far as the latter is concerned, by bromide of +potassium or the cautious use of chloral. Cooling drinks should be +allowed, cool applications made to the head, and the body should be +repeatedly sponged with cooling and disinfecting lotions. If the +stomach is retentive, quinine in moderate doses may be given in acid +solution, alternating with a simple fever mixture; but if nausea and +vomiting are present, the first purpose will be to allay them by the +appropriate measures already discussed. + +Epistaxis is a frequent symptom, but usually requires no special +attention. Occasionally it is profuse, and then should be promptly +checked, since serious exhaustion may follow its continuance. If, +therefore, mild astringent applications do not arrest it, recourse +must be had to the tampon saturated with diluted Monsell's solution. + +The urine must be closely watched and frequently analyzed in relapsing +fever. In some epidemics serious alterations in this secretion are +rare; in others it is not uncommon for the urine to be scanty, and to +contain albumen or blood. When this latter condition is presented, +especially if at the same time uraemic symptoms exist, dry cups should +be applied over the kidneys, to be followed by the use of dry heat, +and free perspiration should be promoted by hot-air baths or by the +hot wet pack. It is probable that jaborandi given in repeated small +doses, so as to avoid any depressing effect on the heart, will be +found valuable in such cases. Infusion of digitalis, with spirit of +nitrous ether or with acetate of potassium, may also be used with +advantage. + +Absolute rest must be insisted on throughout the entire period of +paroxysm and relapse. The records of every epidemic present instances +of sudden death from cardiac syncope following trifling exertions. The +patients should therefore be kept strictly quiet in bed from the +initial rigor until their strength is fully restored after the +relapse. As the danger of collapse is especially great at the time of +the critical fall in temperature, the patient should be closely +watched as the end of the initial paroxysm and of the relapse +approaches. If there is any sudden rise of temperature, with head +symptoms due to hyperpyrexia, large doses {433} of quinine, ice to the +head, cold spraying, or the cold bath must be promptly used. As +sweating begins the body must be covered with a warm blanket and warm +stimulating drinks be administered. If any marked tendency to collapse +is observed, the subcutaneous injection of strychnia or of ether and +digitalis, conjoined with diffusible stimulants internally and hot +applications externally, are to be employed immediately. The special +remedies required for the various complications and sequelae have +already been sufficiently indicated. + +I desire in conclusion to acknowledge the important assistance +received from Drs. Geo. S. Gerhard, Louis Starr, Charles Shaffner, and +R. G. Curtin, who, under the supervision of my colleague, the late Dr. +Edward Rhoads, and myself, recorded the histories of most of the cases +which serve as the basis of this article, and also tabulated them for +statistical purposes.[43] + +[Footnote 43: Reference must also be made to the interesting +observations on spirilla published by Mulhauser in _Virchow's Archiv_ +for July 9, 1884, after this article had been printed. His results go +to confirm the view that the spirillum of Obermeier is the essential +cause of relapsing fever.] + + + + +{434} + +VARIOLA. + +BY JAMES NEVINS HYDE, M.D. + + +Variola is an acute, febrile, contagious, and systemic affection, +preceded by an incubative period, characterized by the evolution of +symptoms in a relatively determinate order, with a cutaneous +efflorescence successively papular, vesicular, and pustular in type, +followed by crusting, and terminating either fatally or by complete +convalescence, with or without sequelae in the form of multiple, +circumscribed, and superficial cicatrices. + +SYNONYMS.--_Lat._, Variola; _Eng._, Small-pox; _Fr._, Petite Verole; +_Ger._, Pocken; _Ital._, Vajuolo. + +HISTORY.--Small-pox is a disease which, there is reason to believe, +was first developed in the earliest ages of which the human family has +record. Originating probably in China, India, and the adjacent +countries of the Asiatic continent, its extension over Europe and +America was, without question, in the line of progress pursued by the +advancing centres of traffic and population. The earliest traces of +its ravages can be dimly recognized in the descriptions of writers in +the middle and latter parts of the sixth century. In the early years +of the tenth century, however, a remarkably accurate picture of the +disease was drawn by Rhazes, a physician of Bagdad. His treatise, +translated by Greenhill for the London Pathological Society,[1] sets +forth the views of an Egyptian physician named Ahron, who wrote in the +sixth century. After these dates the remarkable political and social +changes in Europe, which are to be attributed either directly or +remotely to the Crusades, contributed largely to the opportunities for +the spread of the disease and to the occurrence later of those +decimating epidemics which became veritable scourges. In the last +century the resulting mortality in some of the countries of Europe was +often equal to the entire population of one of their largest cities. +If a modern traveller could find himself transported to the streets of +the city of London as they appeared in the early part of the present +century, it is probable that no peculiarities of architecture, dress, +or behavior would be to him so strikingly conspicuous as the enormous +number of pock-marked visages he would encounter among the people at +every turn. In the face of all cavil and sophistry, medical science +will always count among its greatest triumphs the modifications which +variola has undergone since its preventive treatment was established +upon a satisfactory basis by the discovery of the immortal Jenner. + +[Footnote 1: _A Treatise on the Small-pox and Measles_, by Abu Becr +Mohammed Ibn Zacariya Arrazi, London, 1848.] + +{435} The bibliography of the disease is extensive, and the list of +authors contributing to the subject is enriched by the names of such +men as Boerhaave, Van Swieten, Sauvages, Willan, E. Wagner, Johanny +Rendu, Hebra, and, more lately, Kaposi. + +ETIOLOGY.--Respecting the etiology of variola, it can scarcely be +affirmed that our knowledge has been greatly extended since the date +of the experiments of Jenner. There is no historical knowledge of its +generation de novo; and the earliest cases of the malady must +therefore be classed with the exceedingly rare instances of +spontaneous cow-pox which have proved such a boon to the +vaccini-culturists. To-day every case of small-pox is justly regarded +as having been directly or indirectly transmitted from one or more +individuals affected with a similar disorder. It is thus recognized as +specifically infectious, contagious, and inoculable, its transmission +occurring, first, without contact, by atmospheric conduction of a +volatile contagious principle of unknown nature; second, with contact +either by (_a_) actual transference of dry or moist infectious +secretions deposited upon a susceptible surface, immediately or +through the medium of garments, bed-clothing, paper money, and similar +material substances; or (_b_) by inoculation of unprotected persons +with the pathological product of an infected organism. There is no +doubt but that the contagious principle displays its greatest +activities in connection with the contents of the lesions undergoing a +change from the vesicular to the pustular phases, though from the +beginning to the end of the disease it is probable that all the +tissues and fluids of the infected body are in various degrees capable +of producing the malady in those who are unprotected. Furthermore, +whether associated or not with an organic substance, the contagium of +the disease is known to preserve the power of reproducing itself for a +period lasting for weeks, months, and even a longer time. A field for +its activities once secured, there is a period of time during which +few if any evidences of its progress are declared, this period being +abruptly terminated by distinct and characteristic symptoms. This is +known as the period of incubation. + +The nature of the contagium in small-pox has been the subject of much +speculation, careful investigation, and experiment, the results having +established but few facts of any practical value. There is at present +no proof that any bacteria, vegetable germs, or other minute organisms +foreign to the human body are the essential causes of the disease. It +is certain that in health the human body is completely enveloped in a +volatile medium emanating from the secretions of the glands of the +skin, which can be recognized by some of the keen-scented lower +animals when it is wafted through the air at a distance of several +hundred feet from a single individual. It is reasonable to conclude +that not only in small-pox, but in other contagious and infectious +diseases, these emanations possess a pathological character, and +become capable of transmitting such maladies from diseased to healthy +organisms. Certain also it is that when the subjects of these diseases +are crowded together, as in prisons, hospitals and camps, this +contagious element gathers an unwonted intensity. By far the larger +number of all transmissions of variola occur after inhalation of the +infective medium--in other words, by the avenue of the lungs. It is +probably for the same reason that the disease spreads more widely and +with greater virulence during the cold seasons of the {436} year, in +this latitude especially from December to February--a time when the +ventilation of inhabited dwelling-houses is usually much less perfect +than in warmer weather. + +The disease affects individuals of all ages and both sexes, not +sparing the foetus in utero, and, in the case of the latter, occurring +both with and without previous infection of the mother of the unborn +child. Nowhere are its ravages so extensive and followed by such fatal +results as among those who have long been unprotected by previous +vaccination. Among the debilitated, as also among the very young and +the very old, small-pox is liable to be followed by severe +complications and a fatal result. Negroes, possibly in consequence of +tendencies inherited through generations of unvaccinated ancestors, +are particularly prone to the disease. Lastly, there is occasionally +noted an individual idiosyncrasy, in consequence of which either a +remarkable susceptibility to the disease exists or a no less singular +immunity against its encroachment is conferred. + +Thus, physicians, much exposed to its influences in the discharge of +their professional duties, are known to be relatively exempt, while +other individuals, few in number it must be admitted, have either had +repeated attacks of the malady itself, or, after each exposure to its +contagious principle, a recurrent illness of variable type. In the +immense majority of all cases, however, one attack confers immunity +upon the sufferer against subsequent invasion of the disease for the +remainder of life. Upon a few occasions I have known variola to occur +in individuals previously affected with cutaneous diseases, especially +the eczematous--a fact which merely suggests that such pre-existing +disorder of the integument conferred no immunity against infection. + +SYMPTOMATOLOGY.--The earliest symptoms of small-pox may be +occasionally recognized during the stage of incubation, which, as +described above, embraces a period of from ten to fifteen days, though +these limits are not absolutely fixed, since both shorter and longer +incubative periods have been at times established. During the interval +the patient may appear to enjoy perfect health, or, on the other hand, +suffer from an ill-defined malaise, with anorexia, languor, insomnia, +and allied symptoms. Close observation of the patient thus affected +will often reveal the existence of a peculiar pallor of the face, +accompanied by a skin-color which suggests a slight degree of +sallowness of the complexion. These rather indeterminate symptoms are +naturally most marked toward the completion of the period of +incubation. + +The latter terminated, the period of invasion follows, and extends +from the conclusion of the incubative stage to the moment when the +first cutaneous lesions of variola appear upon the surface. The +symptoms which characterize the onset of this period of invasion are +conspicuous and characteristic. There is often a sharp vespertine +rigor or a more or less continuous chilliness, accompanied by +sensations of "creeping" over the surface, lasting even for several +hours. Meantime, the temperature rises to 103 degrees or 105 degrees +F., the pulse running up to 120 or 130 beats per minute. In this +febrile condition there is commonly complaint of a characteristic +aching in the head and back, intense, scarcely intermittent, and so +peculiar as to have frequently furnished a clue to the diagnosis of +the approaching malady. These sensations are quite analogous to the +substernal and other pains which frequently precede the first +explosions {437} of syphilis, and are all, without question, due to +the circulation of a poisoned blood, the influence of which is in this +manner confessed by the nervous system. In the case of infants and +young children the invasion of small-pox is frequently ushered in by +delirium and convulsions--symptoms which are to be explained by the +facts just named. + +This complexus of febrile and nervous symptoms, varying somewhat in +intensity and possibly interrupted by sensations of chilliness, may be +recognized as continuing on the second and third days of the period of +invasion. Meantime, there may be noted a dusky hyperaemia of the +pharynx and tonsils, the surface of which may even display elevated +points which develop later into papules. In exceptional instances the +intensity of the poison is such that the system fails to rally before +the violence of the onset, and a fatal result ensues before the +characteristic exanthem appears upon the skin. + +On the second and third days of the invasion stage of the disease, if +they are displayed at all, the variolous rashes appear. Too much +attention can scarcely be paid to the importance of their recognition +on the part of the diagnostician. Often indeed have practitioners been +deceived by their occurrence, having been either completely blinded to +the serious nature of the malady in progress, or, as Bartholow[2] has +well shown, having supposed that they were dealing with a concurrence +of variola and scarlatina or rubeola. + +[Footnote 2: "The Variolous Diseases," _Med. News_, Mar. 4, 1882, p. +232.] + +Hebra was the first to point out the significance of the rash known as +roseola variolosa or erythema variolosa. Occurring at about the dates +named above, it is in a few patients pronounced and vivid, even in +solitary instances rivalling in severity the exanthem which succeeds +it. In others, the majority of all patients in some epidemics, it may +be entirely wanting. The writer has certainly observed its most +typical development in women who were either menstruating or in the +puerperal state. It is said also to be relatively frequent in subjects +of a tender age. Kaposi[3] has recognized it in all its manifestations +at every age. + +[Footnote 3: Consult the admirable chapter on variola in his treatise, +_Path. u. Therap. der Hautkrankt_, Wien, 1882.] + +It appears in the form of puncta, striae, or diffuse and uniform +blushes covering extensive areas of the integument, livid red, +purplish, or brownish-red in hue, paling under pressure, but never +leaving upon the skin over which the finger-nail is quickly drawn the +characteristic whitish streak by which many practitioners test the +scarlatinal rash. The surfaces involved may be either not raised or +slightly elevated above the general level of the skin, and are usually +circumscribed. The regions chiefly involved have been carefully +described by Th. Simon, and are hence sometimes called Simon's +triangles. Thus the groin, the internal face of the thighs, and the +hypogastric region may be involved at once (femoral triangle of +Simon); the surface of the axilla, the pectoral region, and the inner +face of the arm (brachial triangle of Simon), as also the extensor +faces of the knees and the elbows, the dorsum of the feet, and indeed +every portion of the surface of the body. + +In the midst of these rash-covered areas may also appear petechial or +hemorrhagic, dark-red, pin-head to bean-sized maculae, which undergo +color-changes both in lighter and deeper shades as the invasion period +{438} lapses. In lieu of these, however, transient wheals may come and +go over the surface, and even the erythema described above may assume +an erratic phase and appear in one part only to disappear and recur at +another. None of these flash-light warnings of the oncoming exanthem +are proportioned to the latter in the matter of extent and intensity +of development. They may be followed by grave or mild manifestations +of the disease. The subsequent eruption may also be much more +abundantly developed in regions where the invasion rashes have not +appeared, and the latter completely fade before the former have +advanced to occupy the field thus deserted. + +The invasion stage of variola commonly occupies three days. Rarely it +extends into the fourth, fifth, and even the sixth, day after the +premonitory chill and fever. + +Upon its subsidence the exanthem of the disease as a rule promptly +appears. Simultaneously, the temperature abates, the rapidity of the +pulse diminishes, and there is marked amelioration of the general +symptoms. The patient, frequently deceived by the completeness of this +defervescence, is apt to conclude that he is convalescent from his +disorder, and is thus often astonished at the discovery of the +exanthem upon the person, usually the face. In other cases, more +commonly those of a grave character, there is failure of this +defervescence, the febrile symptoms continuing or even increasing in +severity. + +The eruption first appears in the form of pin-head sized and larger, +firm, conical, discrete, coherent or confluent, reddish papules, +sometimes accompanied by mild sensations of a pricking or painful +character, often exciting no subjective symptoms by which their +presence could be declared. To the touch they are characteristically +indurated, and suggest the hardness of small shot imbedded in the +skin. They appear first and in greatest abundance upon the face and +scalp, involving later and progressively the trunk, the extremities, +and the palmar and plantar surfaces. It is at this moment that the +eruption most resembles that to be recognized in measles (the +distinction between the eruptive symptoms of the two diseases will be +considered later). At times a reddish areola surrounds each lesion, +especially those appearing upon the trunk. All are situated about the +orifices of the follicles and glands of the skin. + +On the first and second days of the eruption the papular lesions +multiply in number, involve an increasingly large area, and +individually augment in size; so they appear first upon the head, and +are successively presented to the eye upon the lower portions of the +body. The older lesions are usually recognized upon the scalp, face, +neck, and shoulders; the more recent upon the extremities. By the +third day of the eruptive stage there is usually evident at the apex +of the older lesions a minute vesicle containing a drop of pellucid +serum, which rapidly changes in character and size till a distinct +vesicle is formed with cloudy or lactescent contents. Early in their +career an apicial depression can be seen, which later deepens into a +characteristic umbilication. This umbilication in the vesicular stage +is somewhat peculiar. It is more than a mere depression of the summit, +such as might be made by thrusting a blunt-pointed pin centrally and +downward so as to carry the roof-wall before it. It is made clinically +most distinct by the fluting or puckering of the peripheral part of +the roof-wall, giving the lesion a crenated appearance which is not +{439} assumed by any other cutaneous efflorescence of multiple +development. It may be regarded as pathognomonic of variola. + +The pock is usually mature by the sixth day of the eruption. It is +pea-sized and globular in shape; its umbilication has been usually +quite removed by the complete filling of its chamber with distinctly +purulent contents; it is often surrounded by a halo due to hyperaemia +or exudation; and, the total number of individual lesions being then +fairly determined, it is often closely set against its fellows, islets +of unaffected integument having meantime become fewer and more +contracted. The face, covered with this eruption, then exhibits a +typical aspect. The entire integument becomes swollen and brawny or +oedematous. The eyes are thus closed by the tumid lids, which are +separable with difficulty, and this, too, even though they be the seat +of comparatively few lesions. The nose, lips, cheeks, and ears are by +similar processes deformed and given a most repulsive unsightliness. +Mucus and puriform secretions gather and dry about the mucous outlets. +The skin of other parts of the body (hands, feet, genitalia, and the +entire extremities) is in a similar condition, merely most noticeable +in the exposed and disfigured visage. + +The fever of maturation or suppuration, or, as it is often called, the +secondary fever, is lighted to activity with the onset of the +suppurative process. The temperature rises to a point ranging between +101 degrees and 105 degrees F., the pulse-rate simultaneously rising +to 100 and even 150 in the minute, varying of course with the age of +the patient and the severity of the attack. During its continuance, +from the eighth or ninth to the eleventh or twelfth day of the +disease, the victim of the malady is in a deplorable and critical +condition. The intense grade of cutaneous inflammation, with its +resulting subjective sensations of burning pain and tension, the +soreness of the mouth (tongue, pharynx, inside of lips, and palate), +due to the existence of pus-filled pocks upon the buccal membrane, +and, for similar reasons, the dysphagia and irritation of the larynx +and tracheal membrane, are all sufficient to account for the general +condition. In cases of mild grade the patient lies conscious, but in a +stolid apathy, listlessly accepting the services of his attendants. In +others there is delirium of low or high grade, often sufficient to +demand constant surveillance, lest in consequence the patient do +serious injury to himself. + +The behavior of the pustules which appear upon the mucous surfaces +accessible to the eye is modified somewhat by the heat, moisture, and +friction to which these surfaces are exposed. Typical, fully-distended +pustules occasionally persist upon the soft palate and the inside of +the lips. Soon, however, the macerated roof-wall yields, leaving a +reddish floor where the mucous membrane is exposed, denuded of its +epithelial layer or covered with a new tender and hyperaemic pellicle. +In grave and severe cases these pustular lesions may extend deeply +into the mucous tracts, involving the trachea, bronchi, or alimentary +canal. In an autopsy made by the writer on the body of a male subject +dead of unmodified variola, there was no portion of the alimentary +canal from the mouth to the anus which was not studded by thickly-set +pustules. The urethra, vagina, vulva, external auditory canal, and +conjunctivae are, in severe cases, similarly involved. According to +Kaposi, the tympanum is usually exempt. + +The period of desiccation begins usually on the thirteenth or +fourteenth {440} day of the disease, and, according to the severity of +the previous pathological processes, requires for its completion from +one week to a fortnight. Its onset is characterized by a second marked +but gradually developed defervescence. With a diurnal temperature +successively less elevated above the normal standard there is a +corresponding fall of the pulse-rate. As the disease has by this date +taxed the vital resources of the system to the utmost limit, the +exhaustion resulting may be declared by a pulse which is flagging, +weak, and even in the matter of frequency much below the standard of +health. + +The cutaneous lesions now again undergo a change. Some of the pustules +rupture, and their viscid contents, oozing forth, concrete into a +yellowish crust which gradually assumes a brownish hue. Others +desiccate en masse, the roof-wall first collapsing upon the contents, +thus producing an appearance which again suggests umbilication of the +lesions. This is sometimes termed a secondary umbilication. The +desiccation en masse is doubtless due to the evaporation of a portion +of the fluid exuded into the superficial strata of the integument, and +the consequent inspissation of the pus. Often the face at this moment +is totally concealed by a dense, dry, brownish or even blackish mask, +composed of the crusts furnished by numerous individual lesions. At +the same time the tumefaction of the skin subsides, and the subjective +sensations to which it gave rise gradually disappear. Beneath the +crusts cicatrization advances till the former are lessened, and +finally, becoming detached, fall in quantity from the surfaces +subjected to friction. Beneath them are seen brownish and violaceous +blotches, the integument thus stained slowly losing its abnormal +color. It is thus seen to be the seat of multiple, slightly depressed, +shining scars of a dead white color, which in the course of time lose +somewhat of their disfiguring prominence, but which when typically +distinct persist for a lifetime. This exfoliation of crusts continues +till the skin is completely rid of its pathological products, the +process being completed with entire restoration to health about the +conclusion of the fourth or fifth week of the disease. Meantime, in +favorable cases, convalescence progresses pari passu. The patient has +a returning appetite, decadence of symptoms originating in impairment +of function of the mucous membranes, and gains in weight till the +restoration to sound health is complete. + +Such is the history in outline of what may be regarded as a typical +form of uncomplicated variola. It should not be forgotten, however, +that in different epidemics there are marked differences in the career +and manifestations of the malady, and that even among the cases +observed in a single locality visited by the disease the same +divergence of symptoms is no less conspicuous. This diversity is due +to several causes, irrespective of the remarkable modifications +displayed in the variolous who have been previously vaccinated. +Individual susceptibility is doubtless to be considered in this +connection, as also the temperament, bodily vigor, and hygienic +surroundings of those who are infected. It is possible also that the +intensity of the poison may be subjected to occasional modifications +in its transmission from individual to individual. In this way the +following types of variola present themselves in clinical forms with +divergent features: + +CONFLUENT VARIOLA (variola confluens).--This virulent form of {441} +small-pox is ushered in by a relatively short incubative period, +followed by a severe invasion of the disease. The premonitory chill is +violent; the cephalic and lumbar pains are excruciating; the fever, +rising to a high grade, 106 degrees to 110 degrees F., with few and +slight remissions, scarcely subsides, if at all, with the appearance +of the eruption, the latter developing early, and, to borrow an +expression from syphilographers, exploding with violence over large +areas of the surface of the body. The initial lesions of the exanthem +are dense and deeply-set papules, so closely coherent even at this +moment that they scarcely leave between them interspaces of sound +skin. During the vesiculo-pustular transformation which they promptly +undergo on the second day there is a more or less complete coalescence +of the elements of the eruption, which circumstance has given this +form of the disease its name, confluent variola. This confluence is +most conspicuous upon the face and hands, where large flat vesicles +run together, form pus-filled bullae, and finally convert the surface +on which they rest into a single, large, many-chambered pustule. All +this occurs upon an enormously swollen and inflamed skin, disfiguring +every feature of the face and wellnigh obliterating every external +distinction between the scalp, nose, eyes, and mouth. Here and there +the mass is elevated by the quantity of exuded pus to a more notable +projection from the surface. Pustules filled with blood may appear at +several points. At others, the suppurative inflammation may be seen to +have eroded the derma, which is covered with a diphtheritic membranous +exudation similar to that covering the mucous membranes lining the +mouth, nose, and ears. Naturally, the skin in its totality often +yields to these destructive processes and in large patches falls into +gangrene. + +The confluence of the lesions is less marked in other parts of the +body than the face and hands, yet the entire surface may be covered +with a coherent exanthem which becomes elsewhere, in large areas, +confluent. The writer has seen patients in whom the head of a pin +could not be placed upon an unaffected patch of skin in any portion of +the body. The parts subjected to pressure in the reclining posture, +such as the back, shoulders, and buttocks, are especially liable to +this coalescence of the pustular lesions. + +In confluent variola too, as already intimated, the mucous surfaces +suffer proportionately. Pasty accumulations of muco-pus and +diphtheritic exudation, like macerated chamois leather, cover the +tongue, which is often so enormously swollen as to bulge between the +teeth and project from the mouth. These exudations line the mouth, +pharynx, larynx, and even the bronchi. Beneath these masses the eroded +mucous surface is dry, livid red in color, and has a varnished aspect. +Gangrene here may lead to necrosis of the cartilages of the larynx. +Aphonia is often complete, deglutition impossible, respiration +difficult. The stench arising from the patient is intolerably fetid +and pervading, and a single exhalation will poison the best-ventilated +apartment. The submaxillary and sublingual glands are enlarged and the +neighboring lymphatics swollen. + +The patient who is plunged into this grave condition is the victim of +a fever which is unquestionably septicaemic in character; he has a +small, frequent, and often fluttering pulse; his mental condition is +betrayed by a delirium of varying grade or he lies comatose. In this +state a fatal {442} result is often induced by either exhaustion of +the vital forces or an intercurrent malady, such as pleurisy, +pneumonia, cardiac inflammation, oedema of the glottis, or an +uncontrollable diarrhoea. In yet other cases the patient falls into a +typhoid state, and, after surviving for a fortnight or more with a low +fever, a broncho-pneumonia, or a diarrhoea, succumbs to an inevitable +exhaustion, the surface of his body being yet covered with a dry, +blackish, and fetid crust. + +The expression of an intense variolous poison is known as hemorrhagic +variola; also as purpura variolosa and black pox. A large number of +such cases have been designated and treated as black measles, the real +nature of the malady having been mistaken. + +The law readily observed by the diagnostician of diseases in general +must here be recognized. There are no hard and fast lines in nature. +Hemorrhagic variola occurs, without question, in different types. At +the one extreme are classed the inevitably fatal cases, where the +patient sinks smitten by the malady even before the exanthem is +developed; at the other are found the cases of confluent variola, not +necessarily fatal, in the course of which hemorrhagic lesions appear +in variable number, blood either filling the pustules after the latter +have arrived at maturity, or forming ab initio purpuric pocks +intermingled with the typical lesions of the variolous exanthem. +However ill-defined the limits between these classes may be, the +symptoms of hemorrhagic variola are sufficiently characteristic to +require separate description. According to Kaposi, it occurs in the +two following types: + +The first form is termed variolic purpura. Its incubative period is +brief and distinguished by unusual conditions of malaise and lumbar +pain. On the fourth day there is an intense fever with rapid pulse, +and this is speedily followed by a deep purplish-red staining of the +face, neck, trunk, and extremities, the skin thus affected being +slightly tumid and quite dry. Minute maculo-papules can be +distinguished here and there over the surface, often closely set +together, and presenting the characteristic color described above. At +this stage of the disease the eruption greatly suggests an intense +rubeolous exanthem, and has been, as a result, repeatedly mistaken for +the so-called black measles. But the excruciating pains persist, there +is often coincident delirium, and the pin-head sized maculo-papules +noted above become lenticular in shape, cease to lose their color +under the pressure of the finger, extend peripherally even in a few +hours, flatten and become purpuric patches of a bluish-black shade, +palm-sized and even larger, covering extensive areas of the +integument, new lesions forming in unaffected islets of the skin; +conjunctival ecchymoses appear at the angles formed by the lids, and +finally encircle the cornea with an annular purplish-black cushion. +The mucous surfaces become dry, crack, and bleed where the epithelium +is torn, and become covered with offensive crusts. The odor exhaled by +the patient is intolerably fetid. He lies stupid as the march to a +fatal issue is hourly hastened. Hemorrhages occur from the larynx, +bronchial membrane, intestinal surfaces, and even into the parenchyma +of the viscera, the muscles, serous membranes, periosteum, and +neurilemma. The urine is retained in the bladder; the respirations +rapidly increase in frequency; the pulse flutters; and death closes +the scene between one and two days after the onset of the malady. In +several cases observed by the writer, {443} occurring in infants and +children, the entire course of the malady was completed in twelve +hours. + +In the second and much rarer form of hemorrhagic variola there are the +usual unfavorable portents of intense prodromic symptoms. On the +fourth day the skin is swollen and indurated in consequence of the +development within its structure of numerous firm, roundish, slightly +acuminate papules, so thickly set together that it is wellnigh +impossible to distinguish between them. These are early in betraying +the bluish-black hue significant of hemorrhage into their mass. They +multiply in number and increase in size, while their hemorrhagic +stains widen and sweep from each as a centre, like the waves that +spread from a pebble thrown into smooth water. In these cases, more +often than in those first described, pus-filled pocks may develop over +some portions of the surface, while in others a species of gangrene +occurs in consequence of the separation of the derma from the +subcutaneous tissues by effused blood. At times pustules of somewhat +typical aspect are formed and subsequently filled with blood by a +hemorrhage from below. The accompanying symptoms are grave, but less +rapidly fatal than in the other types of the disease. Delirium, +stupor, an intense fever, and a rapid, feeble pulse are commonly +noted. A fatal result is usually reached in from four to five days. + +Hemorrhagic lesions, isolated or confluent, are seen also in severe +forms of variola, not of the two types described above. Thus, in +confluent small-pox, especially when occurring among the unvaccinated, +some of the pustules on the face, the back, or possibly the legs, +where varicosities of the veins permit a passive engorgement of the +tissues with blood, may become the seat of a hemorrhage. For these +local causes are often etiologically effective. In other cases the +appearance of the hemorrhagic lesions seems to be due to a dyscrasia, +such as that recognized in phthisis, chronic alcoholism, and +haemophilia. + +Aside from the trivial accidents to which the exanthem may be subject, +the hemorrhagic types of variola may be regarded as necessarily grave +and in a large proportion of cases inevitably fatal. That they are all +truly the results of variolous poisoning is shown, first, by the +occurrence of intermediate forms; second, by the occasional +transmission of the disease in its typical aspects to the partially +protected. + +VARIOLOID is that form of variola in which the disease is modified, +either in its course, duration, or intensity of symptoms, such +modification usually resulting, directly or indirectly, from the +protective influence of vaccination or from a previous attack of +variola. + +The symptoms of the class of patients commonly regarded as suffering +from varioloid are all those of variola, modified, however, in the +direction of a mitigation of their intensity and dangerous character. +It is thus evident that there is no strict line of demarcation between +the very mildest physical expression of the variolous poison and that +variola vera which presents atypically benign symptoms in any stage of +its career. Within this wide range of possibilities cases of varioloid +occur which certainly differ from each other by very marked degrees. + +The invasion stage of varioloid may be shorter or longer than that +occurring in variola vera, and may be insignificant or intensely +marked as regards the severity of its symptoms. According to +Bartholow[4] the {444} invasion rashes are here of common occurrence; +and the more extensive the latter, the less copious the subsequent +eruption. It must be admitted that a personal experience has not +confirmed us in this view. + +[Footnote 4: _Loc. cit._] + +After the high fever and severe cephalic and lumbar pains of this +stage there may follow, in the case of varioloid, a complete +defervescence and the appearance of a very copious exanthem. With +this, however, the apogee of the disease may be reached, and the +subsequent symptoms be altogether insufficient in comparison with +those which have preceded. Thus, the maculo-papules may never reach a +vesicular stage, or, having attained this, the vesicles may not be +umbilicated, or may shrivel after their contents have assumed a +lactescent color, and be succeeded by light superficial crusts which +in a few days fall. Or, again, the pustular stage of the lesions may +be fully developed, even with the production of a halo about the +pocks, while yet there is no swelling of the skin and but trifling +subjective sensations experienced by the patient. The pustules in the +course of from four days to a week desiccate and are shed, leaving +behind them violaceous pigmentations of the surface without persistent +cicatricial sequelae. + +Other cases, again, instead of producing the impression upon an +observer of being illustrations of a malady aborted or cut short at +some period of its career, seem to exhibit merely a modification in +the intensity or distribution of symptoms betrayed in a wellnigh +typical career. Thus, there may be a total absence or insignificant +reminder of the septic fever usually known as the secondary fever of +variola, and the elements of the eruption may be few or appear in +scanty number upon the face and more copiously elsewhere. The latter +may, however, pursue a perfectly typical career and be followed by +characteristic scars. + +There is yet another type of varioloid with which many practitioners +become familiar who have experience in epidemics of small-pox. The +patient exhibits distinct symptoms of malaise in the period of +incubation. The fever of invasion, with its characteristic pains and +nausea, is equally well marked. Defervescence occurs with a trifling +eruption of maculo-papules, which in two days have wellnigh completely +disappeared. There is no secondary fever, but the patient is far from +well. There is a period of anaemia, mental depression, marked languor, +and unmistakable evidences of physical prostration out of all +proportion to the precedent symptoms. In these cases it may well be +believed that the poison has at last produced a strong impression upon +the nervous centres. The most characteristic feature of these cases is +the tedious convalescence from an apparently trifling form of the +malady. + +The identity of varioloid with variola is abundantly shown--first, by +the occurrence of intermediate forms of every grade, from the mildest +evidence of variolous poisoning to typically developed cases of +variola vera; second, by the fact that patients affected with +varioloid are capable of transmitting variola to the unprotected; +third, by the anatomico-pathological fact that the structure of the +pock, when it appears, is the same in all. + +A variation as to the form and contents of the lesion of modified +variola occasionally occurs as a consequence of individual +peculiarities or of the special surroundings of the patient. A number +of useless terms have been employed to designate these peculiarities, +the most of which {445} are relics of the superstitions of the past. +In variola siliquosa the pocks are said to contain air only; in v. +pemphicosa, bullous lesions predominate; in v. verrucosa, the papules, +after partial evolution and involution, leave minute wart-like +papillary masses upon the face; in v. crystallina, there are +superficial vesicles only filled with clear serum, which somewhat +resemble those recognized as sudamina. The older English writers with +as little reason described cases of horn-pox, swine-pox, etc., +differing only from those of variola by the anomalous behavior of the +exanthem in the course of its evolution.[5] + +[Footnote 5: Besides the terms given above, Hebra gives the following +list of Latin adjectives which have been employed to describe special +varieties of small-pox, none of which requires special explanation: +variola papulosa, conica, acuminata, globosa, globulosa, tuberculosa, +cornea, fimbriata, miliaris, lymphatica, vesiculosa, pustularis, +rosea, morbillosa, carbunculosa, etc.] + +COMPLICATIONS AND SEQUELAE.--The complications and sequelae of variola +are fewer in number and more restricted in range than those of many +other maladies. This results from the remarkable unity of the disease +as it occurs in its several manifestations among the unprotected, its +relatively rapid progress, and its absolute disappearance on the +completion of its curriculum. There is no chronic form of variola +lingering for weeks and months after the violence of the fever has +abated. + +Furuncles and abscesses occasionally result during or after the +pustular stage of the disease has been reached, sometimes of such +extent as to give exit to large quantities of an ill-conditioned pus. +The tissues, weakened by the suppurative process which the skin has +undergone, may then necrose, and thus lay bare periosteum, cartilage, +or bone. Erysipelas, especially about the face, may close the eyes, +encroach upon the scalp, or spread extensively over other regions. +Muscular paralyses, hemiplegic and paraplegic attacks, albuminuria, +diarrhoea, and the inflammations of chronic type affecting the +thoracic organs may each supervene, and either greatly prolong +convalescence or precipitate a fatal issue. None of them is perhaps +more common than a low typhoid and febrile state, in which the patient +lies after his variola is practically ended, his skin struggling to +regain its normal tone, a fever of remittent type taxing his energies, +his bowels in frequent movements discharging a thin and fetid feculent +matter, while a low delirium renders him insensible to the gravity of +the situation. + +Reference has been made above to the implication of the eyes of the +variolous, and the possibility of the disorder terminating, after an +otherwise favorable convalescence, in total blindness, should not be +forgotten. The cornea may be the seat of pustules or a diffuse +puriform infiltration resulting in ulceration, and eventually +perforation with hernia of the iris. At times it is merely macerated +by the pus continually covering it, and in that condition yields to +even moderate pressure. At others the deeper portions of the globe +fall into inflammation, and there is a resulting cyclitis, +irido-cyclitis, or parophthalmia. + +In the nose severe destructive effects may follow the pustular +involvement of the Schneiderian membrane, including necrosis of the +nasal bones and profuse epistaxis. + +In a similar way, the external ear may be involved, the tympanum +disappear, a severe otitis media supervene, and the mastoid cells +become filled with pus and detritus of necrosed tissue. + +{446} In the larynx, which may be well lined with pustules, as +indicated above, complications may arise in the shape of oedema of the +ary-epiglottic folds,[6] laryngo-oesophageal abscess and various +diphtheritic deposits lining every portion of the mucous membrane. + +[Footnote 6: J. William White, "Surgical Aspects of Small-Pox," +_Medical News_, March 4, 1882, p. 241.] + +Other disorders noted as complicating variola are hydrocele and +orchitis in the male, ovaritis in the female, gangrene of scrotum or +labia, haematuria, peritonitis, adenopathy and lymphangitis and +arthritis, as well as peri-arthritic suppurative inflammation. + +PATHOLOGY AND MORBID ANATOMY.--Ours is a day in which bacteria, +special to each of a number of infectious diseases (lepra, pemphigus, +tuberculosis, etc.), are constantly reported as coming to light under +the persuasive influence of modern staining solutions. With respect to +variola, it may be said that while Cohn, Klebs, Weigert, and others +have, without question, recognized microsphaera, micrococci, and +similar organisms in variolous pus, their causative relation to the +pathological process has certainly not yet been demonstrated. + +The pathological anatomy of the cutaneous lesions of variola has been +very carefully studied by Auspitz and Basch,[7] and Heitzmann.[8] The +following is a condensed account of the results reached by these +observers: + +[Footnote 7: _Virch. Archiv_, Bd. 28.] + +[Footnote 8: _Trans. of Amer. Derm. Ass._, Aug., 1879.] + +First appear circumscribed patches of hyperaemia, in which the +papillary layer of the corium is concerned, and which is followed by +some thickening of the rete, the epithelia involved becoming coarsely +granular. This granular condition is due to an increase of living +matter within the protoplasmic bodies, evident at the points of +intersection of the reticulum of which they are composed, the nuclei +becoming solid and shining, and the threads traversing this +cement-substance between them becoming also increased in thickness. +The papillae beneath increase in size in consequence of their vascular +engorgement, and in consequence of the change experienced by the +connective-tissue bundles, which are partly transformed into +protoplasm, while the protoplasm between them increases also. There +is, in brief, a liquefaction of the glue-giving basis-substance, which +makes visible the reticulum of living matter formerly hidden within +it. In this way the epidermis is raised into the flat solid papules +which are the early lesions of the disease. + +Then follows an exudation of a serous fluid at one or more points in +the papule, the meshes of the reticulum being so stretched and torn +that small chambers are formed filled with the liquid exudate +containing granules. Between these chambers the separating strata of +epithelia are compressed so as to form septa or partition walls. The +neighboring epithelia become granular, divested of their cement +envelope, and transformed into protoplasmic clusters still connected +with the living reticulum by slender threads. An irregular cavity is +thus formed in the thickened rete traversed by septa, the contained +exudation being filled with granules, coagulated fibrin, and lymph. A +few protoplasmic bodies are here also distinguishable, which Heitzmann +regards as either debris of destroyed epithelia or colorless +blood-corpuscles. + +In these changes the connective-tissue beneath participates. The +papillae eventually disappear, the superior portion of the corium +being replaced by {447} clusters of medullary or inflammatory elements +uninterruptedly connected by threads of living matter. + +The pus-corpuscles which eventually appear originate mainly from +transformed epithelia. In the process of transformation the increased +protoplasm of the epithelia first exhibits shining homogeneous lumps, +which, after an intermediate stage of vacuolation, undergo an +endogenous metamorphosis into nucleated bodies with a reticulum in +each. To the number of these there is possibly an addition by the +immigration from below (diapedesis) of leucocytes. + +The question of repair with or without the production of cicatrices +rests upon the behavior of the connective-tissue elements. If these +are not torn asunder, but remain in connection with each other, the +re-formation of a glue-giving basis-substance is possible, and new +bundles of fibrous connective-tissue take the place of the old. If, on +the contrary, the latter are completely destroyed, their place is +filled with the cicatricial new growth. The pigmentation, which is +such a common transitory sequela of the skin lesions, is due both to +the imbibition of the coloring matter of the blood by the epithelia +and by direct hemorrhagic exudation into both the rete and derma. + +The umbilication of the mature pock is doubtless due to the situation +of such lesions at the orifices of the excretory ducts of the +skin-glands. The epidermis, in one or more of its strata, dips +downward to form a living investment for such glands, and in this +situation ties down the centre of the roof-wall of the pustules. +Eventually, it too, as a result of the maceration and tension +incidental to the complete filling of the pock with pus-elements, is +ruptured or stretched, and the umbilication of the pustule disappears. + +The anatomy of the exanthematous lesions in hemorrhagic variola is not +different from that described above. The pocks in such cases are +merely filled with blood instead of with pus or sero-pus. In some +forms of hemorrhagic variola, as indeed would be suggested by their +clinical observation, there is hemorrhage directly into the tissues of +the integument, or, more probably in severe cases, a mere passive +leaking of the sanguineous fluid with its coloring matter through the +relaxed and weakened vascular walls. + +The morbid changes occurring in the viscera are described by +Curschmann as follows: The mucous surfaces may be the seat of +pustules, diffuse purulent infiltration, and catarrhal, croupous, or +diphtheritic inflammation. As regards the extent of diffusion of the +pustular lesions, they occur, according to Wagner, in bronchi of the +second and even of the third order, rarely in the stomach and +intestines, and in the rectum only in its lowest portion. The bladder, +urethra, and serous surfaces are always exempt. The lungs, breast, +liver, spleen, brain, and spinal medulla are variously involved. Often +the tissues of these organs are quite unchanged as regards their +macroscopical appearance. At other times the tissues appear swollen, +granular, and undergo a fatty degeneration. In purpura variolosa the +spleen and walls of the heart, however, are seen to be firm, dark-red, +and more or less indurated. + +DIAGNOSIS.--The establishment of a correct diagnosis where there is +question of variola is one of the most critical and important of the +duties of a physician. Upon such decisions have turned, again and +again, {448} professional success or disaster. To pronounce that case +to be variolous which is not of such a nature is to subject one to the +indignation of the few and the ridicule of the many. On the other +hand, to be guilty of treating a patient with small-pox, and of +remaining ignorant of the nature of the malady, is to subject many +ignorant people to the danger of exposure to the disease and to render +one's self liable for the redress sought by recourse to the civil +authorities and the law. It is difficult to decide which predicament +is the graver. + +Typical variola vera is readily recognized by its characteristic +features. As usual, it is the atypical and modified forms where the +difficulty most often arises and where the danger to the physician is +proportionately increased. + +In the invasion stage of the disease it is often impossible to +recognize any symptoms characteristic of variola. High fever with +severe lumbar pain, considerable gastric distress, and the appearance +of one of the invasion rashes (roseola variolosa) would, however, put +the observant practitioner on his guard. I have often noticed in these +cases a symptom which, apparently insignificant, has on more than one +occasion preceded the eruptive period. It is the occurrence upon the +centre of the two cheeks of a vivid damask-red blush, occasionally +having a purplish-red hue, and with a very remarkable circumscribed +area. This may be recognized in children and adults of both sexes when +it occurs in typical aspect, and is undoubtedly a hyperaemia of the +character of that producing the rashes in Simon's triangles. + +When the variolous exanthem first appears the practitioner should +secure as soon as practicable a history of the invasion stage if this +has not been subject to his personal observation. He should then make +careful inquiry as to the possibility of a neighboring source of +contagion, and ascertain by inspection whether the person of the +patient exhibits the evidences of successful vaccination. In this +connection it is always well to estimate the value of the elements +represented by (_a_) the period ascertained as having elapsed since +the last successful vaccination; (_b_) the typical or atypical +character of the existing cicatrices of vaccinia; (_c_) the unicity or +multiplicity of the cicatrices simultaneously resulting from +vaccinations performed at one and the same date. + +Without question, the first papular lesions of variola resemble those +of rubeola or measles to an extent which has often deceived the most +expert diagnosticians. The distinguishing points are--(1) In measles, +catarrhal symptoms (conjunctival, nasal, laryngeal, bronchial), which +are usually absent in the early stages of variola, and later are +obviously associated with the irritation set up of the pustules of the +maturing period. (2) The difference in the temperature record, that +noted in the invasion stage of variola varying from 104 degrees to 105 +degrees F., while in rubeola it is rarely registered above 103 degrees +F. Moreover, in typical variola the defervescence is marked and +characteristic on the appearance of the exanthem, while in rubeola, +when the rash appears, the temperature is usually sustained at a +maximum, and may even rise. (3) The differences in the rashes of the +two disorders. The papules of variola, even in its confluent forms, +are, when first observed, remarkably discrete and exhibit not the +slightest tendency to grouping, while the maculo-papules of rubeola +are (_a_) developed simultaneously on the face and trunk, while those +of variola {449} commonly appear first on the face and afterward on +the trunk, the older, and larger therefore, in the site of earliest +appearance; (_b_) are set in clusters or groups having a distinct +tendency to crescentic arrangement, a symptom decidedly best +appreciated by the eye when the eruption is viewed in totality or in +large areas with the eye of the observer somewhat removed from the +surface; (_c_) are often made to disappear or pale beneath the +pressure of the finger, while there is greater persistence of color in +the variolous papules; (_d_) are surrounded by little or no halo, each +elementary lesion of the eruption being abruptly defined upon the +sound skin, while the variolous papule is apt to rest upon a circlet +of hyperaemic integument. + +Even with careful observation of all the specific differences between +the two diseases, they may, for a brief time, so resemble each other +as to defy the skill of the expert. In all doubtful cases the +physician should invariably admit the doubt and defer an exact +diagnosis for twenty-four hours. During the delay the variolous +exanthem should betray its individuality by the formation of a minute +vesicular apex at the summit of several papules. + +In scarlatina the uniform diffusion of the exanthematous blush, the +absence of papules and vesico-papules, the continuance of the fever +after the rash has appeared, the characteristic scarlet or +boiled-lobster color of the skin, and the anginose condition of the +throat, are all significant symptoms. In hemorrhagic small-pox the +color of the integument is a much more purplish and lurid-reddish hue, +rapidly reaching that stage where it refuses to pale under the +pressure of the finger, and never leaving in the track of the +finger-nail quickly drawn over its surface the peculiar transitory +yellowish-white line which can be usually obtained in the skin of the +patient with scarlatina. + +The pustular stage of variola might be confounded with the pustular +syphiloderm. But in the latter there should be a history of a chronic +rather than of an acute affection, and, as a result, the simultaneous +appearance of lesions in very different stages of their career, some +distended with pus, others ruptured and crusted, yet others which have +recently formed in the immediate vicinity of the oldest lesions, while +the latter have been in full involution or have been replaced by +superficial losses of tissue. + +The resemblance of pustular variola to certain suppurative and other +disorders of the sebaceous glands is well attested by the name given +by certain French authors to molluscum epitheliale (M. contagiosum, M. +sebaceum)--viz. acne varioliformis. But in the case of acneiform +disorders the concurrence of comedones, the chronic course of the +disease, the absence of fever and systemic disturbance, and the +particularly irregular distribution of the lesions upon the face, with +failure to appear elsewhere,--all these facts forbid the confusion of +the affection with variola. In medicamentous acne, accompanied by the +sudden appearance of numerous pustular lesions symmetrically displayed +upon the surface, there will indeed be a source of error. In such +cases, of course, a history of the ingestion of a medicament capable +of producing a rash will afford valuable aid in the diagnosis. In +pustular forms of dermatitis medicamentosa there will usually be found +a more abundant development of the pus-containing lesions upon the +head and both arms and forearms, with {450} no tendency to extension +over very large areas of the trunk and lower extremities--a +circumstance which a delay of but a few hours will often substantiate. + +The absence of marked defervescence is the most characteristic +difference between variola in its eruptive stage and typhus, typhoid, +and relapsing fevers. Pneumonia, cerebro-spinal meningitis, acute +miliary tuberculosis, and gastric fever are all to be differentiated +from variola by the occurrence of symptoms characteristic of the +involvement of the several organs which in these diseases respectively +are more particularly impaired. + +PROGNOSIS.--The prognosis of variola is wellnigh inseparably +associated with the question of protection by vaccination. Variola +vera in the unprotected is an exceedingly fatal malady, the death-rate +varying in different epidemics according to the severity of each and +the ages and hygienic surroundings of the victims of the disease. +Certainly, from 15 to 50 per cent. of unprotected individuals affected +with the disease occurring in epidemic form in any given community +will perish. This number may, however, be enormously increased, as, +for example, among a large number of unprotected negroes crowded +together in a filthy prison, or when the malady makes a periodical +visitation to an insular community where long isolation has begotten a +carelessness with respect to vaccination. + +With respect to individual cases it may be asserted, first, that an +intense series of prodromic symptoms, followed by the appearance of an +unusually large number of cutaneous lesions, is often unfavorable. +Confluence of the latter adds to the gravity; hemorrhagic and purpuric +symptoms are in the highest degree portentous, and commonly indicate a +fatal result. Women pregnant or in the puerperal state, infants at the +breast, and persons of both sexes at advanced ages, are little able to +resist the ravages of the disease. According to Kaposi, women recently +delivered prematurely or who have lately suffered from an abortion +succumb more often than others of their sex. Chronic alcoholism among +male subjects and the cachexia induced by all chronic visceral and +systemic disorders are sources of weakness which largely increase the +death-list by adding to the heavy strain upon the vital energies. The +prognosis is rendered uncertain or unpromising by extensive +involvement of the mucous as well as of the cutaneous surfaces, by +marked visceral complications, by evidences of shock or exhaustion +before the apogee of the exanthem is reached, by grave sequelae, and +even by simple complications of the malady when, instead of entering +promptly upon convalescence, the patient lingers for weeks in a +typhoid condition. An unfavorable symptom in any case is the sudden +cessation of the processes actively pursued upon the surface of the +body. The swelling of the integument then suddenly diminishes and the +crusts by which it was covered shrivel. The eruption, in brief, seems +to undergo what may be described as a collapse. The pulse at such +moments usually flutters feebly, and there are other portents of +dissolution which the eye of the physician will hardly fail to +interpret correctly. The fluids in such instances mechanically drain +away from the surface of the body to seek the deeper parts. This is +not peculiar to small-pox. Similar phenomena occur even in the case of +other than exudative affections of the skin. In pityriasis rubra the +{451} patient dies leaving an integument apparently unaffected, and I +have seen a patient dead of even multiple sarcoma of the skin when the +tumors were reduced fully one-half in bulk as the result of a similar +cause. + +On the other hand, the practitioner should never forget that even +apparently desperate cases of variola rally and are won back to life. +That the exudative process should be in full evolution at the surface +of the body is, caeteris paribus, certainly so far a good omen. The +most hideous, extensive, and stench-emitting crusts have hidden for a +time the forms that have for many subsequent years not only known the +enjoyment of life, but have made that life of inestimable value to +others. The physician in the presence of this most loathsome and +formidable disease should never despair. + +PROPHYLAXIS AND TREATMENT.--The loftiest end to be reached by the +physician of our day with respect to variola is its complete removal +from all civilized countries, and indeed from the face of the earth, +by the practice of universal vaccination and revaccination. The +evident modifications which the disease has undergone in late years as +a consequence of the extraordinary attention given to this subject is +an earnest of the future. The day is probably not far distant when the +man, woman, and child unprotected by vaccination will properly be +regarded as an enemy of the human race, and treated accordingly. +Evidences of the most satisfactory character as to successful +vaccination should be imperatively required of all applicants for +admission to schools, academies, colleges, charitable institutions, +public libraries, art-galleries, and places of labor controlled by +incorporated institutions; of all members of conventions, +legislatures, political, religious, and deliberative bodies; of every +purchaser of a ticket for purposes of travel; and of every voter. In +addition, there should be in every district a systematic and +periodical inspection of all persons registered in the census by +persons qualified and competent to perform compulsory vaccination. +This is the scientific treatment of variola. + +Respecting the therapeutic management of variola, it must be admitted +that there are no remedies known to exert the slightest influence in +either cutting short the curriculum of the disorder or in checking its +progress in any stage. When vaccination is practised after the disease +is fully developed, the two disorders, vaccinia and variola, +apparently concur, and proceed pari passu to the evolution peculiar to +each. Quinia, the sarracenia purpurea, the salicylate of sodium, +emetics, diaphoretics, purgatives, and other remedies and methods +vaunted as efficacious, have again and again failed to establish the +claims which have been put forth respecting the value of each. + +The most important of the considerations to be regarded at the outset +of the management of the small-pox patient relate to his hygienic +surroundings and nursing--considerations which scarcely differ from +those recognized as of general importance in the case of all septic, +contagious, and filth-producing diseases. + +The timid, the fearful, and the unprotected are to be at once +dismissed from the bedside, and trustworthy attendants secured who +have received protection by either recent vaccination or a prior +attack of the malady. The sick chamber should be sufficiently large +and capable of the most thorough ventilation by free access of air. +Solar light should be excluded {452} as rigidly and completely as +possible, since it is reasonably certain that its access to the face +has an etiological relation to the pitting of that part, often the +most serious sequel of the affection. It is an interesting fact that +pitting is much less frequently noted on those parts of the body from +which light is excluded by the covering of the clothing. The +temperature of the sick room during the febrile stages of the disorder +should not rise above 70 degrees F. nor be permitted to fall below 60 +degrees F. Between these extremes a variation may be made in +accordance with the sensations of the patient. + +During the invasion stage of the disease the patient can rarely +assimilate food, but if this be possible it should be given throughout +the entire course of the disease in the form of animal broths, eggs, +nutritious soups, and milk. Iced and acidulated beverages are often +grateful to the palate, and small lumps of ice should be permitted to +dissolve slowly in the mouth. Lime-water may be required by unusual +gastric irritability. As the disease progresses and the palate and +buccal membrane become painful and sore by reason of the localization +there of pustular and other lesions, various mouth-washes and gargles +may be ordered, such as those containing the chlorate of potassium, +the tincture of myrrh, the tincture of cinchona, or even the milder +demulcent fluids made by the addition of flaxseed, gum acacia, or +powdered elm-bark to water. In almost all such cases the skilled nurse +will accomplish a grateful result by frequently cleansing the mouth of +the sufferer (especially before the deglutition of aliments) by +covering the finger with a soft handkerchief, dipping it in pure hot +water, and then thoroughly and gently cleansing the entire buccal +cavity. The spray of a saturated solution of boracic acid in +rose-water may then be directed over the parts. + +Applications of cool and iced water to the skin are commonly grateful, +and, as a rule, are accompanied by no danger to the patient, though in +the early periods of the disease they unquestionably retard the full +evolution of the cutaneous symptoms. For the pain in the back, +therefore, which is often the most urgent symptom of the invasion +stage of the disease, it is usually preferable to make hot +applications. The large rubber bags now in common use, filled with hot +water and from time to time applied to the lumbar region, may be +employed with good effect simultaneously with iced, spirituous, or +camphorated applications to the head. + +Numerous indeed have been the topical applications made to the surface +of the skin in the pustular stage of the malady, both with a view to +assuage the soreness and pain and to obviate the tendency to pitting. +The opening of the pustules and the evacuation of their contents +(practicable only in other than confluent forms of the disease) has +been practised from an early date, but is ineffectual from the +standpoint of any practical results thus obtainable. The same may be +said of the subsequent cauterization of the floor of the pustular +chamber, which only adds to the distress experienced by the sufferer +in his skin. Medicated unguents, applied to the skin, containing +mercury, iodine, and other substances, are not known to be followed by +any better results. It may indeed be laid down as a general rule that +fatty applications to pus-producing surfaces where the pathological +product is virulent are apt to undergo decomposition and otherwise act +unfavorably upon the tissues--a fact first pointed out by Ricord in +connection with the treatment of the {453} chancroid. Vaseline, as not +liable to undergo chemical decomposition, is not open to this +objection. + +Curschmann, Kaposi, and other authors are in agreement respecting the +value of water-compresses over the surfaces invaded by the eruption--a +method of topical treatment which I desire to fully endorse after +personal observation of its value. Curschmann recommends compresses +dipped in iced, Kaposi those moistened with tepid water. The sensation +experienced by the patient will prove the best guide to the +temperature of this fluid. I prefer a solution containing one drachm +of boracic acid to the pint of water as hot as can be discovered to be +productive of comfort, a drachm or two of glycerine being added to the +solution. The compresses dipped in this (or a carbolated solution, if +the latter is preferred by either physician or patient) should be +assiduously moistened and changed regularly by the attendants just as +long as they can accomplish good. They operate, first, by protecting +the part; second, by keeping it moist; third, by maintaining the +surface temperature at the point most pleasant to the patient; fourth, +by exercising the gentlest degree of equable compression over the +surface. When desired, this may be covered with the Lister protective +material or a piece of oiled silk to prevent evaporation at the +surface. + +In Vienna warm baths, administered either by the process of continuous +immersion so generally practised there or by immersion for from two to +three hours of each day, have been found to furnish the greatest +amount of comfort to the patient. The skin is thus speedily relieved +of its tension, the exfoliation of the crusts is hastened, and the +time required for the evolution of the cutaneous lesions, if not +shortened, is at least not retarded by the accidents of exposure to +the desiccating influences of the air--ends which for the patient are +practically one. In this country, and especially in private practice +outside the larger charities with their ampler provision for these +emergencies, nearly the same result may be reached by wrapping the +patient completely in sheets wrung out of water of the temperature +desired. + +From first to last in the treatment of variola, all indications should +be made subordinate to that most prominently set forth by the general +character of the symptoms--viz. the conservation by every possible +means of the vigor of the patient. The tax upon all reserves of vital +energy is here so enormous and constant that he will gravely err who +for a moment loses sight of this fact. Hence it is that anodynes, +chloral, opium and its alkaloids, the bromide of potassium, and +similar medicaments, introduced either by the stomach or by hypodermic +injection, are to be jealously reserved for emergencies when it would +seem cruel to withhold the temporary comfort they may impart. +Stimulants are of course to be freely employed whenever they are +indicated by exhaustion as this may be shown by a weak pulse and other +failing functions of the body, but are certainly best reserved for +such emergencies. In general, it may be remarked that the fewer the +medicaments ingested by the stomach, and the larger the restriction of +the labor of this organ to the task of sustaining the nutrition of the +body, the better are the chances of a favorable issue. + +It is unnecessary to add that all other indications presented in any +given case are to be met, subject to the conditions indicated above. +Abscesses {454} are to be opened and antiseptically treated; delirious +patients are to be sedulously prevented from doing themselves injury; +daily movements of the bowels are to be secured; while the diarrhoea +of the typhoid state, occasionally resulting from the exhausted +condition of the system when the force of the disease is spent, +demands proper control. + +Cleanliness is to be enforced by every judicious measure. The skin of +the patient is to be washed in tepid water and soap as often as +practicable in the course of the disease, and under no circumstances +are applications of ointments, washes, or lotions to be allowed to +collect in strata upon the surface commingled with the pus and crusts +of the disease. At the time of such ablution, and occasionally +oftener, the linen and other garments of the patient are to be +changed. When the crusts are regularly exfoliating from the surface of +the body general warm baths may be ordered, after each of which the +surface of the body may be anointed with vaseline or covered with a +finely-sifted dusting-powder, such as the corn-starch farina sold by +grocers. + +Inasmuch as hemorrhagic variola is usually hopeless in character, and +remedilessly fatal, Kaposi's liberal use of opiates may be recommended +when euthanasia is all that can be expected. So long as there is the +narrowest chance of recovery resort may be had to ergot, turpentine +and the mineral acids internally, combined with the external use of +styptics and ice. But little confidence can, however, be placed in +these measures, which will prove entirely ineffective in the great +majority of all cases. + +In all fatal cases of variola the duties of the physician are not +ended by the death of the patient. It is for the benefit of the living +that he should require destruction or disinfection and long disuse of +all domestic articles that were employed upon or about the patient. +The lifeless body should be disposed of by cremation, and medical men +should exert their influence in favor of legal enforcement of such a +wholesome practice. + + + + +{455} + +VACCINIA. + +BY FRANK P. FOSTER, M.D. + + +SYNONYMS.--Vaccina, Variolae vaccinae (Jenner), Cow-pox, Cow-pock, +Kine-pox, Kine-pock; _Fr._ Vaccine; _Ger._ Kuhpocken, Schutzpocken, +Impfpocken, Schutzblattern; _It._ Vaccina; _Sp._ Vacuna. + +DEFINITION.--An eruptive disease characterized by a cutaneous lesion +closely resembling that of small-pox, going through the stages of +papulation, vesiculation, pustulation, incrustation, and +cicatrization; differing from small-pox in the mildness or almost +total absence of the constitutional symptoms, by being communicable +only by inoculation, and by the fact that the lesions, as a rule, are +developed only at the points of inoculation and in their immediate +neighborhood. + +This definition holds good for the great majority of cases, but in +each of its parts we must take account of exceptions. For example, the +lesion does not always follow the regular sequence of changes +described. It may stop short at the stage of papulation, constituting +the so-called raspberry excrescence, which will be further referred to +hereafter; it may pass directly from the stage of vesiculation into +that of incrustation, without any such change in its liquid contents +as can properly be said to form a pustule; desquamation may take the +place of incrustation; and, after an evolution otherwise normal, there +may be no formation of a scar, simply because the destructive effect +of the lesion has not extended deeper than the epidermis. The +constitutional symptoms are sometimes severe, but they are always of +very short duration. The disease is said to have been communicated +otherwise than by inoculation in the case of some of the lower +animals. Thus, Chauveau succeeded in producing some of its phenomena +in the horse by causing the virus to be inhaled in the form of spray. +It is doubtful, however, if it is possible to eliminate all sources of +fallacy in such experiments. Finally, a generalized eruption is +occasionally observed, although with great rarity. In stating these +exceptions no reference is intended to cases in which complications +occur. + +NATURE OF THE DISEASE.--Many considerations warrant us in classing +cow-pox among the varioliform diseases--chiefly its general +resemblance to variola, and the fact that individuals who have been +affected by it are thereby more or less fully protected against +small-pox. It has been thought, indeed, that cow-pox was in reality +but a modified form of small-pox; and this idea has been the basis of +one of the theories that have been held as to the origin of vaccinia. +Before enumerating and discussing those theories it will be well to +mention that cow-pox is spoken of as spontaneous, casual, or +inoculated, according to its mode of origin, known or assumed, in +individual instances. + +{456} Spontaneous or original cow-pox is the name commonly applied to +the disease as it is met with in the cow in instances in which its +mode of origin is unknown. Strictly interpreted, this expression +implies a belief that the affection is capable of being developed in a +cow independently of contagion or infection--a notion that seems to be +held by many physicians, but not, so far as the writer is aware, by +those whose study of the subject has been such as to lend any +considerable weight to their opinions. Ordinarily, however, the term +spontaneous cow-pox is employed simply as a convenient expression to +denote the disease as it occurs naturally in cows, without implying +any belief or theory as to its mode of origin. + +Casual cow-pox is the term applied in cases that have been contracted +by accidental inoculation, whether in the cow or in man. It is +manifest that the so-called spontaneous cases are really casual, +unless we accept the doctrine that infection is not necessary to the +development of the disease. + +The term inoculated cow-pox implies that the affection has been +produced by intentional inoculation. Here, again, we are confronted +with an illogical expression, for a disease that is inoculated +accidentally is still inoculated, as much as if it had been conveyed +purposely. It may be said, indeed, that the casual disease is due to +some other form of infection than inoculation, but for such an +assertion there is not a particle of proof. + +Passing from this unsatisfactory nomenclature to a consideration of +the theories that have been held as to the nature of cow-pox, we are +first met with that of its being a disease sui generis, like +small-pox, measles, scarlet fever, and the like, and, like them, +originating only by its own specific contagion, not being capable of +development by a modification of any other contagion, however closely +it may thus be counterfeited. This seems the most rational theory of +the nature of cow-pox, but it cannot be demonstrated except by +disproving all opposing theories; and that has not yet been +accomplished. + +Another theory is, that cow-pox is really small-pox modified, as the +phrase runs, "by passing through the system of the cow." It has been +thought possible, indeed, to specify in what way the cow's system +could impress such decided changes upon the virulent disease small-pox +as to convert it into the mild affection that we know as vaccinia; in +other words, it has been imagined that the function of lactation +accomplished this remarkable result. This notion may have been due to +the observation that so-called spontaneous cow-pox is met with only in +cows that are in milk. The significance of this fact, however, is +really nothing more than that cows in milk are more exposed to +accidental inoculation than other bovine animals--namely, at the hands +of the milkers. The fact that in such cases the lesions are almost +always confined to the teats and the udder, far from affording any +ground for the notion that there is some mysterious connection between +cow-pox and the function of lactation, is but another proof that the +disease is the result of inoculation. The lesions appear at the points +of inoculation, the teats and the udder being the parts handled by the +milkers. Moreover, there is no difficulty in inoculating young calves +or adult bulls, and the lesions so produced do not vary in a single +particular from those observed in so-called spontaneous cases. + +{457} Men have been so carried away with this milk theory, however, as +even to believe that the virus of small-pox might be shorn of its +dangerous properties, so that it would produce only the vaccinal +lesion when inoculated simply by mechanical mixture with milk. During +the late Civil War one of the Confederate Army surgeons actually put +this notion to the test of practice on quite a large scale, +inoculating large numbers of persons with a mixture of small-pox virus +and milk, terming the practice mitigated inoculation. We can scarcely +suppose that he did anything else than variolate these persons, just +as he would have done had he used variolous lymph without the addition +of milk. His experiments show nothing new; they merely furnish a +recent confirmation of the well-known fact, familiar to the old +inoculators, that inoculated small-pox is sometimes exceedingly mild +in a series of cases. + +This theory of the variolous origin of cow-pox, and of the +practicability of converting small-pox into cow-pox at will by +"passing it through the system of the cow," has taken deep root in the +minds of men, especially in Great Britain, where the late Mr. Ceely's +experiments and Mr. Badcock's experience seemed to give it some color. +Some years ago, however, the question was investigated most +practically and thoroughly by a commission appointed for the purpose +by one of the medical societies of Lyons, Chauveau being the recorder. +Their conclusion was--and their reasoning seems to the present writer +incontrovertible--that small-pox and cow-pox were wholly distinct from +each other under all circumstances, and that it was impossible to +convert the one into the other. But the doctrines of the English +investigators, reinforced as they were by the ingenious arguments of +the late Dr. Seaton, were not easily to be overturned in their own +country or in America; consequently, the practice of variolating cows +has been resorted to from time to time for the purpose of obtaining a +stock of vaccinal virus of unquestionable authenticity--the so-called +variola vaccine. This practice is utterly fallacious, and it is also +dangerous, since the disease so produced, however mild it may seem to +be, is nothing more nor less than small-pox, with its infectiousness +by effluvium and its liability to prove serious even when carefully +inoculated. + +Quite recently the experimental investigation of the question has been +undertaken de novo by a well-known English veterinarian, Mr. Fleming; +and, since his conclusions coincide with those of the Lyonnese +commission, it is to be hoped that we have seen the last of this +rough-and-ready method of improvising a case of genuine cow-pox--a +method that, in the light of our present knowledge, can only be +characterized as downright malpractice. + +The third and last theory we have to consider is that which ascribes +the origin of cow-pox to infection from the horse. So far back as +Jenner's time it was conjectured that cow-pox was due to the +accidental conveyance of the virus of the grease (the eaux-aux-jambes +of the French) by reason of the cows being milked by persons who were +also employed in the care of horses affected with that disease. Grease +is an eruptive disease of horses' heels. Doubtless it has often been +confounded with a mere eczematous affection by those who have +repeatedly failed in their persistent attempts to inoculate cows with +it, and, on the other hand, a localized eruption of horse-pox may have +been mistaken for it by those who have {458} supposed themselves to +have succeeded in producing cow-pox by inoculating cows with the virus +of grease, and have consequently given in their adhesion to the grease +theory of the origin of cow-pox. At all events, so far as the writer +is aware, that theory is not now held by any well-informed writer. + +Still regarding the horse as the originator of cow-pox, we must turn +our attention to horse-pox (equinia). Several years ago Depaul of +Paris took great pains to establish the fact that horse-pox (an +affection totally distinct from grease) was an eruptive febrile +disease of horses, an exanthem; that the eruption was generalized, +and, being for the most part concealed by the hair, generally +overlooked; and that it was capable of being conveyed by inoculation, +the lesion being indistinguishable from that of cow-pox. He believed +himself to have demonstrated also that it was the contagion of +horse-pox that gave rise to cow-pox in the cow. + +Depaul's investigations were very keen and his conclusions were +exceedingly plausible, but they cannot be called convincing, +notwithstanding the fact that Constantin Paul succeeded for a time in +popularizing a stock of horse-pox virus as material for vaccination. +At about the same time the Beaugency case of cow-pox was discovered, +and the perfectly satisfactory use that has been made of that stock +may have thrown Depaul's theories and Paul's practice undeservedly +into the background. + +We can only say, in summing up, that the small-pox theory is utterly +untenable, that the horse-pox theory has not been disproved, and that +the theory that regards cow-pox as derived neither from small-pox nor +from horse-pox, but as a disease sui generis, although not proved, is +the most rational of all, and the most in keeping with known facts. + +ETIOLOGY.--Nearly everything that could be said under this head has +already been considered. It may be added that meteorological +conditions have been supposed to favor the prevalence of the disease +among cows. More precise observations are needed to enable us to +determine whether or not there is any truth in this supposition. It +has been said that the affection is most apt to prevail during warm +and moist seasons. This is contrary to what we might have imagined, as +warmth and moisture are quite destructive of the vaccinal virus. Under +ordinary circumstances, however, the contagium often proves +wonderfully tenacious of life, and the disease, once introduced among +a herd of cows, is prone to linger for months, or even years, +attacking animals recently added to the stock and young cows during +their first lactation. As has already been stated, age, sex, and +parturition can be regarded as etiological factors only in so far as +they favor the occurrence of accidental inoculation. In the human +subject vaccinia occurs generally as the result of intentional +inoculation, as will be more fully referred to when we come to the +consideration of vaccination. Insusceptibility is occasionally met +with, both in the cow and in man, but it is very rare. Perhaps it may +be explained in some instances by the subject having really had the +disease, or indeed small-pox, either before or after birth, in so mild +a form as not to have left the characteristic marks. Certain it is +that the lesion does not always leave a permanent scar, especially in +the cow. + +GENERAL COURSE OF THE DISEASE.--This is best studied in cases that +have followed intentional inoculation, for here we know the {459} +chronological sequence of events. Depending somewhat upon the method +of inoculation, and perhaps also to some extent upon the state of the +skin at the site of the inoculation, or even upon a systemic condition +(since some vaccinators hail it as a harbinger of success), at the +time of the operation a ring-like erythema may be seen surrounding the +inoculation. This is exceedingly evanescent, being doubtless due to +vaso-motor action, and is not often witnessed. + +Ordinarily, no effect whatever is observed until after the lapse of +two or three days, when a red papule is formed. This papule increases +in superficial area, but not in height, and gradually loses its +redness. It assumes a circular form, or, in the case of a compound +pock (for that is the proper name for the lesion), a configuration +representing segments of several circles, and as it increases in area +it becomes more and more raised at the border (the bourrelet of French +writers), while the central portion, which also increases in size pari +passu with the peripheral annular vesicle, does not become more +elevated, but remains depressed, giving the pock as a whole the +peculiar shape termed umbilication. Up to the eighth or tenth day, +inclusive, the marginal elevation contains a limpid fluid termed +lymph, and consequently presents a pearl-like lustre. At this period a +rather sudden increase takes place in the corpuscular elements +contained in the lymph, causing that liquid to become thick and +opaque, so that the elevated margin of the pock, which before had +shown the pearl-like lustre alluded to, now comes to look as if made +of tallow. + +At the same time what is known as the areola forms around the pock, +and constitutional symptoms show themselves. The areola is a +circumscribed redness of the skin, perfectly circular in form and of +five or six times the diameter of the pock itself. It is sharply +defined and of a vivid red hue. Usually it is a mere hyperaemia of the +skin, but in some instances, especially where the process of +pock-formation is decidedly pronounced, a few papillary elevations are +to be seen in the immediate neighborhood of the pock, and at that +situation there may also be some lividity. After a few hours' +persistence in the form of a disc the areola begins to disappear, the +redness fading first at the central portion, so that in its declining +stage it assumes the shape of a ring which constantly grows narrower +and narrower at the expense of its inner portion, and finally +disappears altogether. In the cow the areola is only a faint line +immediately around the pock. + +Constitutional symptoms are invariably present in cases that follow +the regular course. The temperature rises one or two degrees +Fahrenheit, the appetite becomes impaired, and sleep is somewhat +disturbed. In many cases, mostly those of secondary inoculation, the +symptoms are more severe; the fever runs higher, and may be +accompanied with transient delirium; nausea is experienced, perhaps +with actual vomiting; and severe pain is felt in the head and along +the spine, the latter being most marked in the cervical region. These +symptoms usually last but a few hours, and they are apt to be +accompanied by a modification of the areola whereby it loses its +disc-like outline and becomes diffused irregularly, especially, if, as +is usual, the inoculation has been done on the arm, in a downward +direction toward the elbow. + +Along with these phenomena intense itching is often felt at the +situation of the pock, being an aggravation of the pruritus that in a +mild {460} form accompanies the greater part of the whole course of +the lesion. Supposing the arm to have been inoculated, the lymphatic +glands of the axilla now become swollen and tender, but their +suppuration is unusual, and is to be regarded as a complication. + +To go back to the pock: some time before the contents of the marginal +elevation become opaque the central portion is converted into a crust +of a brownish color, and finally, from the tenth to the fifteenth day, +the bourrelet itself, having ceased to increase in size, takes part in +the process of incrustation, the completed crust representing the form +of the pock, having a circular ridge at the border, at which part its +color is not so deep as at the centre. The crust usually falls off +between the fifteenth and the thirty-fifth day. It is hard, +translucent, and of a prune-juice color; thick at the centre and thin +at the periphery; smooth on its attached surface and somewhat wrinkled +on its outer aspect; surmounted at the centre by the epidermal debris +produced by the operation of inoculation, mingled perhaps with more or +less dried blood. + +After the crust falls off a reddened surface is left of a cicatricial +nature, usually somewhat depressed below the level of the surrounding +skin, and frequently showing lesser pits, which latter appearance is +termed foveolation. Instead of these pits, radiated striae are +frequently left. Gradually the scar loses its red color, and, like +other scars, finally becomes paler than the surrounding skin. It is +usually permanent. + +IRREGULARITIES IN THE COURSE OF THE DISEASE.--Ever since cow-pox first +became the subject of medical study deviations from its typical course +have been noticed, and have been the theme of a good deal of +speculation. The older writers, indeed, bestowed no little attention +upon what they considered to be not irregular forms of vaccinia, but +distinct affections with which it was liable to be confounded. Their +descriptions of these diseases, which they termed spurious cow-pox, +are, however, so vague as to possess but little more than an +historical interest. In regard to affections met with casually in the +cow, we can often determine their nature only by test-inoculations, +and even that criterion is not always thoroughly convincing; for, on +one account or another, we may fail in the attempt to propagate true +cow-pox, and on the other hand, if we admit that there is a radical +difference between cow-pox and small-pox, it is manifest, bearing in +mind the errors into which experienced investigators have fallen, that +we may propagate small-pox through a long series of experiments +without once suspecting it to be anything but cow-pox. We may, +nevertheless, always determine, provided we succeed at all, whether we +are dealing with a disease that protects against vaccinal and +variolous inoculation. + +In the human subject we seldom meet with affections that counterfeit +vaccinia, although, if we take only the lesion into consideration, +there are certain contagious forms of herpes that may give rise to +doubt, and possibly the same may be true of impetigo contagiosa. + +Turning, then, to the irregularities properly so called, we have first +to consider the absence of constitutional infection. This must not be +confounded with the mere lack of obvious constitutional symptoms; what +is meant by the expression is, that in certain instances the local +lesion may appear typical, and yet no such impression be made upon the +system as to render it proof against subsequent inoculation. Early in +the {461} century the possibility of this lack of systemic infection +was insisted upon by Mr. Bryce of Edinburgh, who invoked it as an +explanation of the occasional failure of vaccinia to protect against +small-pox. The practical question was, how to decide, in a given +instance, whether general infection had or had not taken place. In the +opinion of many observers--and that notion has cropped out every now +and then up to the present day--absence of the areola furnished at +least presumptive evidence that the constitution had eluded infection. +But, whatever may be held theoretically, it must be conceded either +that the general system very rarely fails to feel the impress of the +disease, or else that the criterion is fallacious. For in an +experience of seventeen years the present writer has not known of a +single instance in which a vaccinal lesion that pursued a regular +course in other respects has failed to be accompanied by the areola. +And certainly Mr. Bryce himself must have attached little if any +importance to it, for he took great pains to establish a means of +determining the presence or absence of constitutional infection--the +so-called Bryce's test. This consists in repeating the inoculation at +a certain period in the evolution of the disease, the theory being +that systemic infection does not take place at once, but only after +the lapse of a number of days from the time of the inoculation. Up to +that time a repetition of the inoculation is possible, and, if +systemic infection results from the first one, both lesions will +mature at the same time, the second one following an accelerated +course, reaching its acme rapidly, although dwarfed in size. If, on +the other hand, the first inoculation failed to infect the +constitution, the second one will pursue its course in the usual +manner. Moreover, at a certain time, generally about the fifth day, a +repetition of the inoculation will fail altogether if the original +insertion has really infected the system. The present writer can +testify that Mr. Bryce's statements are correct; he has applied the +test in many cases, but in no instance has he been led to the +conclusion that constitutional infection had failed to take place. He +is inclined to think, therefore, that such failure is exceedingly +rare. + +Passing over the multiplicity of irregularities in the lesion that +were described by the older observers, it seems that there are a few +that are of practical importance. In the first place, there is a +variety of pock to which it is not easy to give a definite name, but +which is characterized by a lack of decided elevation above the +surrounding skin (a deficiency for which it makes up in superficial +area), by the early formation of a thin, flimsy, straw-colored crust, +and by the utter failure of the characteristic firm brown crust of the +typical variety to become developed. This form of irregular pock has +not been seen by the writer of late years, but before animal +vaccination came into general use he met with it frequently, mostly in +cachectic children. Notwithstanding its sprawly, unsatisfactory +appearance, it is undoubtedly genuine, for the typical lesion may be +produced by inoculation with its contents. + +Another irregularity of the pock is what is familiarly termed the +raspberry excrescence. A red elevation forms at the seat of +inoculation, and at first promises to follow the typical course, +although it may be tardy in making it appearance; but it never +advances to full development. It becomes indolent, and may last for +several weeks, or even months, in the form of a hard, flat nodule of a +bright-red color, not unlike a small {462} naevus. In many instances +it has a succulent look, but no lymph can be obtained on puncturing +it. No areola appears at any time, and finally the lesion slowly +disappears, leaving no trace of its existence. It is probably an +abortive form of pock, in which only the papillary layer of the skin +takes part, without any exudation into the epidermis. It is seldom, if +ever, protective against small-pox, for it constitutes no bar to a +subsequent vaccination. This irregular pock has been observed from +time to time ever since the early days of vaccination, but for the +past six years it has been seen more frequently in New York than for +many years before. Now, however, it seems to be growing less common. +The writer is not aware of any satisfactory explanation of its +occurrence. It is seen in all sorts of subjects, and seems to follow +the use of one variety of virus as much as the employment of any +other. + +What has been termed generalized vaccinia is another form of +irregularity. The expression is a vague one, covering as it does not +only the very rare cases of true eruptive vaccinia, in which a general +eruption of pocks takes place as a consequence of constitutional +infection, playing the part of an exanthem, but in addition those +instances, not very uncommon, in which pocks are formed here and there +on the body, probably as the result of the accidental transfer of the +virus from the pock by scratching. Under such favorable +conditions--the immediate transfer of lymph from a pock in which the +specific evolution is going on vigorously--the slightest penetration +of the epidermis with the nails is enough to secure self-inoculation. +In view of this facility with which it may be effected, we should be +very careful not to jump hastily to the conclusion that in any given +case of generalized vaccinia the supplementary pocks are truly +eruptive; as a matter of fact, the present writer has never seen an +instance in which he was convinced that such was the case. Where the +pocks are very numerous, especially in subjects with an irritable +skin, much distress may be caused by the itching and by the +consequences of scratching, and marked febrile reaction may accompany +the process; so that, in view of the great similarity of the lesions +to those of the variolous eruption, much doubt is sometimes +entertained as to whether the disease is not really small-pox. This +question cannot always be definitely settled at first, but the failure +of the secondary fever of small-pox, together with the fact that the +disease does not spread by infection, will generally suffice to decide +it. + +Concerning those cases of generalized vaccinia that are manifestly not +eruptive, it sometimes happens that the cutaneous receptivity is not +exhausted for several weeks, or even months. Such cases set Bryce's +test at defiance, in consequence, probably, of an idiosyncrasy. In +some of these instances the pocks appear in clusters of successive +formation, looking not unlike patches of zoster. Small supplementary +pocks in the immediate neighborhood of the original lesion are not at +all uncommon. + +PATHOLOGICAL ANATOMY.--Avoiding the minute histological details for +which the prescribed length of this article gives no scope, but little +is to be added to what has already been said in the section on the +clinical features of the disease. The lesions of vaccinia are wholly +cutaneous. Confining ourselves to cases that follow a regular course, +there is, indeed, but one, the pock--a term that seems preferable to +vesicle and {463} pustule, since the latter apply only during certain +phases in the development of the lesion. + +A pock may be regarded as essentially a lesion of the epidermis, for +it is in that structure that its most striking features are developed, +and in some cases, although doubtless the papillary layer of the derma +is congested, there is no permanent alteration of tissue below the +Malpighian layer of the epidermis. These are the catarrhal pocks of +Rindfleisch, and it is in such cases, if in any, that no scar (even of +temporary duration) results. The term catarrhal pock, however, is not +vitiated by an extension of the morbid process deep enough to produce +a permanent cicatrix, and it is probable that in most cases the +catarrhal type predominates. By the term diphtheritic pock the same +author refers to cases in which the congestion of the papillary layer +is so intense as to block the supply of blood to the apices of the +papillae, as a result of which they become exsanguinated and necrosed, +forming a white pultaceous layer on the floor of the pock, which is +undoubtedly what Ceely referred to when he spoke of a false membrane. +In some cases even the subcutaneous tissue undergoes necrosis, a sort +of core being included in the substance of the crust that ultimately +forms. + +Whichever of these forms of pock we take into consideration, always +excluding irregularities and complications, we find certain definite +changes in the epidermis. The dome of the pock is formed by the +unbroken transparent horny layer of the epidermis, unaffected by the +morbid process. The cavity of the pock is formed by the squamous cells +of the epidermis being forced out of their normal relations by an +exudation of lymph between them, some of them being tilted up edgewise +while still retaining their connection with the surrounding cells, +thus accounting for the multilocular structure of the pock; for it is +a fact that the circular bourrelet consists not of one ring-like +cavity, but of many separate chambers. The result of this structure +is, that the liquid contained within the pock--the lymph--escapes only +partly through a puncture made in the wall of the vesicle. In order to +evacuate the pock thoroughly it is necessary to make a great number of +punctures or a circular incision following the ring-like ridge of the +bourrelet. + +The lymph contained within the cells of the pock is a liquid which in +its gross physical properties differs but little from the lymph which +exudes from any traumatic surface shortly after the injury has been +inflicted, as in the glazing process that takes place in wounds. +Examined microscopically, however, it is found to contain not only the +fibrin, the salts, the corpuscular elements, and the debris that +ordinary tissue-juice presents, but also certain minute spherical +bodies--termed microspheres, microzymes, vaccinads, etc.--that give it +its characteristic infective quality and justify the title of virus +commonly applied to it. That these minute bodies really constitute the +virulent element of the lymph, or at least that they are the vehicle +of the contagium, is not a mere matter of conjecture, but has been +demonstrated abundantly, notably by Chauveau and Sanderson's diffusion +experiments. Inoculation with the supernatant liquid, containing none +of these bodies, always fails to convey the disease, but it is not +absolutely essential that they should be present in large proportion +in the lymph to render the latter virulent, for Chauveau found that +lymph diluted with thirty times its bulk of water was not without +infective {464} power. It scarcely need be said, however, that the +greater the proportion in which they are present, the greater is the +probability that the lymph will prove infective on inoculation. These +bodies have been supposed to be of a vegetable nature, and Hallier, +Kohn, and others have bestowed no little study upon their botanical +characteristics. Under favorable circumstances they retain their +virulent properties for a long time, especially if kept perfectly dry +and not subjected to a high temperature. The present writer has met +with success in the use of vaccinal virus seven years old. + +The lymph differs somewhat in its gross appearances according as it is +produced in man or in the bovine animal. In the former it is clear and +limpid, and exudes freely in great drops when the pock is punctured in +its peripheral portion; in the latter it is more straw-colored and +more viscid, exuding sluggishly, or even refusing to flow without the +aid of pressure. Moreover, the vaccinads seem endowed with different +properties in the two cases: in man they have a tendency to remain +equably diffused through the liquid, while in the cow they tend to +separate from it and to be deposited upon any solid surface at hand. + +The phenomenon termed umbilication, common to the vaccinal pock and to +that of variola, has given rise to some differences of opinion as to +the mechanism of its production. The term implies a depression at the +centre of the pock. This appearance is not invariable, but it is +constant enough to have met with general acceptance as a +characteristic feature, notwithstanding the undoubted fact that it is +found in lesions that have nothing whatever to do with any of the +varioliform diseases. Not to waste space in discussing the various +theories that have found supporters, it may be said that they have all +been proved to be defective, save only the simple explanation that as +the process of evolution advances the centre of the pock undergoes +desiccation, whereby that portion of the tissue involved is so glued +and drawn together as to become incapable of the swelling that is +still going on in the growing peripheral portion of the lesion. + +The crust into which the pock ultimately becomes converted is not, as +is commonly supposed, mere dried lymph and nothing else; it is dried +tissue enclosing concrete lymph. It generally includes also various +sorts of debris--broken-down epithelium, blood-corpuscles, +pus-corpuscles, and even, in rare cases, a core of sphacelated tissue +like that of a furuncle. + +As has already been said, the cicatrix is to a certain extent peculiar +in that it is usually depressed and foveolated. Too much stress has +been laid upon these features, however, and the truth is that some +traumatic scars cannot be distinguished readily from that of vaccinia, +while, on the other hand, many a genuine pock leaves no permanent +trace behind it. Indeed, in the cow it is the exception for a +noteworthy scar to form. + +SEQUELAE AND COMPLICATIONS.--The most important sequela of vaccinia is +the fact that it protects the subject against small-pox, and on that +circumstance hinges the chief practical interest of the disease. This +leads us at once to the subject of vaccination, and therefore under +that head we shall pursue our consideration of this curious affection. + + +{465} Vaccination. + +SYNONYMS.--"The new inoculation;" _Fr._ Vaccination; _Ger._ +Kuhpockenimpfung, Schutzpockenimpfung; _It._ Vaccinazione; _Sp._ +Vacunacion. + +HISTORY.--Before giving the history of vaccination itself (meaning by +that term the intentional inoculation of vaccinia for the purpose of +protecting the subject against small-pox), it may be well to devote a +few words to a practice that preceded it--that of the intentional +inoculation of small-pox (or simply inoculation, latterly called +variolation). In very early times various Oriental peoples became +aware of the fact that small-pox might be very decidedly mitigated by +inoculation. This was practised in various ways, all of which may be +reduced to the process of inserting small-pox virus into a solution of +continuity. Lady Montagu, the wife of an English ambassador to Turkey, +brought the practice back to England with her, where it soon made its +way into popular favor, and whence it spread rapidly over Europe and +America. Thus contracted, small-pox was shorn of a great part of its +terrors; the eruption was usually trifling in amount, and in every way +the disease was mild as a rule. Still, the mortality was something +worth considering, and, worse than that, the inoculated disease was +communicable by effluvium, so that an inoculated person had to be +secluded carefully for fear of spreading the disease in the ordinary +way. In all cases, too, careful medical treatment was thought +necessary. On the whole, then, while inoculation was undoubtedly a +boon, it was fraught with many grave perils. So great, indeed, were +these perils, and so thoroughly were they appreciated, that the +practice was interdicted by law in most civilized countries so soon as +vaccination had become established in popular favor. + +In several European countries the common people--at least those of +them who had much to do with dairies--gradually became aware of the +existence of the disease termed cow-pox, and of the fact that those +individuals who had accidentally contracted it were rendered proof +against the infection of small-pox. There is even fair testimony to +show that some of these people, particularly the English farmer, +Benjamin Jesty, relying on their observation to this effect, employed +intentional cow-pox inoculation as a protective measure. These facts, +however, do not detract in the least from the credit that all +Christendom has awarded to a man who subjected the popular impression +in question to the test of scientific investigation, proved its truth, +and demonstrated its value to the world. That man was Edward Jenner, +an English country physician. It was in the last quarter of the +eighteenth century that he entered upon his course of inquiry, and on +the eve of the present century he published his demonstration to the +world. It was not a discovery; it was not an invention: it was more +than either, "a matchless piece of induction," to quote the words of +Mr. John Simon. Filled as he must have been with the consciousness of +his great achievement, Jenner set this good example to all +investigators: that he did not make haste to convert the world; he +first convinced himself. It may almost be said, indeed, that, like +Minerva from the head of Jove, the rational and perfected practice of +vaccination sprang complete from Jenner's hands. Doubt and ridicule he +had to encounter at first, and afterward envy and detraction; but the +force of {466} his facts and the symmetry of his deductions were such +that the new inoculation soon spread through the broad world, and has +ever since maintained its sway, save with a few fanatical scoffers. + +That vaccination really does protect against small-pox observation has +taught the whole civilized world, if we leave out of account the few +conscientious and intelligent doubters (made such, doubtless, quite as +much by the extravagant statements often put forth by those who from +time to time think it incumbent on them to defend vaccination, as by +their own misinterpretation of facts) who are to be found associated +with the noisy little body of actual opponents of the practice. One of +the most injurious statements ever made in the advocacy of vaccination +is, that it always protects if properly done. When one of these +illogical defenders of that proposition is confronted with an instance +that disproves his assertion, he falls back on the allegation that in +that instance the vaccination was not properly done. The manifest +absurdity of such an argument strikes the doubter most forcibly, and +inclines him to say to himself, Falsus in uno, falsus in omne. +Unbelief founded on this ground would never have arisen if the plain +truth had always been adhered to: that the protection afforded by +vaccination is not invariable, and that very often it is not +permanent. In the infancy of the practice these facts were not known, +but it is now many years since they became obvious to every +fair-minded observer. The misapprehension of facts lies chiefly in the +false deduction from the circumstance that the great majority of cases +of small-pox occur in persons who have been vaccinated. But the +explanation of this is very simple. Suppose that, of one hundred +persons vaccinated, twenty fail to be protected permanently; that all +persons not vaccinated are unprotected; and that throughout the +civilized world the proportion of vaccinated to unvaccinated persons +is as ninety to ten. Making no pretence of arithmetical accuracy, it +may certainly be said that all these suppositions are well within the +truth. It follows from them that in a community of ten thousand +persons there will be nine thousand who have been vaccinated, and one +thousand who have not. Of the former, eighteen hundred will have +failed to secure lasting protection. Therefore in case of an epidemic +there will probably be a proportion of eighteen cases of small-pox in +the vaccinated to ten in the unvaccinated; and yet this should not +obscure the fact that of the nine thousand vaccinated more than seven +thousand were absolutely protected, whereas of the one thousand not +vaccinated not one could escape the disease if exposed to it. When we +add the further observation that of the eighteen hundred cases of +small-pox among the vaccinated not more than thirty or forty would +probably prove fatal, while of the one thousand cases in the +unvaccinated about two hundred would end in death, we have a striking +demonstration of the efficiency of vaccination. As a matter of fact, +statistics show that the figures here given err rather in allowing too +little than in asserting too much in favor of vaccinal protection. + +The question naturally arises, Why it is that vaccination protects +some persons and does not protect others?--reference being had, of +course, to permanent protection, for it is exceedingly rare for +temporary immunity to be attained if we exclude those instances in +which the variolous infection has taken place before the operation is +resorted to. This {467} question cannot be answered with any +certainty, but various theories have been brought forward, some of +which call for notice. + +In the first place, it has been thought that the revolution of the +system termed puberty was fraught with such a radical change as to do +away with the mild modification due to vaccination. While this theory +has an air of plausibility, it seems to lack proof and not to be +upheld by analogy, for we do not find that children who have had +scarlet fever, measles, and the like often undergo those diseases a +second time on arriving at the age of puberty. + +The only remaining theory that our limits will allow a consideration +of is that put forward by Marson of London, that the degree and +duration of vaccinal protection are proportionate to the perfection of +the vaccinal lesion and to the number of insertions made. In a large +experience with small-pox Marson found that the disease was more fatal +among those whose vaccinal scars were imperfect or few in number than +among those who bore evidence that several pocks had been produced and +had run a typical course. As to the influence of a perfect evolution +of the lesion, but little doubt can be entertained, for we have +already seen that in some instances its course is so different from +what it should be that no protection whatever seems to result. When we +come to consider the number of the pocks as affecting the degree or +the duration of protection, however, an obvious source of fallacy +arises in the fact that we cannot always be sure that some of the +scars on a person having a number of them were not the products of a +repetition of the operation several years after the first--that is to +say, a revaccination, the efficiency of which in restoring lost +immunity is now well established. Nevertheless, as long as the doubt +remains the best course to pursue seems to be to act as if Marson's +theory were in all respects correct, and vaccinate by multiple +insertions. + +We have, then, no positive means of ascertaining who those persons are +that are likely to fail of lasting protection, or how long a time will +elapse before the cessation of their immunity will take place. The +only safety lies in revaccination. But after how many years should +revaccination be resorted to? It has been thought that this question +might be settled by noting at what age, or at what period after +primary vaccination, large numbers of people became susceptible of +revaccination. This test, however, is not altogether trustworthy, for +a renewed susceptibility to vaccinia by inoculation does not +necessarily imply that the liability to take small-pox by effluvium +has been regained. If it did, modified small-pox (varioloid) would be +far more common than it is, for it is certain that revaccination can +be made to succeed in a very large proportion of children long before +they have reached the age of puberty. The fact is, contrary to the +notions of the last generation, that success in revaccination is the +rule, not the exception. Formerly it was not expected to succeed, and +therefore no special pains were taken to ensure success. + +Definite rules cannot be laid down as to the time that should be +suffered to elapse before vaccination is repeated, but in the great +majority of instances safety may be attained by revaccination every +five or six years, and always in the presence of an epidemic, +regardless of the lapse of time; also whenever one's mode of life is +to undergo a noteworthy change, {468} as in emigrating to a foreign +country, on entering the military service, and the like. + +To sum up, then, vaccination almost invariably protects against +small-pox for the time being; generally for a long term of years; +sometimes for a lifetime. Often the protection is absolute; as a rule, +it is very nearly so; in rare instances it is trifling. In general +terms, it may be said that it is scarcely less protective than +variolous infection itself, for death from a second attack of +small-pox is by no means rare. Here the question comes up: Is +vaccination less protective, either in degree or in duration of +effect, than it was at the time of its adoption? Given a typical +vaccinia, we may unhesitatingly answer, No; but do we now so +invariably produce the disease in all its essential features as was +done in Jenner's time? Yes, provided we use proper virus and employ as +much care as was taken by the older physicians, who, trained to the +practice of variolation (the inoculation par excellence of bygone +days), did their work with a gusto now seldom witnessed. But there was +a time, now happily at an end, when it was not easy to obtain +thoroughly good virus, and when, therefore, the result was apt to vary +materially from the standard. This may be conceded without entering +upon the vexed question of the general deterioration of the Jennerian +stock of vaccine. + +Besides immunity from small-pox, there are one or two sequelae of +vaccinia that deserve mention before we proceed to consider what it is +better to class as complications. In the first place, vaccination has +been supposed to confer temporary protection against whooping cough. +The writer is not aware, however, of any precise data going to prove +either the truth or the falsity of this supposition. + +Secondly, by virtue probably of the inflammation that attends the +evolution of the vaccinal pock, vaccination practised in the immediate +neighborhood of a small naevus often cures that blemish, and it has +been done for that purpose in many cases. It has no advantage over +many other measures, however, and there is the disadvantage that the +naevus may so mask the pock as to give rise to some doubt as to the +satisfactory character of the latter. The practice, therefore, is not +to be urged. + +COMPLICATIONS.--These are local and systemic. Those of them that are +at all serious are rare, and can generally be traced to fortuitous +circumstances. + +Inflammatory complications are usually due to undue traumatism at the +time of the inoculation, to injury of the pock, or to the previous +existence of a cutaneous disease or of some dyscrasia. Dermatitis is +the most common. It is usually a mere erythema, but in some instances +lymphangitis, lymphadenitis, phlegmonous inflammation, with diffuse +suppuration, may result. From injury of the pock ulceration and +gangrene may take place, and septic absorption may follow in their +train. These complications are to be treated as if they had occurred +from any other cause. Generally, the mere vaccination is not +responsible for them, but in some instances putrescent vaccine may be +adduced as their source. In such cases the complications, if they can +still be called so, are apt to make their appearance long before the +pock matures, even within forty-eight hours of the vaccination. +Inflammatory complications supervening on the full development of the +pock may invariably be set down as due to some cause not connected +with the quality of the virus employed. + +{469} An undue amount of dermatitis is best treated with some mildly +astringent and anodyne application. The following liniment is +excellent for the purpose: Rx. Unguenti Stramonii oz. j; Liquoris +Plumbi Subacetatis fl. drachm ss; Olei Lini fl. oz. iv.--M. fiat +linimentum. As a rule, it is best to avoid poultices applied over the +pock itself, for they soften the tender structures that make up its +dome and render it prone to rupture, with all the consequences that +may follow its conversion into an open sore. When the latter accident +has occurred, dusting powders will ordinarily suffice to absorb the +discharge, and thus prevent putrefaction--either the ordinary toilet +powder or salicylized or carbolized powders, the basis of which may be +starch with a small proportion of the oxide of zinc. Besides the +antiseptics mentioned, iodoform, boric acid, etc. may be used to +advantage. Liquid applications are not usually so appropriate, but the +writer has known the proprietary preparation termed Listerine to +answer admirably. + +Circumscribed collections of pus are to be treated as under other +circumstances, and burrowing is to be guarded against. It is only in +the worst cases that constitutional treatment of any sort is demanded, +and in these it should be of a supporting nature. + +Passing from the simple inflammatory complications to those of a +specific character, we will first mention erysipelas. Genuine +erysipelas following vaccination is quite rare, but when it does occur +it is prone to prove serious. The writer believes that it always +depends on secondary infection--_i.e._ that the vaccinal wound becomes +the nidus of an erysipelatous contagium already existing in the +patient's surroundings, just as any other traumatic surface might, and +that the vaccinal virus has nothing whatever to do with it. Admitting +that improper virus is apt to give rise to dangerous inflammatory +complications, the latter are not really erysipelatous, whatever guise +they may put on. Erysipelas following vaccination calls for no other +treatment than what is proper for traumatic erysipelas under ordinary +circumstances. + +We now come to the subject of vaccinal syphilis. The question of the +possibility of conveying constitutional taints along with vaccinia was +raised long ago, but, partly relying on certain theoretical tenets, +and partly because of the rarity of well-ascertained facts to shake +the blind confidence felt in the utter harmlessness of vaccination, +the profession fought the suggestion without properly investigating +it. In regard to syphilis, the broad assertion was maintained that two +infectious diseases could not affect an individual at one and the same +time: either syphilis would be communicated alone or vaccinia alone; +moreover, it was affirmed that the juices of a syphilitic person were +not capable of giving rise to the disease by inoculation unless they +happened to proceed from a syphilitic lesion. There was never +sufficient basis for the former of these two doctrines, and the latter +received a rude shock when it was shown by Pallizzari and the +anonymous physician of the Palatinate that the blood of a syphilitic +subject was capable of conveying the taint. Meantime, certain horrible +outbreaks of syphilis were reported, chiefly in Italy, that could not +reasonably be imputed to the ordinary occasions of syphilitic +infection. Even these occurrences, however, failed to shake the +general incredulity, especially in Great Britain, where until quite +recently men's orthodoxy in medical matters was gauged by their +obstinacy in refusing to {470} investigate, far less believe, the +slightest proposition unfavorable to vaccination, and where, also, +observations from beyond the limits of the empire were looked upon as +in all probability fallacious. + +To a Frenchman, M. Viennois, we are indebted for the first systematic +and fair-minded study of the subject of vaccinal syphilis. This writer +demonstrated that the Rivalta cases and those of other like outbreaks +were certainly due to vaccination, but he concluded that they owed +their occurrence not necessarily to the use of lymph from syphilitic +subjects, but to the fact that that lymph contained blood. By this +time it had come to be recognized that syphilis was inoculable by the +blood. But even Viennois's masterly essay, and the facilis descensus +it offered to those English authors who found themselves confronted +with proof positive of their error, failed to make any noteworthy +impression beyond the concession that syphilis might possibly be +communicable in vaccination, but that, if it were, the catastrophe +might easily be escaped by avoiding the use of lymph contaminated with +blood, and that, therefore, the danger was practically no danger at +all, for no one in England would think of using bloody lymph! In all +this the English were slavishly followed by our own countrymen. It is +proper to add, however, that Ballard of London did his best to present +the matter in a proper light to the British profession, and that it is +largely due to his labors and to those of Jonathan Hutchinson (the +latter of whom supplemented Ricord's discovery that vaccine lymph is +never free from blood with abundant clinical evidence of the existence +of vaccinal syphilis unavoidable by the mere observance of Viennois's +safeguard) that we are now freed from the clog of error in this +matter. Nor was it the English alone that so long baffled the +recognition of the truth; in the French Academie de Medicine, Jules +Guerin and his adherents fought desperately against it. + +At the present day we know that syphilis is liable to be communicated +in vaccination, and that, too, without regard to visible blood in the +lymph employed. There are two ways of avoiding it. One is, to use +non-humanized lymph, since the lower animals are insusceptible to +syphilis.[1] This is simple. The other is, to select a human +vaccinifer that is free from syphilis. This is difficult. Too great +reliance, however, should not be placed upon the vaccinifer; it is +possible to convey syphilis even in the use of bovine virus. Suppose +two persons, A and B, are to be vaccinated at one sitting, A being +syphilitic. If A is vaccinated first, and the same lancet, imperfectly +cleansed, is used on B, it is plain that B will be inoculated not only +with vaccine lymph, but also with A's blood. It is of the first +importance, therefore, that this form of vaccinal inoculation of +syphilis should be carefully guarded against; and that can be +accomplished most certainly by using a fresh instrument for each +patient. + +[Footnote 1: Practically, this is certain, although there is some +reason to believe that the disease may be conveyed to monkeys.] + +From a medico-legal point of view it is important to note that +constitutional syphilis may follow vaccination, and yet have nothing +to do with it. Suppose an infant to be born syphilitic, but with no +visible manifestations of the taint. Let that child be vaccinated, and +let the syphilitic dyscrasia afterward break forth. The ordinary +inference would be that the syphilis was due to the vaccination; and +in most instances this view would certainly be urged by the syphilitic +parent, since it would {471} free him from suspicion. It is always +easy to disprove such an allegation, however, for syphilis +communicated in vaccination always shows itself first in the form of a +chancre at the site of the vaccination. Therefore in any given case, +unless this mode of onset can be proved, the syphilis is manifestly +not of vaccinal origin. Some observers, it is true, are of the opinion +that vaccination may evoke a pre-existing syphilis, to use Lanoix's +term--_i.e._ that it may hasten the appearance of the characteristic +manifestations, and even determine their localization at the site of +the vaccinal inoculation. But, even allowing the truth of that +proposition, in such a case the lesion would be constitutional, not +chancrous. + +It is well, nevertheless, to take precautions against being placed on +the defensive in this way; and it may commonly be avoided by declining +to vaccinate infants under three or four months old, since inherited +syphilis generally manifests itself by that time. This prudence on our +own behalf should not be carried so far, however, as to lead us to +deny the benefit of vaccination to very young infants whenever the +prevalence of small-pox is such that they are in obvious danger of +exposure. + +As regards its management, vaccinal syphilis does not differ from the +ordinary form of the affection, and hence demands no other treatment +than what is proper for the disease contracted in the usual way. It +simply originates in an extragenital chancre. + +Concerning the conveyance of other constitutional taints in +vaccination our knowledge is very limited. The present tendency of +pathological investigation is, however, to accord inoculability to +many diseases that formerly were not imagined to possess that quality, +so that in regard to other affections than syphilis it is prudent to +use the utmost care in the choice of lymph. There is one supposed +safeguard that does not seem to have the slightest title to be so +regarded--namely, the notion that a typical pock cannot be developed +on a person affected with a specific cachexia. There is no truth in +the doctrine. Over and over again the writer has seen perfect vaccine +pocks on persons whom he knew to be syphilitic. + +Cutaneous affections of a non-specific character are sometimes +observed to result from vaccination; that is to say, they follow close +upon its performance, without any other known exciting cause. It may +fairly be supposed that in many instances they would have shown +themselves even if the vaccination had not been performed, for it is +often the case that we are unable to speak positively in regard to the +exciting cause of an eruption. Several years ago a striking case in +point was related to the writer by a well-known physician of this +city, S. S. Purple, in whose practice it occurred. Purple had engaged +to vaccinate a child on a certain day, but for some reason the +vaccination was not done. In about a week from the appointed day, +however, erysipelas made its appearance, beginning on the left arm at +the usual site of vaccination, and pursued its course to a fatal +termination. To be sure, we are now speaking of non-specific +affections, but erysipelas illustrates the proposition perfectly, +notwithstanding its specific character. + +Children with a tendency to eczema are prone to suffer an outbreak of +that disease as the result of vaccination. In Jenner's time, indeed, +it was considered not only that there was great risk of causing an +aggravation of any slight eczematous eruption by vaccination, but that +the mere {472} existence of the eczema, even in the most trivial form, +was likely to interfere with the success of the vaccinal inoculation. +This has been the general feeling of the profession. Quite recently, +however, many observations have been recorded tending to show that the +old dread of vaccinating an eczematous child was not altogether +warranted. The question needs further study, and, while it is probably +best to postpone the operation under ordinary circumstances, nothing +should induce us to withhold its protective influence where there is +any manifest danger of actual exposure to small-pox. + +Although eczema is the most common of the cutaneous affections called +forth or aggravated by vaccination, there are various forms of skin +disease, some of them difficult to classify, that occasionally result. +They are usually vesicular, pustular, or furuncular--that is to say, +irritative. In the majority of instances it will be found either that +the pock itself has followed an irregular course, being whitish, +diffuse, and ending in an exaggerated although superficial +incrustation, or that it has been subjected to injury. Still, in some +cases neither of these conditions is the precursor of the skin +affection. In many instances the latter can only be called +nondescript. There seems to be some occult connection between +vaccination and the curious skin disease described by the late Tilbury +Fox of London under the name of impetigo contagiosa; and, indeed, +Piffard of this city has found certain microphytes to be common to the +crusting period of vaccinia and that of contagious impetigo. What the +relation of the two affections is to each other, however, it is +difficult to say. + +Apart from impetigo contagiosa, the cutaneous complications that +follow in the wake of vaccination possess no distinctive features, and +their management differs in no wise from that of the same +manifestations due to other causes. + +THE TECHNICS OF VACCINATION.--This aspect of our theme involves a +number of separate considerations. It will be convenient to give our +attention first to the matter of the choice of virus. The question +arises at once as to the selection between animal vaccine and the +humanized variety. In a broad sense the term animal vaccine +includes--1. Virus derived directly from a case of so-called +spontaneous cow-pox. 2. Variola vaccine--_i.e._ the virus of an +affection of the cow resulting from variolation. 3. The virus of +horse-pox (not strictly vaccinal). 4. Retro-vaccine--_i.e._ the virus +of an affection produced in the cow by the inoculation of vaccinia +from the human subject. 5. The virus of a disease (true vaccinia) +propagated through a series of bovine animals from the so-called +spontaneous cow-pox, being the virus now commonly understood by the +term, and the variety here referred to when it is not stated to the +contrary. + +By humanized vaccine we understand that which is obtained from the +human subject, no matter how short or how long its descent from the +cow. As regards animal vaccine, we may practically exclude from +consideration all but the last variety mentioned, that being the one +to which, in the great majority of instances, the term is now +restricted. This narrows the question down to the choice between virus +that has been propagated through a number of bovine animals +(practically, calves) from the spontaneous disease in the cow, and +that which, whatever its original source, has already passed through +the human system. + +{473} The variety first mentioned, sometimes called primary vaccine, +is generally spoken of by authors as not very trustworthy as regards +its infective power (that is, not to be counted on to take), and as +prone to give rise to undue inflammatory complications when its use +does prove successful. These unpleasant qualities might be explained +by the supposition that primary vaccine is not apt to be at its best +when it is now and then obtained. Practically, however, it may be +dismissed without further consideration, for it is seldom to be had. + +The second form--variola-vaccine--is manifestly improper to be used +whenever genuine vaccine is to be obtained, unless, indeed, we shut +our eyes to the accumulating evidence that variola-vaccine, so called, +is not vaccine at all. Furthermore, it is a question whether its use, +as well as all attempts to produce it, should not be forbidden by law. + +The third variety, if such it may be called, it does not seem +legitimate to use in the present state of our knowledge, since it is +not yet proved satisfactorily that horse-pox possesses the full +protective power of cow-pox, or is free from objections that do not +arise in connection with the latter. + +As to retro-vaccine, while the writer is unable to see any positive +reason against its use, neither can he see any reason why it should be +superior to humanized vaccine, as such, save that during the period of +its bovine propagation it is not liable to become contaminated with +the poison of syphilis. The idea that an enfeebled stock of humanized +vaccine can have new life infused into it by passing through the +system of the cow is not reasonable prima facie, and there are no +particular facts to support it. By ensuring freedom from the danger of +communicating syphilis retro-vaccination doubtless served a good +purpose at one time, but now, since the remarkable and enduring +excellence of the Beaugency stock is so well established, there seems +to be no excuse for a further resort to the practice. + +The last of our five forms of animal vaccine, that produced by the +continued propagation of spontaneous cow-pox through calves, is what +is now known as animal vaccine par excellence. Its advantages over the +other forms are so obvious that it alone should figure in any +comparison between animal and humanized vaccine. That being +understood, what are the relative merits of animal and humanized +vaccine? It should be stated, in the first place, that bovine virus +should be compared with virus that has long been humanized, for lymph +of but a few removes from the bovine animal does not show any +noteworthy differences from animal vaccine itself. + +In behalf of humanized virus it is maintained--1, that it is a more +trustworthy preventive of small-pox; 2, that it is superior in its +infective property, so that it is surer to take; 3, that it is more +prompt in its action, thereby affording more speedy protection to +persons who have actually been exposed to small-pox; 4, that its +virulent property is easier of preservation, wherefore it is more to +be depended on when it is necessary to keep it on hand for a long time +or to transmit it to great distances; 5, that its use requires less +skill, or, rather, less special knowledge of the peculiarities of the +animal virus; 6, that it is less violent in its effects; 7, that it is +less apt to give rise to irregular, and therefore more or less +abortive and non-protective, forms of pock. + +{474} The first of these propositions, which asserts that humanized +vaccine confers greater protection against small-pox than the animal +virus, was warmly maintained by those who opposed animal vaccination +on its first introduction into this country; but now the record of the +past thirteen years, during which period bovine virus has more and +more borne the brunt of the fight against small-pox, has disproved it +in the judgment of all competent and fair-minded observers. So far, +indeed, as the facts have been analyzed, they go to show that the +reverse is the case--that bovine virus confers a more complete and a +more lasting protection. Direct observation on this point is +strengthened by the collateral fact that revaccination became at once +astonishingly successful when the use of animal vaccine first gained +currency, whereas now it is again declining in success; the +explanation of which latter circumstance is, that it is now found +difficult to revaccinate those whose primary vaccination was done with +bovine virus--a striking indication of the permanence of the +protection accomplished with the latter. + +The second assertion--that humanized virus succeeds more readily than +the bovine variety--is still maintained by many, but, it may +confidently be said, by few if any whose experience with good animal +vaccine has been large. The truth is, that every large public +vaccination service in the country is now carried on almost solely +with bovine virus, and that results are thus achieved that were not +dreamed of in former times. Individual experience cannot weigh against +this fact, but may be explained, rather, by what modicum of truth +there may be in the fifth proposition, or by the assumption (surely a +legitimate one, in view of the number of irresponsible and ignorant +purveyors of animal vaccine that have thrust themselves before the +profession since the advantages of the practice were established by +the labors of others) that those whose observation leads them to a +conclusion at variance with that reached by the great majority of +trained observers have really been unfortunate in the quality of the +virus with which they have been supplied. Whatever the explanation may +be, however, there is nothing more certain than that the use of animal +vaccine, properly carried out, is daily furnishing results that have +never been excelled, if they have been equalled, in the employment of +humanized virus on a like scale. + +The third suggestion--that the humanized virus acts the more promptly +of the two, and is therefore to be preferred for immediate +protection--is plausible, since the areola (the alleged sign of +systemic infection) forms somewhat later around a pock produced by +animal virus than around one that is the result of vaccination with +the humanized variety. The difference is one of a few hours only at +the most, and it is not by any means a general occurrence; still, we +may concede that in this respect the use of humanized virus is to be +preferred under certain circumstances. + +As to the fourth statement--that humanized virus is more tenacious of +its infective property--strictly speaking, there is not a particle of +truth in it. In the case of liquid lymph preserved in capillary tubes +it has the semblance of truth, but, for reasons that will be more +fully set forth hereafter, that is because it is difficult to get the +virulent portion of bovine lymph out of the tube. In the form of dried +lymph (the only form that ought to be used) animal vaccine may be sent +to all parts of the world, and may be kept any reasonable length of +time and without {475} special care, without undergoing sensible +deterioration, if tested by one who is familiar with its peculiarities +and aware of the care that should be taken in using it. Under ordinary +circumstances there is no difficulty about preserving animal vaccine +with its energy practically unimpaired. + +The statement that the use of humanized virus demands less special +knowledge than that of bovine virus is conceded at once. That special +knowledge is easily mastered, however, and no man fitted to practise +medicine will look upon its acquirement as a bugbear or a hardship. + +The impression, almost universal thirteen years ago, that humanized +vaccine is less severe in its local and constitutional effects than +the animal virus has been eradicated from the minds of all but those +who still follow the teachings of the older writers rather than yield +to what daily experience has been teaching during these thirteen +years, or those who reason from exceptional cases rather than from a +general drift. The truth seems to be this: with revaccinated adults +animal vaccine acts somewhat more severely than the humanized virus; +in infants, on the other hand, its action is not so violent as that of +the humanized variety. + +Concerning the seventh and last claim put forward in behalf of +humanized vaccine--that it is less apt to give rise to irregular or +spurious pocks--we may say that no form of irregularity has been +observed by those who have lately used the bovine virus that was not +well known to the older writers, who founded their observations +wholly, or almost wholly, on the use of the humanized virus; nor is +there any proof that such irregularities are more common now than +formerly. The truth seems to be, that these irregular forms of pock +seem to prevail at certain times, and not at other times, regardless +of the particular stock of virus used, other things being equal. Why +this should be so we do not know, but the fact is beyond dispute. + +To sum up, then, we can only say that in barely one particular--that +of promptness of action--can humanized virus justly be credited with +any superiority, while in every other essential respect it is +inferior, so far as any difference is to be observed. + +What, on the other hand, are the points of superior excellence +attaching to bovine virus? Setting aside certain extravagant +assertions that have sometimes been made in its behalf, such as that +it far exceeds the humanized virus in its protective virtue (which may +be true, but is not yet proved), they may be put in general terms in +the form of a denial of all the particular claims that we have +enumerated as having been put forth for its rival. Such a denial, it +has been seen, seems to the writer to be justified, save in the one +particular that perhaps we should accord to humanized virus the merit +of speedier action, and consequently greater certainty of protection, +in cases of actual exposure to small-pox. + +Besides these negative points in its favor, the foremost advantage of +animal vaccine is the guarantee it gives that, properly used, no +syphilitic contamination will result. On this point no argument is +needed, for the cow is insusceptible to syphilis. + +A second consideration in its favor is, that it can always be had in +large quantities at short notice. The young practitioner of the +present day can scarcely appreciate the importance of this fact, but +whoever remembers the comparative helplessness in which, in past +years, he has found himself in the face of a sudden outbreak of +small-pox, not knowing which {476} way to turn for an adequate supply +of vaccine, will at once concede its force. + +On the whole, then, it must be said that bovine virus is entitled to +the preference as a rule, but that possibly it is well to resort to +humanized lymph of early removes under the special circumstances above +referred to. On no account should long-humanized vaccine be used so +long as our present stocks of animal virus maintain the excellence +they have thus far preserved, nor should humanized virus of any sort +be preferred in the general run of cases. + +Passing now to a consideration of the various forms of vaccine, +disregarding its source, there are practically these three: the crust, +liquid lymph preserved in capillary tubes, and dried lymph. + +Until recently the crust, or scab, was much used in this country. Its +capability of being preserved unimpaired for a long time was a valid +excuse for this, especially in regions remote from the great channels +of communication, and it was in such districts that the use of the +crust was chiefly practised. That excuse scarcely exists now, for +there are few physicians who cannot obtain a better form of vaccine +within a very short time. The objections to the crust are two: 1. Most +crusts are inert. Especially is this true of bovine crusts, which are +wellnigh worthless. It must be confessed, however, that when once a +crust has proved itself active it may be trusted to retain its +infective property for a very long time. The writer has made +successful use of crusts seven years old that had made the voyage to +Japan and back; and they were bovine crusts too. Still, the rule is, +that crusts are untrustworthy. 2. Their use is apt to be followed by +undue inflammation, probably of septic origin, for they almost +invariably contain putrescent or readily putrescible elements. It has +even happened to the writer to cut open a crust that to all appearance +was typical and innocent, and to find in its interior a cavity +occupied by a pulpy, stinking slough. Manifestly, such material is +unfit to be introduced into the system of any human being. + +In regard to liquid lymph in tubes, it is not much used in this +country, and its employment elsewhere is on the decline. At first +thought, it would seem to be the best form of all, but experience does +not bear out this view. In this form humanized lymph is vastly +superior to animal lymph, but with every possible care in charging and +sealing the tubes it is not uncommon to find their contents putrid. +There are low vegetable organisms that are supposed to prey on the +vaccinad. If there is any truth in this supposition, those organisms +are certainly favored in their destructive luxuriance by keeping the +lymph liquid, thus furnishing them with the best possible +culture-fluid. Be this as it may, the fact is well ascertained that +tube-lymph does not keep well. It has been mentioned already that +bovine lymph stored in tubes is decidedly inferior to the same form of +humanized lymph. This was long ago recognized by propagators of animal +vaccine, but the cause remained a mystery until Warlomont of Brussels +suggested that it was due to one of the physical peculiarities of +animal lymph--that, namely, as already hinted at, by virtue of which +its formed elements tend to attach themselves to any surface presented +to them, leaving the supernatant liquid a mere inert compound of +water, albumen, and salts; so that in the case of tube-lymph the +virulent elements remain attached to the glass, and only the inert +constituents {477} are really used. This theory is exceedingly +ingenious and plausible, but the writer is not aware that it has been +proved. He does know, however, that in some South American countries, +where calf lymph in tubes is used with success, the custom is to grind +the tubes to powder, and inoculate with the resulting magma, glass and +all. This practice is certainly not to be commended. + +Dried lymph is the most efficient of all forms of vaccine, and, kept +as it ought to be, it retains its infective power long enough to +answer all ordinary requirements. The writer has used it three years +old with success. It may commonly be counted on for six weeks. One +fact should be borne in mind, however: the longer dried lymph has been +kept the more care is necessary in its use, for by long keeping it +becomes very hard, so that it is a work of patience to dissolve it off +from the surface on which it was deposited. Failure to accomplish its +solution is the most common cause of a lack of success in its +employment. + +The various forms of stored vaccine are esteemed by the writer in the +following order: 1, dried bovine lymph; 2, dried humanized lymph; 3, +humanized tube-lymph; 4, humanized crusts; 5, bovine tube-lymph; 6, +bovine crusts. + +The age and other circumstances under which it is best to vaccinate +children constitute a point for practical consideration. It may first +be mentioned that pre-natal vaccination has been advocated by some +authors; that is to say, the vaccinal infection of the foetus in utero +by vaccinating the mother during gestation. There seems to be +respectable testimony going to show that the end may thus be +accomplished, but a weighty objection arises in the fact that this +mediate vaccination of the foetus produces no physical sign of its +success, so that doubt must always be felt as to whether or not the +procedure has been efficacious. Moreover, it is seldom indeed that a +child needs protection before its birth, provided we protect the +mother, for it is well known that vaccinia will overtake and destroy +the variolous infection, even when the latter has had two or three +days' start. The practice has been chiefly urged by Bollinger. It is +not likely to come into general use. + +There is no special objection to vaccinating an infant at any time +after birth, but usually it is well to defer the operation until the +child is about three months old, unless there is actual danger of +exposure to small-pox. Yet it is not well to postpone vaccination +until the period of dentition, for the combined irritation of the two +disturbing elements may prove decidedly uncomfortable if not serious. + +Something is to be said as to the time of the year to be chosen. In +New York the bad custom prevails, especially among the poorer classes, +of having children vaccinated only in April, May, or June--just the +part of the year in which erysipelas is most rife. The hot months +should not generally be chosen, for any source of irritation is apt to +be felt more severely by infants during the summer heat. However, no +circumstances should be looked upon as a positive bar to vaccination +in case of actual danger of exposure to small-pox, and in large towns +children should never be taken into public conveyances or carried into +any promiscuous assemblage until they have been protected by +vaccination. + +The next question is as to the part of the body that should be +selected for the inoculation. The region of the insertion of the left +deltoid muscle {478} is usually chosen--the left rather than the +right, because most nurses habitually carry an infant on their own +left arm, so that the child's left arm is uppermost, and hence less +exposed to injury. The region of the deltoid insertion is +comparatively free from the irritation of muscular contraction, and it +is easily accessible. If two insertions are made, it is well to make +one of them over the deltoid insertion and the other at a point about +an inch distant on the line of the posterior border of the same +muscle, for there the lymphatic connection with the axillary glands is +less free, so that adenitis is not so much to be feared. To avoid a +scar in a locality that may be exposed to view on certain occasions +some mothers prefer that their daughters should be vaccinated on the +lower limb. To this there is no special objection, further than that +the lower limb is rather more exposed to rough handling than the arm. +If the leg is chosen, the point of junction of the two heads of the +gastrocnemius is an eligible situation. + +The actual operation is performed in various ways. The old inoculators +generally made an incision through the whole thickness of the skin, so +that a pellet of subcutaneous fat rolled up into the little wound. +This is wholly unnecessary; furthermore, it is objectionable, for it +decidedly increases the risk of inflammatory complications. Still more +to be avoided are the methods by inserting a seton imbued with the +virus and by hypodermic injection or other like procedures. The best +way is, simply to remove the horny layer of the cuticle, so as to +expose the succulent portion of the epidermis. This surface is +somewhat red, and from it a slight exudation of lymph will be +observed, but there need not be the least flow of blood. By this +procedure it is not uncommon to vaccinate a sleeping child without +waking it. It is not only admissible, but preferable, not to wound the +derma at all. Such an abrasion is easily made with an ordinary lancet, +which, contrary to the advice sometimes given, should be very sharp; +but no cutting or scratching should be done with it, only scraping +with the convex part of its edge, precisely as in using an ink-eraser. +Scratching instruments (such as the rake-like vaccinator often used or +a row of needles set in a handle) are not easy to adapt to varying +degrees of plumpness of the arm, and are apt to make too deep +scratches, one at either side, while the skin between the two is +scarcely touched. Whatever instrument is chosen, it should not be used +again until it has been thoroughly cleansed--made chemically +clean--which can be accomplished only by heating it or by wiping it +off and then dipping it into a strong disinfectant solution. + +Some individuals are refractory to vaccination, but complete +insusceptibility is exceedingly rare. Various expedients have been +resorted to in rebellious cases, such as vesication with +ammonia-water, maceration of the skin for some hours with glycerine, +and the like. The writer has known these devices to succeed, but he +has not seen the slightest advantage in the plan recommended by Ceely, +that of using a wound some hours old rather than one just made, +although he has tried the experiment many times. It is not necessary +to make a large abrasion; one as large as the little finger-nail is +ample. + +The next step is to apply the virus, and it should be so applied as to +bring it into contact with every part of the denuded surface. In what +is known as arm-to-arm vaccination, or its equivalent, calf-to-arm +{479} vaccination (by all means the most successful method, although +not often practicable in this country), the liquid lymph, fresh from +the vaccinifer's pock, is simply applied, when it will at once become +diffused over the abraded surface without any special pains being +taken to accomplish that end. + +If dried lymph is used, particular care should be taken to see that it +is actually dissolved and transferred from the substance on which it +was dried to the abraded surface. Failure to accomplish this is the +cause of almost all the lack of success that inexperienced vaccinators +meet with. The lymph should be moistened with water, or, if it is +quite old, with glycerine, before the abrasion is made, so that it may +have time to dissolve. It should then be rubbed upon the abraded spot +vigorously, and at least for the space of a full minute. + +In the use of tube-lymph no other precautions are necessary than in +arm-to-arm vaccination, but, simple as this method is, its results are +unsatisfactory. + +Crusts should be reduced to a powder, and then made into a thin paste +with water or glycerine. A convenient way of powdering a crust is to +rub it on a file or between two files. The paste is to be well rubbed +upon the abrasion. The insertion of a solid piece of crust into a +valvular incision is not to be recommended. + +When the operation is finished it is well to keep the arm bare for +about five minutes, but not necessarily until the spot has become dry. +It is not well to apply any sort of plaster, but means should be taken +to prevent the underclothing from sticking to the abrasion. For this +purpose there is no objection to the shields that are furnished by the +surgical instrument-makers. Usually, however, nothing of the sort is +necessary. + +THE STORAGE AND PRESERVATION OF VACCINE VIRUS.--Lymph should usually +be taken on the eighth day, inclusive--never after the areola has +formed. On the other hand, the writer's experience does not lead him +to coincide with those who state that the earliest lymph that can be +obtained is the most energetic. If it is to be dry-stored, the +substance to be coated with it (slips of quill, ivory, wood, +whalebone, glass, and the like) should be laid gently in the pool of +lymph that exudes on puncturing the pock, and allowed to dry, +preferably without the aid of artificial warmth. The layer of lymph +should be plainly visible after it has dried. A second coating is +advisable, as it serves to preserve the first. + +Capillary glass tubes are either cylindrical or furnished with a +bulbous expansion at the middle, the latter form being most commonly +used. To charge a tube make sure that both ends are open, and then +submerge one end in the pool of lymph. Capillary attraction will cause +the tube to fill, and the process may be facilitated materially by +inclining the tube toward a horizontal direction, so that the +capillary attraction is not opposed by that of gravitation. Care +should be taken to keep the applied end of the tube constantly +submerged, or bubbles of air will enter it. The sealing may be done +with a blowpipe, by simply holding the ends in a flame, or by means of +sealing-wax or some similar substance. The satisfactory charging of +tubes demands some practice, but a little patience will enable any +intelligent person to succeed. + +In regard to crusts, they should never be removed until the surface +beneath has become cicatrized and they have been partially detached by +the natural process. A crust torn off prematurely should never be +used, {480} and the same may be said of secondary crusts--_i.e._ those +that form by the desiccation of the discharge from the raw surface +left when the primary crust has been removed forcibly. + +For the preservation of vaccine in these various forms tubes need only +be kept in a cool place. Dried lymph and crusts should be guarded +against dampness even more than against warmth. Their preservation may +be decidedly favored by over-drying, either in an exhausted receiver +or by keeping them in a closed vessel in the presence of sulphuric +acid, chloride of calcium, or some other substance having a strong +affinity for water. It is needless to say, however, that they should +not come into actual contact with any such agent. While this +artificial desiccation tends powerfully to preserve dried lymph, it +makes it more difficult to use. When dried lymph or a crust is to be +sent by mail or other conveyance, it should be wrapped in some +impermeably envelope, for which purpose gutta-percha tissue is very +convenient. Both these forms of virus should be kept in a cool place. +There is no objection to keeping them on ice, provided they are well +protected against moisture. + + * * * * * + +In conclusion, the writer wishes to say that the limited space at his +command has compelled the assumption of a dogmatic rather than an +inductive form in the construction of this article. To the reader who +may wish to pursue the subject further--and it will well repay +thorough study--he would recommend the following bibliography: + +Ballard: _On Vaccination: its Value and Alleged Dangers_, London, +1868. + +Bousquet: _Nouveau traite de la vaccine et des eruptions varioleuses_, +Paris, 1848. + +Bryce: _Practical Observations on the Inoculation of Cow-pox_, +Edinburgh, 1809. + +Ceely: _Observations on the Variolae Vaccinae_, Worcester, 1840. + +Chauveau et al.: _Vaccine et Variole_, Paris, 1865. + +Depaul: _Nouvelles recherches sur la veritable origine du virus +vaccin_, Paris, 1863; _De l'origine reelle du virus vaccin_, Paris, +1864; et al.: _De la syphilis vaccinale_, Paris, 1865. + +Hardaway: _Essentials of Vaccination_, Chicago, 1882. + +Hering: _Ueber Kuhpocken an Kuhen_, Stuttgart, 1839. + +Jenner: _An Inquiry, etc._, 2d ed., London, 1800. + +Sacco: _Trattato di Vaccinazione_, Milano, 1809. + +Seaton: _A Handbook of Vaccination_, London, 1868. + +Steinbrenner: _Traite sur la vaccine_, Paris, 1846. + + + + +{481} + +VARICELLA. + +BY JAMES NEVINS HYDE, M.D. + + +Varicella is an acute disorder of infancy and childhood, in the course +of which appears a cutaneous exanthem of vesicular type, accompanied +at times by systemic symptoms of moderate severity, terminating in the +course of from three days to a fortnight, after the formation of +relatively few crusts upon the skin, with occasionally persistent +cicatrices. + +SYNONYMS.--_Eng._, Chicken-pox; _Ger._, Windblattern, Schafpocken; +_Fr._, Varicelle; _Lat._, Variola notha, seu spuria; _Ital._, +Morviglione. + +HISTORY.--The literature of the disease which is now best recognized +under the title of varicella has been, in the history of medicine, +wellnigh inextricably confused with that of variola. In the latter +part of the seventeenth and the early part of the eighteenth century +the distinction between typical forms of the two disorders became +apparent, and was described by Willan and Harvey in England, and other +writers in Germany, France, Holland, and Belgium. Among those who have +contributed to its literature may be named Hebra, Kaposi, Trousseau, +Simon, Thomas, Guntz, Henoch, Kassowitz, and Boeck. + +ETIOLOGY.--Varicella is essentially a disease of early life, occurring +almost exclusively in infants and young children. It is a contagious +disorder, and at times, especially in hospitals and asylums for +children, occurs in apparently epidemic forms. The question relating +to the inoculability of the contents of its vesicular lesions is still +open, positive and negative results being recorded by different +experiments.[1] + +[Footnote 1: The writer has purposely avoided, in the brief space here +devoted to the disease under consideration, entering into a discussion +of the question respecting the relation sustained by varicella to +variola. On one side are the views entertained by the Vienna school of +dermatologists, according to which there is but a single virus in +these several forms of disease--the variolous poison. On the other are +the opinions and the practice, largely based upon the latter, of most +English and American physicians, who deny the existence of any +relation between the pathological states recognized by them as +occurring in two entirely distinct affections. + +My personal view may be briefly formulated as follows: Practically and +clinically, it is useful to regard these disorders as of a distinct +nature. The arguments, however, in favor of such absolute distinction +are not irrefutable. There is probably in both forms of disease but a +single virus, that of variola; but this, modified by evolution among +generations of vaccinated children, has, in this process of natural +cultivation or attenuation, produced a malady of tender years whose +attacks do not protect from variola and occur irrespective of +vaccination.] + +SYMPTOMATOLOGY.--The period of incubation of the disease cannot be +said to be definitely established. At times, without question, an +entire fortnight elapses between the dates of exposure and the +evolution of the disease, but both longer and shorter intervals have +been recorded. + +{482} If there be a prodromal stage of the disease, certainly in the +vast majority of the little patients it cannot be recognized. During +the last month the writer has observed the evolution of the disease in +twenty children gathered together in the Chicago Home for the +Friendless, no one of whom was recognized as ailing before the +eruption appeared. Occasionally the disease is preceded by mild or +even severe febrile symptoms, accidents sufficiently common in this +class of patients. + +The exanthem, commonly the first symptom of the disorder, occurs in +the form of reddish puncta, from which rapidly develop rosy-colored +maculations, and these become tensely distended, transparent or +slightly yellowish vesicles, of the average size of a split pea, +though they are occasionally smaller or may enlarge to the dimensions +of a bean or small nut. The eruption appears first upon the upper +segment of the body, implicating the chest in front and behind, the +neck, the scalp, particularly the extremities, and quite sparingly the +face also, which may, however, entirely escape. In cases where the +eruption is profuse it may be completely generalized, involving +largely the trunk and extremities, the lesions, upon the back +particularly, being as closely set together as in discrete variola. In +many, even the majority, of cases the exanthem is much less profusely +developed, not more than a dozen or twenty vesicles springing from the +surface. + +The vesicles are superficial in situation, the firm papule which +precedes the variolous rash being altogether wanting. They are at +first transparent, their contents plainly showing through their +translucent roof-wall, composed only of the stratum corneum of the +epidermis. They are both acuminate and globular, and occasionally rest +upon a slightly hyperaemic integument. Umbilication rapidly occurs at +the apex, and simultaneously their contents become lactescent and +gradually sero-purulent. Occasionally vesicles are transformed into +genuine, coffee-bean-sized, pustules. Intermingled with these are +often seen illy-developed and abortive vesicles. + +By the end of a period lasting from twelve hours to the second or +third day involution has usually begun, and the lesions, with and +without rupture--more often the latter--desiccate, and are thus +transformed into yellowish or yellowish and brown, circular, +circumscribed crusts resting upon an apparently unaltered integument. +These crusts are often so firmly attached that they do not fall +spontaneously before the lapse of from five to eight days. When this +exfoliation is ended there are left slightly hyperaemic pigmented +patches of corresponding size where the crusts had rested. A +destructive process occasionally results upon the surface of the face +at the base of such vesiculo-pustular lesions as have formed there, in +consequence of which a small depressed and superficial cicatrix is +left, which does not differ from that resulting from discrete variola. +These scars may be superficially seated and transitory in character, +or much deeper and persistent through life. + +Throughout the course of the disease systemic symptoms may be +altogether wanting, or may occur in a mild, and much more rarely in a +severe, type. In some cases the temperature is increased by one or two +degrees upon the appearance of the exanthem, and often a febrile +movement of moderate grade may persist for forty-eight hours or +somewhat longer. Defervescence, however, is always rapid and perfect. +In very {483} rare cases there is a subsequent successive new +development of scanty vesicles, whose appearance is heralded by mild +exacerbations of fever. + +Occasionally the vesicles may be recognized upon the mucous surfaces +of the lips, inside of the cheeks, tongue, palate, conjunctivae, and +progenital regions of both sexes. Still more rarely the glands of the +throat become slightly tumid and painful. + +The complexus of symptoms, in the large majority of all these little +patients, is that which pertains to a disorder of distinctly mild +type. The eruptive lesions are scanty and productive of but trifling +subjective sensations. Occasionally they are picked or scratched, and +thus become the seat of either pain or pruritus. In the febrile stage +the child is noticeably fretful for a period of perhaps twenty-four +hours. At the end of that time older children are frequently observed +engaged in their customary amusements in the nursery. + +Severe types and complications of varicella are in general limited to +the little patients who are recognized as suffering from hospitalism. +Among these we see erysipelas, severe vaccinal eruptions, lesions of +inherited syphilis, and the sequelae of morebilli and scarlatina, +which the disease both precedes and follows. + +PATHOLOGY.--The anatomical structure of the lesions in varicella is +largely a matter of inference, since there has been but small +opportunity of studying the disorder as displayed in sections of the +morbid integument. Manifestly, the exanthem is exudative in type, the +serum in circumscribed areas lifting the superficial layer of the +epidermis from the deeper parts of the derm. Unquestionably, septa +occur in typically developed varicella chambers, similar to those seen +in variola--a pathological fact which is the corner-stone of the +doctrine relating to the unity of the two disorders. The serum +contained in these septa possesses an alkaline reaction. The formation +of a cicatrix is evidently due to the intensity of the process in +certain exceptional lesions, as a result of which the papillae of the +corium are superficially destroyed. These sequelae are often due to +the picking and scratching of the lesions. + +DIAGNOSIS.--Varicella is to be distinguished from eczema pustulosum by +its mild febrile symptoms, the discreteness of its pustular lesions, +the absence of itching, and of infiltration of the skin in patches, +and its tendency to symmetrical development. + +From impetigo and the impetigo contagiosa of Fox of London it will +often be scarcely differentiated. Inasmuch as these disorders are +frequently recognized among children suffering from varicella or +varicella convalescence, it can scarcely be doubted that these +diseases have been in the past often confounded, and that in many +cases it is practically impossible to distinguish between them. +Decided elevation of bodily temperature, umbilication of +symmetrically-disposed lesions, and a rapid involution of the disease +point to varicella. The two forms of impetigo occur without fever, are +usually scantily developed, and are much more apt to be pustular in +type, lacking, moreover, the halo of the varicella lesions. The latter +are also, on an average, smaller and more numerous. The two forms of +impetigo, finally, never display the generalized eruption of severe +varicella. The non-contagious variety of impetigo is much more +decidedly pustular in its lesions, and the latter spring from a deeper +plane of the epidermis. + +{484} As to the eruptions due to vaccinia and vaccination, there can +be but little doubt that these also have been frequently confounded +with varicella. Efflorescences having origin in this way are very +largely impetiginous in type, and the conditions named above are then +to be regarded as distinctive differences, so far as any distinction +can, under these circumstances, be recognized. Impetigo, impetigo +contagiosa, and varicella are all sufficiently common accidents after +vaccination. No reliance can be placed upon characteristics described +as connected with a certain stuck-on appearance of the crust regarded +by Fox as characteristic of the crusts in impetigo contagiosa. In all +these vesiculo-pustular disorders of childhood desiccating serum and +sero-pus upon the surface result in the formation of crusts which have +a similar (so-called) stuck-on appearance. + +Variola and varioloid of infants and children are to be distinguished +from varicella by the evidence of origin from such contagious +maladies; by the occurrence of prodromal symptoms; by the greater rise +in temperature during the febrile stage; by the typically papular +stage of the exanthem at its outset, and no less typically pustular +stage before the occurrence of desiccation; by the confluence of +lesions in confluent cases; and by the much longer and evidently +graver stadium of the disease. Distinctions between mild varioloid and +severe varicella in infancy and childhood will always tax to the +utmost the skill of the diagnostician. The sooner it is generally +understood that intermediate forms occur which cannot be positively +assigned to the one or to the other category, the better it will be +for both the profession and the laity. The fact that in the one case +there is generation of a variolous poison capable of producing a +contagious disease in adults, and in the other a malady which is known +to affect children only, renders the decision important. Scattered +papulo-vesicular and vesiculo-pustular lesions appearing after a high +fever, and pursuing a period of evolution longer than forty-eight +hours, should always awaken suspicion. Superficial lesions, on the +contrary, distinctly vesicular on the third day, or commingled with +minute, very superficial pustules, should be regarded as +characteristic of varicella. + +The so-called varicella prurigo of Hutchison of London[2] includes +several of the disorders considered above under the titles impetigo, +impetigo contagiosa, and the vaccine rashes. The irritable condition +of the skin resulting from several of the exanthemata leaves it prone +to the development of a long list of cutaneous lesions, some of them +accompanied by pruritus in various grades, to each of which might be +given, according to the caprice of authors, a separate name. + +[Footnote 2: _Lect. on Clin. Surg._, Lond., 1878, p. 15 _et seq._] + +PROGNOSIS.--The prognosis of varicella, per se, is always favorable. +Only in the hospital cases, complicated by erysipelas and scarlatina +convalescence, may grave results be anticipated. The milder attacks +may leave persistent relics of their career in the form of one or more +depressed and persistent cicatrices, which become less conspicuous as +the patient approaches adult years. + +TREATMENT.--Varicella is, in a large proportion of cases, successfully +treated by domestic management and the simpler remedies familiar to +those in charge of the nursery. Confinement for a brief time to the +{485} cradle or bed, and a proper regulation of the temperature of the +room and of the diet, are usually all that is required. Special +remedies may be indicated in isolated cases, but certainly none such +are demanded by the varicella. Efforts should be made to protect the +face lesions from the traumatism of picking and scratching, with a +view to prevent pitting. + +Isolation of patients is not requisite, nor any process of +disinfection other than that which is incidental to a fresh supply of +pure air. Vaccination should be practised alike in the case of +children who have and who have not suffered from the disease. + + + + +{486} + +SCARLET FEVER. + +BY J. LEWIS SMITH, M.D. + + +HISTORY.--The terms scarlet fever and scarlatina are used synonymously +to designate one of the most common and fatal of the eruptive fevers. +Whether this malady occurred prior to the Christian era is uncertain. +It is believed by some that the plague of Athens, 430 years before +Christ, vividly described by Lucretius, and by Thucydides, who was +attacked by it, was scarlet fever of a peculiarly malignant type +(Richardson); but, as will be seen from the following extracts from +Thucydides, the plague differed in important particulars from +scarlatina of the present time: "Internally, the throat and the tongue +were quickly suffused with blood, and the breath became unnatural and +fetid. There followed sneezing and hoarseness; in a short time the +disorder, accompanied by a violent cough, reached the chest.... The +body externally was not so very hot to the touch, nor yet pale: it was +of a livid color, inclining to red, and breaking out in pustules and +ulcers." Loss of sight and gangrene of the extremities were common +results in those who recovered, and adults appear to have been +affected as frequently as children. "The dead lay as they had died, +one upon another, while others, hardly alive, wallowed in the streets +and crawled about every fountain craving for water. The temples in +which they lodged were full of the corpses of those who died in them." +Lucretius says of this plague, "If any one for a time escaped death +(as was possible, either by reason of the foul ulcers breaking or by +means of a black discharge from the intestines), yet consumption and +destruction awaited him at last; or, as was often the case, an +excessive flux of corrupt blood, attended with violent pains in the +head, issued from the obstructed nostrils, and by this outlet the +whole strength and substance of the man passed away. He, moreover, who +had escaped this violent flux of foul blood was not certain wholly to +recover, for still the disease was ready to pass into his nerves and +joints, and into the very genital organs of the body. And of those who +suffered thus, some, fearing the gates of death, continued to live, +though deprived by the steel of the virile part, and some, though +without hands and feet, and though they lost their eyes, yet persisted +to remain in life, so strong a dread of death had taken possession of +them. Upon some, too, came forgetfulness of all things, so that they +knew not even themselves." + +Gangrene of the extremities, loss of sight, a violent cough, loss of +memory, etc. are not symptoms of scarlet fever, so that in my opinion +{487} the plague of Athens, if correctly described by the historian, +was a different malady. + +Caspar Morris, in his essay on scarlet fever, states his belief that +Seneca, who lived in the first century of the Christian era, described +an epidemic of the malignant form of scarlatina in his portrayal of +the pestilence that visited Thebes during the half-mythical age of +Oedipus, six centuries before Christ. Seneca's description of the +symptoms of this plague is as follows: + + Piger ignavos + Alligat artus languor, et aegro + Rubor in vultu, maculaeque caput + Sparsere leves; tum vapor ipsam + Corporis arcem flammeus urit + Multoque genus sanguine tendit + Oculique regent, et sacer ignis + Pascitur artus. Resonant aures, + Stillatque niger naris aducae + Cruor; at venas rumpit hiantes. + +Languor, redness of the face, light spots upon the head, distension of +the cheeks with blood, distortion of the eyes, a flushed appearance of +the limbs, tinnitus aurium, and a discharge of black blood from the +nostrils, certainly indicated a very malignant form of disease, but to +believe that it was identical with the scarlet fever of the present +time requires considerable credulity. From the fact that it devastated +Thebes we infer that it occurred largely among adults, differing, +therefore, from the modern scarlet fever, whose victims are chiefly +children. The same uncertainty hangs over epidemics during the first +centuries of the Christian era. + +The first clear and undoubted portrayal of scarlet fever is found in +the medical literature of the sixteenth century. Sydenham and his +contemporaries in the seventeenth century witnessed epidemics of it, +studied its nature more thoroughly, and consequently acquired a more +accurate knowledge of it than that possessed by their predecessors. It +was in this century that measles and scarlet fever were +differentiated. During the last two hundred years scarlatina has been +the subject of monographs too numerous to mention. It has long been +regarded as one of the most important maladies of childhood, on +account of its frequency and the great mortality that attends it, so +that numerous cases and many epidemics are every year related in the +medical journals. By this vast accumulation of observations and the +patient and thorough use of the microscope our knowledge of scarlet +fever has become full and accurate. + +As with most of the infectious maladies, scarlet fever extended to the +Western World through European shipping. It was brought to North +America about the year 1735. Tardily it spread to South America, where +it appeared in 1829, and more recently it has been established in +Australia. It entered Iceland in 1827, and Greenland in 1847. + +ETIOLOGY.--The evidence is strong that scarlet fever does not +originate de novo--that it does not spring from certain atmospheric or +telluric conditions, but is produced by a definite specific principle, +since countries have been free from it for centuries till it was +imported by commerce. That it appears in certain localities without +any known exposure is attributed to the fact that the poison is so +subtle and transmissible that it is {488} conveyed long distances in +articles of merchandise, even in small packages, so that those who +chance to open them or come in contact with them are infected. It is +believed that reading matter transmitted through the mails has in many +instances been the medium of infection. + +The theory that the acute infectious maladies are caused by +micro-organisms, or, as they are now designated, microbes, commonly +discarded at first and believed to be chimerical, is rapidly gaining +ground in the profession, and appears to be fully established as +regards certain of them. These parasites, barely visible under high +powers of the microscope, and ascertained to be vegetable by their +behavior under certain chemical agents, exist in immense numbers in +the blood, tissues, and secretions of patients suffering from the +infectious maladies, especially in the graver cases of them; and the +microscope shows that these organisms vary in shape and appearance so +as to admit of classification. + +The germ theory has now become so important that it cannot be ignored +in a monograph relating to so important an infectious malady as +scarlet fever. The relation of microbes to the infectious diseases has +been made the subject of investigation by Pasteur, Toussaint, and +others in France, and by many in Germany, with most interesting +results. The belief held by many, and which seemed very plausible, was +that the microbes, instead of sustaining a causative relation to the +maladies in which they occur, were the result of these maladies--that +they sprang into existence in consequence of the vitiated state of the +blood and tissues, just as fungi appear on decaying substances or as +the Oidium albicans appears in certain morbid conditions of the buccal +surface and secretions. Obviously, in order to elucidate this matter +and determine the relation of these parasites to the diseases in which +they occur, it was necessary to experiment on animals, but, +unfortunately, as a bar to successful experimentation many of the most +important infectious maladies which afflict the human race, as typhus +and typhoid fevers, the marsh fevers, and syphilis, do not occur in +animals, or they occur in a changed and mitigated form. Others, +however, can be produced in their typical character in animals, as +diphtheria, and others still originate in animals and are transmitted +from them to man, as anthrax or splenic fever of the herbivora and +hydrophobia. Very interesting and important results have been produced +by experimental researches with the microbes of certain of these +diseases, which, if applicable to the common and fatal infectious +maladies of an analogous nature in man, may yet result in immense +benefit in mitigating the virulence of those affections which are the +scourge of childhood and which sensibly diminish the increase of +population. It has been found possible to cultivate the microbes +contained in the blood, tissues, and secretions in certain of the +infectious diseases, and after a series of cultivations, so that these +organisms are far removed from the animal substance which contained +them, and with which they were so intimately associated in the +individual, they have been employed for inoculation--with this +important result, that the primary disease was reproduced. This seems +to indicate beyond question the causative relation of these parasites +to the diseases in which they occur. Experiments with the result which +I have stated have been made with the microbes of splenic fever, +chicken cholera, murrain, and certain other maladies. + +Pasteur employs as the media for cultivation--(1st) urine neutralized +{489} by a few drops of potash solution; (2d) a liquid prepared by +boiling for twenty or thirty minutes the yeast of beer in water, +neutralizing, and filtering; and (3d) chicken tea, prepared by boiling +equal parts of water and the lean of muscles a quarter of an hour, +filtering, and neutralizing. A small drop of infected blood is placed +in the liquid of cultivation, and the microbes which it contains +multiply so abundantly that the liquid becomes turbid in a short time, +and they are found in all parts of it. A drop of this liquid is added +to another portion of the medium, and this also soon becomes turbid +from the immense development of organisms which have the same +microscopic appearance and character as those in the drop of blood. +The process is repeated many times, until the microbes are far removed +from their original source in the blood and tissues, and a drop of the +last cultivation, whether it be the fiftieth or the hundredth, is +inserted under the skin of a healthy animal selected for the +experiment. If it be true, as stated by the experimenters, that the +original disease is thus reproduced with the microbes of at least +three or four distinct maladies, this age is distinguished by one of +the most important discoveries ever made in pathological studies. It +remains to determine whether this great discovery is of general +applicability to the infectious diseases with which man is afflicted. +If so, it is not improbable that we are on the eve of finding a method +by which some at least of these maladies may be prevented or +mitigated, as small-pox has been since the time of Jenner. The result +of experiments made by Pasteur with the microbes of that fatal malady +of the herbivora, known under the various names of splenic fever, +anthrax, wool-sorter's disease, and charbon, encourages this belief. +Originating among the herbivorous animals, it has in many instances +been contracted by individuals who have rapidly perished. Many engaged +in assorting alpaca and mohair have lost their lives by it, some with +all the symptoms of profound blood-poisoning, without external +lesions, and others with redness and swelling at some point of +infection where a sore or abrasion existed, but with speedy +blood-contamination. + +The microbe of this malady, the Bacillus anthracis, occurs in the form +of straight filaments with little movement or only with oscillation, +and producing bright-shining spores. Now comes a very interesting and +important result of experimentation: Pasteur states if several days +elapse between the cultivations the virulence of the parasite +diminishes, so that he has been able to produce by inoculation with it +a mild and never fatal form of charbon, which affords immunity in the +animal from any subsequent attack. This opinion was sustained by a +trial experiment on sixty sheep. Toussaint and Chauveau claim that +they produce a similar attenuation of the virus by defibrinating +infected blood, heating it to 55 degrees C. (131 degrees F.) and +filtering it. These experiments awaken the hope that the time will +come when the acute infectious maladies in man, scarlet fever among +others, will be rendered less virulent. That one of them--to wit, +small-pox--has for nearly a century been under our control certainly +encourages the belief that there is some way to mitigate others of the +same class which are equally fatal if not so loathsome. + +As yet, observers do not agree in regard to the parasite which is +supposed to sustain a causative relation to scarlet fever. Klebs +states that it is highly probable that both measles and scarlet fever +are produced by {490} micrococci, and he has sketched the design and +described the development of a microbe which he designates the Monas +scarlatinosum. + +The _London Medical Times and Gazette_ for Jan. 28, 1882, contains an +account of the supposed discovery of the scarlatinous microbe by +Eklund of Stockholm, an authority in the microscopic examination of +parasites. He says that scarlet fever is rarely absent from the +Swedish capital and from the barracks and dwellings on the isle of +Skeppsholm. In the urine of scarlatinous patients he has constantly +found a prodigious number of discoid corpuscles, oval or round, their +diameter being less than 1/1000 millimetre and from 1/30 to 1/10 that +of a red blood-cell. They are colorless or yellowish white, surrounded +by a distinct cell-wall, each containing a well-defined nucleus of a +deeper hue. Sometimes one or more microbi may be seen. They exhibit +rotatory or oscillatory movements, especially observed when a drop of +water is added to the fluid. They multiply, as he has frequently seen, +by fission--first in the microbes, next in the nucleus, and lastly in +the cell-wall. He cannot say whether they develop into a mycelium. At +any rate, the development of fine filaments seems to be exceptional. +He has never seen them adhere in moniliform chains nor massed as +zooglaea. He considers them to be veritable schizomycetes, and +proposes the name Plox scindens. + +Eklund asserts that he has found these same organisms in vast numbers +in the soil- and ground-water of the isle of Skeppsholm, in the mud of +the trenches dug for the water-mains, and in the greenish mould upon +the walls of the old barracks, where scarlet fever was most rife. He +states that scarlet fever has occurred in children after drinking milk +mixed with the ground-water of the island, and he observed a case +which followed immersion in one of the trenches of the island and the +drying of the clothes in a small room. In another instance scarlet +fever broke out in a block immediately after exposure of the +ground-water by excavations. + +It is evident that the discovery of this microbe under such +circumstances does not prove that it is the cause of the disease. This +can only be determined by inoculation, or by experiments which furnish +the conditions of scientific exactness. Although great progress has +been made in parasitology during the last decade, it is evident that +several years of observation and experimentation must elapse before it +is clearly and definitely ascertained whether or to what extent +microbes cause scarlet fever and the other exanthematic fevers with +which it is classified. + +Whether the specific principle of scarlet fever be a micro-organism or +a chemical substance, its mode of action and effects have been +ascertained by clinical observations. Without doubt it commonly enters +the system by the breath, but it may enter in the ingesta, and it +infects the blood. That it resides in the blood has been ascertained +by inoculation with this liquid, by which scarlet fever has been +reproduced in its typical form. From the blood it enters the tissues +and secretions. Hence handkerchiefs or linen containing the saliva or +mucus of a patient, the epidermic scales shed abundantly in the +desquamative period, and probably also the urinary and fecal +evacuations, contain the poison, so as to be highly infectious. Even +the discharge of a scarlatinous otorrhoea is thought by some to be +contagious for a considerable time. + +Scarlatina is communicable not only by direct exposure to a patient, +{491} but also by exposure to objects which happen to be in his room +during his illness, and to which the poison becomes attached, such as +clothing, books, and toys; small packages, even letters, it is +believed, from cases which have occurred, sometimes convey and +disseminate the contagious principle. + +In England observations have been made which show that scarlatina has +been communicated by infected milk. The disease occurred in the family +of a milkman, and the milk, before it was distributed, remained for a +time in a kitchen which had been occupied by the patients. This milk +was taken by twelve families, and in six of these the disease occurred +almost simultaneously at a time when few cases were occurring in the +locality. There had been no direct exposure to the carrier of the milk +nor to members of the affected family (Taylor). In another instance a +woman and her son had scarlet fever while they were serving milk to +several families, and the disease appeared in all these families +except one, which consisted of old people (Bell). It is known that +milk absorbs volatile substances so as to be flavored by them, as is +shown in the experiment of placing it in an open vessel in a box with +a pineapple; and it may in a similar manner become infected by the +specific principle of scarlet fever, or it may be infected by detached +particles of epidermis; which is not improbable when one convalescing +from scarlet fever is allowed to milk the cows or prepare the milk for +distribution. + +The scarlatinous virus surpasses that of any other eruptive fever +except small-pox in its tenacious attachment to objects and its +portability to distant localities. Hence in the literature of the +disease are the records of many cases in which the poison was conveyed +long distances, retaining its virulence to the full extent and causing +an outbreak of the malady in the localities to which it was carried. +In New York, so frequently has scarlet fever as well as measles and +diphtheria been contracted from the persons or clothing of well +children who come from infected houses, that the Health Board now +excludes from the public schools all children who come from such +houses, even though they live on separate floors from those occupied +by the sick. In one instance that came under my notice a washerwoman +whose child had scarlet fever communicated the disease to an infant in +the household where she was employed, by placing her shawl over the +cradle in which it was lying. A physician of my acquaintance went from +a scarlet-fever patient to a family several streets distant, and took +one of their children upon his lap. After the usual incubative period +this child sickened with a fatal form of the malady, and the remaining +children of the household were in time affected. In New York scarlet +fever has seemed to me to be not infrequently communicated through +school-books, which, profusely illustrated by pictures and rendered +attractive to the young, are often allowed to lie upon the bed of a +scarlatinous patient and be handled by him during convalescence, or +even during the course of the fever if it be mild. The young librarian +of the circulating library of a Sunday-school, whose pupils came +largely from the tenement-houses, was occupied a considerable part of +a day in covering and arranging the books. After about the usual +incubative period of scarlet fever he sickened with the disease. His +two sisters were immediately removed to a rural township three hundred +miles away, and to an isolated house where scarlatina had never +occurred. About one {492} month after his recovery, and after his room +had been disinfected by burning sulphur and his bed-clothes and linen +had been thoroughly washed, and all articles suspected to hold the +poison had been either disinfected or destroyed, the brother visited +his sisters in the country. Three weeks subsequently to his arrival +one of these sisters sickened with scarlet fever, and a week later the +other also. It seems that the exposure must have occurred several days +after his arrival in the country from some book or other infected +article in his possession. About two months elapsed after the last +case; the family had returned to the city, the infected room in the +country-house had been thoroughly fumigated by burning sulphur from +morning till evening, when a little girl from an inland city remained +a few days in this house, and probably often entered the room where +the young ladies had been sick. In a few days she also sickened with a +fatal form of scarlatina. Such histories and experiences are not +infrequent. They are common during epidemics of scarlet fever. They +indicate an extraordinary attachment of the scarlatinous poison to +objects, and show that it is not gaseous nor readily volatilized. + +A striking example of this fixity of the poison occurred in the +practice of the late Kearney Rogers, formerly a prominent and much +esteemed surgeon of New York City. Six children in a family had +scarlet fever. Three and a half months subsequently another child, +living at a distance, was allowed to return home and occupy the +apartment in which the sickness had occurred. One week subsequently to +the date of the return this child sickened with the same malady. +Elliotson states that a patient with scarlet fever was admitted into +one of the wards of St. Thomas's Hospital, and for two years +subsequently young persons who were admitted into the ward were apt to +take the disease. Richardson of London relates the following +experiences of a family whom he attended in a rural district: "At a +short distance from one of our villages there was situated on a slight +eminence a small clump of laborers' cottages, with the thatch peering +down on the beds of the sleepers. A man and his wife lived in one of +these cottages with four lovely children. The poison of scarlet fever +entered the poor man's door, and at once struck down one of the +flock." The remaining children were now removed some miles away, and +after several weeks one of them was allowed to return. Within +twenty-four hours it also took the disease, and quickly died. The +walls of the cottage were now thoroughly cleaned and whitewashed, the +floors scoured, and all the wearing apparel either destroyed or +washed. Four months elapsed after the last sickness when one of the +remaining children returned. "He reached his father's cottage early in +the morning; he seemed dull the next day, and at midnight I was sent +for, to find him also the subject of scarlet fever. The disease again +assumed the malignant type, and this child died." Richardson believes +that the contagium was attached to the thatch, which could not be +thoroughly disinfected. The fact of this remarkable long-continued +attachment of the poison to objects, indicating by this fixity that it +is a solid, is consonant with the theory that it is an organism. + +INCUBATIVE PERIOD.--The duration of the incubative period varies in +different cases. It is sometimes less than twenty-four hours, as in +{493} the above case reported by Richardson; in the following +well-known case, observed by Trousseau, it was one day. A girl arrived +in Paris from Pau, where there was no scarlet fever, and occupied the +same apartment with her sister, who was sick with this disease. +Twenty-four hours after her arrival she also was attacked with the +same malady. + +Russeberger attended a child who was exposed at noon to scarlet fever, +and took the disease on the following night. B. W. Richardson +(_Clinical Essays_, 1861, vol. i. p. 94) gives his own experience: He +had applied his ear to the chest of a patient suffering from scarlet +fever, and was conscious of a peculiar odor emitted from the patient. +He was immediately nauseated and chilly, and from that moment he dated +the beginning of an attack of scarlet fever. In the _Transactions_ of +the Clinical Society of London, vol. xi. 1878, the late Charles +Murchison gives the statistics of 75 cases, showing the incubative +period, as follows: + + In 4 cases it was not more than 24 hours. + " 2 " " " " 30 " + " 3 " " " " 36 " + " 4 " " " " 40 " + " 1 " " " " 41 " + " 4 " " " " 58 " + " 1 " " " " 54 " + " 1 " " " " 2-1/2 days. + " 31 " " within (time not accurately ascertained) 4 days. + " 2 " the incubation did not exceed 4-1/2 days. + " 17 " " " " " 5 " + " 2 " " " " " 6 " + +In three cases Murchison believes that the incubation was precisely +fixed at thirty-six hours, three days, and four and a half days. + +Watson says that a man reached Devonshire on mid-day to see his +daughter, who had scarlet fever. Two days later he was also attacked. +Rehn saw a child who was attacked two days after its grandmother +returned from a case of scarlet fever; and Zengerle, a girl of ten +years, residing at Wangen, where there was no scarlet fever, who took +the disease two days after her mother had returned from visiting a +family affected with it. Loochner states that a boy aged four and a +half years was attacked one and a half days after admission into the +infected wards of a hospital. Armistead, in his annual report on the +health of the Newmarket rural district, states that three children, +coming from a different part of the district, visited Westley, and +stayed next door to a child who had scarlet fever six weeks +previously, and who was allowed to play with these children on the +evening of Aug. 13th and morning of the 14th. The family then returned +home, and on the 18th, four days after the exposure, all three +children sickened with scarlet fever (_Brit Med. Jour._, Sept. 30, +1882). + +Ordinarily, therefore, the incubative period, though varying in +different cases, is within six days. Many cases, however, occur in +which it seems to be longer. Thus in my practice scarlet fever +appeared in a family on April 26, 1882. The patient was immediately +removed to the third floor and the other children to the basement. All +communication between the infected room and the basement was +forbidden, but on May 8th, twelve days after the separation, one of +these children sickened with the disease. {494} Many observers--among +whom may be mentioned Niemeyer and Copland--believe that the +incubative period may be longer than one week, but, on account of the +subtlety of the poison and the many modes of transmission, it is +possible that in the instances of an apparently long incubative period +there were other and unsuspected exposures. When scarlet fever has +been communicated by inoculation, as in the experiments of Rostan and +others, the incubative period has been about seven days, but Gerhardt +states that a man was attacked four days after an abscess was opened +by a knife used upon a scarlatinous patient. This variation in the +incubative period, which also occurs in some other infectious +diseases, as diphtheria, is probably due mostly to individual +differences, some being more susceptible than others; but it may be +due partly to those obscure meteorological conditions which we +designate the epidemic influence. Probably, as a rule, when the +disease is quickly developed after exposure, the attack is more severe +than when several days elapse. + +CONTAGIOUSNESS.--The area of the contagiousness of scarlet fever is +small. It apparently embraces only a few feet. Therefore, close +proximity is the necessary condition of its propagation. Hence many +who are exposed, particularly of those who are remotely exposed, do +not contract the disease. There is also an idiosyncrasy in some +children, so that they resist infection even when repeatedly and +closely exposed. In the _New York Medical Record_ for March 23, 1878, +C. E. Billington states that of 90 children in 26 families who were +exposed to scarlet fever, 43 contracted the disease and 47 escaped; +whereas, as is well known, comparatively few unprotected children +escape pertussis, variola, varicella, or measles if exposed to either +of these diseases. By strict isolation, therefore, the spread of +scarlet fever is more easily prevented than that of most other acute +infectious maladies. In the New York Foundling Asylum for a number of +years children with scarlet fever were isolated in a small room +attached to one of the wards. The door between the two rooms was +closed, and not opened during the continuance of the sickness. +Entrance into the small room was through another door, and a nurse was +assigned to the scarlet-fever cases, with strict directions that she +should not mingle with the other children. These simple precautions +were found sufficient in the various epidemics of scarlet fever which +occurred in the city to prevent the spread of the malady through this +institution; whereas, similar measures were much less effectual in +arresting the spread of measles and pertussis. Consequently, an +outbreak of scarlet fever in this institution was usually limited to a +few cases, while the extension of measles and pertussis was arrested +with difficulty till a more efficient quarantine was established. + +VARIATIONS IN TYPE.--The type of scarlet fever varies greatly in +different epidemics, and frequently also in cases which occur in the +same epidemic, even in the same family. One child may have scarlatina +so mildly that little treatment is required and convalescence soon +begins, while another has the malignant form, and soon succumbs, +notwithstanding the prompt employment of the most efficient and +appropriate measures. Ordinarily, however, if the first case in a +family be very severe, subsequent cases will present a similar type; +but there are notable exceptions. This variation in type in different +years and different epidemics is probably not equalled in any other +infectious malady. Consecutive {495} epidemics may present this +variation, or the same type may continue for a series of years, and +then, from some unknown cause, change to one milder or more severe. In +England, during Sydenham's life, scarlet fever was so mild that he +regarded it as a trivial affection, requiring little attention, like +rotheln of the present time, but after the death of Sydenham, Morton +and his contemporaries in London found, to their sorrow, that the type +of scarlet fever was very different from that described by Sydenham's +pen. The late Graves of Dublin and his contemporaries treated a mild +type of scarlet fever with a very small percentage of deaths--much +less than that during the preceding generation--and they attributed +their success to their greater knowledge and more appropriate use of +remedies than their ancestors possessed and employed. By and by the +type changed, the mortality of former years was restored, and they +discovered that their previous success in saving life had been due not +to their skill, but to the mild form of the malady. A distinguished +physician of New York treated more than fifty cases of scarlet fever +in one of the institutions without a single death. A few months +afterward the type of the malady changed, and his own son perished +from it. + +SURGICAL AND OBSTETRICAL SCARLATINA.--After surgical operations, and +sometimes in surgical cases not requiring operative measures, a +scarlatinous efflorescence occasionally appears upon the whole or +nearly the whole body, and remains for several days. The following +were cases of the kind alluded to. They occurred in Guy's Hospital, +and were published by H. G. Howse in _Guy's Hospital Reports_ for +1879: On March 15, 1878, Jacobson performed osteotomy upon a child +suffering from extreme rachitis. The operation was followed by a +moderate febrile movement (100 degrees to 101 degrees), and after +three days by the appearance of an efflorescence, with sore throat and +the strawberry tongue. The osteotomy had been performed under carbolic +acid spray and with all the details of antiseptic surgery. The rash +soon faded, the temperature fell, and the child, temporarily separated +from the other patients from the suspicion that the disease was +scarlet fever, was brought back to the ward. The subsequent history +confirmed the diagnosis of scarlet fever, for the skin desquamated, +and on April 1st abundant albumen was found in the urine. The case +terminated favorably. Three months previously the same operation had +been performed on the other leg, with no unfavorable symptoms. On +April 5th, three weeks after the osteotomy, a lipoma was removed from +another patient aged twenty-one years. The following day the +temperature rose to 101 degrees, and remained at that till April 8th, +when it suddenly increased to 103 degrees, and a rose-rash occurred +over the body, with sore throat. On April 9th, Howse excised the +elbow-joint of a girl of sixteen years having pulpy disease. On the +10th her temperature began to increase, and on the 11th reached 105.8 +degrees. Toward evening a roseoloid eruption appeared over her body, +and she was isolated. On April 12th, Dr. H. excised a fibroid bursa +patellae from a woman of twenty-nine years. On the following day her +temperature was 99 degrees, but on the 14th it rose to 100 degrees, +and on the evening of the 15th she had rigors and headache. On the +morning of the 16th the temperature was 102.5 degrees, and a roseoloid +eruption occurred over the face and chest. The surgeons now perceived +that an epidemic of the so-called surgical scarlatina was occurring, +so as to justify the postponement of other operations. + +{496} In the same volume of _Guy's Hospital Reports_, James F. +Goodhart gives the histories of nearly thirty cases of this disease +occurring during a series of years in the same hospital. The patients +were chiefly children, having the most diverse surgical ailments, +among which may be mentioned hip disease and abscess, genu valgum +without operation, necrosis of femur, hydrocele with explorative +operation, a scald, a sinus over the great trochanter, spinal disease +with abscess, tenotomy for club-foot, and vesical calculus with +operation. The most common disease was caries or necrosis with +abscess. In cases operated on the intervals between the operations and +the occurrence of the efflorescence varied from two days to more than +two weeks. Goodhart, after a careful examination of these cases, came +to the conclusion that they were for the most part examples of true +scarlet fever, especially as a considerable proportion of them +occurred in groups, and there was a known exposure of some of the +patients to children admitted into the hospital with the sequelae of +scarlet fever. + +In the _British Med. Jour._ for Jan., 1879, George May, Jr., reported +a case of efflorescence in surgical practice which appears to have +been scarlatinous. A child was operated on for the radical cure of +hernia on Dec. 4th. Toward the close of the same day he became +restless, vomited, and his pulse on the following day rose to 136. +Forty-eight hours after the operation a rash appeared on the chest and +arms, the abdomen became tense and painful, and on the following day +he died. The poison, however, in this case may have been septic. + +Hillier remarks (_Diseases of Children_): "In the hospital for sick +children, of the children who contract scarlatina a very large +proportion have been the subjects of a surgical operation within a +week before the rash appears." Gee says (Reynolds's _System of +Medicine_): "It has been doubted by some whether the scarlatiniform +rash which sometimes follows operations is really scarlatinal. The +eruption appears from the second to the sixth day after the operation, +and in the cases which have caused the doubt is very fugitive and the +first and only symptom. Yet that the disease really is scarlet fever +would seem to be proved by the following observations: first, that the +disease occurs in epidemics; secondly, that in a given epidemic a +severe case occasionally relieves the monotonous recurrence of the +very mild form; thirdly, that a precisely similar scarlatinilla +attacks in the same epidemic patients who have not been subjected to +operation and who have no open sore; and lastly, by way of a veritable +experimentum crucis, that, however freely these patients are exposed +to ordinary scarlet fever contagion afterward, they do not contract +that disease." Paget and other distinguished London surgeons who have +observed this complication of surgical cases, believe that the +patients have been previously exposed to the scarlatinous poison, and +that the surgical diseases or operations furnish favorable conditions +for the occurrence of scarlet fever, so that the exposure, which +probably would have been without result in ordinary health, causes an +outbreak of the malady. + +Those who have reported cases of this form of efflorescence have for +the most part neglected to state whether the patients had had scarlet +fever previously, knowledge of which would have aided in the +diagnosis; but from an examination of the histories of cases, +especially those {497} published in the London journals in the last +four or five years, there can, I think, be little doubt that surgical +maladies of a certain kind, especially traumatism, do produce a state +of system which predisposes to scarlet fever, so that this class of +patients are especially liable to contract it. Therefore, in my +opinion, a considerable proportion of reported cases of surgical +scarlatina are genuine, but in a considerable number, perhaps an equal +number of such cases, the histories and symptoms indicated a septic +rather than scarlatinous efflorescence, and in not a few instances, +when consultations have been held, opinions differed, some +diagnosticating scarlet fever, others septicaemia. In some of the +cases I find it stated that the fauces presented the normal +appearance. Now, faucial redness is so generally present in scarlet +fever, antedating that of the skin and coexisting with it, that its +absence is strong evidence that the disease is not scarlatinous. +Moreover, when, as was true of certain of the reported cases, the rash +appeared irregularly upon the surface, and faded away in two or three +days with the abatement of the fever, and the conditions for septic +absorption were present, the efflorescence was probably septicaemic. + +The following were apparently cases of septicaemia efflorescence: A +child aged five years (_Brit. Med. Jour._, Feb. 15, 1879) had +inflammation of the lymphatic glands in the groin, which suppurated. +At the time when the abscess was fully formed a rash appeared over the +entire body. It consisted of numerous red points, but was paler than +that of ordinary scarlet fever; temperature never above 99 degrees; no +sore throat nor desquamation of cuticle. No child exposed to her took +scarlet fever, and her sickness could not be traced to infection. In +the _British Med. Jour._, Jan. 4, 1879, L. Braxton Hicks states that +his son, attending school at Reading, was seized with a severe attack +of pyrexia, accompanied on the second day by delirium and the +occurrence of a rash like scarlet fever over the entire surface. He +had no decided redness of the fauces, though it was perhaps slightly +flushed. The right buttock was swollen from inflammation, and a large, +deep-seated abscess formed near the tuberosity of the ischium. When +the delirium abated the boy said that he was standing the day before +the fever began with his legs far apart, when a schoolfellow stretched +them farther by suddenly pulling on one of them. The rash, which was +nearly universal, lasted three days, and was not followed by +desquamation. No case of scarlet fever occurred in the school before +or afterward. In the same volume of the _British Medical Journal_, +Surgeon Frolliott of the East India Service relates the case of a +private, aged twenty-three years, and three years in India, who, when +on duty in the Punjab, was injured by the explosion of an Afghan +powder-magazine. The accident occurred Dec. 21, 1878. On Dec. 25th a +bright scarlet rash appeared upon the abdomen and spread over the +entire body. The following day the eruption was very vivid, like a +boiled lobster, and it lasted five days. The temperature, which in the +beginning had been 101 degrees, abated to the normal after the rash +appeared. No soreness of throat nor redness of the buccal surface +occurred, but the epidermis desquamated even from the palms of the +hands and soles of the feet. Now, the febrile movement of scarlet +fever does not cease while the efflorescence is distinct. It does not +even diminish when the eruption appears, while in the above case it +fell to the normal--a common {498} occurrence in septicaemia, even +when the blood-poisoning is profound. Moreover, scarlet fever is so +rare in India that Frolliott, after twelve years' service, had only +heard of one case among Europeans and natives. The surgeons who +consulted over the case of this private disagreed in opinion, some +regarding the disease as septicaemic, others as scarlatinous. But a +better knowledge of the clinical history of scarlet fever on the part +of these army surgeons would, I think, have removed all doubt as to +the diagnosis. + +It is the opinion of some reputable surgeons that the exposure of +traumatic patients to the scarlatinous poison sometimes aggravates the +inflammation of wounds, causing them to assume an unhealthy appearance +even though no scarlatina be produced. The late Solly made the remark, +"Whenever a case of surgery in private practice takes on a highly +phlegmonous appearance I am always sure to find break out, in the +inmates of the house, either erysipelas or scarlet fever" (_British +Med. Jour._, Feb. 15, 1879). We will see that the scarlatinous poison +sometimes causes pharyngitis or nephritis without producing the +general disease. In a similar manner it seems that it may aggravate +open wounds, intensifying the inflammation in them, while there is no +efflorescence or other symptom to show that scarlatina itself is +present. The poison appears to act entirely locally in such cases. + +Paget, in his _Clinical Lectures_, says: "I think it not improbable +that in some cases results occurring with obscure symptoms within two +or three days after operations have been due to the scarlet-fever +poison, hindered in some way from its usual progress." Playfair, in +his remarks on the puerperal state, adds: "Mr. Spencer Wells informs +me that he has seen cases of surgical pyaemia which he had reason to +believe originated in the scarlatinal poison; and his well-known +success as an ovariotomist is no doubt, in a great measure, to be +attributed to his extreme care in seeing that no one likely to come in +contact with his patients has been exposed to any such source of +infection." Opinions like these, held by such prominent members of the +profession and sustained by many observations, should certainly induce +physicians to prevent, so far as possible, any exposure of their +surgical patients, especially if they have any sores or wounds, +whether by traumatism or the scalpel, to the scarlatinal poison. + +OBSTETRICAL SCARLATINA.--Women during convalescence after childbirth +are very liable to contract scarlet fever. In the New York Infant +Asylum, which has maternity wards, a woman was admitted from a house +in which scarlet fever was prevailing, and assigned to a cot next that +occupied by one of the waiting women, who was confined soon afterward. +Her labor was favorable, but three days afterward she took scarlet +fever, and another lying-in-patient contracted it from her. The sore +throat and desquamation were characteristic. It has come to my +knowledge that a physician of New York, in whose family scarlet fever +was occurring, attended three women in succession in their +confinement, and all contracted scarlet fever, which presented the +characteristic symptoms, and two of them died. Experienced and +cautious physicians of New York, aware of the danger, do not go +directly from a scarlatinous patient to an obstetrical case, but avoid +the risk by intermediate visits to other patients or by remaining for +a time in the open air. + +{499} Playfair, remarking on this subject, says: "There is good reason +to believe that the contagium of zymotic diseases may produce a form +of disease indistinguishable from ordinary puerperal septicaemia, and +presenting none of the characteristic features of the specific +complaint from which the contagium was derived. This is admitted to be +a fact by the majority of our most eminent British obstetricians, +although it does not seem to be allowed by continental authorities, +and it is strongly controverted by some writers in this country. It is +certainly difficult to reconcile this with the theory of septicaemia, +and we are not in a position to give a satisfactory explanation of it. +I believe, however, that the evidence in favor of the possibility of +puerperal septicaemia originating in this way is too strong to be +assailable. The scarlatinal poison is that regarding which the +greatest number of observations has been made. Numerous cases of this +kind are to be found scattered through our obstetric literature, but +the largest number are to be met with in a paper by Braxton Hicks. Out +of 68 cases of puerperal disease seen in consultation, no less than 37 +were distinctly traceable to the scarlatinal poison. Of these, 20 had +the characteristic rash of the disease, but the remaining 17, although +the history clearly proved exposure to the contagium of scarlet fever, +showed none of its usual symptoms, and were not to be distinguished +from ordinary typical cases of the so-called puerperal fever. On the +theory that it is impossible for the specific contagious diseases to +be modified by the puerperal state, we have to admit that one +physician met with 17 cases of puerperal septicaemia in which, by a +mere coincidence, the contagion of scarlet fever had been traced, and +that the disease nevertheless originated from some other source--a +hypothesis so improbable that its mere mention carries its own +refutation." + +Parturition, like traumatism, furnishes in an eminent degree the +conditions in which septic poisoning occurs, and the efflorescence +which often accompanies septicaemia bears, as we have seen, a very +close resemblance to that of scarlet fever. Hence in many instances +the same difficulty is present in making a differential diagnosis +between septic and scarlatinous blood-poisoning in obstetrical cases +which occurs in surgical practice. But, according to my observations, +an efflorescence occurring during the week following parturition is in +most instances septic. It is only in exceptional cases that it is +scarlatinous, and there is little danger that the accoucheur, engaged +in general practice and visiting scarlatinous patients, will +communicate scarlet fever through his person or clothing if he +exercise proper precautions. His short stay in the sick room and his +out-door exercise in visiting cases prevent infection of his person or +dress. But if, as Playfair believes, the scarlatinal poison sometimes +produces in parturient women a puerperal fever in which the +characteristic scarlatinal symptoms are lacking, and which, in the +present state of our knowledge, is not distinguishable from ordinary +septic fever, certainly the scarlatinous virus sustains a much more +frequent causative relation to childbed fever than has been heretofore +supposed. + +Infants under the age of six months do not ordinarily contract scarlet +fever, although fully exposed, and those under four months nearly +possess immunity. Still, this disease has been observed in new-born +infants, contracted, apparently, through the placental circulation. +{500} Tourtual states that a woman waited upon her own husband and +child, both of whom had scarlet fever, during the eighth and ninth +months of her pregnancy, till near her confinement. Though she had no +symptoms of scarlet fever, her infant had unusual redness of the skin +and buccal surface and difficulty of swallowing up to the fifth day. +On the ninth day desquamation began, and at a later stage the nails of +the fingers and toes separated. A case having a history in some +respects similar is related by Megnert, but the symptoms were +anomalous for scarlet fever, and the disease may have been ordinary +septic fever. On the other hand, in one instance in my practice a +mother had scarlet fever, beginning about the third day after her +confinement, and although she suckled her infant and it was constantly +in bed with her, it had no symptoms of scarlet fever, although it +became affected immediately afterward by a severe form of eczema, +probably from the altered quality of the milk; and in two instances +observed by Murchison new-born infants remained healthy, although +their mothers suffered from scarlet fever. + +After the age of six months the liability to scarlet fever increases +till the close of infancy, children between the ages of six months and +one year being less liable to contract the malady than during the +second year, and those in the second year being less liable to it than +those in the third year. Murchison collected the statistics of deaths +from scarlet fever in England and Wales during a series of years +ending with 1861. The number of deaths aggregated 148,829, and the +percentage of deaths at different ages was as follows: + + Deaths under 1 year, 6.7 per cent. + " between 1 and 2 years, 14.09 " " + " " 2 " 3 " 16.00 " " + " " 3 " 4 " 15.13 " " + " " 4 " 5 " 11.9 " " + " " 5 " 10 " 25.9 " " + " " 10 " 15 " 5.8 " " + " " 15 " 25 " 2.6 " " + " " 25 " 35 " 0.8 " " + " over age of 35 years, 0.8 " " + +Among the deaths were ten cases above the age of eighty-five years, so +that scarlet fever, though especially a disease of childhood, may +occur in any decade of life; but old age, like early infancy, almost +possesses immunity from it. + +I have preserved the records of the ages of 145 consecutive cases +occurring in private practice. If we add to these 58 cases observed by +Prof. Octerlony (_Amer. Jour. of Med. Sci._, July, 1882) we have the +statistics of the ages of 203 cases, which are embraced in the +following table: + + Under 1 year, 3 + From 1 to 2 years, 25 + " 2 " 3 " 43 + " 3 " 5 " 57 + " 5 " 10 " 53 + " 10 " 15 " 13 + " 15 " 20 " 3 + " 20 " 30 " 4 + " 30 " 40 " 2 + --- + Total, 203 + +{501} CLINICAL FACTS REGARDING SCARLET FEVER.--As a rule, scarlet +fever occurs but once, one attack conferring immunity from the disease +for life; but there are exceptions. In 1869, I attended a child with +fatal scarlet fever who three years previously, it was stated, had +passed through a first attack with all the characteristic symptoms. +The following case occurred in a family attended by the late Dr. +Herzog: R----, a boy of six years, had scarlet fever in a mild form in +January and February, 1875, followed by moderate desquamation. In July +of the same year he was kicked by a horse in the street, receiving a +deep scalp-wound which required three stitches. Three days afterward +he had, to appearance, a second attack of scarlet fever, attended by +high febrile movement, and followed also by desquamation. It was +believed by Dr. H. to be a genuine case, and was so treated. I am not +able to state as regards the presence of soreness of the throat, and +doubt arises whether this second attack may not have been septicaemic. +In April, 1876, a third attack occurred, which I saw from the +beginning. It was accompanied by all the characteristic +symptoms--injection of the fauces, an efflorescence continuing the +usual time, followed by desquamation and albuminuria, the latter +continuing several weeks. Richardson states that three distinct +attacks occurred in his own person, and a student attending the +lecture at which this was mentioned informed the doctor that he also +had had scarlet fever three times. + +Sometimes a second attack occurs so soon after the first that it has +been described as a relapse. The following was a case in point in the +practice of Godneff (_Meditz. Vestnik._, No. iv., _N.Y. Med. Rec._, +April 30, 1881): A youth of seventeen years contracted scarlet fever +while taking care of a child. It began with a chill, and he had the +usual efflorescence, sore throat, and tumefaction of the cervical +glands. An exudation appeared upon his tonsils and uvula, and his +temperature reached 104 degrees. The urine contained a trace of +albumen, the rash in due time faded, and the epidermis exfoliated. On +the fifteenth day, when he was about ready to leave the hospital, he +again had a chill, followed by fever. The temperature reached 105.2 +degrees, the rash reappeared over the entire surface except the face, +diphtheritic exudations occurred upon the fauces, and the urine, the +quantity of which was diminished, again became albuminous. This second +efflorescence faded on the twenty-fourth day, and on the +twenty-seventh exfoliation began. Hillier says: "I have seen a young +woman in the fever hospital suffering from a second attack of +scarlatina, the first attack having occurred five weeks previously. +She had quite recovered from her first illness, and was acting as +nurse. In both seizures the rash, the sore throat, and other symptoms +were characteristic. The relapse or recurrence was less severe than +the primary disease." Cases of a fourth, or even of a greater number +of attacks, have been reported. The first seizure is sometimes milder, +but in other instances is more severe, than those which follow. + +Exposure to the scarlatinous poison not infrequently produces +pharyngitis without the occurrence of scarlatina, and the inflammation +is apt to be severe, accompanied by pain in swallowing and marked +febrile movement. This phlegmasia is distinguished from scarlet fever +by its shorter duration and the absence of the efflorescence. It +occurs in adults as well as in children, and in those who have had, as +well as in those who have not {502} had scarlatina. So far as I have +observed, it is very seldom accompanied or followed by any of the +complications or sequelae so common in and after scarlet fever. It +cannot be distinguished from ordinary pharyngitis except in the manner +in which it occurs, and one attack does not preclude another. The late +George B. Wood made the remark that he never attended a case of +scarlet fever without suffering from sore throat. The following were +examples of this form of pharyngitis: On Jan. 17th, 1882, I was called +to a boy of three years with severe scarlet fever, ushered in by +convulsions. On the following day his sister, aged seven and +three-fourths years, whom I had attended a year previously during a +severe attack of scarlatina, and who had been almost constantly with +the brother, became very ill, with a temperature of 103.5 degrees. +Examination revealed severe inflammation of the fauces, without +pseudo-membrane or any other exudation except muco-pus. On Jan. 19th +an older brother, nine years, whom I had attended in scarlet fever +three years previously, was affected in the same way, his temperature +being 104 degrees and his respiration guttural and noisy, especially +during sleep, in consequence of the great amount of faucial swelling. +At times he was delirious. The inflammation in both cases began to +abate about the third day, and had disappeared by the close of the +week. That the contagium of scarlet fever may be received into the +system and cause pharyngitis, while the patient has immunity from +scarlet fever through a previous attack, and that this inflammation +may occur any number of times, as in the case of Dr. Wood, are +remarkable facts. + +Now and then cases occur which appear to show that the scarlatinous +poison may affect the kidneys, producing nephritis, while there is no +other manifestation of its influence. Thus in my practice a lady of +about forty-five years constantly attended her son, sleeping by his +side, during an attack of scarlet fever. Her health had previously +been good. When the boy was convalescent, as her appetite failed and +she was indisposed, a careful examination revealed the fact that she +had albuminuria, although she had had no sore throat or other symptom +of scarlet fever. After several weeks of treatment her disease was +removed, and she has remained well since. In the _British Med. Jour._ +for Nov. 29, 1879, it is stated that in a family four girls were found +to be suffering from desquamative nephritis. One of them had recently +had scarlet fever, but the other three had presented no symptoms +whatever of this disease. Such cases, although probably rare, appear +to show that, as the scarlatinous poison may produce inflammation of +the fauces without the occurrence of scarlet fever, so it may cause +nephritis without producing the general disease, or apparently +disturbing the functions, or changing the state of other parts, except +the kidneys. + +SYMPTOMS.--ORDINARY FORM. Scarlet fever usually begins abruptly, so +that the exact time of its commencement can be fixed. If any +premonitory symptoms occur, they are slight, so as scarcely to attract +attention, as languor or the appearance of fatigue. A dusky aspect of +the surface may occasionally be observed during the few hours +preceding the attack. In some children the first symptom is +chilliness, and occasionally a distinct chill occurs. In the adult a +chill is ordinarily the first symptom. With or without the initial +chilliness, febrile movement occurs, of variable intensity according +to the severity of the type, and {503} accompanied by such symptoms as +usually arise in a febrile state of system, as cephalalgia, anorexia, +and thirst. The pulse rises to 110, 120, or more per minute, the +temperature to 102 degrees, 103 degrees, or 104 degrees; the skin is +hot, face flushed, and the eyes bright. Even in cases that are not +malignant or grave, and that give indications of a favorable result, +there is often more or less stupor, with transient delirium and sudden +starting or twitching of the extremities, showing that the +cerebro-spinal axis is involved. + +Vomiting is a common symptom in the beginning of scarlet fever, +occurring before the appearance of the efflorescence. It therefore has +diagnostic value when the nature of the case is still doubtful. In +some patients it is an initial symptom, but in others some hours have +elapsed when it occurs. I recorded its presence or absence in 214 +patients, with the following result: present in 162 patients, absent +in 52. In severe forms of the disease it is rarely absent, and if it +do not occur it is probable that the case will be mild, requiring +little treatment and having a favorable termination. In epidemics of +unusual mildness the number of cases without vomiting may be in excess +of those in which this symptom occurs. It appears to be due to +functional disturbance of the cerebro-spinal system, and it may +therefore be properly regarded as a nervous symptom. In severe cases +the vomiting is apt to be repeated, not only on the first but on +subsequent days, and we shall see that in cases of great gravity, in +which a fatal termination is not improbable, persistent vomiting, by +which the food and stimulants so urgently required are rejected, +interferes seriously with successful treatment. In a few cases +embraced in my statistics nausea without vomiting was recorded. The +bowels in ordinary scarlatina act regularly or are slightly +constipated. Diarrhoea, which so commonly accompanies the persistent +vomiting in malignant cases, if it occur in this form of the malady is +slight and transient and due to accidental causes. The food, if it be +given in the liquid form and cool, is usually taken readily, on +account of the thirst, except when deglutition is rendered painful by +the pharyngitis. + +The symptoms pertaining to the nervous system vary according to the +severity of the disease and the temperament of the patient. Many +children during the progress of the common form of scarlet fever +present a dull or apathetic appearance. They lie much of the time with +their eyes closed; others are more restless, and not a few, if the +fever be considerable, have occasional twitching of the limbs and more +or less headache. Eclampsia sometimes occurs on the first day, +especially in those predisposed to it, even when the subsequent course +of the disease is mild and favorable. This complication, very grave +and usually fatal when it occurs at a later stage, is in most +instances, when it takes place on the first day, readily controlled by +proper remedies and with little detriment to the patient. But if it be +attended by high elevation of temperature and marked drowsiness, +approaching the comatose state, it is very serious upon the first as +well as upon subsequent days. Nervous symptoms occurring in the +beginning of scarlet fever, when it has the ordinary favorable type, +begin to abate in three or four days, but if they supervene at a later +date, and especially in the declining stage, they possess more +gravity, since they then not infrequently result from and indicate +renal complication. + +{504} Early in the disease, nearly as soon as the commencement of the +fever, the faucial and buccal surfaces become inflamed, as shown by +redness, swelling, and tenderness. The physician summoned in the +beginning of an attack will already, at his first visit, observe +hyperaemia of the fauces, with points of deeper injection than over +the general faucial surface, and soon the buccal surface also +participates. The inflammation at first produces preternatural +dryness, and this is followed by a viscid secretion. The papillae of +the tongue enlarge and become prominent, giving rise to the appearance +known as strawberry tongue which is so common in scarlet fever. This +state of the buccal and faucial membrane continues throughout the +disease. A thin fur appears upon the tongue on the first day, and it +increases on the second and third days, after which it is apt to be +detached, exposing the surface of the organ, which has a deep red hue, +but in not a few patients the fur remains or is reproduced as soon as +shed. Except in the mildest cases the Schneiderian membrane also +participates in the inflammation as the disease advances, so that a +thin, irritating discharge, containing leucocytes or pus-cells, flows +from the nostrils. The skin is hot and dry, and cutaneous +transpiration nearly checked. The respiratory system is rarely +involved in any notable manner unless there be a complication. Many +have no cough whatever, while others have a slight cough, due to the +fact that the inflammation, of a catarrhal form, has extended from the +fauces to the surface of the glottis. Slight acceleration of +respiration, corresponding with the degree of fever, may also be +observed. The kidneys commonly act regularly and normally during the +first days, any serious impairment of their functions being rare +before the close of the first week. + +When the symptoms described above have continued from six to eighteen +hours the efflorescence appears. It is first observed about the ears, +neck, and shoulders, in reddish patches fading into the normal hue. +These patches extend and unite, and in the course of a few hours the +trunk and upper extremities, and finally the legs, are covered. The +scarlatinous rash usually, when fully developed, resembles that +produced by external heat or the application of a sinapism. It has +been likened to the appearance of a boiled lobster, but there are +numerous minute points of a deeper or duskier hue than the surface +generally. In many patients the rash appears, especially over the +abdomen and lower extremities, as minute, thickly-set points, with the +skin of normal appearance between them. Henoch of Berlin says of +scarlet fever: "In general, the moderate grades of eruption prevail, +the skin, when seen from a distance, presenting a diffuse, more or +less scarlet redness, while on closer inspection it is found that this +redness is composed of innumerable red points closely situated +together, and separated from one another by very small paler portions +of skin. The dark-red points appear to correspond to the +hair-follicles." On passing the finger over the efflorescence no +distinct prominences are observed, but a sensation of roughness is +sometimes imparted from engorgement of the cutaneous papillae. The +rash disappears on pressure, but it immediately reappears when the +pressure is removed. Its slow return is evidence of sluggish +circulation, and it indicates a grave and dangerous form of the +malady. The color is then usually a dusky instead of a bright red. The +efflorescence is most marked in dependent parts, as along the back, +over the chest and {505} abdomen, and in the flexures of the joints. +Parts pressed upon by the bed-clothes, which confine and intensify the +heat, present a deeper coloration than other portions of the surface. +Often, especially in mild cases, the rash is absent from portions of +the surface where it commonly appears, while it presents a typical +character elsewhere. Tardy and incomplete establishment of the rash +when the symptoms indicate an attack of ordinary or more than ordinary +severity is commonly due to some perturbating cause, especially +diarrhoea. In the _London Lancet_ for Aug. 16, 1879, cases are related +of supposed scarlet fever without the rash, cases in which pharyngitis +and stomatitis with the strawberry tongue occurred, without +efflorescence upon the skin; but it is to be remembered, as stated +above, that the inflammations which commonly attend or follow scarlet +fever, particularly the pharyngitis and nephritis, not infrequently +occur in those who have already had scarlatina, and occur more than +once from fresh exposure to scarlatina patients. These inflammations, +occurring under such circumstances, appear to be purely local +maladies, produced by the scarlatinous virus; and it seems to me a +question whether, in the so-called scarlatina without efflorescence, +the inflammations which are present, and which undoubtedly have a +scarlatinous origin, are not local in their nature, instead of being +local manifestations of the constitutional disease. The burning and +itching sensation produced by the rash increases the restlessness of +the patient, and is sometimes the most annoying of the symptoms. + +The temperature in the common favorable forms of scarlet fever usually +varies from 101 degrees in the mildest cases to 103 degrees or 104 +degrees in those more severe. If it attain 105 degrees or over, the +case is properly designated grave or severe. The febrile movement +commonly fluctuates but little from day to day till the fourth or +fifth day, when, if the case be favorable and no complication occur, +it begins to decline. The temperature is as high in the beginning of +the attack as subsequently. + +The symptoms pertaining to the digestive system during the initial +period of scarlet fever have been sufficiently described. The +subsequent symptoms referable to this system do not differ materially +from those present in the beginning, except the absence of vomiting. +The lips are dry and often cracked. The inflammation of the mouth and +throat continues, with anorexia and thirst. With the decline of the +disease the appetite gradually returns, but it is not till the close +of the second week that it is fully restored. Great and continued +disturbance of the digestive apparatus, seriously interfering with the +nutrition, pertains to the malignant forms of scarlet fever. + +The urine is high-colored, and in robust children during the first +days of scarlet fever it frequently deposits urates on cooling. Gee, +who has carefully investigated the state of the urine in scarlet +fever, says that the quantity of water is diminished and the urea is +not necessarily increased during the pyrexia; that the chloride of +sodium is diminished till the fourth, fifth, or sixth day, and that +the phosphoric acid is diminished during the climax of the pyrexia, +though not during the first three or four days. In one case he made a +daily estimation of the amount of uric acid, and found it greatly +diminished on the second and third days, normal on the fourth, and +much increased on the fifth. He believes that similar variations are +common in the quantity of the products excreted {506} in the urine. +Bile may also appear in the urine, coincident with a yellow tinge of +the conjunctiva.[1] + +[Footnote 1: Article on scarlatina in Reynolds's _System of +Medicine_.] + +The duration of scarlet fever varies in different cases. If the attack +be very mild, with little efflorescence, the febrile movement may +decline by the fourth or fifth day; but if the disease be severe, +little or no amelioration of symptoms may occur before the twelfth or +fourteenth day, even when no complication has occurred to increase the +temperature or cause aggravation of symptoms. Octerlony, who estimated +the duration of scarlet fever from the commencement of febrile +symptoms to "the disappearance of fever, with marked improvement in +leading symptoms," ... "found that the average duration of the disease +in forty cases was six and one-sixth days. The minimum duration in a +very slightly-marked case was three days: the maximum duration was +fourteen days." In general, prolongation of fever beyond the usual +time is due to some complication--more frequently to unusually severe +pharyngitis, with accompanying cellulitis, than to any other cause. + +The malady whose commencement was so abrupt declines gradually. In +ordinary cases, by the close of the first week or in the beginning of +the second the rash becomes less and less distinct, and finally +disappears, as do also the redness and swelling of the buccal and +faucial surfaces. The engorgement of the tonsils and of the papillae +of the tongue subsides, the appetite returns, the countenance +brightens and becomes natural, and the child, who during the height of +the fever scarcely noticed objects or noticed them with indifference +or even repugnance, can be amused as before his sickness. + +Desquamation succeeds. This begins at about the sixth day, and is not +completed till the tenth or twelfth day; often not till the close of +the third or in the fourth week. The amount of desquamation +corresponds with the intensity and duration of the efflorescence, or +rather of the dermatitis which produces the efflorescence. If the +efflorescence have been slight and partial, it will be slight, perhaps +scarcely appreciable, but if the rash have been general, full, and +protracted, exfoliation occurs upon every part. It begins about the +face and neck, and within a day or two appears upon other parts. Where +the skin is thin the epidermis as it is detached presents a +furfuracous appearance; where it is thick, as upon the palms of the +hands or soles of the feet, it separates in layers of considerable +thickness. + +Such is a brief description of scarlet fever when it pursues its +normal course without any disturbing element, but there is no other +disease in which complications and sequelae so frequently occur. The +liability to them renders the prognosis in every case doubtful. They +largely increase the percentage of deaths. They occur both in mild and +severe forms of scarlatina. + +The difference in type in different cases and epidemics has already +been alluded to. Scarlet fever is sometimes so mild, and its symptoms +so slight, that the diagnosis is necessarily uncertain. In the spring +of 1866 I was called to an infant thirteen months old who had slight +pharyngitis and an indistinct rash over a part of the surface. In two +days the eruption had disappeared, and the health within a day or two +later was apparently fully restored. Diagnosis would have been +doubtful except for sequelae {507} which clearly indicated the +scarlatinous nature of the attack. In another instance two children +passed through the entire course of scarlet fever playing every day in +the street. Although the intelligent grandmother saw the rash upon +them, its nature was not suspected, as it was midsummer and cases of +prickly heat common, till nearly two weeks afterward, when one of the +children had nephritis and anasarca ending fatally. In cases so mild +as these the heat of surface is but slightly increased, the pulse but +little accelerated, and the rash usually does not occupy so much of +the surface as in ordinary cases; the appetite is not lost, though +diminished, and the thirst is moderate. + +Between scarlet fever so mild that it terminates in four or five days, +and that of the grave or malignant type presently to be described, all +grades of severity exist. Scarlet fever occurs in all forms from mild +to severe, but certain symptoms characterize grave or malignant +cases--symptoms which are absent or much less prominent in ordinary +scarlet fever. Therefore the grouping of cases according to the type +is proper, and facilitates the studying of the disease. + +GRAVE FORM (malignant scarlet fever).--This form of the disease is in +some epidemics common, while in others it is rare. The symptoms which +characterize it are severe from the beginning, those of the nervous +system predominating at first, such as intense cephalalgia, +restlessness or stupor, sudden twitching of the muscles, and perhaps +delirium, or even convulsions. Many pass rapidly into coma and die +within two or three days, succumbing to the intensity of the +scarlatinous poison while the malady is still in its commencement. The +rash is dusky. It disappears by pressure, and returns slowly when the +pressure is removed, showing extreme sluggishness of the capillary +circulation. Some patients are very drowsy, lying in a semi-comatose +state except when aroused, and if aroused are very restless. Others +are constantly restless. If placed in one position on the bed, they +throw themselves in another in a half-conscious or unconscious state. +They do not speak, or they mutter like those affected by the graver +forms of typhus, calling the names of playmates or talking +incoherently about things which interested them when well. The +thermometer placed in the axilla is found to rise above 103 degrees, +which is a safe average, to 105 degrees or even 107 degrees, and the +heat of the surface is pungent except when the case approaches a fatal +termination, when the extremities, ears, and nose may be cool while +the trunk and head are extremely hot. The pulse from the first is +rapid, ranging from 130 as the minimum in a malignant case to a +frequency which can scarcely be counted. A very frequent pulse is +nearly always feeble and compressible. Irritability of the stomach is +one of the most common symptoms in grave cases, so that many patients +immediately reject the nutriment and stimulants which are so urgently +required to sustain the vital powers. The vomiting, therefore, if +frequent and severe, greatly increases the danger, and in not a few +instances this symptom is associated with diarrhoea, which also tends +to increase the prostration. + +Severe and dangerous nervous symptoms, due to the intensity or +activity of the scarlatinous poison, occur chiefly within the first +three or four days. Grinding the teeth, sudden muscular twitching, +delirium, convulsions, and profound stupor occur for the most part +within this time. Afterward the danger is mainly from exhaustion, +unless in the {508} second week or subsequently, when nervous symptoms +may arise from uraemia. + +Those who survive the onset of malignant scarlet fever often have in +the course of a few days severe pharyngitis, with extension of the +inflammation to the lymphatic glands and connective tissue around the +angle of the jaw. These inflammations cause more or less external +swelling. The faucial turgescence around the entrance of the larynx, +with the accompanying secretion of viscid mucus or muco-pus, often +causes noisy respiration, and many at this stage of the attack breathe +with the mouth constantly open to facilitate the ingress of air. + +Ordinarily, no discharge occurs at first from the nasal surface, but +as the disease continues, if the type remain severe, defluxion of thin +muco-pus takes place from the Schneiderian surface, which frequently +excoriates the cheek. The lips also are apt to be sore and swollen. + +In malignant cases the disease is more protracted than when the type +is mild. Thus in a recent case in my practice the rash was still +distinct at the close of the second week, though the temperature had +fallen from 105 degrees to 102 degrees and some desquamation had +appeared. Long continuance of the febrile movement is, however, +oftener attributable to some inflammatory complication than to the +primary disease. + +In all epidemics of a severe type cases now and then occur in which +the poison is so intense, or it acts with such frightful energy, that +death occurs even within the first day. The patient is overpowered at +the outset of the disease by the virulence of the specific principle, +perishing in coma, preceded perhaps by convulsions. The autopsy in +such cases reveals hyperaemia of the brain and cranial sinuses, blood +of a dark-red color, capillary hemorrhages in various parts, a flabby +heart, and perhaps some engorgement of the spleen and kidneys. + +Usually, malignant scarlet fever exhibits its severe type from the +first, but cases sometimes occur which seem mild and favorable for a +few days, when severe symptoms suddenly supervene. This change from a +mild to a dangerous disease is, however, most frequently, I think, due +to some complication. + +IRREGULAR FORMS.--Deviation from the normal type in scarlet fever is +usually due to some perturbating cause, which is often a pre-existing +or co-existing disease, or a disordered state of system through causes +distinct from the scarlatinous disease. Thus, a little girl in my +practice had the symptoms of scarlet fever, such as febrile movement +and inflammation of the buccal and faucial surfaces, nearly a week +before the scarlatinous eruption appeared. During this time the +patient had an intestinal catarrh, with diarrhoea, which declined when +the rash occurred. This intestinal disease was the apparent cause of +the irregularity in the malady. If scarlatina occur during a severe +attack of entero-colitis attended by purging, the defluxion from the +external surface may be such that no efflorescence appears. Severe +scarlet fever itself sometimes appears to cause gastro-intestinal +catarrh so as to produce an afflux of blood toward the intestinal +tract and away from the skin. Practitioners occasionally meet cases +like the following, which I recall to mind: In a family where +scarlatina was prevailing a little child early after the commencement +of symptoms which seemed to be plainly referable to this exanthem was +seized with vomiting and purging, which continued till death {509} +occurred on the third day. No efflorescence appeared upon the skin, +but the symptoms indicated the presence of severe intestinal catarrh, +complicating and masking scarlatina. We are aided in the diagnosis of +such cases by observing the faucial redness, and we may discover a +faint efflorescence upon parts of the surface, as about the groin or +in the flexures of the joints. In another instance an infant in the +warm months having protracted entero-colitis, the usual summer +epidemic of the cities, had the characteristic symptoms of scarlet +fever, which was present in the family, but the diarrhoea continued +and no rash appeared. + +In one who is much reduced by an antecedent disease, as phthisis, or +who has a disease, chronic or acute, which produces a decided afflux +of blood away from the surface and toward the interior of the body, +the eruption is commonly tardy in its appearance, indistinct, or +wholly absent. Thus, severe inflammations of internal organs not +infrequently render scarlet fever irregular. On the other hand, some +maladies occurring in connection with this exanthem do not change its +symptoms, but themselves undergo modification. Pertussis may be cited +as an example, the cough of which is sometimes modified by an +intercurrent attack of scarlet fever, the symptoms of the latter +disease undergoing little change. + +Scarlet fever may also be irregular without any apparent perturbating +cause. In 1867 I attended a young lady whose previous health had been +good, and whose brother was sick at the time with scarlet fever. She +had considerable febrile movement, with severe pharyngitis, and, +though her surface was repeatedly examined, no efflorescence was seen. +Two weeks subsequently she was affected with severe nephritis, +anasarca, effusion into at least one of the pleural cavities, oedema +of the lungs, and probably hydro-pericardium, the case ending fatally. +Rilliet and Barthez state that a second attack of scarlet fever is +more apt to be irregular than the first. Probably this opinion is +correct, especially if only a short time have elapsed between the two +seizures. Still, as we have already stated, both seizures may be +typical, and the second more severe than the first. + +It would be impossible to make a clear and positive diagnosis of +certain cases of irregular scarlet fever, in which cerebral, +pulmonary, or gastro-intestinal symptoms predominate, were it not for +the fact that they occur in connection with other cases of scarlet +fever or are followed by sequelae which evidently have a scarlatinous +origin. + +Occasionally, the eruption, if it be intense or if a certain condition +of system be present in the patient, is accompanied by more or less +extravasation of blood-corpuscles from the capillaries, so that the +redness does not entirely disappear on pressure, usually in points. In +rare instances certain of the exanthematic fevers present an extreme +hemorrhagic character, so as to be beyond the reach of remedies, and +of necessity speedily fatal. Hemorrhagic cases of this severe form are +probably more common in variola than in the other fevers, but I have +met a notable case in what was diagnosticated scarlatina. In June, +1881, a man in his thirty-second year, whose previous health had not +been good, though he had no defined ailment and had been able to +follow his occupation of harness-maker, suddenly became very ill, with +high febrile movement and faucial inflammation, attended by marked +prostration. After some hours an intense eruption of a scarlatinous +appearance covered nearly the entire surface, and on the following day +hemorrhages began to occur. The urine {510} contained a large +proportion of blood; each conjunctiva was raised by hemorrhages +underneath (ecchymosis), so that its natural color was lost and the +eyelids closed with difficulty; and blood flowed from the nostrils, +gums, and under the skin, forming hemorrhagic points and blotches. One +of the consulting physicians, perceiving the resemblance to +hemorrhagic variola as described by Hebra, suspected that we had a +case of this formidable malady to deal with, but the time for the +appearance of the variolous eruption passed by without its occurrence. +Death took place on the fifth day. The temperature during the sickness +was high, though the record of it has been mislaid. Fortunately, such +severe hemorrhagic cases, which are necessarily fatal, are rare. + +COMPLICATIONS AND SEQUELAE.--Scarlet fever, if its type be severe, is +in itself dangerous to life. Many, as we have seen, perish from its +direct effects when it produces profound blood-poisoning. But, while +the ordinary epidemics of this malady are necessarily attended by a +large mortality from the virulence and depressing effect of the +specific principle, unfortunately, of all the diseases of modern +times, scarlatina ranks first as regards the number and gravity of its +complications and sequelae, so that nearly or quite as many perish +from these as from the direct effect of the poison. + +Nervous accidents occur chiefly at two periods--to wit, in the first +days, when they are due to the severity and malignancy of the malady +and to the impressible nervous temperament of the child, and in the +declining stage, or after the termination of the fever, when they +occur from uraemia. If the type be malignant, delirium, jactitation, +profound stupor, and convulsions frequently occur on the first and +second days; and they are symptoms which properly excite the utmost +alarm and demand all the resources of our art, since they indicate a +form of the disease which is apt to end in speedy death. The eyes have +a dull or wild expression, the conjunctiva is suffused, the heat of +surface pungent, the pulse rapid and compressible or feeble, rising +above 150, even to 200, per minute, and the temperature is always +elevated to a degree that involves danger, the thermometer not +infrequently indicating 105 degrees or 106 degrees. But this severe +form of scarlet fever, attended by so great elevation of temperature, +is much less dangerous than in former times, even though it be +complicated by delirium and convulsions, since we no longer hesitate +to reduce bodily heat, when excessive, by the free use of cold baths, +and have discovered potent agents in the bromides and chloral for +controlling convulsions. Nevertheless, not a few perish in the +commencement of scarlet fever with predominating cerebral symptoms, as +delirium or eclampsia, followed by coma, under the best possible +treatment. Sometimes the symptoms have closely simulated those of +acute meningitis, and if the rash have been delayed and the sore +throat is as yet slight, the physician may suspect that he is dealing +with this disease; but autopsies in such cases show no inflammatory +lesions, but only congestion of the cerebral and meningeal vessels. + +As is stated in a preceding page, in every case of normal scarlet +fever inflammation of the faucial surface is present, as indicated by +redness, tenderness, and increased secretion of mucus or muco-pus. It +precedes the efflorescence on the skin, and is announced by pain in +swallowing and on pressure with the fingers behind and below the +angles of the jaw. In that form of scarlet fever which has been +designated anginose the {511} pharyngitis is severe, and is a +prominent element in the malady, the uvula, the pillars of the fauces, +and the faucial surface in general being infiltrated and swollen. +Nevertheless, this inflammation, with the accompanying tumefaction, is +properly a part of the disease, rather than a complication, if it +abates with the subsidence of the scarlet fever or begin to abate soon +after, and if it produce but slight destructive change in the tissues +of the neck. The secretions from the fauces may be foul and offensive; +even superficial ulcerations or gangrene may occur upon the faucial +surface, causing it to present a dark brown or jagged appearance, and +the tissues of the neck may be infiltrated to a certain extent, and we +designate the disease a form of scarlet fever under the title +anginose. But when this condition is greatly aggravated, so that there +is extensive infiltration and swelling of the tissues of the neck, +with an amount of ulceration or gangrene which in itself involves +danger, continuing after the primary disease abates, prolonging the +fever and reducing the strength, it is proper to regard the state of +the throat as a complication. In addition to the pharyngitis, which is +severe as described above, the sides of the neck around the angles of +the jaw become swollen, hard, and tender. The inflammation has been +propagated to the deeper structures of the neck. Poisonous substances, +the result of decomposition or vitiated secretions, traverse the +lymphatic vessels from the faucial surface, and, being intercepted in +the lymphatic glands, cause adenitis, and the inflammation extends +from the glands to the adjacent connective tissue, which becomes hard, +tender, swollen, and infiltrated with inflammatory products. This +tumefaction sometimes begins by the second or third day, but it is +usually about the close of the first week or in the beginning of the +second week that it becomes so considerable as to constitute a source +of danger and anxiety. It is in most cases bilateral, though one side +may begin to swell before the other and remain larger throughout. + +In severe cases of this complication the tumefaction extends from ear +to ear, filling up the space below and around the angles of the jaw +and under the chin. Not only is deglutition difficult, but it is +difficult to open the mouth sufficiently to inspect the fauces, and +attempts to do so cause much pain. The lymphatic glands, which lie in +the inflamed area and participate in the inflammation, are greatly +enlarged by hyperplasia, the round granular lymph-cells multiplying so +abundantly that the glands increase to many times their normal size. +Most of the tumefaction is, however, due to extension of the +inflammation to the connective tissue of the neck. The cellulitis, +which resembles that occurring in other conditions, is attended by +distension of the capillaries, the abundant formation of young round +cells, and transudation of serum (Billroth). A moderate amount of +tumefaction may disappear by resolution, but if it be considerable it +seldom abates in this way, but by the tedious and exhausting process +of suppuration or gangrene. If the swelling at its most prominent +point present a reddish hue, all hope of producing resolution must be +abandoned; it cannot be effected by any medicine or appliance within +the resources of our art. The abscess which forms is apt to be +diffuse, so as to involve danger of pyaemia, unless it be soon opened +and properly washed out. With the discharge of the pus the swelling +gradually softens and declines. In other cases gangrene results. The +vessels in the inflamed part are compressed by the inflammatory +products, so that {512} they no longer convey the blood which is +required for the purpose of nutrition. It is a law of the economy that +whenever the circulation ceases, the tissues which receive their +nutritive supply through the obstructed vessels lose their vitality. +Hence gangrene occurs in all that portion of the swelling in which the +circulation is arrested. The skin over it peels off, the dead tissue +underneath is brown or dark, and soon, if life be prolonged, the +slough begins to separate. The prognosis as regards this complication +depends largely on the size of the slough. If it be large, death will +probably result, since the strength of the system is already reduced +by the primary disease, and the reparative process will necessarily be +slow, while abundant suppuration tends to increase the exhaustion. In +some of the worst cases of cervical gangrene which I have seen the +slough has laid bare the muscles and vessels of the neck, producing in +one case a cavity or excavation sufficiently large to admit a hen's +egg. Often the slough extends under the skin, so that the deepest +recesses of the cavity are not visible, and occasionally in cases +which have ended fatally in my practice severe hemorrhage occurred +from the concealed vessels. If the ulcerative or gangrenous process +extends so deeply into the tissues of the neck that hemorrhages occur, +death is the common result; but if the destructive action be of +moderate extent and other conditions favorable, we may expect recovery +through cicatrization, with perhaps some deformity by contraction of +the cicatrix. + +When the inflammation of the connective tissue of the neck is +extensive, involving both the lateral and anterior regions of the +neck, the patient is in a perilous state. The cellulitis, when +extensive and accompanied by much swelling, may produce oedema of the +glottis, may obstruct respiration by compressing the air-passages or +the laryngeal nerves, may cause compression of the jugular veins, and +thus give rise to dangerous cerebral symptoms, or may lay bare and +injure important muscles and nerves, as we have seen. If the +ulceration or gangrene be extensive, and death do not occur by +hemorrhage from arterial or venous twigs, septic poisoning may occur, +increasing still more the fatal nature of the malady. + +Some cases of this complication are melancholy in the extreme, as one +related by Cremen, in which ulceration of the pharynx occurred, +allowing the escape of food and preventing deglutition. In severe +scarlatinous pharyngitis the inflammation is apt to extend along the +Eustachian tube, causing its occlusion. This accident will be +considered when we treat of otitis media, another grave complication. +It often also extends into the nares, causing catarrh of the +Schneiderian mucous membrane, with discharge of muco-pus from this +surface. Not infrequently ulceration or gangrene occurs in the faucial +surface, producing more or less destruction of tissue and forming +excavations which connect with the throat, while the cutaneous surface +retains its integrity and is not even reddened. The following case +shows how grave the complication which we are now considering +sometimes is when the external surface of the neck is not involved, +and how the inflammation by extension outward from the fauces may +involve the middle ear. + +_Case 1._--Annie K----, aged two and a half years, an inmate of the +New York Foundling Asylum, was well, except an eczema of the scalp, +until the night of April 3, 1882, when she was attacked with vomiting +and {513} diarrhoea. She was feverish and drowsy, and at 2 P.M. on the +4th the scarlatinous efflorescence appeared upon her neck, body, and +lower extremities; tongue coated; pharynx red; temperature (axillary) +103 degrees; pulse 160. The symptoms and aspect indicated a grave form +of the malady, and the usual sustaining treatment was ordered. On +April 5th the temperature was 102 degrees, pulse 144, tongue less +coated, eruption fading, less stupor, no albumen in urine. April 6th, +morning temperature 102 degrees, pulse 160; passed a restless night; +stools thin and too frequent; has grayish patches in the throat: P.M. +temperature 103-1/5 degrees, pulse 150. April 7th, the diarrhoea +continues, and she has a copious muco-purulent discharge from the +nostrils; P.M. temperature 103-3/5 degrees, pulse 160. April 10th, the +temperature has continued at about 103 degrees; the patient is very +sick, with a constant foul-smelling discharge from the nostrils; +breath very offensive; temperature 103.5 degrees, pulse about 180. +April 12th, general appearance a little better, but the posterior +surface of the fauces is completely covered by a thick +pseudo-membrane; had four loose stools last night; temperature and +pulse the same as at last record; a dark, offensive, and jagged +coating over the fauces, and a dark, foul discharge from the nostrils, +as before; examination of the chest negative. April 14th, is much +prostrated; temperature 104.5 degrees, pulse rapid and weak; +respiration noisy, diminished resonance over lower two-thirds of left +side of chest; ulcers upon the mouth and tongue; fauces red and +ulcerated. April 17th, pulse 150, temperature 100.5 degrees; general +appearance somewhat better, but the diarrhoea continues, and patches +of a diphtheritic character have appeared upon the lips; moist rales +in left side of chest. The symptoms continued nearly the same until +April 23d, when she died. A dull percussion sound and distinct +bronchial respiration were observed in the left scapular region during +the last days of her life. + +Autopsy nine hours after death by the curator, Dr. W. P. Northrup: +Body well nourished; the tissues have a jaundiced hue; lips sore; on +turning the head to one side pus runs from the left ear and dirty +muco-pus from the mouth. Brain normal; on opening the petrous portion +of the left temporal bone the middle ear is found full of pus, which +communicated freely with the external ear through a perforated +membrana tympani; the Eustachian tube cannot be traced in the sloughy +tissue, and a passage filled with pus extends from the ear to the +fauces; opposite the greater cornua of the hyoid bone are two deep +ulcers, each having about the diameter of a ten-cent piece, with +sloughy and offensive base and sides; the left ulcer communicates by a +ragged and wide sinus with a dark and sloughy cavity of about four +drachms capacity; this cavity is located in the neck under the angle +of the jaw, apparently occupying the site of a disintegrated gland, +and it opens upon the surface of the fauces. The surface of the larynx +has a dusky, dirty appearance, sprinkled with little cheesy-looking +spots, and covered by a dirty, foul-appearing liquid, as if some of +the ichorous pus had escaped into it from the neck; about one and a +half inches below the vocal chords there is an unmistakable +pseudo-membrane; below this, near the bifurcation, the trachea has a +bright-red color, as if a pseudo-membrane had been peeled from it, +leaving the surface raw. The detachment of a pseudo-membrane from this +part, if it did occur, must have been ante-mortem, for the organ had +been carefully handled {514} in making the autopsy. Between the apex +of the left lung and the median line the tissues of the neck, +dissected upward, are found indurated, yellow, and giving an offensive +odor, showing that the cervical cellulitis had extended downward +farther than usual. The bronchial glands have undergone hyperplasia, +being enlarged and hard. The right lung is normal; about one-half of +the left lower lobe is consolidated, and when cut is found to be +gangrenous and offensive. The liver is apparently somewhat enlarged; +spleen normal in size; gastric mucous membrane has a congested +appearance and is covered with mucus; mesenteric glands enlarged, +pale, and firm; Peyer's patches swollen and pale; at lower end of +ileum some pigmentation of these glands; in large intestine the +solitary glands are enlarged, and a few of them pigmented; kidneys +pale, cortex thickened, and markings indistinct. Microscopical +Examination.--In the pia mater perhaps a little increase of cells; +meninges of brain otherwise normal. The trachea shows well-marked +diphtheritic inflammation; it contains a film of pseudo-membrane; +evidences of inflammation occur also upon the laryngeal surface, +though less marked than in the trachea. The solidified portion of the +lung exhibits the ordinary lesions of broncho-pneumonia, with some +interstitial change. In the kidneys we find parenchymatous nephritis, +with some cell-growth in the Malpighian bodies. + +The above case has been related at length, not only because it shows +how severe and destructive the inflammation of the throat, extending +into the tissues of the neck, sometimes is, but because four other +complications or sequelae were also present--to wit, otitis media, +diphtheria, nephritis, and pneumonia. We see from the above case how +formidable a disease scarlet fever sometimes is when attended by the +inflammations to which it so frequently gives rise, for a child older +and stronger than this, if thus affected, would necessarily have +perished with the best possible treatment. + +In localities where diphtheria is endemic, as in New York City and +Paris, scarlet fever is often complicated by a pseudo-membranous +inflammation of the fauces and air-passages. In severe cases of +scarlet fever the Schneiderian as well as the faucial surface is +covered with it, so that it can be readily seen on inspecting the +anterior nares. Occasionally, the pseudo-membrane appears upon the +laryngeal and tracheal surfaces, as in the case which I have related +above and in others presently to be related, causing dangerous +embarrassment of respiration. This complication sometimes begins +almost at the commencement of scarlet fever, but in most instances it +does not occur before the third or fourth day, and it sometimes does +not appear till in the declining stage of the fever. When it begins, +it intensifies the febrile movement and produces general aggravation +of symptoms. + +The common opinion is, that whenever a pseudo-membrane occurs upon the +inflamed mucous surface in scarlatina true diphtheria has supervened; +but there are those who hold that scarlet fever itself, when the +inflammations which attend it are severe, may give rise to +pseudo-membranes, so that what seems to be diphtheritic is but an +element in the primary disease. My convictions are strong that when +pseudo-membranes occur on any of the inflamed mucous surfaces in +scarlet fever, true diphtheria has, with few exceptions, supervened if +the patient live in a {515} locality where diphtheria is prevalent. +That scarlet fever may occur in an individual along with another acute +infectious malady is shown by abundant cases. It often occurs with +varicella, and J. Herzog relates the following case, in which measles +and scarlet fever coexisted:[2] A boy aged eight years had measles, +with the usual catarrhal symptoms, and on the fourth day, as the +temperature was returning to the normal, it rose again suddenly, and +the scarlatinal rash and sore throat appeared. In due time these +subsided, and desquamation occurred. I have seen a similar case in +consultation during the current year, so that there is nothing +improbable in the theory that scarlet fever may coexist with other +infectious maladies; and it is admitted that diphtheria, like +erysipelas, may complicate the most diverse constitutional diseases. +Moreover, when a child with pertussis, measles, typhoid fever, or +tuberculosis suddenly develops a high fever with the occurrence of a +pseudo-membranous inflammation upon the fauces or air-passages, all +admit that diphtheria has supervened, since such inflammation is not +an element in any form or type of either of these diseases; and I see +no reason in the nature of the disease why scarlet fever should not be +equally liable to this complication. + +[Footnote 2: _Berl klin. Woch._, 1882, No. 7.] + +The elaborate treatise by Sanne of Paris on diphtheria contains a +chapter entitled "Secondary Diphtheria." In it the author says, what +all who are familiar with diphtheria will agree to, that secondary +diphtheria does not differ in nature from the primary form, and that +it exhibits a tendency "to occupy the organs which are themselves the +seat of the more pronounced local determinations of the primitive +malady.... Diphtheria is seen in the course or sequel of numerous +diseases. Some appear to have a special proclivity for engendering +diphtheria; these are specific maladies: measles, scarlet fever, +pertussis." I have tabulated as follows Sanne's statistics of +secondary diphtheria: + + Cases Deaths Cures Doubtful + ----- ------ ----- -------- + Diphtheria complicating measles, 100 83 15 2 + " " scarlet fever, 43 22 17 4 + " " pertussis, 20 12 6 2 + " " typhoid fever, 8 8 + " " tuberculosis, 19 19 + +Sanne's statistics relating to the seat of scarlatinous diphtheria are +as follows: + + Fauces alone attacked, 15 cases. + " with larynx " 4 " + " " nasal fossa " 8 " + " " larynx and nasal fossa " 4 " + " " larynx and bronchi " 1 " + " " nasal fossa and lips " 1 " + " " lips and skin " 1 " + " unaffected, 3 " + Diphtheria generalized, 2 " + Larynx only affected, 2 " + Nasal fossa " 1 " + +The opinion of so good an observer as Sanne, that when in scarlet +fever, pseudo-membranous exudation appears upon the mucous surfaces +which are the seat of scarlatinous inflammation, diphtheria has +supervened, and not a croupous form of scarlatinous phlegmasia, +carries with it great {516} weight. That it was diphtheria in four +instances in my practice I had sufficient proof, for this disease +became dissociated from scarlet fever, and extended to other members +of these families as idiopathic diphtheria. + +Nevertheless, one of the most difficult problems which we have to deal +with in certain cases is to distinguish diphtheritic from +non-diphtheritic inflammation; and I see no reason why the +scarlatinous inflammation when intense may not be sometimes +membranous; and those no doubt err who ignore this, and consider every +inflammation attended by a pellicular exudation diphtheritic. We know +that in some cases of dysentery a fibrinous exudation occurs upon the +surface of the colon; that in croupous pneumonia fibrin exudes into +the bronchioles and alveoli of the lungs; and that physicians in +localities where there is no diphtheria meet, though at long +intervals, cases which they designate croupous pharyngitis and +laryngitis; and it seems to me that the intense inflammation of +anginose scarlatina probably sometimes produces the same exudation. +Moreover, it is very difficult to distinguish in the swollen fauces +between a membranous exudation and ulceration or superficial gangrene +so common in malignant scarlet fever. The grayish-white surface, +jagged and foul, may be the one or the other, an exudation or a +sphacelus, and in certain instances it is impossible to discriminate +between the two conditions at the bedside. + +Diphtheria complicating scarlet fever sometimes begins nearly +simultaneously with the latter. Henoch states that exceptionally he +has observed suspicious patches upon the fauces before the appearance +of the scarlatinous eruption upon the skin; and he adds: "I have had +repeated opportunities of observing this unusual beginning. In such +cases we must ask ourselves whether the first affection was really +connected with the second, or whether the former was a true primary +diphtheria, rapidly followed by scarlatina. This opinion is favored by +the fact that I have only observed such cases in the hospital, in +which infection with various forms of contagion can scarcely be +avoided." + +But usually it is not till the third or fourth day of scarlet fever +that this complication begins. The patient has been progressing +favorably with the scarlet fever, till on a certain day a marked +aggravation of symptoms occurs. A higher temperature, more pungent +heat, and the physiognomy of a more serious malady are present. On +inspecting the fauces to discover the cause we observe a pellicle +forming over the tonsils and perhaps other portions of the faucial +surface. Often the entire aspect of the case changes by the occurrence +of this complication, a mild case of scarlet fever becoming grave and +fatal in consequence. Thus in a case which I saw with Dr. Hardy of New +York the membranous inflammation of diphtheria, commencing upon the +fauces on the third day of scarlet fever, extended to the Schneiderian +membrane, and thence along the left lachrymal sac to the eyelids, +producing redness and swelling along the side of the nose and upon the +cheek like that of erysipelas. A thick diphtheritic pellicle occurred +upon the under surface of each eyelid on the left side, with great +tumefaction of both lids, gangrene of the cornea, and destruction of +the eye. The case soon ended fatally. + +The diphtheritic inflammation sometimes extends to the larynx and +trachea, producing hoarseness and more or less obstruction to {517} +respiration. A thin film or flakes of fibrinous exudation, rendering +the respiration noisy, developed on the laryngeal or tracheal surface, +is, I think, not infrequent in diphtheria complicating scarlet fever, +but the rapid development of a thick and firm pseudo-membrane, so as +to imperil the life of the patient from the stenosis in the +air-passages, has been much less frequent in my practice than it is in +primary diphtheria and in diphtheria complicating measles or +pertussis. The following were cases of this severe complication +occurring in a recent epidemic in the New York Foundling Asylum. In +these cases the respiration was noisy, but the obstruction to +breathing seemed to be due to infiltration and swelling around the +aperture of the glottis, rather than to diphtheritic croup, which the +autopsies showed to be present. + +_Case 2._--A child aged three and a half years, who previously had +symptoms of mild catarrhal croup, with moderate redness of the fauces, +sickened with scarlet fever on Oct. 1, 1882, the rash being profuse +and soon covering nearly the entire body. The axillary temperature was +103 degrees, pulse 140; slight stridor in breathing and some cough; +fauces very red, but free from membrane. Oct. 2d, restless, sleeping +but little; has vomited four times. Oct. 3d, temp. 103.5 degrees, +pulse 120; fauces much swollen; still vomiting; rash abundant. 4 P.M., +temp. 104.3 degrees, pulse 128; tongue clean; some discharge from +nares; urine not albuminous, but its quantity diminished. Oct. 4th, +aspect that of very severe sickness; profuse discharge from nostrils; +fauces of a deep red color, and a diphtheritic pellicle over tonsils +and uvula; tumefaction along the sides of the neck; temp. 104 degrees, +pulse 140; breathing moderately stridulous; urine is passed more +freely than yesterday; evening temp. 105 degrees. Oct. 6th, croupy +symptoms more marked; tonsils and uvula greatly swollen, so that the +fauces are almost occluded; temp. 103.5 degrees; breathing difficult, +but apparently sufficient oxygen is received; profuse nasal discharge, +and other symptoms as before. About 1.30 P.M. he was raised to take +some milk, and suddenly became asphyxiated. His face was dusky, his +eyes protruded, and he voided urine and feces. Dr. Swift, who attended +the child, and to whom I am indebted for this history, immediately +performed tracheotomy, which gave temporary relief by the expulsion of +a considerable quantity of pseudo-membrane through the opening. On the +following day the respiration again became obstructed at some point +below the canula, so that it could not be removed; the features grew +livid, and death occurred in convulsions twenty-six hours after the +tracheotomy. + +The autopsy was made by Dr. W. P. Northrup, curator of the asylum, who +found the pharynx covered by a membrane which was traced to the +posterior nares; larynx, trachea, and bronchial tubes as far as the +third divisions also covered with membrane; portions of the tracheal +surface denuded, and the mucous membrane underneath of a bright red +color and smooth; tonsils sloughy and fetid; mucous membrane of +smaller bronchial tubes very red and covered with viscid mucus and +pus; a portion of the left lung, extending from the root posteriorly +to the surface, gangrenous, discolored, and honeycombed; two or three +intensely hyperaemic spots, as large as a bean, in left lung; right +lung congested, but not consolidated; slight catarrh of stomach; +circumscribed areas of congestion in intestines; solitary glands of +intestines swollen, and some {518} of them ulcerated; spleen of normal +size, rather pale; liver congested and somewhat enlarged. + +_Case 3._--Katie, aged six and a third years, was returned to the +asylum on Nov. 18th. Three days later (Nov. 21st) she had sore throat, +reddened fauces, coated tongue, and a faint rash upon the neck, chest, +and arms; eyes injected; temperature 102 degrees. In the afternoon +temperature 103 degrees; eruption still faint. Nov. 22d, temperature +103.5 degrees; an eruption on chest, abdomen, arms, and legs in +patches. Evening, temperature 104 degrees; voice clear. Nov. 23d, +temperature 103.5 degrees; tongue red; fauces deeply reddened, but +without any visible pseudo-membrane; eruption of a scarlatinous +appearance over the back and abdomen; on the extremities dusky, livid +patches. P.M., temperature 104 degrees; is slightly delirious; +eruption abundant. Nov. 24th, temperature 103.5 degrees; eruption well +out on abdomen; it is the same as yesterday upon the extremities, +except perhaps a little more dusky; still no pseudo-membrane to be +seen upon the fauces; is restless and delirious. P.M., during the day +has been very restless, suffering from dyspnoea; no croupy voice nor +croupy cough, though the dyspnoea continues, and a pseudo-membrane is +now visible over the tonsils and adjacent faucial surface; eruption +dusky; skin cool; pulse very frequent and feeble. From this time she +sank steadily, and died at 11.30 P.M. During her sickness her urine +seemed to be diminished, but it was not properly examined. + +Autopsy Nov. 25th by Dr. W. P. Northrup, curator: Points of redness, +apparently a hemorrhagic eruption, over the face, shoulders, and parts +of the trunk; a few of the same on the extremities; no pseudo-membrane +visible in nostrils or in buccal cavity; brain not examined. +Naso-pharynx covered by a thick fibro-purulent membrane. Larynx +contains a well-marked pseudo-membrane, but not continuous. Trachea +covered by a pseudo-membrane, continuous over most of its surface, but +in places broken and flaky. Where it is detached the mucous membrane +is seen underneath, dusky and deeply injected. At the root of the +lungs the pseudo-membrane can be traced along the tubes about an inch +in all directions. Lungs oedematous, with deep congestion in places, +but apparently no pneumonia; about two drachms of clear, straw-colored +fluid in pericardium; a few stringy decolorized clots in the cavities +of the heart; left ventricle contracted. The heart-fibres, carefully +examined, microscopically, in the laboratory, are found to be normal, +not having undergone granular or fatty degeneration. Liver normal in +size; pale-yellow areas upon the superior surface, either from anaemia +or fatty deposition. Kidneys of usual size, capsule not adherent; +pyramids congested; cortex pale; markings distinct. Spleen enlarged +about one-third; consistence normal. Stomach and intestines not +examined. + +_Case 4._--Scarlet fever complicated by diphtheria, nephritis, and +broncho-pneumonia. (History by house physician, Dr. Swift.) Phoebe, +aged three and a quarter years, was delicate, but in her usual health +till Oct. 29, 1882, when she became languid and vomited several times, +and her tongue was coated. Oct. 30th, occasional vomiting; fauces +reddened; tongue coated. Oct. 31st, remains languid; fauces deeply +reddened; a faint scarlatinous eruption over back, wrists, and feet; +temperature 100.5 degrees. P.M., eruption of scarlet fever well out +over the surface; tongue cleaner. Nov. 1st, {519} rash over entire +body; temperature 100.2 degrees. Nov. 2d, fauces deep-red; tonsils and +uvula swollen; diarrhoea and vomiting. Nov. 3d, temperature 102.5 +degrees; the eruption, which has been bright red, is now more dusky. +Nov. 5th, temperature 104.5 degrees; dusky-red color of the eruption; +skin beginning to desquamate in places; urine normal; a discharge from +nostrils. Nov. 6th, temperature 103.5 degrees; eruption still present, +but skin of abdomen and back desquamating; has otorrhoea on both +sides; fauces deeply hyperaemic, but no pseudo-membrane visible upon +them. Nov. 7th, temperature 103 degrees; respiration and cough have a +slight croupy character; other symptoms as yesterday. Nov. 8th, +temperature 101 degrees. A careful inspection of the fauces shows that +it contains no pseudo-membrane; nostrils discharging a dark-brownish +liquid; examination of urine negative. Nov. 11th, eruption, which +appears to have been hemorrhagic in points, is fading and the +desquamation is less. Nov. 14th, nostrils still discharging; glands of +neck swollen. Nov. 16th, temperature 103 degrees; sp. gr. of urine +1010, no casts, nor albumen; the chest seems clear; less discharge +from nostrils; fauces clean and but slightly inflamed. Nov. 17th, +18th, temperature 103.5 degrees; vomits; lungs healthy, but breathes +with considerable effort, though without stridor; urine diminished; +its sp. gr. 1020, albuminous, contains blood-corpuscles and granular +casts. Nov. 19th, is very pallid; temperature 104 degrees; very +restless; vomits; urine diminished; bowels freely open. Nov. 20th, +respiration still embarrassed; subcrepitant rales over the entire +chest and percussion resonance not clear; temperature 102.5 degrees. +Nov. 21st, physical signs the same; temperature 103.5 degrees; +respiration 80. Nov. 22d, urgent dyspnoea; dulness on percussion over +top of right lung and over lower part of left lung; is delirious; no +perspiration; urine scanty; bowels freely open. From this date the +dyspnoea became more urgent, and death occurred at 4 P.M. on the 23d. + +Autopsy by Dr. W. P. Northrup, curator: Body well nourished; slight +oedema of both legs; swelling at angles of jaws, most marked on left +side. Vessels of brain moderately injected; otherwise appearance +normal. Cicatrizing ulcers on both sides of fauces; a diphtheritic +pseudo-membrane on septum of nose, larynx normal. Trachea, upper half +apparently normal; a thin film of pseudo-membrane extends from just +above the bifurcation upward to nearly the middle of trachea. About an +ounce of fluid in each pleural cavity; on the right side a few loose +flakes of fibrin floating in the serum, and consolidation of lung at +apex; collapse in one or two places. Left side, recent adhesions over +whole of posterior surface and base; surface of lower lobe dark, and +when it is detached strings of fibrin adhere to it, and it is +consolidated. The cut surface shows marked oedema, injection, increase +of mucus in bronchi, and disseminated miliary tubercles in every part; +no tubercles in the pleura, and none elsewhere in the body except in +the left lung; tubercles in the lower lobe larger and more thickly +grouped than in the upper lobe. Decolorized clots in heart, extending +from ventricles into auricles of both sides. The capacity of the +ventricles seems normal. Liver and spleen, normal. Kidneys rather +large; capsules not adherent; superficial veins injected. The cut +surface shows congested pyramids and pale cortex; markings indistinct +and irregular; about four ounces of clear straw-colored fluid in +abdominal cavity, and the solitary follicles of {520} large intestines +show pigmentation; two simple intussusceptions, each three-fourths +inch in length, in small intestines. + +Coryza frequently commences at or about the time of the pharyngitis. +The inflammation of the Schneiderian membrane is continuous +posteriorly with that of the fauces, and is announced by redness and +swelling, inability to breathe freely through the nostrils, and an +irritating ichorous discharge. Simple coryza in itself involves little +danger, though it is an unpleasant complication, and in the nursing +infant it may interfere with sucking. Diphtheritic coryza, on the +other hand, which is frequently present when diphtheria complicates +scarlet fever, involves danger, since it is apt to cause ulcerations, +hemorrhages, and septic poisoning. When the local symptoms are +unusually severe and the discharge abundant, it is probable that +inflammation has in some cases extended to the antrum of Highmore. + +Inflammation of the middle ear is another unpleasant and not +infrequent complication. It is attributed to extension of the catarrh +from the pharynx along the Eustachian tube to the tympanum. In a +considerable proportion of cases of otitis media this tube is occluded +by the infiltration and swelling of its mucous membrane, so that the +muco-pus escapes with difficulty or is retained. Hence severe earache, +an increase of the febrile movement, and outward bulging of the +membrana tympani occur. Sometimes headache or other cerebral symptoms +arise, probably from the fact that the meningeal artery, which +supplies the meninges, is connected by anastomosing branches with the +tympanum. In one of the cases related above it will be recollected +that the ulceration and abscess extended from the fauces to the middle +ear, the entire Eustachian tube having disappeared in the ulcerative +process. + +Frequently, the otitis escapes detection, its symptoms being masked or +obscured by the general disease, until the membrana tympani is +perforated and otorrhoea begins; but by careful examination the nature +of the complication can usually be ascertained before the ear is +injured to this extent, for a patient too young to speak will often +press with the fingers against the painful ear or lie with the ear +pressed upon the pillow, evidently having an increase of suffering if +placed in any other position. One old enough to speak and in proper +mental condition makes known the earache as soon as it occurs. + +The mucous membrane of the tympanum, red and swollen from +inflammation, secretes muco-pus abundantly; and this, pent up in the +cavity, must obtain an exit before relief occurs. It is well if this +secretion escape, though with difficulty, down the Eustachian tube. +The destructive action of the pus upon the delicate structure of the +ear is often such that, within a few days, irreparable harm is done +and more or less deafness results. Relief can occur, if the Eustachian +tube remain closed, only by perforation of the membrane and the +discharge of the secretions into the external meatus. When this occurs +the inflammation in the most favorable cases gradually abates, the +aperture in the drum closes, and the integrity of the auditory +apparatus is preserved. In severe cases the mastoid cells +participating in the inflammation become filled with muco-pus and +tender to the touch, and often the collateral oedema causes +tumefaction and narrowing of the external ear, which subside with the +discharge of pus from the tympanum. + +{521} Unfortunately, there is for many a more melancholy history--a +more destructive inflammation, involving permanent impairment or total +loss of hearing. This is especially apt to occur in strumous and +feeble children. All grades of inflammation and destructive action +occur in different cases. The perforation in the drum-membrane may be +large or the membrane may be completely destroyed, and the detached +ossicles escape one by one into the external meatus, and in a few +instances, fortunately rare, this occurs in both ears, producing +complete and permanent deafness. In my own practice this has never +occurred, but I have met one or two adults who were totally deaf from +this cause. + +The mucous membrane which lines the bony wall of the middle ear has +the function of the periosteum, and therefore, when inflamed and +subjected to pressure, is liable to ulcerate. As in other parts of the +skeleton under similar conditions, superficial caries or necrosis of +the underlying bone is apt to occur. The carious or necrotic process +may extend to the mastoid cells. An offensive otorrhoea, continuing +for months or years, indicates the persistence of this pathological +state of the tympanum, which is rendered so obstinate by the presence +of dead bone. A moment's survey of the anatomical relations of the +middle ear shows the danger to which these patients are liable. A thin +bony septum, perforated with blood-vessels and sometimes containing +congenital apertures, separates the tympanum from the cranial cavity +above. Posteriorly lie the mastoid cells, connected with the tympanum +by one large and several small apertures. Anteriorly is the +commencement of the Eustachian tube and in close proximity to the +tympanum lies the carotid canal, and at one point also the superior +petrosal sinus. Virchow has shown how inflammation extending from the +ear in otitis media sometimes produces such compression of the veins +or sinuses by the swelling from the infiltration and exudation that +the circulation is arrested, and the fibrin contained in the blood of +these vessels is precipitated, forming thrombi, with the most +disastrous effect upon the individual. Pus may also burrow in the +interstices of the bone, causing great pain, or the pent-up +secretions, having no outlet for escape, may in time undergo caseous +degeneration, producing the conditions in which tuberculosis so often +originates. + +Death not infrequently occurs in chronic otitis media in another way. +The otorrhoea, after months or years, suddenly ceases, the child +complains of constant severe headache and is feverish, and the case +ends in coma, preceded perhaps by convulsions. Meningitis has +occurred, produced by extension of the inflammation through the thin +bony septum which divides the tympanum from the cranial cavity, and at +the autopsy hyperaemia of the meninges, fibrin, pus, perhaps softening +of the brain and an abscess, are formed in the portion of the +encephalon adjacent to the tympanum. Therefore, otitis media, though +it often ends favorably, is in many patients an obstinate, dangerous, +and even fatal sequel of scarlet fever. + +The complication known as scarlatinous rheumatism is regarded by some +as a synovitis, but its symptoms, especially its shifting from joint +to joint, seem to ally it to the rheumatic affections. In some +epidemics it is common. It usually begins toward the close of the +first week or in the second week, and its common seat is in the ankle, +phalangeal, and wrist joints. It is attended by very little swelling +in {522} most patients, though the joints are tender and painful on +pressure. It does not seem to retard convalescence materially, though +it produces suffering and involves danger as regards the heart. It +subsides in a few days with the ordinary treatment of acute +rheumatism, and even without special treatment, the chief danger being +that, as in idiopathic rheumatism, endocarditis may arise, with +permanent crippling of the valves. The following was a case of +valvular disease having this origin. It occurred in my practice. + +_Case 5._--Freddy M., aged four years, sickened with scarlet fever +March 6, 1879. The usual vomiting occurred on the first day, and the +temperature was 104 degrees. The case progressed favorably till March +14th, when he complained of pain in both wrists, both ankles, and both +knees. On March 17th the general condition was good, the urine +contained no albumen, and apparently few urates, but he still had pain +in the joints of the upper and lower extremities and in the back; +pulse 140, temp. 103 degrees; breathes with a slight moan; urates in +the urine, but no albumen. A distinct mitral regurgitant murmur is now +heard for the first time. Under the use of salicylate of sodium the +pain in the joints soon ceased, but the mitral murmur is permanent. + +The following prescription is for a child of five years: + + Rx. Ol. Gaultheriae fl. drachm iss; + Sodii Salicylat. drachm iii; + Syrupi fl. oz. ii; + Aquae fl. oz. iv. M. + +S. Give one teaspoonful every four hours. + +Of the serous inflammations occurring in scarlet fever, pericarditis +has been, according to Rilliet and Barthez, most frequently observed. +In this country it is probably more frequent than is usually supposed, +but it is less frequently detected than pleuritis, the symptoms of +which are more conspicuous. It is apt to occur in connection with +endocarditis. + +The following case, showing the liability to pericarditis and other +serous inflammation which exists in scarlet fever, occurred in my +practice: + +_Case 6._--C----, girl aged five years and ten months, sickened with +severe scarlet fever on April 4th. Was delirious; pulse 158; had +vomiting and constipation. April 10th, pulse varies from 124 to 153, +no delirium; a considerable quantity of urates in the urine. April +11th, has to-day, for the first time, severe pain in the epigastrium, +with tenderness and moderate distension. Otherwise symptoms favorable, +but severe; pulse 140; respiration moderately accelerated, and +vesicular in every part of the chest. From this date the symptoms +continued about the same till April 14th, when the dyspnoea became +more marked and the action of the heart rapid and tumultuous. The +epigastric pain, distension, and tenderness continued; the percussion +sound was dull over the lower part of the chest; the dyspnoea became +rapidly worse, although the pulse had considerable volume; and at 5 +P.M. death occurred. At the autopsy about one ounce of turbid serum, +with a soft deposit of fibrin, was found in the pericardium. Each +pleural cavity contained from six to eight ounces of transparent +serum, and both lungs were readily inflated, except a little of the +posterior portion of each lower lobe, which could not be; no fibrinous +exudation over the lungs. The liver extended four inches below the +margin of the ribs, and upon its convex {523} surface in the +epigastrium, corresponding with the seat of the pain, was a rough +patch of fibrin about one and a half inches in diameter. The bronchial +mucous membrane was moderately injected, as was also that of the +colon, and the kidneys appeared hyperaemic. + +Among the serous inflammations which complicate or follow scarlet +fever, pleuritis is one of the most important. It usually begins in +the desquamative stage, and is apt to be suppurative on account of the +feeble state of the patient when it commences. It has always, in my +practice, been tedious, as all empyemas are, and it does not differ in +its clinical history from the idiopathic disease. I have met cases of +scarlatinous empyema in which, from opposition of the family or for +other reasons, thoracentesis was not performed, and death occurred; +others in which this operation effected a cure, and one at least in +which the patient recovered by escape of pus through a bronchial tube. +The pleuritis is seldom latent, or so masked by the symptoms of the +general disease that it is apt to be overlooked. On the other hand, +the cough, embarrassment of respiration, and pain referred to the +affected side render diagnosis easy. + +Dilatation of the heart is common in grave cases of scarlet fever, +such cases as are properly termed malignant. It is indicated by a +feeble and quick pulse. Acute infectious maladies, especially those of +a malignant type and accompanied by high febrile movement, are very +apt to cause parenchymatous degenerations in organs, prominent among +which is granulo-fatty degeneration of the muscular fibres of the +heart. This weakens very much the contractile power of these fibres. +But early in malignant cases, probably before the muscular fibres are +damaged, the contractile power of the heart is feeble from impaired +innervation, the result of the general weakness. Hence this organ, +when weakened by structural change and insufficiently stimulated +through diminished innervation, may not fully empty itself during the +systole, and consequently it becomes dilated. Dilatation of the heart +and imperfect contraction of the auricular and ventricular walls are +apt to result in the formation of clots in the cavities of the heart; +and this appears to be the immediate cause of death in not a few +instances. An ante-mortem clot occurring in any of the cavities of the +heart necessarily seriously obstructs the circulation, unless it be of +small size. Hence the dyspnoea, which may occur perhaps suddenly, and +the change of pulse to one of marked feebleness and frequency. Large, +firm white clots are most frequently found in the right cavities. They +interlace with the chordae tendineae, lie even within the +auriculo-ventricular opening, and send prolongations into the +pulmonary artery and the cavae. Associated with the white clots are +dark, soft clots and fluid blood. The left cavities may be contracted +and empty, or they may contain dark, soft clots or white ante-mortem +clots. Clots in the left ventricle are sometimes prolonged into the +aorta as far as the brachio-cephalic branches, while those in the left +auricle may extend to the pulmonary veins. If dilatation of the heart +be so great that clots form in its cavities, speedy death is probable. +Sometimes a patient passes through scarlet fever and appears in a fair +way to recover, when he succumbs to some exhausting sequel distinct +from the heart, and at the autopsy the heart is found dilated and +containing whitish clots, which are probably ante-mortem, and which +hastened {524} death by obstructing the circulation. Under such +circumstances this state of the heart is attributable in great measure +to the complication which has weakened its contractile power. + +The following was a case in point. It occurred in the New York +Foundling Asylum: + +_Case 7._--R. A., aged three years, had scarlet fever, beginning March +23, 1882. The symptoms were favorable at first, but serious +complications and sequelae occurred, which were fatal. The record of +April 18th reads: "Appears well nourished, but is anaemic; has +otorrhoea; no oedema; skin desquamating; dulness on percussion over +upper third of right side of chest, anteriorly and posteriorly; mucous +rales and rude breathing over same area; fine rales posteriorly over +lower part of left side of chest; pulse 160, respiration 68, +temperature 101-2/5 degrees." April 20th, is feeble and takes +nutriment with difficulty; tongue thickly coated; pulse 160, +respiration 68, temperature 101-2/5 degrees. April 26th, condition +about the same as at last record, but he is evidently weaker; the lips +are ulcerated and fauces still swollen. May 2d, cannot speak +distinctly; a brownish, foul-smelling secretion lodges on the spoon +used in depressing the tongue; left side of face swollen. On the +following night eight convulsions occurred, attended by orthopnoea, +and mucous rales in the chest from pulmonary oedema. Diarrhoea +supervened and the patient died about midnight. Autopsy: Body +moderately wasted and very white, several dark-blue spots on scalp and +face from hemorrhages underneath; lips covered with dry crusts; brain +of normal appearance; aperture of the larynx narrowed at the chink by +infiltration and swelling of the tissues; surface of the vocal cords +covered by a thin white film, apparently a fibrinous exudation; +tracheal surface hyperaemic; about a drachm of straw-colored fluid in +each pleural cavity; right lung wholly adherent by recent exudation of +fibrin; left lung also largely adherent. A careful examination showed +the presence of broncho-pneumonia in each lung, with considerable +infiltration of the walls of the bronchi, and cylindrical dilatation +of many of them; cavities of the heart dilated, so that this organ +appears much enlarged, and its shape approaches the globular; its apex +is rounded or obtuse; transverse diameter of the right ventricle, when +its walls were open and drawn apart, was three and one-quarter inches; +that of the left ventricle three and a half inches. Similar +measurements of the heart of another child of about the same age, +believed to be normal, were about one inch less in each direction. All +the cavities contain white firm clots along with soft dark clots. +Liver of normal size, pale; the outer surface and all cut surfaces are +studded with nodules of the size of a pin's head, of a dull, opaque +white color. These white spots, examined microscopically by Professor +Delafield, are found to be neither tubercles nor gummy tumors, but to +consist of polygonal cells, lying in the meshes of the capillary +plexus of veins, which are perfectly preserved. He has not observed a +similar case. The walls of the gall-bladder are one line or more in +thickness, and the gall-duct is pervious. The microscope shows general +hypertrophy of the gall-bladder and hypertrophy of its papillae. The +urine removed from the bladder was found to contain albumen and +hyaline casts, and a microscopic examination showed a small amount of +parenchymatous inflammation. The spleen was somewhat enlarged. +Punctate congestion of small areas of {525} gastric surface, no +increase of mucus; mesenteric glands uniformly enlarged; jejunum, +ileum, and colon exhibited a slightly increased vascularity. The +immediate cause of death appeared to be imperfect contraction of the +heart and the formation of clots in its cavities, due, apparently to +the pleuro-pneumonia as much as, or more than, to the primary disease, +scarlatina.[3] + +[Footnote 3: Dr. Goodhart (_Guy's Hospital Reports_, 1879) reports +several interesting cases to confirm his opinion that acute dilatation +of the heart is a not infrequent sequel of scarlatinous nephritis, and +is the cause of death in some apparently inexplicable cases.] + +There can be little doubt that nephritis in its milder form is much +more common than was formerly supposed. A few years since little +attention was given by a large proportion of physicians to the state +of the kidneys, and the urine was not examined till dropsy made its +appearance, which only occurs in the more severe forms of nephritis +and is a late symptom. It is now known that catarrh of the renal tubes +frequently occurs in a mild form early in scarlet fever, without +causing albuminuria, dropsy, or any notable symptom. It may produce a +smoky color of the urine, and the appearance in it of granular +epithelial cells, with an increase of mucus, but no albumen. With +careful treatment and no exposure to cold, the renal catarrh abates +with the decline of the scarlet fever. It is scarcely severe enough to +merit the name desquamative, tubal, or parenchymatous nephritis, +though it is a mild form of the same pathological state. Steiner +states, as the result of many careful examinations of cases, that +hyperaemia of the kidneys was always present in those who died early +in scarlet fever, and that in a certain proportion of these cases +catarrh of the renal tubules was present in addition to the +congestion. Even in some who died on the second or third day he found +cloudiness of the epithelium in the renal tubes, although the urine +had not indicated such a change. The opinion has even been expressed +that catarrh of the renal tubes is as common in scarlet fever as that +of the bronchial tubes in measles; that is, that it is a uniform +element in the disease; but this appears to be an exaggerated +statement, for others have failed to find any evidence of renal +catarrh in certain cases. + +The nephritis which gives rise to symptoms, and therefore interests +the practitioner, commonly begins in the declining period of scarlet +fever or during the desquamative stage, and is in many instances +plainly attributable to exposure to cold or to currents of air. It +originates either during this period, or, if it have previously +existed as a mild renal catarrh, it now becomes aggravated. Dropsy, +which always attracts attention, does not occur till the nephritis has +continued for some time. + +Why nephritis, with the subsequent dropsy, so frequently occurs after +scarlet fever is not fully understood. Rilliet and Barthez attribute +it to disturbance of the function of the skin. The fact has long been +observed that the kidneys become affected nearly if not quite as +frequently after mild as after severe cases. Indeed, the chief danger +in mild cases, when the patients are but a short time in bed and are +soon allowed to go about, is from the nephritis. Chilling the surface +and checking cutaneous transpiration appear to be the immediate cause +of this inflammation in a considerable proportion of cases. Therefore, +severe attacks of scarlet fever with abundant rash and desquamation, +which require the patient to be kept in bed the proper time and in a +warm room two or three {526} weeks, appear to be less frequently +followed by this renal disease than are milder cases which are more +carelessly treated. + +The most thorough and minute microscopic examination of the state of +the kidneys in scarlet fever which have come to my notice were those +by E. Klein, published in the _Lond. Path. Soc. Trans._, and +illustrated by microscopic drawings. It appears from these +examinations that the changes in the kidneys are complex, among which +we recognize both those of parenchymatous or desquamative nephritis +and interstitial nephritis; but we would infer that the interstitial +nephritis is mild in degree and quite subordinate, or else confined to +portions of the organ, from the fact that so many permanently and +fully recover. The following is a resume of Klein's examinations in +twenty-three cases: We conclude from these microscopic researches that +the anatomical changes of both parenchymatous and interstitial +nephritis are commonly present in greater or less degree in cases of +scarlet fever. If they are mild or confined to portions of the +kidneys, no symptoms occur; but if they are sufficient in extent or +degree to impair the function of these organs, then symptoms, as +albuminuria, diminution of urine, etc., appear. + +1. Parenchymatous Nephritis, Proliferation of Nuclei, Hyaline +Degeneration of Arterioles, the Glomerulo-Nephritis of Klebs.--Klein +found increase of nuclei (probably epithelial) upon the glomeruli and +hyaline degeneration of the intima of minute arteries, especially +marked in the afferent arterioles of the Malpighian bodies. The intima +of these vessels was in places so swollen as to resemble cylindrical +or spindle-shaped hyaline masses, and cause narrowing of the lumina of +the vessels in which this degeneration occurred. Klein observed in +some specimens so great hyaline degeneration of the capillaries of the +Malpighian bodies that circulation through them was obstructed. In the +more advanced or protracted cases this hyaline substance in the +glomeruli began to assume a fibrous appearance. Bowman's capsule was +considerably thickened. This hyaline degeneration of the Malpighian +bodies Klein discovered in the earliest cases which fell under his +observation. + +Also in the earliest cases the multiplication or germination of the +nuclei of the muscular coat of the arterioles was observed, with a +corresponding increase in the thickness of the walls of these vessels. +This change in the muscular element was observed in the arterioles in +different parts of the kidney, but it was most conspicuous in +arterioles at their point of entrance into the Malpighian bodies; and +it was distinctly observed in other arterioles, both in the cortex and +in the base of the pyramids. + +In the glandular portion of the kidneys other anatomical alterations +were observed, indicating parenchymatous nephritis. There were +swelling of the epithelial lining of the convoluted tubes; +multiplication of nuclei of epithelial cells, especially in ascending +tubules, which lay close to the afferent arterioles of Malpighian +corpuscles; granular matter, and even blood, in the cavity of Bowman's +capsule and in the convoluted tubes; cloudy swelling and granular +disintegration of epithelium in some parts of the convoluted tubes; +detachment of epithelium from the membrane of larger ducts of the +pyramids in some cases. These parenchymatous changes are already known +to the profession through the observations and writings of Dickinson, +Fenwick, Johnson, John Simon, and others. + +{527} Klein, in commenting on the hyaline degeneration which he +observed, states that Neelsen found the walls of the capillaries of +the pia mater thickened, highly refractive, and of a lardaceous +appearance in certain acute infectious maladies, as variola, typhoid +fever, measles, and in one case of scarlet fever.[4] Usually, only a +small portion of the capillaries were thus affected, most frequently +at the point of division into branchlets. In a few instances Neelsen +observed degeneration of arterioles extending a considerable distance, +with fusion of the intima, media and adventitia, and chemical +examination showed that the substance produced by this degeneration +had similar properties to elastic tissue. Although the examinations by +Neelsen relate to the pia mater, two of his observations are +especially interesting--first, that the hyaline change affects chiefly +vessels near their point of branching; and, secondly, that the hyaline +substance is of the nature of elastic tissue, for in the kidney in +scarlatinous nephritis the arterioles undergo the change in question +chiefly near their point of branching into the capillaries of the +glomerulus; and the intima being the part which undergoes the hyaline +change, it is probable, in the opinion of Klein, that the same +substance is produced by the degeneration in walls of the vessels of +the kidney which Neelsen observed in the pia mater, and therefore that +it is of the nature of elastic tissue. + +[Footnote 4: _Archiv der Heilkunde_, 1876.] + +This hyaline degeneration of the arterioles is also very marked in the +spleen in scarlet fever; and in studying the minute anatomy of the +intestines and spleen in typhoid fever Klein has found the same +degeneration of the intima of the minute vessels. He believes that +this hyaline change and the proliferation of muscle-nuclei which thus +occur at an early period in scarlet fever in the renal vessels when +the kidneys become affected are due to an irritating cause acting +similarly to that in typhoid fever. + +Klein calls attention to the interesting examinations of the +scarlatinous kidney made by Klebs, who attributed the diminished +urination and the uraemic poisoning in certain cases in which the +kidneys do not exhibit any marked change to the naked eye, to what he +designates glomerulo-nephritis. Klebs says: "In the post-mortem +examination the kidneys are found slightly or not at all enlarged, +firm, ... the parenchyma very hyperaemic. Only the glomeruli appear, +on close inspection, pale like small white dots. The urinary tubes are +often not changed at all. Occasionally the convoluted tubes are +slightly cloudy. The microscopic examination shows that there are +neither interstitial changes nor proliferation of epithelium, the +so-called renal catarrh generally supposed to be present in these +conditions on account of the absence of other perceptible +derangements; and there seems, therefore, leaving out the glomeruli, +the congestion of the kidneys alone to remain to account for the +symptoms during life." But that mere congestion is insufficient to +produce the symptoms appears from the fact that it does not produce +them under other circumstances. Klebs finds, "on microscopic +examination of the glomerulus, the whole space of the capsule filled +with small somewhat angular nuclei, imbedded in a finely granular +mass. The vessels of the glomerulus are almost completely covered by +nuclear masses." + +Klein, commenting on these examinations by Klebs, states that in all +{528} early cases which he examined he observed great abundance of +nuclei of the glomeruli, but a condition like that described and +figured by Klebs[5] he has seen in only a few glomeruli; for a general +state of these bodies, as described by this observer, and such an +excessive proliferation of the nuclei that the blood-vessels are +completely compressed, was not seen in one of the twenty-three cases. +Klein therefore questions whether the diminished urination and +retention of urea in scarlet fever, when the kidneys do not exhibit +any conspicuous catarrhal or other change, is due, unless in +exceptional instances, to compression of the vessels of the glomeruli +by nuclear germination, but believes, rather, that the obstructed +circulation, and consequent diminished urinary excretion, is largely +due to the changed state of the arterioles. Klein adds that perhaps +undue contraction of the arterioles, through stimulation by the +blood-irritant, may also be a factor in causing arrest of circulation +in the Malpighian corpuscles. As regards cases that perished early, he +found the parenchymatous change slight, so that a careful examination +was required in order to detect cloudy swelling and granular +degeneration. + +[Footnote 5: _Handbuch der Pathol._, p. 646, fig. 72.] + +2. Interstitial Nephritis.--A second set of changes Klein observed in +cases that died on about the ninth or tenth day. In such cases he +found changes due to interstitial, in addition to those produced by +parenchymatous, nephritis. Round cells, lymphoid cells, or whatever +else they should be called, were seen in the connective tissue of the +kidneys. In the kidneys of those that died at the end of the first +week after the commencement of nephritis, infiltration with round +cells was observed in the connective tissue around the large vascular +trunks. At a later stage this infiltration had extended into the bases +of the pyramids and into the cortex. The gradual increase in extent +and intensity of this infiltration was so decided in the cases which +Klein observed that he has no hesitation in concluding that when +interstitial nephritis occurs it begins about the end of the first +week, in the manner already stated--to wit, as a slight infiltration +of the tissue around the large vascular trunks, and gradually extends, +so that portions of the cortex, and rarely portions of the base of the +pyramids, are changed into firm, pale, round-cell tissue, in which the +original tubes of the cortex become lost. + +The infiltration of the cortex with round cells, beginning at the +roots of the interlobular vessels, spreads rapidly toward the capsule +of the kidney, and laterally among the convoluted tubes around the +Malpighian bodies.... In the course of this process considerable parts +of the peripheral cortex, occasionally of a more or less distinctly +cuneiform shape, with the base nearest the capsule of the kidney, +become changed into whitish, firm, bloodless, cellular masses, in +which Malpighian corpuscles and urinary tubes are only imperfectly +recognized, being more or less degenerated. In some cases attended by +this infiltration of the cortex Klein observed a more or less dense +reticulation of fibres, especially around the interlobular arteries, +containing in its meshes lymph-cells, chiefly uninuclear. + +In a child of five years that died after a sickness of thirteen days +Klein found evidence of intense interstitial inflammation, and also +emboli, consisting of fibrin with a few cells, in the arteries, both +in those of large size and in the arterioles, chiefly where they enter +the Malpighian corpuscles. {529} He states that in the specimens which +he examined the more intense the degree of interstitial change, the +greater was the enlargement of the kidneys, and the more distinct also +were the evidences of parenchymatous nephritis in the urinary tubes, +which either contained casts or were in the process of destruction. By +being crowded with inflammatory products, especially cells, the +Malpighian corpuscles were obliterated, undergoing fibrous +degeneration. A very curious fact observed was the deposit of lime in +the urinary tubes, first of the cortex, and then also of the pyramids, +at an early stage of scarlet fever, when the kidneys otherwise showed +only slight change. Several observers, as Biermer, Coats, and Wagner, +have each described a case of scarlet fever with interstitial +nephritis, which they consider unusual; but Klein has apparently +demonstrated, as we have seen, by a large number of microscopic +examinations, that this form of nephritis is common after the ninth or +tenth day. + +Nephritis, in proportion to its extent and gravity, is accompanied by +languor, febrile movement, thirst, loss of appetite and strength. At +first the patient experiences but slight pain in the head or +elsewhere, and the quantity of urine is not notably diminished; but as +the disease continues urination becomes less frequent and the urine +more scanty. Albuminuria occurs, while the urea is only partially +excreted, and therefore accumulates in the blood. If the nephritis be +so severe or protracted that this principle accumulates to a certain +extent, grave symptoms occur, as headache, vomiting, apathy or +restlessness, and, more dangerous than all, eclampsia, which is not +unusual in these cases. Microscopic examination of the urine shows the +presence in this liquid of blood-corpuscles, granular epithelial +cells, and hyaline or granular casts, or both. The specific gravity of +the urine is diminished. But a large quantity of albumen in the urine +may render the specific gravity as high or higher than in health. + +The altered state of the blood soon gives rise to transudation of +serum, first observed in most cases as an anasarca occurring in the +feet and ankles. The oedema, if not checked by treatment or through +mildness of the disease, extends over the limbs, scrotum, and +sometimes upon the trunk. It is well if the dropsy remain limited to +the subcutaneous connective tissue, but, unfortunately, it is apt to +occur, if the nephritis continue, in and around the internal organs, +producing, mentioned in the order of frequency, pulmonary oedema, +effusion into the pleural and peritoneal cavities, the pericardium, +the encephalon, and lastly into the connective tissue of the larynx, +causing that very fatal complication, oedema of the glottis. Although +this is the common order in which dropsies occur, exceptions are not +infrequent. Even the anasarca may not be the first to appear, although +in the vast majority of cases it has the precedence. Thus, Rilliet +relates the case of a boy of five years who twenty days after the +occurrence of scarlet fever, and six hours after the appearance of +bloody and albuminous urine, had double hydrothorax, rapidly +developed. As long as the hydrothorax continued no anasarca was +observed, but as it declined anasarca appeared. Legendre cites a case +in which oedema of the lungs occurred without anasarca or other +dropsy. Occasionally, the anasarca and internal dropsies take place +nearly simultaneously. The nephritis and consequent serous effusions +usually appear within three weeks after scarlet fever ends, but cases +occur in which the effusions are first observed as late as the fourth +and fifth weeks. The patient may be {530} considered to possess +immunity from this sequel if he have reached the close of the fifth +week after the abatement of scarlet fever without its occurrence. + +The dropsy is usually acute, but it may assume the chronic form, since +the nephritis which causes it, happily curable in most instances, may, +if neglected, become chronic. Whether the dropsy in itself involve +danger depends in great part on its location. Anasarca and ascites may +exist a long time with little suffering or danger, but a small amount +of serum in certain other localities causes alarming symptoms and +speedy death. Oedema of the lungs, hydro-pericardium, oedema of the +glottis, and intracranial effusions are always dangerous, and the last +two are sometimes fatal within twenty-four to forty-eight hours. +Oedema of the lungs has been fatal within twelve hours from the +occurrence of the first symptoms of obstructed respiration. + +Cerebral symptoms occurring during scarlatinous nephritis are probably +sometimes due to the irritating effect of the retained urea on the +nervous centre. In other cases the cause appears to be cerebral oedema +or compression of the brain by effusion of serum within the ventricles +and upon the surface of the brain. Headache, dull or severe, +dilatation of the pupils or their oscillation in the same degree of +light, vomiting with little apparent nausea, are common symptoms of +scarlatinous nephritis when it has continued a few days, and the +excretion of urea is so diminished that this substance begins to exert +its poisonous effect on the system. Such symptoms are apt to be +followed by somnolence, threatening coma, or by eclampsia, unless the +patients are promptly and properly treated. In some patients that die +of scarlatinous nephritis, death occurring in convulsions or coma, no +appreciable lesions are observed within the cranium, unless more or +less congestion, the fatal ending being attributable to the uraemia. +In other instances we find an effusion of serum within the ventricles +or upon the surface of the brain. Although the symptoms in +scarlatinous nephritis and uraemia may appear very unfavorable, the +prognosis is usually good under prompt and appropriate treatment. Thus +severe convulsions and a degree of somnolence that bordered on coma +may abate, and convalescence be fully established within a few days, +and Rilliet and Barthez announce ten recoveries in thirteen patients +affected with convulsions due to this renal affection. + +ANATOMICAL CHARACTERS.--Scarlet fever being, as we have seen, a +constitutional febrile disease of an ataxic nature, and accompanied by +certain inflammations, necessarily affects the composition of the +blood; but since this disease varies so greatly in type or severity, +the state and appearance of this liquid also vary. At the autopsies of +the more malignant cases we find the blood dark and fluid, with small, +soft, and dark clots in the heart and large vessels. In other cases +the clots are large, firm, and solid, as described in a preceding +page. In malignant cases that end fatally Rilliet and Barthez state +that both the large and small vessels of the cerebral meninges and the +brain are found hyperaemic, but in a variable degree. In those who die +in coma, preceded by delirium or convulsions, during the eruptive +stage, the intracranial congestion is usually marked, with perhaps +some transudation of serum, but without inflammatory lesions. The +fibrin in scarlet fever remains in about normal proportion, except as +it is increased by inflammatory {531} complications. Andral found an +increase in the proportion of blood-corpuscles from 127 to 136 parts +in 1000. + +The respiratory apparatus, except the Schneiderian membrane, is +usually normal when no complications exist. Samuel Fenwick[6] made +post-mortem examinations in sixteen cases of scarlet fever, and +concludes from them that inflammation of the mucous membrane of the +stomach and intestines occurs like that of the skin, followed by +desquamation of the epithelial cells, like that of the epidermis. I +have had the opportunity of examining the stomach and intestines of +those who died of scarlet fever in the eruptive stage, and have not +found any unusual hyperaemia of the gastro-intestinal surface, except +when gastro-intestinal inflammation, usually indicated by diarrhoea, +had occurred as a complication. + +[Footnote 6: _London Lancet_, July 23, 1864.] + +In some cases the abdominal organs exhibit changes which suggest a +resemblance to typhoid fever. The spleen is enlarged and somewhat +softened, and Peyer's patches and the solitary glands are thickened +and prominent, but less in degree than in typhoid fever. The +mesenteric glands also are in a state of hyperplasia. In other +patients these parts appear normal. + +Klein made microscopic examination of the liver in eight cases, and +states that he found granular opaque swelling of liver-cells, and +changes in the internal and middle coats of certain arteries similar +to those observed in the kidneys, which have been described above. He +also found evidences of interstitial inflammation, as an increase of +round cells and connective tissue in the liver. He remarks also that +he observed hyaline degeneration of the intima of arteries in the +spleen. Rilliet and Barthez state that swelling and softening of the +spleen are exceptional in scarlet fever, but are sufficiently common +to merit attention. In post-mortem examinations which I have witnessed +nothing noteworthy has appeared to the naked eye in the state of the +liver, nor ordinarily in that of the spleen. + +The efflorescence, though one of the anatomical characters, has +perhaps been sufficiently described in the foregoing pages. It begins +over the neck, chest, and groins as numerous reddish points not larger +than a pin's head, closely crowded together, but with skin of normal +color between. It is estimated that the aggregate efflorescence and +aggregate normal skin over a given area are about equal. If the +cutaneous circulation be active and the febrile movement be +considerable these spots extend and coalesce, producing an +efflorescence like erythema or like the hue of a boiled lobster, to +which it has been likened. The efflorescence, less upon the face than +upon the trunk, contrasts in this respect with that of measles, in +which the rash is full in the face, often causing some swelling of the +features. It is also less upon the palmar and plantar surfaces than +elsewhere. It scarcely causes any perceptible elevation of the skin, +but in certain localities, as upon the backs of the hands and upon the +fore-arms, it communicates the sensation of slight roughness. The seat +of the efflorescence is mainly in the superficial layers of the skin, +but it is said that it sometimes has occurred upon a cicatrix, as that +from a burn. In the robust and in favorable cases in which the +circulation is active the rash has a scarlet hue, and when the +cutaneous capillaries are emptied and the skin rendered pale by +pressure with the {532} fingers, the circulation immediately returns +when the pressure is removed. In malignant cases the color is not +scarlet, but dusky red, and so sluggish is the capillary circulation +that the skin when pressed upon recovers the blood very slowly. In +grave cases also extravasation of blood in minute points or +transudation of its coloring matter is apt to occur in portions of the +surface, when of course decolorization is not fully produced by +pressure. In cases ending fatally, during the eruptive stage the +efflorescence may entirely disappear in the cadaver, or it remains +upon parts of the surface, especially depending portions. Desquamation +is attributable to the exaggerated proliferation of the epidermis and +the loosening of its attachment by the inflammation. + +DIAGNOSIS.--In the commencement of scarlet fever, prior to the +eruption, no symptoms or appearances exist which enable us to make a +positive diagnosis. Positive statement in reference to the nature of +the attack should be deferred, for the credit of the physician. Still, +if a child with no appreciable local disease sufficient to cause the +symptoms a few days after exposure to scarlet fever, or during an +epidemic of this malady, be suddenly seized with fever, the pulse +rising to 110, 120, or more, and the temperature to 102 degrees, 103 +degrees, or 105 degrees, scarlatina should be suspected. The diagnosis +is rendered more certain at this early stage if vomiting occur, and +especially if the fauces be red, for hyperaemia of the fauces, due to +commencing pharyngitis, is one of the earliest and most constant of +the local manifestations of scarlatina. + +When the eruption has appeared the nature of the malady is in most +instances apparent. The punctate character of the eruption before it +becomes confluent, its occurrence within twenty-four hours after the +fever begins over almost the entire surface, but its absence or +scantiness upon the face, and especially around the mouth, serve to +distinguish it from other diseases. + +Scarlet fever and measles were long considered identical by the +profession, and, though the ordinary forms of these maladies can be +readily distinguished from each other, cases occur in which the +differential diagnosis is attended by some difficulty. But there are +differences in the symptoms and course of the two diseases which aid +in discriminating one from the other. Measles begins with marked +catarrhal symptoms, as if from a severe cold. Mild conjunctivitis, +causing weak and watery eyes, coryza, and mild laryngo-bronchitis, +with accompanying cough, precede the eruption three or four days and +continue during the eruptive stage. The febrile movement in the +prodromic stage of measles is remittent, the evening temperature being +two or three degrees higher than that in the morning. Contrast this +with the invasion of scarlet fever, in which the only catarrh is that +of the buccal and faucial surfaces, and there is consequently little +or no cough, and the febrile movement, ordinarily high in the +beginning, is nearly uniform in the different hours of the day. The +scarlatinous eruption appears, as we have seen, within twelve to +twenty-four hours about the neck and upper part of the chest, and +spreads over the body in a shorter time than that of measles, which +appears on the third day. The rash of measles begins to fade at the +close of the third or in the fourth day after its appearance, that of +scarlet fever not till from the sixth to the eighth day. In nearly all +cases of measles, even when the rash is confluent upon the face and a +{533} considerable part of the trunk, in consequence of the high +febrile movement and vigorous cutaneous circulation, we observe the +characteristic rubeolar eruption upon certain parts of the surface, as +the extremities, which, in connection with the history, renders +diagnosis certain. + +Erythema resembles the scarlatinous eruption, but its duration is +commonly shorter. It is limited to a part of the surface, and it is +accompanied by much less febrile movement. The temperature in erythema +does not usually rise above 100 degrees, unless for a few hours, +whereas in scarlet fever it continues considerably above 100 degrees +for several days. The scarlatinous efflorescence has also a brighter +red or more scarlet hue than that of erythema, except in the more +malignant cases, in which the severity of the symptoms renders the +diagnosis clear. But an important aid in differentiating the one from +the other of these diseases is the fact that in erythema there is, +with few exceptions, no faucial inflammation, and in the few instances +in which it is present it is slight and transient, fading within a day +or two. + +Scarlet fever is readily diagnosticated from diphtheria, although the +affinity is close between these two maladies. The early appearance of +the pseudo-membrane upon the fauces in diphtheria, its absence in +scarlet fever, and the absence of any appearance resembling it until +the fever has continued some days, and the characteristic +efflorescence upon the skin in scarlet fever, render diagnosis easy. +If scarlet fever have continued some days when first seen by the +physician, the diphtheritic pseudo-membrane may be present as a +complication, or the fauces may present an appearance like diphtheria +from ulceration or sloughing and the presence of foul and offensive +secretions, which produce a dark-grayish and fetid mass over the +faucial surface. Under such circumstances the character of the disease +is ascertained by the history of the case, and especially by the +occurrence of the scarlatinous eruption. An erythema transient and +limited to a part of the surface sometimes appears in the commencement +of diphtheria, and at a later period, as a result of the toxaemia, +points of a roseoloid appearance and irregular patches, often located +upon the extremities. Both kinds of rash can be readily diagnosticated +from that of scarlet fever, for the erythema, as has been stated, is +transient and partial, and does not exhibit minute points of deeper +injection, while the toxaemic rash differs in form and aspect from +that of scarlet fever, and appears at a stage of the case when the +scarlatinous efflorescence would have faded or begun to fade. + +The efflorescence of rotheln sometimes closely resembles that of +scarlet fever, though it is usually more like that of measles; but it +is ordinarily accompanied by symptoms which are much milder than those +of scarlet fever, and it begins to abate as early as the third, and +disappears on the fourth, day. The eyes have a suffused appearance, +the temperature may reach 102 degrees or 103 degrees, and the +efflorescence may be as general over the body as that of scarlet +fever, but there is not the aspect of serious indisposition, and the +speedy abatement of the symptoms shows that the disease is not scarlet +fever. + +PROGNOSIS.--The prognosis depends on the form of scarlet fever, +whether mild or severe, the strength of the patient, and the presence +or absence of complications or sequelae. The type of this disease is +sometimes so mild throughout an epidemic or during a series of years +that {534} death seldom occurs, whatever the mode of treatment; but +afterward the type changes, and the percentage of deaths increases and +remains high till another mitigation in the type occurs. + +Sydenham in the middle of the seventeenth century stated that scarlet +fever, as he saw it in London, was so mild that it scarcely deserved +the name of disease: "Vix nomen morbi merebatur." Morton some years +later, and Huxham in the following century, had abundant reason to +regret the change of type, and now throughout Great Britain scarlet +fever is one of the most fatal and most dreaded of the diseases of +childhood. In Dublin during the present century, prior to 1834, +scarlet fever was uniformly mild, so that on one occasion of eighty +patients in an institution all recovered. In 1834 the type of the +disease totally changed and epidemics of unusual virulence occurred. +The type frequently changes from mild to severe or severe to mild, not +only in consecutive years, but in consecutive months. A few years +since a distinguished physician of New York treated about fifty cases +of scarlet fever in one of the institutions without a single death, +but a few months later the type of the malady changed, and his own son +was among those who perished from it. The prevailing type of the +disease should therefore be considered in giving the prognosis when in +the commencement of a case we are asked the probability as regards the +termination. + +Extensive statistics, including those collected by Murchison from +various sources, show that in different epidemics the mortality may +vary as much as from 3 per cent. (Eulenberg of Coblentz) to 19.3 per +cent. (cases seen by myself in New York City in 1881-82, many of which +were complicated by diphtheria), or even to 34 per cent. (epidemic in +the Palatinate in 1868-69). The hospital statistics of Rilliet and +Barthez gave 46 deaths in 87 cases, or about 53 per cent. + +Observations have thus far failed to establish any connection in the +atmospheric conditions of temperature or moisture and the type of +scarlet fever. Grave as well as mild epidemics have occurred in all +climates and seasons. + +The mortality is nearly equal in the two sexes, but age bears a marked +influence on the percentage of deaths. Comparatively few contract +scarlet fever under the age of one year, and the period of its +greatest mortality, since it is of its greatest frequency, is between +the ages of one and six years. The following are statistics bearing on +the relation of the age to the percentage of deaths: + + From the + close of From the + 1st till 5th to + Under close of the 12th + 1 year. 5th year. year. + ------- --------- -------- + Fleishman, Cases 8 204 260 + Deaths 6 88 51 + + 1st to From the + close of 6th to 12th to + 6th year. 12th year. 20th year. + --------- ---------- ---------- + Kraus, Cases 13 113 106 40 + Deaths 4 29 10 2 + + 7th to + 16th year. + ---------- + Voit, Cases 5 166 109 + Deaths 1 24 10 + + 1st to + close of Over + 5th year. 5 years. + --------- -------- + Roset, Cases 43 156 88 + Deaths 26 31 3 + +{535} Under 5th to 10th to Over + 5 years. 10th year. 15th year. 15 years. + -------- ---------- ---------- --------- + Rusigger, Cases 101 126 47 27 + Deaths 21 20 3 0 + +These statistics, which I believe correspond with the observations of +others, show that although few cases occur in the first year, the +percentage of deaths is large, and that a majority of the deaths occur +under the age of six years. After the sixth year the greater the age +the less the proportionate number of deaths. + +Scarlet fever is liable to so many complications and sequelae that a +physician should not predict a certain favorable termination in the +beginning, however mild and regular the symptoms may be. But a +favorable result may be expected if the attack be mild, the +efflorescence appear at the proper time and extend over the entire +surface, the angina be moderate and accompanied by little or no +cellulitis or adenitis, with pulse under 140, temperature not above +103 degrees, and no marked nervous symptoms. + +Whether the complications or sequelae be dangerous depends upon their +character. Rheumatism has never in my practice been dangerous, nor has +it materially retarded convalescence, except when it affected the +heart, causing pericarditis or endocarditis, when it involves great +danger. Nephritis, if it be moderate, attended by little albuminuria +and serous effusion, and by the occurrence of few renal casts in the +urine, commonly ends favorably under judicious treatment, as we have +already stated; but severe nephritis, with abundant albuminuria and +casts and serous effusions, soon gives rise to alarming symptoms, and +is the cause of death in a considerable number of instances. A similar +remark is applicable to the angina, which occurs in all grades of +severity. If it be attended by much cellulitis, with considerable +ulceration or necrosis, the state is one of danger, in consequence of +the difficulty in administering sufficient nutriment, of the +diminished assimilation and of the loss of strength from the prolonged +inflammatory fever, the septic poisoning, and the occasional +hemorrhages. Complication by pharyngeal or nasal diphtheria, now so +common where diphtheria is endemic, also greatly increases the danger. + +Many cases, even when their course is normal and without +complications, involve danger, and some are necessarily fatal, from +the direct effect of the scarlatinous blood-poisoning. Such are grave +or malignant forms of the disease which the experienced eye recognizes +at a glance. Death often occurs rapidly from the toxaemia. Such cases +are characterized by high temperature (105 degrees or 106 degrees), +rapid pulse, a dusky-red hue of the surface from languid capillary +circulation, pungent heat, frequent vomiting, diarrhoeal stools, a +dry-brown tongue, and marked nervous symptoms, such as delirium, great +restlessness, or stupor. Not a few in this form of scarlet fever take +eclampsia, which is apt to be severe and repeated, and to end in fatal +coma. + +Other inflammatory complications and sequelae, which have been +described in the preceding pages, retard convalescence and jeopardize +the life of the patient, such as empyema, endocarditis, pericarditis, +and pneumonia. Otitis media is seldom immediately dangerous, although +it may be painful and involve serious consequences, even a fatal +meningitis, as has been stated above, after months or years of +otorrhoea. Anomalous cases are believed to be, as a rule, more +dangerous than such as are {536} attended by an early and full +efflorescence and have the usual symptoms. + +TREATMENT.--PROPHYLAXIS. Since the discovery by Jenner of the +prophylactic power of vaccination as regards small-pox, the attention +of the profession has been frequently directed to the prevention of +scarlet fever. Belladonna has been employed for this purpose by a +class of practitioners who believe in the theory that an agent which +produces symptoms similar to those of a disease is antagonistic to +that disease, and therefore tends to prevent it, or, if it be present, +to render it milder; and since this herb causes an efflorescence upon +the skin and redness of the fauces, it was selected as the proper +preventive and remedial agent for scarlet fever. Its use, however, for +this purpose has been fruitless, and it is now nearly or quite +discarded. + +It is probable, from a considerable number of observations, that +scarlet fever occasionally occurs in the domestic animals during +epidemics of the disease in children. It is stated that Spinola +observed it in the horse; that Heim saw a dog that occupied the same +bed with a scarlatinous patient sicken with fever, which was followed +by desquamation; that Letheby saw scarlatina in swine, and Kraus in +young cattle. Prominent veterinary surgeons, as Williams of Great +Britain, admit the occurrence of scarlatina in animals, and the hope +has arisen that since small-pox is modified in cattle so as to afford +us the vaccine virus, perhaps scarlet fever may also be modified by +passing through one of the lower animals, so that a milder and less +fatal form of the disease might be produced in man by inoculation from +the animal. This theory, though it deserves investigation, is far from +being established. It has not yet, so far as I am aware, been shown +that scarlet fever is milder in any animal than in man, nor, if we +admit that it is modified in the animal, is it certain that the +disease could be returned to man in the modified form. In the _N.Y. +Medical Record_ for March 24, 1883, some experiments are detailed by +S. W. Strickler of Orange, New Jersey. He cites the experiments of +Caze and Feltz, who injected scarlatinal blood under the skin of +sixty-six rabbits, and of these sixty-two died within eighteen hours +to fourteen days, which indicated a highly poisonous state of the +blood employed, either septic or scarlatinous, and certainly no +mitigation of the virulence of the scarlet fever. Strickler obtained +from Williams of Edinburgh nasal mucus from a horse supposed to have +scarlatina, and with it inoculated twelve children, all of whom had +sores at the point of inoculation, with redness of the skin around the +sores, and in some instances swelling of the adjacent lymphatic +glands. It is stated that the children thus inoculated did not +contract scarlet fever subsequently when they were exposed to +scarlatina. Obviously, there is a serious objection to such +experiments upon children, so that they may not be repeated, but a +movement has been made in one of the New York medical societies +looking to the appointment of a competent committee to investigate +them. Some of the prominent veterinary surgeons of this city do not +attach much importance to the experiments thus far made, as they are +in doubt whether the virus employed was that of the genuine disease. + +It is a matter of great interest and importance, and one not yet +elucidated, whether or to what extent disinfectant and antiseptic +remedies administered internally prevent the occurrence of the +infectious maladies {537} in those who have been exposed, and aid in +curing those who are sick with them. Sodium sulpho-carbolate, from +which, by decomposition in the system, carbolic acid is supposed to be +set free, has been used for this purpose. It is administered to adults +in doses of ten to thirty grains, and to children in doses +proportionate to their age. Declat has prepared a syrup of phenic +(carbolic) acid as a preventive and curative agent in the infectious +diseases. It is now employed by several of the New York physicians, +but thus far the statistics of its use are not sufficient to determine +its efficacy. It is a question whether the so-called antiseptics can, +on account of their toxic properties, be used with safety in doses +sufficiently large to be antidotal to the specific principle of any of +the infectious maladies. + +It is not my intention to recommend in this treatise any remedial +agent that has not been fully tried and its efficacy determined; but +from observations made by myself in nearly twenty families in which +scarlet fever was prevailing, I am convinced that boracic acid (acidum +boricum), an antiseptic recently introduced into our Pharmacopoeia, +deserves trial as a preventive and antidote of scarlet fever as well +as diphtheria. The good result in my practice from the use of this +agent, which only extends over about six months, may be due to the +present type of scarlet fever, but I have been surprised at the +favorable progress of the cases which appeared very grave in the +beginning, at the small mortality, and at the large proportion of well +children exposed to scarlatinous cases that escaped infection, to whom +this medicine was regularly administered. Boric (boracic) acid has +been recently used by aurists with remarkable success in suppurating +and granulating otitis media, and by oculists as an eye-wash. E. R. +Squibbs says of it (_Ephemeris_, May, 1883): "A solution saturated at +ordinary temperatures contains between 4 and 5 per cent.... It is a +very bland and soothing application, whether applied in powder or +solution, relieving irritation and reducing suppuration.... It has +been administered internally in large doses without any disturbing +effects." The preparation which I have employed is one found in the +shops, with the name listerine, prepared by a Western pharmaceutical +firm. It contains, according to the manufacturers, the "essential +antiseptic constituents of thyme, eucalyptus, baptisia, gaultheria, +and mentha arvensis," and also two grains of benzo-boracic acid in +each drachm. The dose of listerine which I have employed for an adult +is one teaspoonful, considerably diluted with cold water. A child of +five years can take ten to fifteen drops every two to four hours. I +call the attention of the profession to the use of boracic acid as an +antidote to the scarlatinous poison, without sufficient experience to +enable me to speak positively of its efficacy, but with the hope and +expectation, from observing its apparent effects in seventeen families +afflicted with scarlet fever, that it will be found a useful addition +to our means of controlling this much-dreaded and fatal malady. + +In the present state of our knowledge the most reliable and certain +prophylaxis is the isolation of patient and nurses, and the thorough +and judicious employment of disinfectants upon their persons and in +the apartments. All furniture and articles not absolutely required +should be removed from the sick room, and no one should be allowed to +enter it except the medical attendant and nurses. Constant ventilation +should be {538} insisted on by lowering the upper and raising the +lower sash of the window two or three inches in mild weather. Even in +stormy weather sufficient ventilation can be obtained in this way +without exposing the patient to currents of air, which should be +avoided. + +Since the exhalations from the body, the various excretions, and the +epidermic cells shed so abundantly in the desquamative period contain +the scarlatinous poison, measures should be employed to disinfect +them, in so far as the comfort and well-being of the patient will +allow. Vessels which receive the excretions should contain carbolic +acid, chloride of lime or other disinfectant, and they should be +immediately emptied and cleaned after use. By the frequent application +of disinfecting washes to the nostrils and fauces the secretions from +these surfaces are to a great extent deprived of their contagiousness. +If otorrhoea occur, boracic acid, so serviceable in its treatment, +acts as a disinfectant, but in addition the ear should be syringed +with warm carbolized water, one drachm of carbolic acid to the pint of +water, and this should be continued during convalescence, for cases +occur which show that the discharge from the ear is probably the +vehicle by which the virus is communicated. Even as late as the fourth +week after the disappearance of the rash children in scarlet fever +experience relief from inunction of the surface, and if carbolic acid +be added to the substance which is employed for this purpose, and the +inunction be made twice daily over the entire surface, contamination +of the air through the exfoliations and exhalations from the skin is +in great part prevented. The late William Budd of Bristol, England, +was in the habit of recommending inunction of the surface twice daily +with sweet oil, which answered the purpose of preventing dissemination +of epidermic particles through the air; and we will presently see how +successful were his precautionary measures. + +A convalescent child should not be allowed to mingle with other +children till three or four weeks have elapsed and desquamation has +ceased; and all who are liable to take the malady should be excluded +from the room in which a case has occurred for a longer period, and +until it has been thoroughly disinfected by burning sulphur or other +methods. + +The New York Board of Health enforces the following excellent +regulations to prevent the spread of scarlet fever as well as other +acute infectious maladies: + +"Care of Patients.--The patient should be placed in a separate room, +and no person except the physician, nurse, or mother allowed to enter +the room or to touch the bedding or clothing used in the sick-room +until they have been thoroughly disinfected. + +"Infected Articles.--All clothing, bedding, or other articles not +absolutely necessary for the use of the patient should be removed from +the sick room. Articles used about the patients, such as sheets, +pillow-cases, blankets, or clothes, must not be removed from the sick +room until they have been disinfected by placing them in a tub with +the following disinfecting fluid; eight ounces of sulphate of zinc, +one ounce of carbolic acid, three gallons of water. They should be +soaked in this fluid for at least an hour, and then placed in boiling +water for washing. + +"A piece of muslin one foot square should be dipped in the same +solution and suspended in the sick room constantly, and the same +should be done in the hallway adjoining the sick room. + +{539} "All vessels used for receiving the discharges of patients +should have some of the same disinfecting fluid constantly therein, +and immediately after being used by the patient should be emptied and +cleansed with boiling water. Water-closets and privies should also be +disinfected daily with the same fluid or a solution of chloride of +iron, one pound to a gallon of water, adding one or two ounces of +carbolic acid. + +"All straw beds should be burned. + +"It is advised not to use handkerchiefs about the patients, but rather +soft rags, for cleansing the nostrils and mouth, which should be +immediately thereafter burned. + +"The ceilings and side-walls of a sick-room after removal of the +patient should be thoroughly cleaned and lime-washed, and the woodwork +and floor thoroughly scrubbed with soap and water." + +By such measures of prevention there can be no doubt that the number +of cases of scarlet fever would be greatly reduced. + +Budd for years recommended similar precautions in the families which +he attended, and the following is his testimony in regard to the +result: "The success of this method in my own hands has been very +remarkable. For a period of nearly twenty years, during which I have +employed it in a very wide field, I have never known the disease to +spread beyond the sick-room in a single instance, and in very few +instances within it. Time after time I have treated this fever in +houses crowded from attic to basement with children and others, who +have nevertheless escaped infection. The two elements in the method +are separation on the one hand, and disinfection on the other."[7] + +[Footnote 7: _British Medical Journal_, Jan. 9, 1869.] + +HYGIENIC TREATMENT.--The room occupied by a scarlatinous patient +should be commodious and sufficiently ventilated. Its temperature +should be uniform at about 70 degrees during the course of the fever. +When the fever begins to abate and desquamation commences, a +temperature of 72 degrees to 75 degrees is preferable, so that there +is less danger that the surface may be chilled during unguarded +moments, as at night, when the body may be accidentally uncovered, +since sudden cooling of the surface at this time may cause nephritis +or some other dangerous inflammation. Henoch does not believe in the +theory that the nephritis is commonly produced by catching cold, but +many observations show that those who are carefully protected from +vicissitudes of temperature, who remain during convalescence in a warm +room, and are protected by abundant clothing, more frequently escape +this complication than such as are under no restraint of this kind and +are carelessly exposed in times of changeable weather. Nevertheless, +it is true that a certain proportion suffer from nephritis however +judicious the after-treatment may be. The best hygienic management +does not always prevent its occurrence. The patient should not, +therefore, leave the house until four weeks after the beginning of the +fever, and in inclement weather not till a longer time has elapsed. So +long as desquamation is going on and the skin has not regained its +normal function the patient should remain indoor, and when finally he +is allowed to leave the house he should be warmly clothed. + +THERAPEUTIC TREATMENT.--In order to treat scarlet fever successfully +it is necessary to bear in mind that it is a self-limited disease, +running for a certain time and through certain stages, and that it is +not {540} abbreviated by any known treatment. Therapeutic measures can +only moderate its symptoms and render it milder. The severity of the +disease is indicated by its symptoms, and the symptoms are to a +certain extent under our control. + +MILD CASES.--A patient with a temperature under 103 degrees, and with +only a moderate angina, does not require active treatment, but, +however light the disease, he should always be in bed and in a room of +uniform temperature, as stated above. Instances have come to my notice +in the poor families of New York in which scarlet fever was not +diagnosticated, and the patients were allowed to go about the house, +and even in the open air, in the eruptive stage, till some severe +complication or an aggravation of the type created alarm and medical +advice was sought, when it appeared that a grave and dangerous +condition had, through carelessness and ignorance, resulted from a +mild and favorable form of the malady. The physician, when summoned to +a case however mild, should never fail to take the temperature, note +the pulse, inspect the fauces, and inquire in reference to the fecal +and urinary evacuations, that he may detect early any unfavorable +changes which may occur. + +Since in all cases angina and more or less blood-deterioration are +present, the following prescription will be found useful in mild as +well as severe scarlet fever: + + Rx. Potass. Chlorat. drachm ii; + Tr. Ferri Chloridi fl. drachm ii; + Syrupi fl. oz. iv. M. + +S. Half a teaspoonful every hour to two hours to a child of three +years; a teaspoonful to a child of six years. + +Small doses of this medicine frequently administered act beneficially +on the surface of the throat and tend to prevent the anaemia which is +so common after scarlet fever. If the medicine be given gradually +diluted with only a moderate amount of water, the effect is better on +the inflamed fauces. Potassium chlorate is known to be an irritant to +the kidneys in large doses, causing intense hyperaemia of these +organs, with bloody urine or suppression of urine. The melancholy fate +of Fountaine, who died from the effects of one ounce of this medicine, +is known to the profession. I have seen a similar instance in a child. +But doses of one to four grains, according to the age, can be +administered with safety to children, so that half a drachm to a +drachm and a half are taken in twenty-four hours. A quantity much +exceeding this amount involves risk. In mild cases it is not necessary +to treat the throat by topical measures, the above prescription +producing sufficient local effect, but camphorated oil may be used +externally. I ordinarily prescribe quinine in small doses for this +form of scarlatina, as in the following formula: + + Rx. Quiniae Sulphat. gr. xvi; + Ext. Glycyrrhizae scruple ss; + Syr. Pruni Virginianae fl. oz. ii. M. + +S. One teaspoonful every fourth hour to a child of three to five +years, the potassium chlorate and iron mixture being administered +twice between. + +The treatment of scarlatina by antiseptic remedies will be considered +hereafter. + +{541} The itching and dryness of the surface, which increase the +discomfort of the patient in mild as well as severe scarlatina, are +relieved by frequently anointing the whole body with vaseline, cold +cream, or butter of cocoa. Carbolic acid is an efficient remedy for +pruritus, while it is also a disinfectant. It may be used in the +following formula: + + Rx. Acidi Carbolici drachm i; + Vaseline oz. iv. M. + +S. To be applied over the entire surface. + +In New York leaf lard has long been employed as an unguent over the +entire surface in scarlet fever, and patients experience benefit from +it. Alcohol and water or vinegar and water are sometimes employed for +the same purpose. The linen should be changed every day and the bed +thoroughly aired. + +ORDINARY CASES AND CASES OF SEVERE TYPE.--A safe temperature in +scarlet fever may be considered at or below 103 degrees. If it rise +above this, measures designed to abstract heat are very +important--more important even in many cases than the medicinal agents +which are commonly used to combat this disease. Since a high +temperature retards assimilation, promotes deleterious tissue-change, +and causes rapid emaciation and loss of strength, measures designed to +reduce it are urgently needed. "The production of heat depends chiefly +on oxidation of the constituents of the body" (Billroth). Therefore +fever indicates an increase of the oxidation and a molecular +disintegration above the healthy standard. Hence the augmentation of +urea in the urine and the progressive emaciation and loss of weight +which characterize the febrile state. Fever also diminishes the +secretions by which food is digested and destroys the appetite, so +that repair of the waste is insufficient. Moreover, a high temperature +continuing for a time tends to produce degenerative changes, +albuminous and fatty, in the tissues, the more rapidly the higher the +temperature, so that the functions of organs are seriously impaired. +Among the most dangerous of the tissue-changes is granulo-fatty +degeneration of the muscular fibres of the heart. In dogs and rabbits +that have perished from a high temperature artificially produced by +experimenters granular clouding of the elementary tissues has been +found after death.[8] A high temperature, therefore, in itself +involves danger, and if it occur in an ataxic disease like scarlet +fever, and be protracted, it greatly diminishes the chances of a +favorable issue. + +[Footnote 8: See experiments by Mr. J. W. Legg, _Lond. Path. Soc. +Trans._, vol. xxiv., and others.] + +The temperature can be reduced without shock or injury to the child by +the judicious use of cold water externally. The cold-water treatment +is not necessary if the temperature be under 103 degrees, though +useful if judiciously employed by sponging when the temperature is at +102 degrees or 103 degrees; but if it rise above 103 degrees it is +required, and the more urgently the higher the temperature. The +external use of cold water as an antipyretic in the febrile diseases +is now almost universally recommended by physicians, but it still +meets with opposition on the part of families, especially in the +treatment of the exanthematic fevers, and the directions for its +employment are therefore not apt to be fully carried out during the +absence of the medical attendant. The old theory that the fevers +require warmth and sweating has such a firm hold on the popular mind +that some years longer will be required for its removal. + +{542} The modes of applying cold water recommended by cautious and +experienced physicians are various. Von Ziemssen recommended that the +patient be immersed in water at a temperature of 90 degrees, and cool +water be gradually added till the temperature fall to 77 degrees. In a +few minutes the patient is returned to his bed, his surface dried, and +he is covered by the proper bed-clothes, when his temperature will +probably be found reduced two or two and a half degrees. If the +patient complain of chillness or his pulse be feeble, he should be +immediately removed from the bath and stimulants administered, either +whiskey or brandy, for if the extremities remain cool and the +capillary circulation sluggish, the effect may be injurious, since +some internal inflammation may arise to complicate the fever. Under +such circumstances increased alcoholic stimulation is required. + +The cold pack is also effectual for reducing the temperature. The +patient is placed upon a mattrass protected by oil-cloth, and is +covered by a sheet wrung out of water at a temperature of 70 degrees. +This is covered by one or two blankets. In half an hour he is returned +to bed, and will be found to have a temperature two or three degrees +less than that before the bath. Another method is to apply the sheet +wrung out of water at 90 degrees, and then reduce the temperature by +adding water at a lower degree from a sprinkler. In most cases, +however, I prefer to reduce the temperature by the constant +application to the head of an india-rubber bag containing ice. The bag +should be about one-third filled, so that it should fit over the head +like a cap. At the same time, as a potent means of abstracting heat, +at least when the temperature is at or above 104 degrees, a similar +application should be made by an elongated rubber bag lying over the +neck and extending from ear to ear. Cold applied over the great +vessels of the neck promptly abstracts heat from the blood, while it +diminishes the pharyngitis, adenitis, and cellulitis; which is an +important gain. At the same time, it is proper to sponge frequently +the hands and arms with cool water. If the temperature with this +treatment be not sufficiently reduced, one or two thicknesses of +muslin frequently wrung out of ice-water should be placed along the +arms and upon either side of the face. By such local measures, which +are agreeable to the patient and without any shock or perturbing +effect on the system, we can reduce the temperature two or three +degrees. By adding alcohol or one of the alcoholic compounds to the +water the popular objection to the use of cold is overcome. + +Trousseau, in the treatment of sthenic cases attended by a high +temperature, was in the habit of placing the patient naked in a +bath-tub and directing three or four pailsful of water to be thrown +over him in a space of time varying from one quarter of a minute to +one minute, after which he was returned to bed and covered by the +bed-clothes without being dried. Reaction immediately occurred, often +with more or less perspiration. This treatment was repeated once or +twice daily, according to the gravity of the symptoms. Trousseau, +alluding to this treatment, says: "I have never administered it +without deriving some benefit." But the application of cold water in a +manner that does not excite or frighten the patient seems preferable. +Henoch, having a large experience, gives the following advice in +reference to the water treatment: "If the fever continue high and the +apparently malignant {543} symptoms described above develop, the head +should be covered with an ice-bag, ... and the child placed in a +lukewarm bath, not under 25 degrees R. (88.25 degrees F.). I decidedly +oppose cooler baths, because in scarlatina, which presents a tendency +to heart-failure, cold may produce an unexpected rapid collapse more +than in any other affection. But I strongly recommend washing the +entire body every three hours with a sponge dipped in cool water and +vinegar."[9] In grave cases with a high temperature the application of +cold should be sufficient to produce a decided reduction of heat, +otherwise the full benefit from its use is not obtained. With proper +stimulation and proper precautions prostration does not occur from the +ice-bags to the head and neck and cool sponging of other parts, so +long as the temperature does not fall below 102 degrees or 103 +degrees. The danger alluded to by Henoch can only occur from the use +of the pack or general bath, and the water treatment can be +efficiently carried out and the temperature sufficiently reduced +without resorting to these. Even Currie of Edinburgh, who first drew +attention to the benefit from the cold-water treatment of scarlet +fever in an age when the sweating treatment, and even the exclusion of +cool and fresh air from the apartment, were deemed necessary, +recommended cold affusion only in sthenic cases with full and strong +pulse, and he mentions as a warning two cases with quick and feeble +pulse and cool extremities in which death occurred immediately after +the use of the water. + +[Footnote 9: _Diseases of Children._] + +Sodium salicylate is in some instances a useful remedy for the +reduction of heat in the infectious diseases. It seems to be more +decidedly antipyretic than quinine in the febrile and inflammatory +diseases, though somewhat depressing to the heart's action. James +Couldrey writes to the _London Lancet_ (Dec., 1882, p. 1064) that he +has derived great benefit from its use in seven cases of scarlet +fever. He administered it every two hours till ringing in the ears was +produced, and afterward every four hours, prescribing one grain for +each year in the age of the patient. It is, in my opinion, a proper +remedy when the pulse is full and strong and the temperature is not +sufficiently reduced by the cold-water treatment. + +Aconite and veratrum viride reduce fever, but they are too depressing +to be safely employed in grave scarlet fever, and their antipyretic +effect is less than that of water. The use of digitalis might be +suggested by the quick and feeble pulse in certain cases that are +attended by high temperature, but the judgment of the profession is +for the most part against its use in such cases. What Stille and +Maisch state of its employment in typhoid fever appears equally +applicable to scarlet fever: "Even its advocates have not shown that +it abridges the disease or lessens its mortality, while it is +abundantly demonstrated to impair the digestion, reduce the strength, +and even to occasion sudden death. The use of digitalis in other forms +of fever is equally unsatisfactory, and justifies the judgment of +Traube, that the true field of action for digitalis is not fever." + +Quinine is the medicine which above all others has been heretofore +most used, by almost common consent of the profession, to reduce the +temperature in malignant scarlet fever, but its use for this purpose +is, according to my observations, far from satisfactory. To obtain its +{544} antipyretic action it must be administered in large doses, and +if any of the quinine salts in ordinary use be administered by the +mouth in sufficient quantity, they are apt to be vomited. To a child +of five years five grains should be administered twice daily by the +mouth, or ten grains of a soluble salt, as the bisulphate, may be +given per rectum, dissolved in a little warm water. Administered per +rectum, it is frequently not retained unless held for a time by a +napkin. A considerable proportion of the malignant cases are attended +by not only irritability of the stomach, already alluded to, but by +diarrhoea, so that quinine, if administered at all, should be employed +hypodermically. The double salt of quinia and urea answers for this +purpose, as it is very soluble in water and does not produce +inflammation of the connective tissue. When the antipyretic doses of +quinine are discontinued, this agent may be prescribed as a tonic in +the doses recommended for the treatment of mild scarlet fever. + +In severe cases with frequent and rapid pulse, in which ante-mortem +heart-clots are apt to occur, the ammonium carbonate is often useful. +It should be dissolved in water and given in milk, in as large doses +as five grains every hour or second hour to a child of five years. It +aids in producing stronger contraction of the cardiac muscular fibres, +and thus diminishes the danger of the formation of thrombi. Ten-drop +doses of the aromatic spirits of ammonia may be employed instead of +the carbonate, given in sweetened water. It is especially useful if +the stomach be irritable. + +In severe cases attended by considerable angina and foul and offensive +secretions upon the faucial surface an antiseptic, as boracic acid in +small quantity, should be added to the potash and iron mixture +recommended above. If no drink be allowed for a few minutes after the +dose, so as not to wash it too soon from the fauces, the antiseptic +effect is more certainly produced. Those old enough should be directed +to hold the medicine for a moment like a gargle in the throat before +swallowing it. I employ boracic acid by preference, as in the +following formula: + + Rx. Acid. Boracic. drachm ss; + Potass. Chlorat. drachm ii; + Tr. Ferri Chloridi fl. drachm ii; + Glycerinae, + Syrupi _aa._ fl. oz. i; + Aquae fl. oz. ii. M. + +S. Give one tablespoonful every two hours to a child of five years. + +More minute directions will presently be given for the treatment of +the pharyngitis when we speak of the complications. + +Alcohol, whether administered in one of the stronger wines, as sherry, +or in whisky or brandy, is a most useful remedy in scarlet fever, and +is indeed indispensable in all grave cases which are attended by +feeble capillary circulation and evidences of prostration. Milk is +also the best vehicle for this agent. The wine-whey or milk-punch +should be given every hour or second hour. In scarlet fever, as well +as diphtheria, comparatively large doses are required, as a +teaspoonful of the stimulant every hour or second hour for a child of +five years. + +During convalescence the hygienic treatment already described is +important. Nutritious diet and a moderate amount of alcoholic {545} +stimulants are required, while the patient is kept indoors and +protected from currents of air as long as desquamation is occurring. +More or less anaemia is present in most convalescent patients, so that +a mild tonic containing iron will aid in restoring the health. Elixir +of calisaya-bark and iron; preparations of beef, iron, and wine, or +the following prescription, will be found useful under such +circumstances: + + Rx. Ferri et Ammon. Citrat., + Ammon. Carbonat. _aa._ gr. xxiv; + Syrupi fl. oz. i; + Aquae fl. oz. ii. M. + +S. Dose, one or two teaspoonfuls, according to the age, every third +hour. + +ANTISEPTIC TREATMENT.--It is still to be determined whether or to what +extent antiseptics, administered internally, antagonize and control +the scarlatinous poison, and are therefore curative of scarlet fever. +The most important agent of this class, carbolic acid, can only be +employed in small doses, for a dose much exceeding a drop for a child, +or even exceeding a fractional part of a drop for a young child, might +produce poisonous symptoms. Carbolic acid is a cardiac and arterial +sedative, and it appears to reduce temperature. Intra-uterine +injections of carbolized water in the treatment of puerperal fever are +known to reduce temperature, even when there is no septic matter in +the uterus to be disinfected and washed away, as in a case related to +me in which the fever proved to be due to measles. It is not +improbable that the antipyretic action in patients of this class who +have no septic substance within the uterus is due largely, if not +mainly, to the absorption of carbolic acid from the uterine surface +and its sedative action on the vascular system. Whether this agent, so +highly extolled by Declat, and to which I have alluded in a preceding +page, can be safely employed in doses large enough to be efficient and +curative will be determined by future observations. The same remark is +applicable to the sulphocarbolate of sodium, whose antiseptic action +is supposed to be due, as already stated, to the liberation of +carbolic acid in the system. Since boracic acid does not seem to have +any deleterious action, this agent has been administered to most of my +scarlatinous patients during the last year, in addition to the older +and better known remedies, and with a very small percentage of deaths. +What may be the result in a more severe type of the disease remains to +be seen. + +TREATMENT OF COMPLICATIONS AND SEQUELAE.--Local measures designed to +diminish or cure the pharyngitis are important in all but the mildest +cases. They are more especially required in the anginose variety and +in those not infrequent cases in which diphtheria complicates +scarlatina. Formerly it was necessary, in making applications to the +fauces, to employ the brush or probang for those too young to use the +gargle, but hand-atomizers, as Richardson's or Delano's, which are now +in common use, afford a quick and easy method for making such +applications. Six or eight compressions of the bulb of a good atomizer +are sufficient to cover the fauces with the spray. Those +hand-atomizers in the shops which have slender metallic points are apt +to prick the buccal surface and cause bleeding if the child resist and +toss the head. To prevent this, I am in the habit of directing +india-rubber tubing to be drawn over the point in such a way as not to +obstruct its action. The following will be found useful mixtures for +the atomizer: For ordinary cases, {546} + + Rx. Acidi Carbolici drachm ss, vel. Acid. Boracic. drachm ii; + Potass. Chlorat. drachm ii; + Glycerinae fl. oz. ii; + Aquae fl. oz. vi. M. + +If the surface of the throat be covered by foul secretions, + + Rx. Acidi Carbolici drachm ss; + Potass. Chlorat. drachm ii; + Glycerinae fl. oz. j; + Aquae Calcis fl. oz. vii. M. + +Or else, + + Rx. Tinc. Ferri Chloridi fl. oz. ss; + Acidi Sulphurosi fl. drachm ii; + Potass. Chlorat. drachm ii; + Glycerinae fl. oz. i; + Aquae q. s. ad. fl. oz. vi. M. + +If diphtheritic exudation complicate the scarlatinous angina, or the +surface of the throat in consequence of ulceration or necrosis present +an appearance like that in diphtheria when the exudation begins to +soften, being foul, jagged, of a dirty brown appearance from dead +matter and fetid secretions, the following should be prescribed for +use in the atomizer: + + Rx. Acidi Carbolici drachm i, vel. Acidi Boraci drachm iii; + Liq. Potassae fl. drachm i; + Potass. Chlorat. drachm ii; + Glycerinae fl. oz. ii; + Aquae Calcis fl. oz. viii. M. + +Liquor potassae, although a very efficient solvent of +pseudo-membranes, is too irritating for use in the atomizer unless +largely diluted. One part to eighty, as in the above mixture, will not +be found too concentrated. The following powder, used every third hour +through the insufflator, is also useful in cases of diphtheritic +exudation: + + Rx. Acidi Salicylici drachm ii; + Bismuth. Subnitrat. oz. ii. M. + +To be used every third hour. It is the favorite remedy of some of the +prominent New York physicians in the local treatment of diphtheria. + +The following mixture is also beneficial for local treatment when the +faucial surface is foul and offensive from the exudations and +secretions. It should be applied by a large camel's-hair pencil every +three to six hours: + + Rx. Acidi Carbolici gtt. x; + Liq. Ferri Subsulphatis fl. drachm ii; + Glycerinae fl. oz. i. M. + +In all cases of scarlatinous pharyngitis sufficiently severe to +require special treatment, cool applications should be made over the +neck from ear to ear, as by two thicknesses of muslin frequently +squeezed out of cold water, or by the elongated india-rubber bag +already recommended in our remarks relating to methods to reduce +temperature. + +In the first days of scarlet fever the coryza is slight, and no +discharge from the nostrils occurs, so that no local treatment is +required; but before the termination of the malady, in cases of +ordinary gravity, a nasal discharge usually supervenes, producing more +or less redness and {547} excoriating the upper lip. Moreover, in +localities where diphtheria occurs, if this malady complicate scarlet +fever, it is apt to affect the nostrils at the same time that the +fauces are invaded. These conditions require local treatment of the +nares. It should be remembered that the Schneiderian membrane is +midway in sensitiveness, as it is in location, between the +conjunctival and buccal surfaces, and is readily irritated by strong +applications. Medicinal applications made to it must be much milder +than those which the fauces tolerate. They should always be applied +warm, and a teaspoonful of any mixture properly employed is sufficient +for each nostril at one sitting. The applications should usually be +made every two or four hours, according to the gravity of the case and +the amount of discharge. The best instrument for this purpose is a +small syringe of glass or brass with curved neck and bulbous tip. The +child's head should be thrown back and the piston depressed rapidly, +so as to thoroughly wash out the nasal cavity. The application can +also be made through an atomizer with a rounded tip or a tip covered +by rubber tubing. The following is a useful prescription: + + Rx. Acidi Carbolici drachm ss; + Sodii Chloridi drachm ii; + Aquae Oj. + +The substitution of 2 or 3 drachms of boracic acid in place of the +carbolic acid makes a nicer preparation. If the diphtheritic +pseudo-membrane appear in the nares, the officinal lime-water, +injected every hour or second hour, is beneficial in consequence of +its solvent action on pseudo-membranes. + +It is evident, from what has been stated above, that the condition of +the ear should be closely observed in and after scarlet fever. If the +patient have earache, considerable relief may be obtained in the +commencement by dropping a few drops of laudanum and sweet oil into +the ear and covering it by some hot application, either dry or moist, +which will retain the heat. A light bag containing common table-salt, +heated, or dry and hot chamomile flowers will also answer the purpose. +Water as hot as can be well tolerated dropped into the ear or allowed +to trickle from a fountain syringe, so as to fill the ear, is also +very beneficial in allaying the pain. If a few drops of laudanum be +added it is more useful. If the pain be not quickly relieved, a leech +should be applied at the base of the tragus. O. D. Pomeroy, an +experienced aurist of New York, says: "Leeching employed at the right +time rarely fails to subdue the pain and inflammation. The posterior +face of the tragus is ordinarily the best place for applying the +leech, but it may be applied in front of the ear or behind, wherever +the tenderness on pressure is greatest. In my opinion, paracentesis +may frequently be rendered unnecessary by the timely use of one or two +leeches applied to the meatus." + +If the otitis continue, as shown by pain in the ear, of which children +old enough to speak bitterly complain, and which causes those too +young to speak to press their fingers into or against their ears, this +inflammation should not be neglected, as it may involve serious +consequences. Multitudes of children have had permanent impairment or +even loss of hearing, with caries or necrosis of the walls of the +middle ear and of the mastoid cells, which might have been prevented +by prompt and skilful {548} management of the ear in the early stage +of the inflammation. If, therefore, the otitis continue without +mitigation of pain after the above measures have been employed, +paracentesis of the drumhead is probably required. The following +directions for performing this operation, which will be useful to +country practitioners who may not be able to obtain the assistance of +a specialist, are from the pen of Pomeroy: "The forehead mirror should +be worn, in order to leave the hands free to operate by either +artificial or day light. A good-sized speculum is introduced into the +meatus. Then an ordinary broad needle, about one line in diameter, +with a shank of about two inches, such as oculists use for puncturing +the cornea, should be held between the thumb and fingers, lightly +pressed, so as not to dull delicate tactile sensibility. The part +being well under light, the most bulging portion of the membrane +should be lightly and quickly punctured with a very slight amount of +force. The posterior and superior portion of the membrane is most +likely to bulge. The chordae tympani nerve ordinarily lies too high up +to be wounded. The ossicles are avoided by selecting a posterior +portion of the membrane. After puncture the ear should be inflated by +an ear-bag whose nozzle is inserted into a nostril, both nostrils +being closed, so as to force the fluid from the tympanum. The puncture +may need to be repeated at intervals of a day or two, provided that +the pain and bulging return." + +Albert H. Buck of New York, in a highly instructive paper read before +the International Medical Congress in 1876, writes as follows of +paracentesis of the membrana tympani in scarlatinous otitis: "In this +one slight operation, which in itself is neither dangerous nor very +painful, lies the power to prevent the whole train of disagreeable and +dangerous symptoms." Buck relates an instructive example: The age of +the patient was three years, and the earache had been complained of +only about twenty-four hours. "Toward morning," says he, "I was sent +for, as the pain had become constant.... An examination with the +speculum and reflected light showed an oedematous and bulging membrana +tympani (posterior half), the neighboring parts being very red, though +as yet but little swollen. In the most prominent portion of the +membrane I made an incision scarcely three millimetres (one-tenth +inch) in length, and involving simply the different layers of the +membrana tympani. This was almost immediately followed by a watery +discharge (without the aid of inflation), which ran down over the +child's cheek. At the end of three or four minutes the child had +ceased crying, and in less than a quarter of an hour she was fast +asleep. At first, the discharge was very abundant and mainly watery in +character, but it steadily diminished in quantity and became thicker, +till finally, on the fourth day, it ceased altogether. On the tenth +day the most careful examination of the ear could not detect any trace +of either the inflammation or the artificial opening." The ear had +probably been saved from ulceration of the drum membrane, +long-continued suppurative otitis, and perhaps from permanent +impairment of hearing. + +When an opening has been made in the membrana tympani either by +incision or ulceration, it is advisable in some instances to inflate +the tympanum by Politzer's method, which has been alluded to above. +The nozzle of an india-rubber bag, with a flexible tube attached, is +introduced into the nostril on the affected side, and both nostrils +are compressed {549} against it. The patient fills his mouth with +water, which he swallows at a given signal, as after the words one, +two, three, spoken by the operator. During the act of swallowing, +which opens the Eustachian tube, the rubber bag is forcibly +compressed, which forces the air along the tube into the middle ear +and facilitates the escape of the pent-up secretions in the tympanic +cavity. + +If the otitis have continued unchecked by treatment until the +secretions within it, after days and nights of suffering, have escaped +by ulceration through the drumhead, the opportunity for prompt and +certain cure is passed. Still, the patient under these circumstances +may quickly recover, or there may be the other alternative described +above, in which the ear is badly damaged and chronic inflammation +established in the walls of the tympanum, giving rise to an offensive +otorrhoea. In this state of the ear internal remedies are indicated, +such as surgeons employ in suppurative inflammations of bone occurring +in other parts of the system. Cod-liver oil and iodide of iron are +required, especially by patients of strumous diathesis, the object +being to promote a more healthy state of system, so as to prevent +extension of the inflammation and facilitate the healing process. +Carbolized solutions, as the following, syringed warm into the ear in +which otorrhoea is occurring, are useful in promoting cleanliness and +increasing the comfort of the patient: + + Rx. Acidi Carbolici drachm ss; + Glycerinae fl. oz. ii; + Aquae fl. oz. iv. M. + +But recently a much more effectual curative agent for local treatment +has been discovered in boracic acid, by the use of which the discharge +more quickly diminishes and the condition of the ear more certainly +and rapidly improves than by the use of the carbolized mixtures. When +the inflammation is recent and the ear sensitive and painful, the +following prescription should be used: + + Rx. Acidi Boracici drachm iiss; + Morphiae Sulphat. gr. i; + Glycerinae, + Aquae _aa._ fl. oz. i. M. + +S. Drop one to three drops into the ear three times daily. + +If the acute stage of the otitis have passed, with fever and pain, and +no tenderness be present on pressure, the following prescription, +which causes too much pain in the acute stage, will be found useful to +check the inflammation and otorrhoea and restore a healthy state to +the granulating surface: + + Rx. Acidi Boracici drachm iiss; + Alcohol. + Aquae _aa._ fl. oz. i. + +S. Drop one to three drops into the ear three times daily. + +The beneficial effects observed from the use of boracic acid in aural +surgery have given it nearly the same position as a curative agent to +diseases of the ear which atropine holds to diseases of the eye. +Recently, aurists are employing finely-triturated powder of boracic +acid dusted into the ear. The patient lies upon the side with the +affected ear uppermost. The ear is thoroughly cleaned by syringing +with tepid water, and by means of a little scoop made of stiff paper +or pasteboard or the segment {550} of quill as much of the powder is +introduced into the ear as would cover a five-cent silver piece. By +working the ear it descends to the drumhead. I can bear witness to its +efficacy in the otorrhoea of children when it is used in this manner +three times daily. + +The following astringent has also been employed with good results for +the otorrhoea resulting from scarlet fever as well as from other +causes: + + Rx. Zinci Sulphatis, + Aluminis _aa._ gr. v; + Aquae fl. oz. i. M. + +A few drops of this should be dropped into the ear, or, if the ear be +sensitive and painful, five drops should be added to a teaspoonful of +warm water and dropped or syringed into the ear. + +But in recent times aurists have discovered a remedy superior to the +above in iodoform, the action of which is safe and efficient for +protracted otorrhoea with granulations, and it is superseding to a +great extent the agents heretofore used in the treatment of this +disease. The ear should first be thoroughly cleaned by syringing with +warm water and dried, and iodoform, to which a little balsam of Peru +is added to cover the disagreeable odor, should be pressed down to the +bottom of the auditory canal by any convenient instrument. It is +anodyne, astringent, and disinfectant, and should be employed in a dry +state in considerable quantity. + +The sequelae of otitis media, such as granulations sprouting out from +the drumhead, some of which may be of large size and are known as +polypi, may require treatment by the aurist. A polypus may sometimes +be removal by the forceps or better by the snare. Polypi not large and +favorably located can sometimes be cured by an astringent powder, as +iodoform, sulphate of zinc, or alum, or by applying the liquid +subsulphate of iron. The otitis externa produced by the irritating +discharge which flows from the middle ear soon disappears when the +flow ceases. + +The renal affection, which, as we have seen, so often commences in the +declining period of scarlet fever or during convalescence in mild as +well as severe cases, is frequently more dangerous than the primary +disease. It largely increases the percentage of deaths. A clear +appreciation of its therapeutic requirements is important, since by +judicious treatment many recover who would inevitably be sacrificed by +improper measures. The family should be informed that the danger from +scarlet fever does not cease with the decline of the eruption, and +that the kidneys may become seriously affected by too early exposure +of the patient to currents of air or sudden changes of temperature, by +which cutaneous transpiration is checked. He should therefore be kept +indoors in a comfortable and uniform temperature three or four weeks +after the termination of the fever, until desquamation has entirely +ceased and the new epiderm is sufficiently thick and firm to protect +the surface. During the changeable temperature of the autumnal, +winter, and spring months even longer confinement at home may be +advisable. + +The nephritis and consequent albuminuria antedate by some days the +occurrence of dropsy, and a physician should never discharge a +scarlatinous patient without one or more examinations of his urine. +When his visits cease the nurse should be instructed to make the +examinations by heat and nitric acid during the ensuing month, and if +any evidence, however slight, appear that the kidneys are involved, he +should be notified, {551} in order that appropriate treatment may be +immediately commenced. Early and correct treatment of the nephritis is +attended by much better results than delayed treatment, and many more +patients are doubtless now saved than in former times, when little +attention was given to the state of the kidneys until dropsy or other +prominent symptoms appeared. I have found no mother or nurse so +ignorant that she could not properly employ the test of nitric acid +and heat, and, if she be solicitous for the welfare of the child, she +will not hesitate to carry out the directions and immediately notify +the physician if the tests employed produce the least cloudiness or +turbidity of the urine. + +The patient as soon as nephritis commences, as shown by the state of +the urine, should be put to bed in a room of warm and equable +temperature (72 degrees to 75 degrees F.). His diet should be liquid, +consisting of milk, farinaceous food, and a moderate quantity of +animal broths. He may drink liquids freely, especially water not too +cool, to which spiritus aetheris nitrosi is added. If he be prostrated +by the primary disease, alcoholic stimulants should be allowed. + +The indications are to relieve the hyperaemic kidneys by diaphoresis +and purgation. To produce the former the patient should be immersed in +a warm bath at about the temperature of the body (98 degrees to 100 +degrees), in which, if he be quiet and comfortable, he should remain +from fifteen to twenty minutes, but if restless and frightened by the +water a less time, after which he should be placed in a warm bed and +well covered by blankets. If perspiration result, the bath has been +useful, and it may be employed in grave cases two or three times +daily. If perspiration do not result, it may be produced by +surrounding the body either by hot dry or moist air. Hot dry air may +be produced by burning alcohol in a thin layer upon a plate under a +chair upon which the patient sits while he is surrounded by a blanket, +or he may be covered in bed and the hot air introduced under the +bed-clothes. In New York a convenient apparatus is used for this +purpose, consisting of a small sheet-iron pipe enclosed in a small box +of the same material. The box is in the form of a trunk, with a handle +for convenience in carrying, and the lower end of the pipe, which +extends nearly to the floor, contains an alcohol lamp. Hot moist air +may be produced by placing against the patient bottles of hot water +surrounded by towels wrung out of water. The steam arising from them +and enveloping the body and limbs produces a prompt sudorific effect. +There is in use in this city, in the treatment of these and similar +cases requiring diaphoresis, a convenient apparatus for generating +steam. It consists of a cylinder pierced with holes for the admission +of air and containing a spirit lamp, over which is a pan or pail +holding a little water. The patient, nearly naked, is placed in a +chair with the apparatus underneath, and is covered by a blanket, so +that the steam surrounds the body. This gives rise to free +perspiration, which continues after the patient is placed in bed. This +treatment should be repeated one or more times daily, according to the +gravity of the case. + +The sudorific effect of the treatment by external warmth described +above should be aided by employing diaphoretics. Those which have been +most used are the acetates of ammonium and potassium, the bitartrate +and citrate of potassium, and spiritus aetheris nitrosi. If employed +when the surface is cool, they act rather as diuretics than +diaphoretics. {552} These agents, being simple in their action and +without deleterious effects, may be given frequently and in large +proportionate doses for the age. + +But lately a diaphoretic which far surpasses these in efficiency has +been discovered in pilocarpine, the active principle of jaborandi. +Being soluble in water and tasteless, it is easily administered, and +is retained when, on account of the uraemic poisoning present in +scarlatinous nephritis, the stomach is irritable and other medicines, +as digitalis, are rejected. Ether may be employed with it, or the +amount of alcoholic stimulant may be increased at the time of its +exhibition in order to guard against any depressing effect. To a child +of two years one-fortieth to one-twentieth of a grain may be given +every six hours by the mouth. It may also be employed hypodermically, +as one-twentieth of a grain to a child of five years. It has both a +diaphoretic and diuretic action, while it stimulates both the salivary +and mucous secretions. According to one observer, an adult when fully +under the influence of pilocarpine secretes from one pint to one quart +of saliva within two hours, and Leyden reports a case of diphtheritic +nephritis in which the quantity of urine rose from half a pint to five +pints daily. But its most prompt and certain action is upon the +sweat-glands. Hirschfelder speaks of its beneficial action in +relieving various forms of dropsy, and adds: "In one morbid condition +of the kidney, however, jaborandi is the remedy par excellence, and +that is the acute parenchymatous nephritis which frequently follows +scarlatina.... This disease heals spontaneously if the danger that +threatens life from reduction of the urine and from the effusions of +fluid into the cavities of the body be averted. In this disease +jaborandi works wonders." I have also found it an invaluable agent +when the older remedies failed and death seemed imminent. The +following cases, in which the beneficial action of this agent was +apparent, occurred in my practice: + +_Case 8._--G----, male, aged five years and six months, sickened with +scarlet fever on June 2, 1882. It began with vomiting, and was +attended by a degree of febrile movement which indicated an attack of +rather more than the average gravity. The fauces at one time exhibited +a slight exudation like that of diphtheria. In the declining stage of +the malady rheumatic pain and tenderness occurred in the wrist and +finger-joints, but not in those of the lower extremities. The case, +however, progressed favorably, and during the convalescence my +attendance ceased. On June 24th my attention was again called to the +child, when the urine was found to be scanty and very albuminous. +External measures, such as are described in the foregoing pages, were +employed, and the infusion of digitalis with potassium acetate ordered +to be given every three hours, but this medicine was for the most part +vomited. The bowels were kept open by jalap and the potassium +bitartrate. The urine, however, continued scanty, and on June 28th +severe convulsions occurred. At this time the quantity of urine was +only fl. oz. ij in twenty-four hours. The pulse in the convulsions was +quick and feeble, the skin very hot, and the axillary temperature 103 +degrees. The eclampsia continued one hour, and were controlled by +large and repeated doses of bromide of potassium, aided by clysters of +five grains of hydrate of chloral in water. Muriate of pilocarpine was +now directed to be given in doses of one-thirty-second of a grain +every three hours, dissolved in cold water. This agent was not +vomited, and it must have been given by the parents in their fright +and {553} anxiety in larger or more frequent doses than were directed, +for on July 1st the bottle containing one grain was empty. Free +diaphoresis resulted from the pilocarpine, and the quantity of urine +was increased. The mother stated that the child had taken only two +doses, or one-sixteenth of a grain, of pilocarpine when the diuretic +effect was apparent and free diaphoresis also occurred. She also +stated subsequently that the quantity of urine was larger when the +pilocarpine was administered every third hour than when given at a +longer interval. A flaxseed poultice on which mustard was dusted was +also applied over the kidneys. On June 29th the pulse was 96, +temperature 100.5 degrees; occasional convulsive attacks occurred, +which were readily controlled by enemata of hydrate of chloral. On +June 30th the symptoms were all better; no more attacks of eclampsia +had occurred, and the urine was more abundant and less albuminous. The +mother remarked that the new medicine (pilocarpine) had settled the +stomach and increased the urine. The patient continued to improve, and +on July 4th the record states: "Now takes the pilocarpine, gr. 1/32, +every six hours; passes urine freely since yesterday; has not vomited +since he began to take the pilocarpine; pulse 106, axillary +temperature 99 degrees; is playful and takes milk freely, nearly three +quarts in twenty-four hours, with some farinaceous food. Digitalis +with potassium acetate is also given in occasional doses." July 6th, +pulse 92, temperature 99 degrees; perspires much, and urine nearly +normal in quantity and character. + +_Case 9._--Mary S----, aged five years, on Dec. 22, 1882, presented +the symptoms of severe nephritis. Her brother had scarlet fever two +weeks previously, and she had sore throat at about the same time, but +without efflorescence; pulse 98, temperature 98.5 degrees; her urine +highly albuminous, and reduced to fl. oz. iv in twenty-four hours; +bowels constipated. Ordered a single dose of + + Rx. Hydrarg. Chlor. Mitis gr. iii; + Resin. Podophylli gr. 1/6. M. + +The muriate of pilocarpine was also ordered, gr. 1/20, but the patient +vomited soon after taking it. Another dose was retained, and was +followed by considerable perspiration. Dec. 23d, had one stool from +the powder of yesterday. Has taken five doses of pilocarpine, but +vomited after three of them. The last dose was administered at 10 +P.M., and the mother says she "sweat fearfully" during the night. The +patient was kept warm in bed; stimulating poultices of mustard and +flaxseed, one to sixteen, were constantly in use over the kidneys, and +the pilocarpine was administered three or four times a day. The record +for Dec. 26 states: "Took the pilocarpine four times since yesterday +morning, and each dose is followed by perspiration lasting from one to +one and a half hours; quantity of urine, from fl. oz. vj to fl. oz. +viij daily; vomited twice yesterday, not to-day; pulse 104, +temperature 97.75 degrees; complains of frontal headache; bowels +regular; has considerable salivation. The patient is warm in bed, and +the flaxseed and mustard poultice over the kidneys is continued." Dec. +28th, specific gravity of urine 1019; urine still quite albuminous, +and containing blood-corpuscles and granular casts, also crystals of +oxalate of lime. Dec. 30th, takes gr. 1/20 pilocarpine twice daily, +and occasional doses of infusion of digitalis; urine more abundant; +its specific gravity 1014, slightly albuminous, and containing {554} +very few granular casts and blood-corpuscles; has lost its smoky +appearance; reaction alkaline; perspiration slight; patient +convalescent. + +In another instance, a child of five years, from three to four weeks +after scarlet fever was noticed to have anasarca of the face and +extremities, with scanty and albuminous urine. One-thirty-second of a +grain of muriate of pilocarpine was administered every six hours +without the desired sudorific effect. It was then administered every +four hours, with an increase of perspiration and urination, so that +the nephritic symptoms were relieved and the patient apparently out of +danger within three or four days. + +In a fourth patient, a girl of three years, having scarlatinous +nephritis, with symptoms very similar to those in the last case, the +administration of one-twentieth grain doses of pilocarpine in +conjunction with the hot-air bath, was followed by increased +perspiration and urination, and progressive and rather rapid +convalescence. This child had been taking bichloride of mercury in +one-fiftieth grain doses, prescribed by a homoeopathic physician, +without appreciable benefit. It had been for the most part vomited. + +Given, as in the above cases, in moderate doses and with sufficient +interval, pilocarpine has never in my practice had any deleterious +effect, and I regard it as a very important addition to the remedies +for the relief of scarlatinous nephritis. It is apparently the most +useful and important diaphoretic for this disease which we possess. + +Cathartics, especially those of a hydragogue nature, are also very +beneficial. Their action is more certain than that of most +diaphoretics and diuretics, and their employment is imperatively +required in severe or dangerous cases in which it is necessary to +remove as soon as possible the serum or urea which endangers life. +Young children or those with delicate stomach, and those much +enfeebled by the primary disease, may take magnesia, either the +citrate or the calcined. A good cathartic for ordinary cases is a +mixture of jalap and potassium bitartrate, the pulvis jalapae +compositus, consisting of one part of jalap and two of cream of +tartar. Ten grains of the mixture may be given to a child of five +years, and repeated according to circumstances. Its effect is +increased by dissolving a teaspoonful of potassium bitartrate in a +gobletful of water, and allowing the patient to drink from it. The +following is a good cathartic in some instances, especially if the +stomach be irritable, so that the more bulky and nauseating cathartics +are rejected. Care should be taken to obtain a good article, as some +of the podophyllin of the shops is not reliable: + + Rx. Resinae Podophylli gr. j; + Sacchari scruple j. M. + Ft. in chart. No. v.-x. + +S. Give one powder, and repeat according to circumstances. + +In the treatment of one of the cases reported above it will be +recollected that the mild chloride of mercury mite was given with the +podophyllin, with a good result. + +After the use of laxative agents the kidneys, being less congested on +account of the diversion that has occurred, often begin to excrete +urine more freely. But if the patient be anaemic or enfeebled and the +symptoms are not urgent, it is frequently better to avoid active +catharsis, which {555} more or less reduces the strength, and employ +remedies of a sustaining character, as in the following case, which +occurred in my practice: A little boy, pallid and scrofulous, began to +have anasarca after scarlet fever, chiefly in the scrotum, accompanied +by a moderate degree of ascites. The urine, which was passed in nearly +the normal quantity, contained albumen, but not in large amount. This +patient gradually and fully recovered, with no treatment except the +use of an oil-silk jacket over the kidneys and abdomen to promote +diaphoresis, and the use of iron. Such a patient, treated by the +powerful eliminatives which we employ for the more urgent and robust +cases, would probably have been injured rather than benefited. No +treatment can therefore be recommended in a treatise on scarlatinous +nephritis which will be strictly applicable for all cases. Variations +are demanded according to the state of the patient and the form and +gravity of the disease. + +Diuretics which do not stimulate the kidneys are proper at an early as +well as late period of the renal malady, and digitalis is the one +usually prescribed. I do not hesitate to order it from the first day +in combination with the acetate of potassium. One teaspoonful of the +infusion may be given every third hour to a child of five years. The +following formula is for one of this age in good general condition: + + Rx. Potass. Acetatis oz. ss; + Infus. Digitalis fl. oz. vi. M. + +The following formulae are recommended by Meigs and Pepper: + + Rx. Potass. Bitart. drachm i; + Spt. Junip. Comp. fl. drachm ii; + Spt. Aether. Nitros. fl. drachm i; + Tr. Digitalis, minim xv; + Syrupi fl. drachm v; + Aquae fl oz. ii. M. + +Dose one teaspoonful every two hours to a child of two to four years. + + Rx. Potass. Acetat. drachm i; + Tr. Digitalis fl. drachm ss; + Syr. Scillae, fl. drachm i-ii; + Syr. Zingib. fl. drachm v; + Aquae q. s. ad fl. oz. iii. M. + +Dose, a teaspoonful every two or three hours to children two or three +years old. + +Local treatment is important. L. Thomas, Romberg, and others recommend +the application of leeches, three or more, over the kidneys. Thomas +says: "In many cases the abstraction of blood causes immediate and +permanent relief; the fever and the pain in the region of the kidneys +cease, the secretion of urine becomes augmented, the albuminuria +lessens from day to day, and the moderate degree of dropsy that has +been developed disappears." It is only in the more robust children, +who have been but little reduced by the primary disease, that leeching +is, in my opinion, admissible. In the majority of cases instead of +depletion a poultice slightly irritating, so as to cause redness of +the skin, should be applied over the kidneys, or for older children, +not likely to be frightened by the process, the dry cups may be +applied daily. In subacute cases, not attended by any alarming +symptoms, sufficient redness may be produced by one of the irritating +plasters which the shops contain, constantly worn. + +{556} Eclampsia, described in the preceding pages, is produced, as we +have seen, during the course of scarlet fever by the irritating effect +of the scarlatinous poison upon the nervous centres, but, occurring +after the decline of scarlet fever, it is ordinarily produced by the +retained urea. The same remedies are required to control the +convulsive movements as when they occur under other circumstances. The +bromide of potassium should be immediately administered in large and +frequent doses whenever eclamptic symptoms arise. During eclampsia a +child of three years should take five grains of this agent every five +to ten minutes till the attack ceases, and then at longer intervals. +The hydrate of chloral is a more powerful agent, and if the eclampsia +be not quickly controlled, I commonly employ it per rectum, dissolved +in one or two teaspoonfuls of water. For a child of three to five +years five grains should be thrown into the rectum by a small glass or +gutta-percha syringe, and retained by pressure. Properly administered +and retained, it rarely fails to control the eclampsia within ten or +fifteen minutes. Subsequently, occasional doses of the bromide should +be given to prevent the occurrence of eclampsia while the measures +described above are being employed to relieve the uraemic condition. + +Rheumatism, endocarditis, and pericarditis, arising as complications +or sequelae, require the treatment which is appropriate when they +occur under other circumstances, but the remedies should not be +depressing, as the system is already enfeebled by the primary disease. +The rheumatism, if mild, usually abates in a few days without +medication, and the affected joints require only some soothing lotion +and support by a bandage. The following liniment may be applied upon +muslin and covered by cotton wadding: + + Rx. Acid. Carbolici fl. drachm i; + Tinc. Belladonna fl. oz. i; + Ol. Camphorati fl. oz. ii; + +If the rheumatism be severe and affect several joints, the sodium +salicylate should be prescribed, as in the idiopathic disease, with an +occasional opiate to procure rest. + +Endocarditis and pericarditis require rest in the horizontal position, +avoidance of all excitement, the use of the tincture or infusion of +digitalis or of the fluid extract of convalaria to procure a slow and +steady action of the heart. Three drops of the tincture of digitalis +or five minims of the fluid extract of convalaria may be given every +four hours to a child of five years. The same external measures should +be employed as in acute pleuritis. I prefer the application of a thin +poultice of flaxseed containing one-sixteenth part of mustard and +covered with oiled silk. The cardiac inflammations, as well as +rheumatism, require opiates in sufficient doses to procure rest and +sleep. + +Pleuritis, which we have stated is apt to be suppurative, demands the +same treatment as the idiopathic disease when it occurs in cachectic +patients. + + + + +{557} + +RUBEOLA.[1] + +BY W. A. HARDAWAY, M.D. + +[Footnote 1: In the preparation of this article the writer has +consulted the following works: Thomas, in _Ziemssen's Cyclop. Pract. +Med._, vol. ii., N.Y., 1875, Am. edit.; Bohn, in _Gerhardt's Handbuch +der Kinderkrankh._, Zweiter Band, Tubingen, 1877; Squire, in Quain's +_Dict. Med._, N.Y., 1883; Ringer, in Reynolds's _System Med._, vol. +i., Phila., 1879; Meigs and Pepper, _Dis. of Children_, Phila., 1882; +J. Lewis Smith, _Dis. of Children_, Phila., 1882; Hebra, _Dis. of +Skin_, London. 1866; Vogel, _Dis. of Children_, N.Y., 1871; Niemeyer, +_Handbook of Pract. Med._, N.Y., 1869; Trousseau, _Clinical Med._, +Phila., 1871. Other references will be found in the foot-notes to the +text.] + + +SYNONYMS.--Rubeola, Morbilli, Measles, Masern, Flecken, Rougeole. + +DEFINITION.--Measles is an acute infectious disease involving the skin +and mucous membranes, characterized by successive stages and a +maculo-papular eruption, which terminates in a fine branny +desquamation. In normal cases it runs a definite course, which from +the date of invasion to the end of desquamation occupies about +fourteen days. It is highly contagious, and occurs, as a rule, but +once in the same person. + +HISTORY.--The word rubeola is probably of Spanish origin and was +formerly written rubiola or rubiolo. The designation morbilli is the +diminutive of the Italian il morbo, the plague. Although it is +doubtful, as claimed by Willan, that the Greek and Roman physicians +were acquainted with measles, there is no question that Rhazes was one +of the first to describe the affection correctly. Rubeola is said to +have been distinguished from variola by the Arabians in the twelfth +century; but, nevertheless, as late as the middle of the seventeenth +century we find Sennertus discussing the question "why the disease in +some constitutions assumed the form of small-pox, and in others that +of measles;" and in a posthumous work of Diemerbroeck, published in +1687, it is asserted that small-pox and measles are only different +degrees of the same affection.[2] According to Mayr, the merit of +having shown measles to be a distinct malady from scarlatina must be +ascribed to Forestus and Sydenham. It is not clear, however, that the +two diseases were accurately differentiated till the close of the last +century, and notably by Withering in 1792. + +[Footnote 2: _Cyclop. Pract. Med._, London, 1834, p. 625.] + +ETIOLOGY.--The exact nature of the measles contagium has never been +satisfactorily established, although we are in possession of numerous +researches in that direction, which, however, are to a great extent +contradictory. A brief examination of these various observations will +not prove uninteresting. Hallier found in the blood and sputa numbers +of free cocci, which fructified upon various substrata, but was +invariably the same fungus--mucor mucedo verus, Fres. In 1862, +Salisbury[3] published {558} his observations on the relation of the +straw fungus to measles. He recorded instances of inoculation with +this organism that resulted, according to him, in the production of a +modified form of rubeola, and, moreover, was protective against +further attacks of the same disease. In an exhaustive paper bearing on +this question H. C. Wood[4] quotes certain experimental inoculations +made by William Pepper, which showed conclusively that measles was not +propagated in this way, and that where any symptoms were developed +they were not those of true measles, nor did they protect the subjects +from unquestioned measles. Salisbury also claimed that measles had +occurred in camps where damp and mouldy straw had been employed for +bedding. J. J. Woodward in his work on _Camp Diseases_ points out that +camp measles prevailed almost exclusively in regiments from the rural +districts, while men enlisted in towns and cities were more or less +completely exempt. The explanation was, that those from the country +had hitherto escaped the disease, while townspeople had suffered from +it at some previous time--a condition of affairs inconsistent with the +theory of the straw fungus. Coxe and Felz found numerous bacteria in +the blood of measles patients, especially in regions where the +eruption was most pronounced. The nasal mucus also contained similar +germs. Inoculation of the blood from the subjects of measles upon +rabbits did not produce an analogous affection (Thomas). Klebs[5] +obtained micrococci from the trachea and from blood taken from the +hearts of infant cadavers. "In the latter, collected in flattened +capillary tubes, there developed balls of micrococci; in the trachea +both micrococci and bacteria were present in large quantities. Under +observation, pale, finely-granular micrococcus balls developed and +changed very quickly to bacteria, which moved about very actively. +These sought the periphery, about 1/2 mm. distant from the centre of +development, and formed a zone, comparable with a hedge or fence that +is composed of rods. From this were formed new masses of micrococci, +but further no regular process of arrangement or development could be +observed." + +[Footnote 3: _Am. Jour. Med. Sci._, July and Oct., 1862.] + +[Footnote 4: _Ibid._, Oct., 1868, p. 333.] + +[Footnote 5: _Wurzbr. Verh._, N. F., v., 1874, quoted by Forchheimer +in Supplement to _Ziemssen's Cyclopedia_, W. T., 1881, p. 102.] + +Braidwood and Vacher,[6] as the result of a number of experiments, +believed that they had sufficient evidence for concluding that the +most active mode of the transmission of measles was through the +breath, and accordingly instituted a series of experiments by +carefully examining the breath of children in the acute stage of the +disease.[7] With this object in view they coated over with glycerine +the inside of several clean glass tubes of a diameter of a half to +three-quarters of an inch. As soon as the nature of the eruption was +manifest the patient was required to breathe through one or more of +the tubes, and so on each day till the eruption had faded. Upon +examination of the glycerine with an one-eighth objective every +specimen showed numerous sparkling bodies, something like those found +in vaccine, but larger. Some were spherical; others were elongated, +with sharpened ends. They were most abundant during the first and +second days of the eruption. Healthy children and patients suffering +from typhoid and scarlet fevers were made to imitate these {559} +experiments, but no such bodies were to be seen in their specimens. +They conclude from these observations that the small spherical +elements discovered in the breath are perhaps the active agents in the +propagation of measles. Upon post-mortem of patients who had died of +rubeola these germs were found in the lungs and liver, and, +particularly, close to the walls of the capillaries. They believe that +the "lungs are the favorite breeding-ground of the contagium." + +[Footnote 6: _Brit. Med. Jour._, Jan. 21, 1882.] + +[Footnote 7: Several years ago Ransome of Manchester obtained +particles from the breath of two persons suffering from measles +(Squire).] + +That inoculation of morbillous blood may convey the disease was first +demonstrated by Home in 1757, which experiments were verified by +Speranza in 1822 and by Katona in 1842. The inoculations of the latter +are especially noteworthy, as they numbered more than a thousand. No +person inoculated by him died, and only 7 per cent. of the +inoculations failed. On the other hand, inoculations made by Mayr gave +negative results. It is stated that Monro and Locke communicated +measles by inoculating with the tears and saliva. Attempts of the same +kind were fruitlessly made in Philadelphia in 1801, although the +blood, the tears, the nasal and bronchial mucus, and the exfoliated +lamellae of the epidermis were successively employed in the trials.[8] + +[Footnote 8: Rayer, _Diseases of the Skin_, Phila., 1845.] + +Mayr has shown that the nasal mucus is capable upon inoculation of +propagating the disease. He performed the experiment upon two healthy +children living at a distance from each other, at a time when the +disease had ceased to be epidemic. Some nasal mucus taken from the +patient during the stadium flavitionis, and kept fluid in a glass +tube, was the same day placed upon the mucous membrane of each of +these children. In one of them the first symptom of sneezing occurred +after eight days, in the other at the expiration of nine days. Febrile +symptoms set in two days later. In each child the rash appeared on the +thirteenth day after infection. The inoculated disease was mild and +regular in its course. + +While it is perhaps true that the contagion of measles is not so +tenacious as that of small-pox and scarlatina, it is a matter of +observation that susceptible persons are liable to contract the +disease, even if not directly exposed to its influence. There is +incontestable evidence that it is conveyed by fomites--a fact well +worth bearing in mind. + +It is but just to say that so excellent an observer as Mayr taught +that measles could not be conveyed by clothes, linen, etc. unless +transferred immediately from one individual to another. Panum, +however, showed that contagion could be carried many miles by an +unaffected third person without losing its activity. Aitken[9] has +also pointed out the fact that children's clothes sent home in boxes +from schools where the disease has raged communicated the disease, and +that susceptible children who had slept in the same beds, in the same +rooms, after they had been occupied by persons suffering from measles, +have taken the malady. Squire observes that the contagium of measles, +except in the catarrhal stage, is not far diffusible in the air, but +clings to surfaces, and may be thus carried from place to place; on +the other hand, children have been brought, while in full eruption, +into a house among others, and nursed in a room apart, without any +extension of the disease to the most susceptible. + +[Footnote 9: _Science and Pract. of Med._, Phila., 1868.] + +{560} Various circumstances render it probable that measles is most +readily propagated during the stage of efflorescence; but that it is +also highly infectious during the prodromal period is now universally +acknowledged. + +According to Niemeyer, the probability of infection during the +prodromal stage is supported by the wonderful spread of measles +through schools; for, while the strictest surveillance is established +over children with any suspicious eruptions, and those known to have +had the disease are not allowed to return till long past the stage of +desquamation, no heed is paid to those exhibiting the premonitory +cough and coryza. There is no reason for believing that measles can be +propagated during the period of incubation; on the other hand, there +is no satisfactory argument for the denial of its infectiousness in +the desquamative stage. Although Panum is inclined to doubt its +contagiousness at this time--and his observations are worthy of the +greatest confidence--other good authorities differ from him +materially, and extend the stage of personal infection to a period of +from three weeks (Squire) to forty days (Hillairet). + +Reasoning from analogy, we would naturally expect that the period of +incubation in measles suffered a certain amount of variation; the +result of numerous observations confirms this expectation. It is +manifestly a difficult matter in densely populated communities to +establish with accuracy the date of a given infection, but from a +study of more or less carefully noted cases it will be found that the +period of incubation may vary from three to thirty days. For the vast +majority of cases the average time between the reception of the +measles poison and the appearance of the characteristic eruption will +be about from thirteen to fourteen days. Panum, under exceptionally +favorable surroundings, found it more frequently fourteen than +thirteen days. Therefore, deducting the three or four days occupied by +the invasion stage, we shall find that the real incubation period is +from nine to ten days from the date of exposure. Mayr's two cases of +inoculation with nasal mucus showed no departure from this rule, but +in the inoculations made by Katona with blood the prodromic symptoms +made their appearance in seven days, the cutaneous lesions developing +two, and at the most three, days afterward. + +Minor epidemics of measles are said to occur every three to five +years, more extensive and severe ones every seven or eight years. In +the centres of population measles may be said to be endemic; in +isolated regions the visitations of the disease may be widely +separated. Measles is a less severe disease in warm than in cold +climates, and, as a rule, we also find the affection more common and +more intense in the fall, winter, and spring than in the summer +months.[10] Epidemics of measles are usually short, and it is thought +that there is a definite relation between the severity of their onset +and their duration, this being in general short in proportion as the +given epidemic was at first severe (Mayr). Intestinal complications +are more frequent in summer, and involvements of the respiratory +organs more common in winter. The varying aspects of different {561} +epidemics--sthenic, asthenic, etc.--depend on changes in the weather, +season of the year, the presence of complications, and other agencies +not very clearly understood. Epidemics of whooping cough may precede, +accompany, or follow in the wake of measles, and it has therefore been +suggested that it stands in some peculiarly close connection with the +latter; but, aside from this often-observed coincidence, we are not +justified in our present state of knowledge in assuming any definite +relation of cause and effect between the two diseases. + +[Footnote 10: Aitken (_op. cit._, p. 295) declares that the mortality +returns from England and Wales show that the influence of season is +most trifling. Occasionally it has been found that the deaths in +summer exceeded those in winter, but we believe that the statement +made above is, in the main, correct. For instance, Parson's figures +for Berlin for the years 1863-67, inclusive, are: spring, 11.9 per +cent.; summer, 13.3; autumn, 33.4; winter, 41.4. Voit's statistics in +an average of thirty years at the Children's Clinic at Wurzburg +establish the same general principles (Thomas).] + +There would seem to be neither geographical nor racial bar to the +propagation of measles, for it has been observed in all countries and +among all peoples. As in the case of other zymotic diseases, a +tolerance is established for measles in countries where the disease is +more or less constantly prevalent; but where the affection becomes +epidemic for the first time, or reappears after many years, it rages +with terrific violence. This fact was particularly exemplified in the +epidemic in the Faroe Islands, and more especially in the recent +(1877) visitation of the Fiji Islands, where one-fourth of the +population succumbed in a comparatively short time. + +It is quite probable, as asserted by Mayr, that children affected with +scrofulous complaints, as well as those who are the subjects of +diseases of the respiratory organs--pertussis, bronchitis, or +tuberculosis--are eminently susceptible of measles; but his statement +that sufferers from epilepsy, chorea, and paralysis exhibit an unusual +power of resistance cannot be accepted without reservation. Acute +diseases often appear to delay the outbreak of measles, so that the +latter does not appear till convalescence from the former (Thomas). +The development of vaccinia is occasionally interfered with by an +attack of rubeola; on the other hand, the two diseases may be seen +running their courses together.[11] The emphatic statement made by +Hebra, that measles is never seen to occupy a patient simultaneously +with another acute exanthem, has not been confirmed by other +observers. My own experience furnishes several examples. Measles may +also occur during the course of other acute or chronic maladies. From +a study of the literature of measles complicating pregnancy and +parturition Underhill[12] finds it to be quite uncommon, due probably +to the fact that most adults are insusceptible of further attacks; but +when it does occur in pregnancy he regards it as a very serious and +frequently fatal complication. Underhill believes measles to be most +fatal when it supervenes soon after delivery, while those who are +confined during the course of the malady stand a better chance of +recovering from it. That puerperal women are not always unfavorably +affected by measles is well shown in two remarkable cases reported by +Nelson[13] of St. Louis and Chantier[14] of Geneva, in which the +mothers were safely delivered, though suffering from measles +contracted at the end of their pregnancies. + +[Footnote 11: Hardaway, _Essentials of Vaccination_, p. 60.] + +[Footnote 12: _Obstet. Jour. Great Britain and Ireland_, July, 1880.] + +[Footnote 13: _St. Louis Courier of Med._, Sept., 1879.] + +[Footnote 14: _Annales de Gynecologie_, May, 1879.] + +All ages are susceptible to the measles poison, and the apparent +exemption enjoyed by adults is due to the fact that most grown-up +people have already suffered the disease in childhood; but in Panum's +epidemic, mentioned above, it was discovered that nearly all who had +not had measles {562} elsewhere, or were not old enough to have been +exposed at the last visitation, sixty-five years before, acquired the +affection regardless of age. It is quite probable, however, that the +law of decrease of susceptibility with age holds good for measles as +well as for variola, etc., but to a less degree. It will therefore be +seen that measles is not essentially a disease of childhood. Although +there is no special limit to the susceptibility of rubeola at one +extreme of life, it would seem to be quite well established that it is +much modified at the other--namely, that infants under six months are +rarely attacked. This latter fact is conceded by individual +experience, by the records of epidemics, and by the testimony of most +observers.[15] + +[Footnote 15: On the other hand, as quoted by Forchheimer (_loc. +cit._), H. C. Fox publishes some tables which show that for England +and London a much larger number of young children are attacked by +measles than other statistics would lead us to believe.] + + +-------------+-------------+ + | England. | London. | + +------+------+------+------+ + | | Fem- | | Fem- | + |Males.| ales.|Males.| ales.| + ---------------------------------------+------+------+------+------+ + Under one year | 3022 | 2530 | 3571 | 2987 | + One and under two years | 6086 | 5825 | 8630 | 8050 | + Two " " three " | 3178 | 3255 | 4683 | 4757 | + Three " " four " | 1730 | 1851 | 2594 | 2620 | + Four " " five " | 980 | 1028 | 1358 | 1466 | + |------+------+------+------| + |------+------+------+------| + Five and under ten years | 255 | 278 | 301 | 316 | + Ten " " fifteen " | 29 | 38 | 24 | 32 | + Fifteen " " twenty " | 9 | 13 | 9 | 11 | + Twenty " " twenty-five " | 7 | 9 | 5 | 7 | + Twenty-five " " thirty-five " | 5 | 8 | 5 | 7 | + Thirty-five " " forty-five " | 3 | 5 | 2 | 3 | + ---------------------------------------+------+------+------+------+ + +Even sucklings do not enjoy a complete immunity from measles. +Steiner[16] states that he has met with it in children only four or +five weeks old. Monti has recorded ten cases of rubeola in children +under two months of age. A case is reported by Kunze where a mother in +the stage of efflorescence gave birth to a child, which contracted the +disease five days afterward. Quite a number of cases of congenital +measles have been put on record from time to time; but Thomas, after a +careful investigation, says that he has been able to discover but six +authentic accounts of such occurrences.[17] That children born to +mothers suffering at the time of parturition from measles may yet +escape it themselves is proven by the cases of Nelson and Gautier +mentioned above. Whether a pregnant woman attacked by measles +transmits the disease to the foetus in utero, thereby securing +immunity from it in after life, is a question difficult of decision, +especially as we have not yet been able to decide this same inquiry, +with infinitely better opportunities, for vaccinia.[18] + +[Footnote 16: _Compendium of Children's Diseases_, N.Y., 1875, p. +396.] + +[Footnote 17: I believe that, under certain circumstances, the +erythema papulatum of the new-born is often mistaken for measles.] + +[Footnote 18: See experiments of Burckhardt, Rickett, Gart, and +others, quoted in Hardaway's _Essentials of Vaccination_, p. 38.] + +There is no good reason to believe that sex is of much importance in +establishing a predisposition to measles, although the statement has +been repeatedly made that males are more frequently attacked than +females. {563} Fox's statistics show a slight preponderance in favor +of the male sex; but a careful examination of accessible statistics +proves, as would be expected, that this degree of susceptibility +varies at different times in obedience to circumstances not readily +understood. + +By the older writers (Willan, Rosenstein, Fuchs) it was very +dogmatically asserted that one attack of measles completely +extinguished all future susceptibility to the disease. Of late years +this dogma has met with much opposition, and numerous observations +have been recorded which, if entirely trustworthy, would lead us to +believe that rubeola may occur not only twice, but several times, in +the same individual. While from analogy and actual experience we are +quite sure that the recurrence of measles is not so uncommon an event +as it was once held to be, a closer examination of the question in all +its bearings clearly confirms us in the belief that subsequent attacks +are much more infrequent than is now thought to be the case by many, +and that other diseases, more or less resembling true measles, are +largely responsible for errors of diagnosis in this regard. Panum +found that all the old people who had measles during the epidemic on +the Faroe Islands in 1781 escaped it in 1846. Both Rosenstein and +Willan declared that they had never witnessed an instance of the true +recurrence of measles. Among other facts, it may be stated in this +connection that Woodward (_loc. cit._) has shown that during our late +war, while members of regiments recruited from the rural districts, +who had never before had measles, largely took it when exposed to its +influence, regiments from the cities, who had presumably acquired the +disease in childhood, remained almost entirely exempt.[19] Other +arguments of a similar sort could be readily adduced. There is no +question that mistakes in diagnosis have occurred from confounding +rotheln, roseola, etc., which closely simulate measles, with that +disease. Those particularly engaged in the treatment of cutaneous +affections could multiply instances of such errors. It is quite +significant that for certain analogous infectious diseases--_e.g._ +variola and scarlatina--the same frequency of recurrence is not +claimed, although as a matter of fact they do occur. The explanation +would seem to lie in the fact that neither small-pox nor scarlet fever +is so closely counterfeited by other skin affections, notably by +rotheln, as is measles. But it would be entirely contrary to analogy +and indubitable experience to go to the extreme of the older writers +and absolutely deny the possibility of second, and even third, attacks +of rubeola. The frequency of such cases is, however, as Henoch[20] +truly states, much overestimated. + +[Footnote 19: These observations of Woodward were made without any +reference to the question at issue.] + +[Footnote 20: _Lectures on Diseases of Children_, N.Y., 1882, p. 282.] + +Occupying quite a different position from the measles induced by +reinfection from without are the so-called relapses of rubeola. These +relapses, which may occur in from two to four weeks after the original +invasion, are analogous to the similar occurrences in scarlatina and +typhoid fever. I am cognizant of but a single case of this sort, but +Steiner and other accurate observers record a number of such +instances. + +SYMPTOMS AND COURSE.--It is generally stated that the stage of +incubation exhibits no symptoms whatever; but it is undoubtedly true +that the patient will sometimes appear dull and listless, and, on +occasion, even give evidence of some slight and ephemeral elevations +of temperature. {564} As a rule, however, this period is devoid of any +marked indication of the presence of the measles poison in the +system.[21] + +[Footnote 21: Some writers describe a much more marked train of +symptoms as prevailing at this time than seems warranted by general +experience, and Rehn has gone so far as to declare that the prodromal +period, as usually understood, properly commences in the stage of +incubation. Bohn is inclined to a similar view. The prodromic stage of +authors is, then, to be looked upon as the "period of the mucous +membrane exanthem."] + +The prodromal stage is usually ushered in by symptoms of general +malaise, fretfulness, more or less frontal headache, shiverings, +nausea, loss of appetite, excited sleep, and sometimes delirium. +Vomiting is not so common in measles as in scarlatina, and may occur +at any time previous to the appearance of the rash. The tongue is apt +to be coated, although it may remain clean; the taste is bad, and +pressure over the stomach and bowels occasionally elicits considerable +pain; an aching pain over the sternum is also noted. As a general +thing, at this time patients are drowsy and inclined to sleep much. +Meigs and Pepper found this a very constant symptom, which they state +is in no way alarming unless associated with other more serious +symptoms of local or general disturbance. Constipation is present in +some cases, or the bowels may be relaxed or remain in their natural +state. + +The prodromal fever of measles follows a peculiar course. It is +remarkably remittent in character, and is rarely of such intensity as +to threaten life, as is often the case in scarlet fever. The +temperature will rise on the first day to 102 degrees-104 degrees F., +and the height of the fever at this time will measurably foreshadow +the character of the subsequent course. On the second day of the +prodromal stage the fever suffers a marked remission, or may even +entirely disappear, to again rise in the evening. Smith has observed +two exacerbations in the day. Again, in some instances, after the high +initiatory fever, the temperature may remain normal till just before +the rash comes out (Bohn). It is this peculiar behavior of the fever, +together with the fact that the child may regain its usual vivacity in +the fever-free intervals, which so often misleads the physician into +the diagnosis of malarial poisoning. + +The most pronounced feature of this stage of the disease is, beyond +all others, the catarrhal affection of the mucous membranes. The +mucous membranes of the eyes, nose, mouth, and air-passages are all +more or less involved, and the patient suffers in varying degrees from +photophobia, coryza, hoarseness, cough, and pain in swallowing. +Sneezing is frequent and annoying, and slight epistaxis is not +uncommon. The cough usually appears on the first day, simultaneously +with the fever. It is not very troublesome at first, but by the fourth +day it becomes more frequent, assuming a hoarse, barking, paroxysmal +character. Expectoration is scanty, and auscultation reveals a harsh +vesicular murmur or else sibilant rales. Alarming but not dangerous +attacks of false croup may come on during the night. Many observers +have called attention to the red spots (papules) in the oral cavity, +which make their appearance during the period of invasion. According +to Bohn, usually on the second or third day from the beginning of the +fever there appear upon the slightly hyperaemic mucous membrane of the +soft palate, palatal arch, and uvula small or large, dark, red spots +that spread to the mucous membrane of the cheeks, and sometimes to the +hard palate, lips, and gums. Soon they become more defined, and are to +be distinguished by shape and coloring {565} from the membrane upon +which they are situated. According to the same authority, they also +afford an index to the intensity and extent of the coming cutaneous +eruption. It is also stated that if the latter partakes of a +hemorrhagic character, the spots on the mucous membrane may also +become livid. This same punctate reddening has been demonstrated in +the epiglottis, larynx, and trachea (Gerhardt), and upon the bronchi +and small intestines of children who had died during this stage of the +eruption. It is also to be noted on the conjunctivae. It has been +assumed that this period of this disease is not to be looked upon as +the stadium prodromorum, but as the period of the "exanthem of the +mucous membrane." This view of the pathology of measles seems to me +most reasonable; but in whatever way we may look upon the question, +the practical importance of this precutaneous eruptive stage is to be +insisted upon for diagnostic purposes, just as is the analogous +eruption upon the mucous membrane in small-pox. + +In ordinary cases of measles we do not find such profound reaction of +the nervous system as in scarlatina. I believe that convulsions in the +prodromal stage are much more common than available statistics would +have us believe; at least, this is my own experience. Meigs and Pepper +met with convulsions but five times in 314 cases at the beginning of +the eruption, while Rilliet and Barthez observed but one convulsion in +167 cases. Thomas says that convulsions are almost always absent. On +the other hand, Trousseau and Bohn expressly declare that they are +very common, the former stating that they occur with greater frequency +than in scarlatina. I consider that convulsive seizures occurring in +connection with marked catarrhal affection of the mucous membranes are +very important aids in forecasting a probable attack of rubeola. +Fortunately, convulsions at this stage are not very serious unless +repeated or injudiciously treated. + +The duration of the period of invasion in regular cases is from three +to five days, with an average of about four, but in perfectly +uncomplicated attacks this period may be extended to six or eight +days, or even longer. But that the duration of this stage may be much +shorter than the average is not sufficiently insisted upon by writers. +Ringer,[22] for instance, says that he had an opportunity of testing +the earliest appearance of the rash in an epidemic of measles in a +large public school for boys under twelve. In every case during the +epidemic the rash appeared on the first day, the cases being severe, +though of short duration, the temperature rising to 103 degrees and to +104 degrees F. In some instances the rash preceded (?) the fever. +Thus, several of the boys feeling poorly, their temperature was +carefully taken night and morning under the tongue, and in several +cases the rash appeared in the morning about the face and collar-bone, +while the temperature remained normal, and did not rise till the +evening, when it ran up to 101 degrees-103 degrees F., and even +higher. These cases certainly resemble rotheln more than measles. In +two cases, which I observed under very favorable conditions, the +eruption commenced to appear on the morning of the second day, and +more or less similar experiences are recorded by others. + +[Footnote 22: _Handbook of Therapeutics_, 6th ed., London, 1868--note +to p. 26.] + +The skin eruption, which appears, as a rule, on the third, fourth, or +fifth day of the attack, is ushered in with an increase in the general +and {566} local symptoms of the disease. It is particularly to be +remarked that the fever does not subside at this time, as is the case +in variola. The eruption appears first upon the face, about the cheeks +and forehead, then on the chin and neck, and thence gradually +overspreads the trunk, and finally reaches the extremities. When the +eruption is intense no part of the body is free from it, the rash +being found upon the palms and soles and upon the hairy scalp. The +cutaneous lesions proper consist at first of hyperaemic spots of about +a line in diameter, which gradually increase in size, until at their +full development they may attain a diameter of from one-twentieth to a +quarter of an inch. In the beginning they bear a very close +resemblance to the sub-papular lesions of small-pox. The +maculo-papules, when fully developed, are slightly elevated above the +level of the skin, the elevation, however, being more appreciable to +touch than sight, have a smooth velvety feel, and are so arranged as +to enclose areas of healthy skin. In the individual spots we may +frequently observe one or several minute, darker-colored papules, due +to follicular congestion, which when more intense constitutes the +morbilli papulari presently to be described. The maculae are, as a +rule, roundish, or they may be moon-shaped, or their borders may +present an indented or notched appearance. Where the capillary +circulation is active--on the cheeks, for example--or upon parts +subjected to pressure, the eruption may become confluent; that is to +say, the usually pale intervening skin becomes injected or the papules +coalesce, and in this way produce a uniform redness over large single +tracts of skin. This scarlatinoid rash, however, never occupies the +whole surface of the body, but only limited regions, and in other +situations may be detected the characteristic discrete papules of +rubeola; the color is not uniform, but is broken here and there by the +darker streaks and spots of the measly eruption. The rash, which +disappears upon pressure to return when the pressure is removed, is of +a more or less rosy red, with a tendency in some to deep red, and has +occasionally a purplish hue. According to Mayr and Hebra, it is of the +precise color which is obtained by adding a little yellow or brown to +a red pigment. + +According to the researches of Thomas, Squire, and Wunderlich, as +abstracted by Seguin, the fever of the eruptive period is divided into +a moderately febrile stage and the fastigium or acme. The moderately +febrile stage averages thirty-six to thirty-eight hours, and is made +up of one or two exacerbations of 100.4 degrees to 102.2 degrees F., +but not quite so high as the initial fever. If there are two +exacerbations, the second one is the higher; the intervening +remissions are not so low as those of the prodromal stage, yet even +now the norm may be noted on a single occasion. The fastigium +commences early in the day or in the evening; if the rise should occur +in the morning, the evening temperature rises still higher, with or +without a slight remission the following morning, and the next evening +attains the maximum. If the acme begins in the evening, the remission +on the next morning is either absent or very slight. The greatest +height of the fever in normal cases corresponds to the greatest +intensity and development of the eruption. This rule is not +invariable, however, for sometimes the fever is higher soon after the +eruption appears, and has fallen when the exanthem has reached its +highest point. The whole fastigium lasts from one and a half to two +{567} and a half days, so that the complete eruptive fever occupies +from three to four and one-half days.[23] The pulse in general +preserves a proportionate correspondence to the temperature, and never +attains the great frequency to be observed in scarlatina. + +[Footnote 23: According to Ringer, the highest temperature reached in +normal cases is 103 degrees F. Thomas places it as high as 104 degrees +F., but states that it may go up to 105 degrees F. without the +intervention of any complication.] + +The general symptoms, with the exception of the fever, do not greatly +differ from those common to the prodromal stage. The skin is hot and +more or less swollen, particularly about the face; there are anorexia, +photophobia, lachrymation, and sometimes epistaxis; the cough +continues, and is generally frequent and harassing, and attended with +little or no expectoration; the voice is hoarse. The tongue is coated, +principally in the middle, through which the swollen papillae +protrude, while the tip and sides are red. The blotchy redness of the +oral cavity is visible for some days, and finally becomes +indistinguishable from the surrounding congestion. The tonsils +sometimes become considerably enlarged, though suppuration must be +rare. Enlargement of the glands behind the jaw and in the neck and +groin are to be observed. At the outset of the eruption a profuse +diarrhoea supervenes in most cases--a symptom which Trousseau rightly +insists to be an essential feature of measles. This occurrence is +interpreted by some writers as an evidence of the implication of the +mucous membranes in the specific exanthem of the disease. This flux, +which is sometimes accompanied by a little blood and tenesmus, rarely +continues long, and may be succeeded by a degree of constipation. The +respiration is generally somewhat accelerated, mostly in +correspondence to the amount of fever present. Some degree of deafness +is not uncommon, owing to the extension of inflammation along the +Eustachian tubes. The urine is scanty and high colored; there is +sometimes scalding in urination and vesical tenesmus, and at the acme +of the fever traces of albumen may be detected. + +The eruption, in fact, generally occupies the skin an average of four +days, and, although this period may be shortened materially, it is +less apt to be lengthened. The duration of the eruption at its maximum +of development over the whole surface is about half a day, more or +less, and, as a rule, corresponds with the greatest elevation of the +temperature. The retrocession of the rash takes place in the order of +its appearance--viz. first from the face, then from the trunk and +upper parts of the extremities, and last from about the feet and +hands, where, indeed, it may remain vivid, or even progress for a +short time longer, after the eruption has begun to subside in other +situations. Sometimes the almost faded spots will be temporarily +renewed by an abnormal rise in the temperature. + +With the decline of the eruption the other symptoms begin to subside. +The cough loses its hacking, paroxysmal character, and becomes less +and less frequent, and gradually disappears. The voice regains its +normal tone, the tongue loses its fur, cleaning up in patches, and +expectoration, which was absent or scanty and viscid in the beginning, +increases and is free, the masses coughed up being coin-shaped and +floating in a clear watery mucus--a symptom much dwelt upon by the +older writers. The behavior of the temperature at this period--the +stage of decline--is quite {568} characteristic. The fall usually +begins at night, and generally the next morning it has reached the +norm or else fallen below it. On the other hand, the descent may be +less precipitate, and the fall continues less rapidly all through the +day; or there may be a slight rise again in the evening, the norm +being reached the following morning. The termination by lysis--that +is, slight elevations in the evening for several days--is much rarer, +and while it may occur in perfectly regular cases, it should put the +medical attendant on his guard against complications. + +The comparatively normal course of measles portrayed in the preceding +paragraphs does not always occur, but, on the contrary, the disease +may depart from the more usual type in one or more particulars, either +in especial stages of its progress or in the greater or less intensity +of the malady as a whole. + +In addition to those cases of measles where the eruptive and catarrhal +symptoms are so slight as to almost escape observation, except for the +existence of other cases in the same house or family, there are to be +recognized two other trivial varieties of the disease--namely, measles +without the catarrh, and measles without the rash. + +That the eruption of measles should occur upon the skin without +implication of the mucous membranes seems to be much more doubtful +than that the catarrh should appear without the eruption. It is quite +probable, at any rate, that many so-called cases of rubeola sine +catarrho are merely instances of rotheln, which we know may occur +without any reference to an existing epidemic of measles. But that +this form of measles does exist is admitted by trustworthy observers, +although its diagnosis under any circumstances must be a matter of +great difficulty. Measles without the eruption (rubeola sine +eruptione) is more readily recognized, especially and only, however, +when a susceptible person is exposed, and as a result acquires the +characteristic catarrhal symptoms. Since in recent years more +attention has been paid to the eruption on the mucous membranes, it +may be that its discovery in these situations may lend positive +assistance to the diagnosis in such cases. It is hard to understand +how this variety of measles, which presents no inflammatory changes in +the skin, should be followed by desquamation; yet this observation has +been made. The assertion that these anomalous forms of the affection +afford no protection against subsequent attacks seems to be founded in +error, and is undoubtedly due to the confusion existing between +measles and rotheln or other exanthems. + +Continental writers, especially, describe a form of measles called by +them inflammatory or synochal. It is simply an exaggeration of the +symptoms, particularly those appertaining to the mucous membranes, +found in ordinary measles (morbilli vulgaris). The prodromal stage is +much more violent, the nervous symptoms more threatening, the +implication of the mucous membranes more pronounced and persistent, +the febrile movement is of a higher inflammatory character, and the +eruption, which instantly covers the whole body (Vogel), is made up of +dark-red or purplish spots which fade slowly. It is this form of +measles, according to Niemeyer, which is chiefly attended by croupous +instead of catarrhal laryngitis, in which the inflammation of the +air-passages often extends to the alveoli of the lungs, and in which +the gastric and intestinal coats are often affected with catarrh. + +{569} Let the contagion of measles be a grade more virulent, or +perhaps the resisting power of the patient more feeble, and the case +will assume the features of the septic, typhous, or hemorrhagic +variety (rubeola nigra). It is said that the hemorrhagic measles is +most apt to occur in epidemics; certain it is that the dreaded black +measles of former times is very infrequent now-a-days, due, no doubt, +to a more rational treatment and a better hygiene. Isolated cases, +however, are occasionally encountered. As a rule, from the beginning +all the symptoms evidence an overwhelming of the system by the +virulence of the poison--a condition of things much more common in +scarlatina. The pulse becomes weak, thready, and frequent; the +temperature lacks the typical remittent character of normal measles; +there is unusual prostration; and the nervous centres are profoundly +concerned, as shown by delirium, convulsions, and coma. The eruption +lags, and finally makes its appearance in an imperfect or irregular +manner. The spots are of a livid hue, interspersed with larger or +smaller ecchymoses. Hemorrhages from the mucous cavities take place, +and the patient dies in convulsions or sinks into fatal coma. It has +been said that the grave constitutional symptoms do not generally make +their appearance till the eruptive stage, but I know from experience +that the patient may be overwhelmed quite early, as in purpura +variolosa. + +Too much stress should not be laid on these different types of the +disease, whether mild or grave, since they depend upon a common cause, +however much modified in one way or another; but they may be allowed +to stand for the sake of clinical convenience. + +Measles may also present certain irregularities in its various stages +without necessarily departing from the otherwise benign character of +the disease. + +As stated elsewhere, it is believed by some writers that a greater +part of the period of incubation is occupied by symptoms which already +indicate the activity of the measles poison in the system, and that, +therefore, this stadium in reality lasts but a few days. This opinion +does not seem to be generally accepted; at any rate, I think we are +quite safe in saying that in the majority of cases no departure from +the usual latency is observed. The deviations in the stage of invasion +have been considered above, and mostly concern its duration and the +character of the temperature. Evanescent rashes, which have nothing in +common with the specific exanthem, are sometimes observed at this +period. The eruption of measles may present certain peculiarities. +First, as to localization. Instead of coming out on the face first, it +may primarily develop on other parts of the body, provoked into +existence, as it were, by local exciting causes; thus, where ointments +or plasters have been applied or upon a part subjected to constant +pressure. It may affect only one-half of the body, or entirely spare +paralyzed extremities (Mayr). In some instances the papules are so +sparse, indistinct, and short-lived as to be scarcely appreciable. + +Second, as to the physical characters of the eruption. Hebra and Mayr +recognize the following modifications: + +Morbilli laevis. The efflorescence is smooth and flat, and the +individual lesions are separated from each other by normal integument. +This is the common form of measles. + +{570} Morbilli papulosi. The papules are dark red and more elevated, +are about the size of hempseeds, and situated at the mouths of the +hair-follicles. + +Morbilli vesiculosi. In this variety the mouths of the hair-follicles +are filled with fluid and produce delicate transparent vesicles. + +Morbilli confluentes. The maculae are here so crowded together that no +healthy skin intervenes. + +Morbilli haemorrhagici. The efflorescence consists of maculae or +papulae of a dark-red color, due to extravasations of blood, and do +not fade on pressure. It is well to mention in this connection the +fact, particularly noted by Meigs and Pepper in this country, that +hemorrhages into the skin may occur in cases which otherwise run a +benign course. They are best seen after the eruption has faded. In +some cases the efflorescence of measles may remain visible for a week +or ten days. + +As heretofore observed, there may be a relapse of the measles eruption +after some weeks, accompanied by fever. It is said that the spots +appear on parts of the skin hitherto normal (Thomas). So far as I +know, Hebra was one of the first to point out the fact that the +so-called striking-in of the eruption was the result, and not the +cause, of some complication in the disease; for, as this author +states, before the rash fades or disappears the internal disease is +always present. It is well known, for instance, that syphilitic +eruptions will sometimes disappear upon the supervention of some acute +intercurrent affection, such as pneumonia, acute rheumatism, etc.; but +no one will suppose for a moment that the retrocession of the +syphilides was the cause of these affections.[24] The pathological +explanation seems obvious. + +[Footnote 24: See Bumstead and Taylor on _Venereal Diseases_, 4th +edit., p. 513.] + +COMPLICATIONS.--The complications of measles consist, as a rule, in +the exaggerated morbid action of organs or parts that are essentially +implicated in the disease; therefore we are most apt to encounter such +affections as laryngitis, bronchitis, pneumonia, etc. Inflammation of +serous membranes, on the other hand, are rare; thus, pleurisy is +infrequent unless in connection with a lobar pneumonia. + +The exact causes of the complications are not always obvious, but in +many instances can be traced to the previous bad health of the +patient, to the influence of insanitation, or, finally, to certain +ill-understood features attendant upon some epidemics. + +Simple bleeding from the nose, not associated with the hemorrhagic +diathesis, is not an uncommon accompaniment of the prodromal stage, +and is rarely a dangerous symptom--rather the contrary. It may also +arise after the development of the rash, and occasionally proves a +complication of serious import. + +The aural complications, unlike those in scarlatina, are generally not +sufficiently prominent at first to attract attention. The symptoms, +particularly pain and deafness, are apt to be masked. Purulent +processes and consequent perforation may occur during the eruption, +but are more frequent at the stage of desquamation (Spencer).[25] + +[Footnote 25: Oral communication.] + +Various disorders of the skin have been observed during the course of +measles--viz. miliary vesicles, and even pustules, as already +described; herpes facialis, zoster femoralis (Thomas), and +erythematous rashes, which {571} may precede, accompany, or, it is +said, follow the eruption. Of considerably more importance is the +pemphigoid eruption mentioned by several observers. In Henoch's[26] +case, a girl of four years, the usual remission of the fever on the +evening of the second day was absent, and from the third day there +appeared over nearly the whole surface blebs filled with a limpid +fluid, which varied in size from a hazel-nut to a thaler, and even +larger. The cheeks and the backs of the hands were each covered with a +single bleb. The exanthem was of a hemorrhagic character, and the +intervening skin was red and the face swollen. The bullae appeared not +only where the eruption existed, but also on parts of the body free +from it. The fever remained at the same height till the fifth day, +when, upon the cessation of the bullous eruption, it fell to 100 +degrees F. A.M., and 101 degrees F. P.M. The child died on the eighth +day of a pneumonia which developed between the sixth and seventh days. +Other cases have been reported by Steiner, Kluppel, and Loschner. +Henoch rejects the theory that the bullae are the result of the +morbillous dermatitis, but thinks that they are merely instances of +the coincidence of a contagious pemphigus. + +[Footnote 26: _Berl. klin. Woch._, No. 13, 1882.] + +The severe affections of the eye described by continental +writers--blennorrhoea, keratitis, iritis, etc.--are certainly very +rare in this country as complications of measles. Various so-called +strumous disorders of this organ, as will be seen hereafter, not +uncommonly, however, come under the care of the ophthalmologist as +sequelae of the disease. + +The tonsils and the mucous membrane of the pharynx may become severely +inflamed. The tonsils are sometimes very much enlarged, but +suppuration, if it occur, is certainly rare. Slight ulceration of the +gums close to the teeth is occasionally noted, also aphthous +ulcerations on the lips, tongue, and gums (Ringer). + +Some degree of laryngitis is an accompaniment of all cases of measles. +It has already been stated that catarrhal or false croup is frequently +observed during the stage of invasion. Inflammation of the larynx may +be present in all grades of severity. Rilliet and Barthez found +ulcerations and erosions, especially of the vocal cords, upon +post-mortem examination of a large proportion of measles subjects; and +Gerhardt, both during life and by autopsy, has verified these +observations. Loeri[27] states that inflammatory changes are more +marked in the larynx and trachea than in the pharynx. According to his +examinations, hemorrhages or ecchymoses seldom occur, but more +frequently superficial or even deep catarrhal ulcers, especially on +the anterior aspect of the posterior wall of the larynx at the apices +of the cartilages of Santorini, or on the posterior portion of the +vocal cords. The physical condition of these parts readily accounts +for the frequent and harassing cough and attacks of spasmodic +laryngitis which are such frequent complications of the invasion and +eruptive stages of measles. + +[Footnote 27: _Jahrb. f. Kinderheilk._, xix. B., 1 H.] + +There may be an extension of the tracheo-bronchitis to the finer +bronchial tubes, thus producing capillary bronchitis (suffocative +catarrh). It is apt to prove fatal to very young children. It occurs +more generally during or after the eruption. + +Pneumonia is one of the most frequent and, directly and indirectly, +most dangerous complications of measles. Catarrhal pneumonia +(broncho-pneumonia) is, for obvious reasons, more common than the +lobar or {572} croupous variety. Pneumonia may develop at almost any +stage of measles, but experience does not confirm the statement +occasionally made that it is most frequent in the initial stage. Most +observers will agree as to its greater frequency just at the end of +the eruption or during the desquamative period. The occurrence of +epileptoid convulsions, or an untoward increase of the fever, or an +unexplained continuance of the same, should direct the attention of +the attendant to the chest, if his anxiety have not already been +aroused by a change in the character of the respiration or other +symptoms. It may be mistaken for meningitis (Squire). In estimating +the prognosis it should be remembered that croupous and catarrhal +pneumonias run quite different courses. The influence of inflammation +of the lungs upon the rash is quite decided. If an intense pneumonia +should develop in the initial stage, the eruption will be pale and +sparse, or else absent; if the eruption is already out at the time of +the attack, it may become temporarily more vivid, to rapidly fade +later.[28] + +[Footnote 28: A scanty rash by no means indicates an unfavorable +course of the disease; this symptom is only serious when evidently due +to some complication.] + +Chadbourne[29] has the merit of calling attention to the occurrence of +heart-clot and subsequent pulmonary oedema as a fatal complication of +measles. In a number of autopsies he found that in each case the heart +contained clear gelatinous clots of a very firm consistence, which in +most instances extended to the pulmonary arteries, and in some to the +extent of one and one-fourth inches. In the series of cases observed +by him pneumonic consolidation was mostly absent, and there was very +little evidence of collapse, but the lungs were exceedingly +oedematous. But Keating has also found heart-clot to be the cause of +death in some cases, and believes, as the result of his +investigations, that the presence of large numbers of micrococci in +the blood and in the white blood-corpuscles is responsible for this +condition.[30] + +[Footnote 29: _Am. Jour. Obstet._, Oct., 1880.] + +[Footnote 30: _Phila. Med. Times_, Aug. 12, 1882.] + +There is a strong tendency in measles to intestinal catarrh. As +already stated, a quite sharp diarrhoea is not uncommon at the +beginning of the eruptive stage; but, unless it should prove very +profuse and long-continued, it is not to be looked upon as of very +serious import, especially if the other general symptoms of the +disease are following a normal course. In other instances the bowel +affection may be much more severe, giving rise to tenesmus, bloody +stools, and the other phenomena of colitis. In weakly children the +early diarrhoea may persist in spite of treatment for many days; +indeed, under the influence of high temperatures it may take on a true +choleraic character. Diarrhoea is a very frequent and grave +complication of the broncho-pneumonia of measles. + +Acute miliary tuberculosis as an immediate concomitant of measles is +rare. According to Thomas, the disease at times immediately follows +the exanthem, and reaches a fatal issue in a few days or weeks. The +tubercles are more particularly to be found in the lungs and in the +membranes of the brain. + +Among the more common disturbances of the nervous system convulsions +play an important role. The epileptoid seizures of the prodromal stage +generally terminate favorably, but in some cases of a malignant +character the onset of the disease may be ushered in with fatal {573} +convulsions. Convulsions in the later stages are apt to have a lethal +termination, as they usually occur in connection with some grave +complication, particularly of the thoracic organs. + +Diphtheria is an exceedingly grave complication of measles, although +not necessarily a fatal one. It is of less frequent occurrence than in +scarlatina. It may attack any of the usual oral, nasal, or laryngeal +regions, sometimes extending into the bronchi, but suffers no +modifications in its symptoms and course from the primary disease. It +may also rarely involve other parts--_e.g._ genitals, eyelids, etc. +There is reason to believe that it is most prone to attack those cases +in which the mucous membranes have undergone the greatest inflammatory +alterations.[31] + +[Footnote 31: Loeri (_loc. cit._) says that diphtheria may appear at +any stage of measles, and commences generally in the larynx, and +sometimes in the trachea simultaneously; seldom in the pharynx, as in +primary diphtheria or in that complicating other diseases than +measles.] + +Many other complications of measles have been recorded in literature +(see Thomas, _op. cit._); but it is no doubt true, as observed by +Bohn, that very few of them have a real essential connection with that +affection, and might as readily be associated with any other malady, +especially in already vitiated constitutions. In the above sketch the +endeavor has been made to indicate those disorders which from the +nature of measles would seem to have a more or less close and definite +relationship to it. It is certain that the more serious complications +and sequelae of measles are comparatively infrequent in private +practice in America, although common enough in continental Europe, and +to a certain extent in the children's asylums and foundling hospitals +in this country. + +SEQUELAE.--It is a difficult matter to dissociate the complications +and sequelae of measles. Properly speaking, the sequelae are to be +looked upon as the complications which have continued in existence +after the subsidence of the exanthem; but it is also customary to +include under this head certain affections that are the result of the +derangement of the system by the morbillous process. + +As would be expected, among the most frequent sequelae of measles are +those diseases which have their seat in the mucous membranes. Thus, we +may observe various grades of inflammation and ulceration of the +larynx, trachea, and bronchial tubes. According to Loeri, follicular +ulcers of the larynx always give a bad prognosis, for these cases +usually succumb to tuberculosis. It is not uncommon to observe a +bronchial catarrh, apparently simple in nature, which persists with +frequent exacerbations for many months. The very frequent +broncho-pneumonia, which occurs as a complication, always remains as a +sequel, or it may develop after the morbillous process has come to an +end. In favorable cases recovery may take place in two or three weeks, +or, preceded by hectic and progressive emaciation, the disease may +prove fatal after a number of months. But even here it is not +impossible for affected persons to recover. + +Chronic pulmonary tuberculosis is one of the most formidable and +frequent sequelae of measles. It is a not uncommon occurrence that, +with the exception of some trivial bronchitis, a patient may +apparently recover his health completely, and only after a lapse of +time slight daily elevations of temperature, accompanied by loss of +appetite and emaciation, {574} first give warning of the impending +danger. This form of phthisis may follow either croupous or catarrhal +pneumonia. Granular meningitis or general miliary tuberculosis also +frequently follows in the wake of measles, connected in many cases +with foci of caseous degeneration in the involved lymphatic glands or +unabsorbed pneumonic exudation. + +Various gangrenous affections, particularly of the oral cavity (noma) +and genitals, but also of the skin, subcutaneous connective tissue, +cartilages of the nose, ear, etc., are often to be observed after an +attack of measles. Cancrum oris is to be especially noted. + +Albuminuria is not an essential sequel of measles, although it may +occasionally occur as the result of great exposure and neglect. + +A large group of chronic affections may follow in the track of +measles, either in the form of sequelae to the complications which +arise during the course of the disease or in the nature of secondary +accidents. Some few, perhaps, are more common after measles than after +any other complaint, but the majority are such as might arise in +weakly children subsequent to any specific disturbance of the health. +In addition to those already mentioned we may especially designate +chronic intestinal disease, together with ulcerations and strictures +of the bowel; chronic coryza, in varying degrees of obstinacy and +severity; chronic ophthalmia, under which title may be included +ciliary blepharitis, granulations, trachoma, phlyctenular +conjunctivitis, ulcers of the cornea, etc. (Michel[32]); aural +affections in the form of chronic suppurative inflammation, and, more +rarely, chronic catarrh of the middle ear (Spencer); certain cutaneous +diseases, more especially in my experience furunculosis and pustular +eczema; chronic bone and joint disorders (strumous), which, according +to Gibney,[33] may not only be evoked in the already hereditarily +predisposed, but also induced when the diathesis has not heretofore +existed; and, lastly, various derangements of the nervous system. + +[Footnote 32: Oral communication.] + +[Footnote 33: See valuable statistical article in _N.Y. Med. Record_, +June 3, 1882.] + +In Thomas's valuable and freely-quoted monograph on measles (_op. +cit._) it is stated that secondary measles can exert various +influences upon the primary disturbance. In most instances when +measles attacks a person already the subject of some other disease, +particularly when the latter belongs to the common complications of +the former, it usually is aggravated. This is a matter of common +experience; but this author further declares--and supports his +assertion with numerous references--that, on the other hand, should +measles appear during the existence of a disease to which it does not +usually give rise, it may favorably influence the course of the +latter. In spite of the cases quoted in support of this view, such +results would appear to be contrary to pathological laws.[34] + +[Footnote 34: Thus, while Thomas seems to be without personal +experience in the matter, he quotes without dissent a number of +observations in support of his assertion--viz.: Behrend saw a chronic +eczema of the scalp permanently disappear after measles; Rilliet found +that a chronic coxitis improved noticeably after measles; various +chronic skin symptoms, and also chorea, epilepsy, incontinence of +urine, mania, worms, dropsy, joint diseases, ophthalmia, gonorrhoea, +etc., have been known to recover under the same influence. Gibney +(_loc. cit._) in his valuable paper states that he can readily believe +that, occasionally, any acute disease, occurring in the course of a +chronic one, will prove beneficial to the other, but that he is far +from considering this to be anything more than an exception to a very +general rule to the contrary. Chronic joint disease, he continues, is +especially a disease of exacerbations, and any one not familiar with +their natural history may interpret the post hoc as a propter hoc. +Gibney has collected 24 cases of chronic bone disease in {575} +children, 21 of whom were under ten years of age and all under +thirteen. On analysis he found that 12 of these came out of the +intercurrent disease in a worse condition, 11 were unaffected, and 1 +only seemed a little better. In my personal experience I have +invariably seen the eczemas of children made worse by measles. I have +no wish to dispute the trustworthiness of the statistics quoted by +Thomas; indeed, I regard them as mostly thoroughly reliable instances +of exceptions to a general pathological law; but I wish it to be +clearly understood that they are such, and that measles is not a +disease to be slightly regarded as to its effects upon the system.] + +MORBID ANATOMY.--The normal rash of measles is not to be observed on +the dead body, and the only lesions of the skin to be noted are those +resulting from extravasation of blood into that tissue. Examination of +the skin removed during life from a patient with measles reveals the +following anatomical changes, according to Morris.[35] In the earliest +stages are found usually slight hyperaemia around the orifice of a +sebaceous follicle, with slight swelling from effusion of plasma. +Occasionally swelling alone is present, and more rarely hyperaemia +only. Round the small hyperaemic papule thus developed--often pierced +by a hair--a roseolar patch, due to congestion of the papillary body, +soon makes its appearance. Slight exudation of plasma, with a few +corpuscles, usually follows, and produces elevation of the papule +itself. As most of the deaths in measles are due to the presence of +some complication, the post-mortem changes will be found to correspond +to the lesions produced by these diseases, principally affections of +the respiratory organs and intestinal tract. + +[Footnote 35: _Skin Diseases_, Phila., 1880, p. 57.] + +DIAGNOSIS.--As a rule, the diagnosis of measles offers no great +difficulties, especially if a correct clinical picture of the disease +has been thoroughly impressed upon the mind. The salient points may be +thus summarized: A period of incubation of about fourteen days--_i.e._ +from the date of infection to the commencement of the eruption; a +prodromic stage of about four days, ushered in with fever and marked +implication of the mucous tract, notably cough, coryza, epistaxis, and +photophobia; in this stage may also be noted the punctated redness of +the conjunctivae and of the palatal mucous membrane, which is to be +regarded as a diagnostic sign of great value and importance; finally, +there appears at the conclusion of the stage of invasion, +simultaneously with increase of the febrile movement, a characteristic +eruption upon the cutaneous surface, this eruption coming out first +upon the face, and composed of large maculo-papules of brownish-red +color, arranged in a crescentic form with tracts of normal integument +intervening. Of all the symptoms of measles, the catarrh of the mucous +membranes is undoubtedly the most pathognomonic. In the colored races, +where the recognition of the skin lesion is often a matter of +difficulty, this combination of symptoms should be borne in mind.[36] + +[Footnote 36: Corre (_La Mere et l'Enfant dans les races humaines_, +Paris, 1882) states that measles and scarlatina exist in all climates +and among all races; however, they are less frequent in warm than in +cold climates. This relative rarity may be only apparent, and has only +been established by reason of the difficulty of recognizing exanthems +among dark-skinned peoples. In the negro the eruption (of measles) +often escapes observation, but the general symptoms, the angina, +coryza, and bronchitis, and the special coloration of the +bucco-pharyngeal membranes, permit the establishment of the diagnosis. +The skin appears more tense, and the face especially is puffed and +glossy; in passing the hand over the different regions of the body +slight elevations are felt--a difference in the level of the skin +exists in the affected and unaffected portions. On examining the +surface of the body obliquely at a well-pronounced angle of incidence, +these elevations can be perceived by the eye. Desquamation, which is +very manifest in the negro, also confirms the diagnosis; this +desquamation is formed of epidermic debris; it gives rise to a {576} +white dust, which is well defined against the black skin. The skin +itself seems to have lost its gloss; it is completely dry, and no +longer gives the abundant and odoriferous secretion characteristic of +the subjects of that race.] + +In the way of conjectural diagnosis, the presence of an epidemic of +measles in the community should be taken into account. Although +measles possesses features so characteristic and pronounced, there are +a number of other diseases with which it may be confounded, especially +in its earlier stages. + +There is no other disease which presents so close a resemblance to +measles as does rotheln, and it must be confessed that under certain +circumstances the question of diagnosis is a perplexing one. In +rotheln the appearance of the eruption is often the first symptom of +the affection, whereas in measles there is a prodromic period, having +a peculiar remittent type of fever, which continues for three or four +days. According to Liveing, the short duration of the febrile attack +before the eruption appears is one of the most constant and +distinctive features wherein rotheln differs from ordinary measles. In +some instances, in rotheln the premonitory fever is not at all +appreciable. The catarrhal involvement of the mucous membranes is not +nearly so marked as in measles, while the very frequent sore throat +bears more resemblance to the angina of scarlet fever. In many +instances, although by no means constantly, the eruption of rotheln +first appears on the chest, and not on the face, as is the rule in +measles. It is quite evident that the eruptive spots of rotheln have +presented different physical features in different epidemics; but, as +a general thing, it may be said that they are smaller than those in +measles, of a paler color, and, according to Thomas, not so angular, +less indented, and not so often provided with processes, therefore +less apt to assume the crescentic arrangement so often seen in +measles.[37] The incubation period is longer in rotheln than in +measles. + +[Footnote 37: According to Curtman (_St. Louis Courier Med._, June, +1882), the eruption of rotheln consists, when not confluent, of single +papules, each separated by a distinct small red areola. Not +infrequently the papules are large, and sometimes a few pass into +vesicles or pustules. In measles the papules are very small, mostly +confluent, from four to six landing on a single areola, which is +larger than that of rotheln.] + +In scarlet fever the incubation stage is shorter than in measles, and +the constitutional symptoms are apt to be more pronounced; the +temperature is higher, the pulse more rapid, and vomiting more +frequent. The stage of invasion in scarlatina is but twenty-four +hours; in measles, seventy-two. There is absence of the characteristic +catarrh of measles, and the presence of severe sore throat, strawberry +tongue, and swelling of the lymphatics at the angle of the jaws. In +measles the rash begins on the face; in scarlatina, on the neck and +chest. In measles the eruption consists of large papules arranged +somewhat crescentically, with intervening normal skin, followed by +bran-like desquamation; in scarlatina the rash is made up of large +patches formed of minute red spots on a bright red, hyperaemic base, +and is followed by desquamation in large lamellae. In measles the rash +is brightest on exposed parts; in scarlatina, most vivid on covered +regions. The sequelae of the two diseases are quite different. + +There is no great difference in the duration of the invasion stages of +variola and rubeola; but in the former disease we have the marked +lumbar and sacral pains and vomiting, while in the latter the +catarrhal symptoms and photophobia are pathognomonic. When the +eruption of {577} small-pox appears there is subsidence of fever; in +measles, an exacerbation. A point of great importance in the diagnosis +of variola is found in an examination of the mouth and pharynx, for in +these situations on the fourth day we will often find the vesicles +fully developed, while on the skin they are still in the stage of +papulation. When measles assumes the papular form (morbilli papulosi, +rougeole bouttoneuse), it is often confounded with the papular stage +of small-pox. I have seen a number of such mistakes made. Attention to +the general symptoms of the two diseases, however, and particularly an +examination of the mucous membranes, will generally clear up any +doubt. At any rate, the question will generally settle itself in the +next twenty-four hours, for if it be variola the papules will have +undergone their specific development and the rubeolous elevations will +have become more decidedly macular. + +Typhus sometimes offers a certain resemblance to measles. According to +Buchanan,[38] the eruption of typhus is occasionally, though not +commonly, a good deal like that of measles, and appears about the same +time after invasion. Coryza, when present and distinct, points to +measles. The eruption of typhus is of a smaller pattern, discrete, and +not raised; that of measles, often coalescent, crescentic, and +elevated. Subcuticular mottling is present in typhus, and absent in +measles. The palatal mucous membrane should always be examined in +suspected measles. + +[Footnote 38: Art. "Typhus" in _Reynolds's System Med._, Am. ed., p. +262.] + +As I have never been able to convince myself of the existence of an +independent disease called roseola, I am at a loss to give the points +of differential diagnosis; on the other hand, the various forms of +symptomatic erythema, occurring either as the result of numerous +slight derangements of the system, or in connection with grave +constitutional disease, should be carefully considered. In the first +group of cases the absence of premonitory symptoms, catarrh, etc., and +the presence of the smooth, rose-colored macules, mostly on the trunk, +and in the latter the existence of symptoms belonging to the primary +disease, should prove of assistance. The erythema papulatum of +new-born children I have seen mistaken for measles, but the fact that +rubeola is exceedingly rare in sucklings, and the absence of fever and +catarrhal disturbances, are sufficient grounds for a differential +diagnosis. + +The erythematous syphilide (roseola syphilitica), particularly when +accompanied by fever, may bear some resemblance to the rash of +measles; but the history of the case, the circumscribed, indolent +character of the syphilide, in many instances sparing the face, the +absence of pathognomonic catarrhal symptoms of measles, and the +coexistence of other features of syphilis, are quite distinctive. + +PROGNOSIS.--The prognosis of normal uncomplicated measles is very +favorable. Thus, of 257 cases observed by Meigs and Pepper (_op. +cit._), all terminated favorably. But in coming to any conclusion in +regard to prognosis a number of different factors must be taken into +consideration. Among the more important are--the hygienic surroundings +of the patient, the age, the nature of the complications, whether the +measles be primary or secondary, and the character of the epidemic. In +the first place, rubeola in foundling hospitals and among the poorer +classes in large cities gives a larger ratio of deaths than among the +well-to-do members of the community. For instance, Bartels has shown +that catarrhal pneumonia, one {578} of the most frequent causes of +mortality in this disease, is particularly prone to occur among those +dwelling in crowded, poorly-ventilated houses. Then, again, the +asylums and hospitals for children are peopled in many instances with +the victims of depraved constitutions, who readily succumb to +intercurrent maladies. + +Leaving out of consideration sucklings under six months of age, in +whom measles is rare and said to be slight, most deaths from the +disease occur among very young children, from their greater liability +to complications. According to Beddoes,[39] the mortality from measles +is, beyond all comparison, greatest in the second year of life, and by +the tenth has become quite trifling. An examination of the statistics +bearing on this question coincides with this general statement; but +Fox's tables, already quoted, would show that more infants under one +year of age die of measles than has hitherto been supposed. The +susceptibility to measles decreases with years, perhaps on account of +the fact that most adults have already contracted the disease; but +when it does attack the unprotected adult it may prove fatal. This +statement is borne out by the large death-rate in the so-called camp +measles of our late war.[40] The ravages of measles in virgin +communities have been referred to in preceding pages. The general +temper of the epidemic must also be considered, since it is well +recognized that the essential character of epidemics differs much as +to severity. + +[Footnote 39: Art. "Mortality" in _Quain's Dictionary Med._, p. 1002.] + +[Footnote 40: In the general field hospital at Chattanooga the +death-rate was 22.4 in 100 cases. In General Hospital No. 1, at +Nashville, it was 19.6 in 100, or nearly 1 in 5. Many died or became +permanently disabled from the sequelae (Bartholow).] + +Such complications as diphtheria, catarrhal pneumonia, diarrhoea, +convulsions, etc. necessarily affect the prognosis of measles most +seriously. More patients die of measles in the second than in the +first week of the disease. The careful studies of temperature made by +Thomas, Bohn, and others show that an unusually high and increasing +fever in the prodromal stage is of ill omen, particularly on the +second and third days, and a fever heat measuring over 105 degrees F. +at any stage should be considered as very unfavorable.[41] +Particularly to be feared is continuation of the fever after the +subsidence of the eruption, or a sudden elevation after the normal +curve has been reached. In fact, it is a safe rule to look upon all +anomalies of the curve with suspicion. Secondary measles, or measles +grafted upon some serious existing affection, is particularly fatal. + +[Footnote 41: In adolescence a body heat of 107 degrees F. has been +safely passed during the decline of measles with no marked +complication (Squire).] + +TREATMENT.--There is no remedy which will destroy the susceptibility +to measles. The future may develop some form of vaccination against +rubeola, for, certainly, the hopes held out by the inoculation of +measles upon the healthy subject have not been realized, as this +procedure merely reproduces the original complaint, without any +diminution in its intensity, and does not lessen the probability of +complications (Mayr). The matter of carrying out a practical and +efficient quarantine in measles is one of unusual difficulty, for the +reason that the disease is capable of active propagation at a +time--the prodromal stage--when it is not yet sufficiently +characteristic for positive diagnosis. But, as measles is by no means +as trivial a disease as would seem to be the common impression, I hold +it as a well-established principle of preventive medicine that a {579} +strict isolation should be enforced whenever, from the nature of the +case, it is at all possible; certainly, very young children and those +suffering from or showing a tendency to other diseases should be +jealously shielded from exposure. + +The usual precautions as to disinfection and purification of the room, +bedding, and utensils used by patients should be observed, as in other +infectious diseases. Squire is of opinion that there is danger of +personal infection for perhaps a month, and Hillairet that isolation +for forty days should be enjoined. It is quite certain that inunction +lessens the danger of infection, and Kaposi[42] is authority for the +statement that a warm bath administered after the completion of +desquamation, or about fourteen days from the beginning of the attack, +will effectually prevent contagiousness. + +[Footnote 42: _Pathologie u. Therapie der Hautkrankh._, Wien, 1880.] + +The apartment occupied by a patient suffering from measles should be +kept at a uniform temperature of from 66 degrees to 70 degrees F., and +free ventilation, at the same time avoiding draughts, should be +enforced. The room should be kept moderately dark. The bed-clothing +should be light, yet sufficiently warm, and the old notion of keeping +the patient in a profuse sweat the better to bring out the eruption +should be discouraged. The diet should be bland and nutritious, and +may preferably consist of milk, gruel, tapioca, and such like +substances. As convalescence progresses there may be a gradual return +to more substantial food. The patient may be allowed cool water in +moderation, as it is cruel and useless, and even harmful, to restrict +one suffering with fever to warm or sweetened drink. The patient +should be confined to his room until convalescence has been fully +established, and should not be allowed to leave the house, both on his +own account and that of others, until the usual health has been +regained. Any of the lingering results of the disease, such as +bronchitis, otorrhoea, conjunctivitis, etc., should receive prompt +attention; iron and cod-liver oil should be prescribed for the weakly +and strumous, and regular hours of sleep, careful diet, and +appropriate bathing and exercise should be advised. It may be said, +without exaggeration, that neglect of the after-care of measles +patients is, in some instances, more to be deprecated than a similar +neglect in the actual treatment of the disease itself. + +Since we are powerless to cut short an attack of measles by any +remedial agents at present known to therapeutics, the intervention of +the physician is limited to assisting the cases through to a safe +termination. Quite a number of cases, as seen in private practice, +require no special medicinal treatment, or at most one that is merely +symptomatic. The value of the so-called specific treatment, such as by +carbonate of ammonium, etc., has not been verified by experience. + +In ordinary uncomplicated attacks, if the temperature should run high, +in addition to the general rules as to diet and hygiene referred to +before it will usually be found advisable to put the patient on some +diaphoretic mixture, to which may be added a mild opiate. I know of +nothing better than the formula found in the work of Meigs and Pepper +on the _Diseases of Children_: + + Rx. Potass. Citrat. drachm i; + Spt. Aetheris Nit. fl. drachm ii; {580} + Tr. Opii Deodorat. minim xii vel xxiv; + Syrupi fl. drachm ii; + Aquae fl. oz. ii. M. + +S. A teaspoonful every two or three hours for a child of five years of +age. + +Aconite in small doses has been well spoken of in this connection, but +I have no personal experience in its use. Bromide of potassium, +together with a few drops of syrup of ipecac., dissolved in syrup of +wild cherry, acts pleasantly both on the cough and the nervous system. + +The inunction of fatty substances, as originally proposed by +Schonemann, and recently urged by Milton,[43] is an excellent routine +practice, and in addition to adding very much to the patient's +comfort, has, perhaps, the merit of lessening somewhat the danger of +infection to others. For this purpose one may use leaf lard, cold +cream, or vaseline, to each ounce of which it is well to add a few +minims of carbolic acid. + +[Footnote 43: _Archives of Dermatology_.] + +Stimulants are rarely needed in uncomplicated measles, but Squire very +wisely calls attention to the great value of wine in the depression +following upon the crisis. + +In spite of some excellent authority to the contrary, I cannot see +that any benefit is to be derived from using severe measures to bring +out an eruption that has undergone retrocession. As stated in another +part of this article, the so-called striking-in of the rash is the +result of the supervention of some complication, and not the cause of +it; therefore, a rational course of action would be to ascertain the +nature of the complicating trouble, and to endeavor to correct it, +which, at the same time, would be the very best means of restoring the +normal course of the disease. + +Quinia is of great value in controlling the excessively high +temperature which is sometimes observed either in connection with, or +independent of, complications. If the quinia should prove ineffectual +or else be rejected by the patient, the physician should not hesitate +to abstract heat by cold water in the shape of the wet pack or the +general bath. I think the latter method is to be preferred. It is but +to employ the gradually cooled bath of Ziemssen, perhaps, commencing +at 90 degrees F. and going to 80 degrees or 70 degrees F. The +condition of the patient, as ascertained by the thermometer and also +the state of the pulse, must be the guide as to the duration and +repetition of the baths. In Germany excellent results are claimed for +the treatment of hyperpyrexia in measles by the cold pack, even when +the excessive temperature is due to such a complication as +broncho-pneumonia. + +There is little hope from therapeutical interference in malignant +forms of measles, but the medical attendant should endeavor to reduce +temperature and support the strength by free stimulation and +nourishing food. + +It will now be advisable, at the risk of some repetition, to call +attention to the treatment of some of the more prominent disturbances +and complications of measles. + +Epistaxis, if severe, should be checked by cold applications and +astringents. Plugging will rarely be found necessary. Trousseau +recommends the injection of water as hot as can be borne. Ergotine by +the mouth or hypodermically will sometimes prove highly valuable. + +The lids should be anointed with vaseline or cold cream to prevent +their sticking together, and it is well to occasionally evert them to +see that no {581} serious mischief has happened to the eye. If the +conjunctivitis is intense, the discharges should be removed and cold +compresses applied. + +Since aural complications are due to extension of inflammation from +the oral and nasal cavities, Spencer urges the importance of early and +systematic treatment of these parts. He advises astringent +applications (Monsell's solution 1 to 4 of glycerine) to the +pharyngeal mucous membrane. Ointments of boracic acid, zinc, or +iodoform are likewise useful when introduced through the nostril. +Earache will require warm opiated poultices and inflation. Otorrhoea +is best treated after the dry method. + +For sickness of the stomach a spice poultice may be applied and small +bits of ice given to suck. If constipation exist, a little oil or +syrup of rhubarb or some stewed prunes, or an enema, may be ordered. +Active purgation should be withheld. + +The early diarrhoea need give little concern, as it usually soon +ceases; but if it should persist, recourse must be had to more +energetic measures, such as the use of opium by mouth or enema, given +cautiously in the case of children, vegetable and metallic +astringents, and the application of hot poultices to the abdomen. The +diet should be carefully guarded. + +The cough, even in mild cases, generally requires some slight +palliative, such as syrup of ipecac., and an occasional small dose of +Dover's powder. Loeri very properly advises against the use of +irritating expectorants. I think it advisable to keep the chest well +smeared with camphorated oil, over which should be worn an oil-silk +jacket. These simple measures, perhaps, diminish the tendency to +thoracic complications. The sometimes violent paroxysms of false croup +are very satisfactorily managed, after the manner of Graves, by gently +pressing a sponge, soaked in very hot water, under the chin and over +the front of the neck. When the dyspnoea is alarming, emetics, and the +general warm bath should be brought into requisition. + +Convulsions in the early stage require little treatment other than the +warm bath and appropriate doses of the bromide of potassium; occurring +later, they are very fatal under any treatment, as they generally +supervene in connection with some of the grave complications of the +disease. Chloral, preferably by enema, and chloroform may be tried. +The management of the severe bronchitis and pneumonia of measles +requires great care and circumspection on the part of the physician. +The application of a well-made flaxseed poultice, which should be +neither too heavy nor too hot, is to be regarded as invaluable. To the +flaxseed may be added a small quantity of mustard. Over the whole is +to be placed an oil-silk jacket. Alcoholic stimulants, nourishing, +easily-digested food, and expectorants containing carbonate of +ammonium are to be recommended. + +For the treatment of the other complications and sequelae of measles +the reader is referred to the appropriate sections of this work. + + + + +{582} + +ROTHELN.[1] + +BY W. A. HARDAWAY, M.D. + +[Footnote 1: In the preparation of this article the author has +consulted the following authorities: Emminghaus, in _Gerhardt's Handb. +der Kinderkrankh._, Zweiter Band, 1877; Thomas, in _Ziemssen's Cyclop. +Pract. Med._, vol. iii., Am. ed., 1875; Squire, in _Quain's Dict. +Med._, 1883. References to current literature will be found in +foot-notes to the text.] + + +SYNONYMS.--Rubeola, Rubella, Roseola, Epidemic Roseola, German +Measles, French Measles, Hybrid Measles, False Measles, Rubeola +Morbillosae et Scarlatinosae. + +DEFINITION.--Rotheln is an acute infectious disease, presenting an +eruption of reddish macules upon the skin, accompanied by mild +catarrhal symptoms, and usually producing but slight disturbance of +the general system. It is self-protective, and occurs but once in the +same individual. It has no relationship to measles or scarlatina. + +HISTORY.--A rapid glance at the interesting historical evolution of +rotheln to a specific position among the acute infectious diseases is +all that our space will allow. Some writers have attempted to show +that this affection was known to the Arabian physicians; but since it +is only in comparatively recent times that the contagious epidemic +exanthemata in general have been thoroughly differentiated, it is +quite likely that the modern conception of it was not held by them nor +by other medical men till many centuries later. Indeed, in our day, +physicians are yet to be found, though the number is rapidly +diminishing, who refuse to recognize in rotheln a distinctive specific +malady. Certain German observers in the middle of the last century (De +Bergen, 1752; Orlow, 1758) favored the idea of specificity, but these +views were soon disputed. In the years following a number of other +physicians announced their belief in the specific nature of rotheln, +while, on the other hand, various noted authorities still insisted +upon its connection with scarlet fever or measles. In 1815, Maton, an +English physician, most unequivocally declared that he had observed +cases of an eruptive disorder which resembled neither measles, +scarlatina, nor roseola, and which was worthy of a new designation.[2] +In the second and third decades of this century Hildebrand, and +afterward the celebrated Schonlein, taught that rotheln was a hybrid +of measles and scarlatina, although at this time Wagner (1834) +advocated the essential independence of rotheln. There is no doubt +that under the name of rubeola sine catarrho Willan, Bateman, and +later writers described what we now call rotheln, for they stated that +this variety of measles was not self-protective. Space will not allow +of a detailed mention of the various writers who, during the first +half of this century, {583} have contended for or against the autonomy +of rotheln. It will be well to state, however, that Hebra, from the +standpoint of the dermatologist, very properly regards the manifold +roseolae of Willan as in many instances merely symptomatic erythemata, +or else as irregular forms of measles or scarlatina; but he also fails +to recognize the distinctive features of rotheln. Even so recent a +writer as Niemeyer declares that roseola arising from infection +consists in a modification of measles or scarlet fever. It is only in +the last twenty years that our present exact ideas of rotheln have +obtained. For example, while Trousseau[3] asserts that rubeola +(rotheln) is a perfectly distinct nosological species, he speaks of +the rash as appearing and disappearing alternately for some days, of +its frequent recurrence in the same individual, etc. American +physicians were almost entirely ignorant of rotheln till within the +last ten years, when they were made acquainted with it through the +medium of a careful paper on the subject from the pen of J. Lewis +Smith of New York.[4] Before this time, however, cases had been +described by Homans, Sr., of Boston (1845), and in 1853 and 1871 by +Cotting. Very few authorities now dispute the distinctive specific +nature of rotheln; which statement is borne out by the fact that at +the last meeting of the International Medical Congress, held at London +in 1881, there were but two dissentients to this view in the section +before which it was discussed.[5] + +[Footnote 2: Squire, _Trans. Internat. Med. Congress_, London, 1881.] + +[Footnote 3: _Clinical Medicine_, vol. ii.] + +[Footnote 4: _Archives of Dermatology_, Oct., 1874.] + +[Footnote 5: See especially Kassowitz's paper, "Die Wirkliche Stellung +der sogenannten Rubeola," etc., _Trans. Internat. Med. Cong._, 1881.] + +ETIOLOGY.--The contagium of rotheln is unknown, but that the disease +is contagious has been fully demonstrated by numerous observations of +epidemics and sporadic cases. From my own experience I should judge +that unprotected persons are not so susceptible of it as is known to +be the case under similar conditions in measles;[6] yet cases are +recorded which would prove that the contagion may be conveyed through +a third person and for some distance. It is probable that the vehicles +of contagion are the same as in measles. At what period of its course +the disease is most capable of transmission has not been +satisfactorily determined. Squire is of the opinion, however, that the +disease is contagious before the appearance of the rash, and may +continue so for some days or for two or three weeks. Rotheln may be +called a disease of childhood for the same reason that the other +contagious exanthemata are--namely, that the majority of adults have +already been attacked. From an examination of available statistics I +am inclined to regard the ages between five and fifteen--the years of +school attendance--as the period of life most susceptible of the +influence of rotheln, although, of course, no time of life is entirely +exempt. The non-susceptibility of sucklings, as in measles, holds true +as a rule, although I am in a position to supply exceptions to this +from my own experience, as well as from that of others. Sex seems to +be without influence in determining liability to the disease. + +[Footnote 6: In this regard it resembles scarlatina more than measles, +for I have a number of times seen the disease introduced into +families, where it would attack one or two of a number equally +exposed. J. L. Smith regards it as feebly contagious, and quotes +Chadbourne's experience to the same effect. Liveing declares that +rotheln is more distinctly epidemic in Great Britain than either +measles or scarlet fever, although probably less contagious.] + +The period of incubation is not very definitely settled, and, indeed, +{584} owing to the generally trivial character of the affection, +evidence on this point is difficult to obtain. Taken as a whole, it is +probably longer than is observed in measles. According to J. Lewis +Smith, in the epidemic observed by him the incubation period varied +from seven, or less than seven, to twenty-one days; Emminghaus places +it at from two to three weeks; Thomas, from two and a half to three +weeks; Squire, mostly a fortnight, the extreme being twenty-one days; +Cheadle, from eleven to twelve days. + +There is nowhere recorded a trustworthy instance of a second attack of +rotheln, although from analogy such an event is to be expected. As in +measles, true recurrences of rotheln--that is, the result of a fresh +infection--are not to be confounded with relapses. I have never +witnessed a relapse, but cases of such a nature have been recorded by +other observers (Lindwurm, Emminghaus, Kortlin, Kingsley). + +Rotheln is a disease sui generis, and is in no way related to either +measles or scarlatina; that is to say, it is not an irregular form of +either of these nor a hybrid of them, nor has it ever been observed to +propagate anything but itself. That it is not connected with any of +the symptomatic skin eruptions--the so-called roseolae--is proved by +its contagiousness and epidemic character. I quite agree with other +observers in declaring that rotheln has very little clinical +resemblance to scarlatina, and that, on the other hand, in the +greatest number of cases the points of likeness are with measles. In +the section on diagnosis the differential points between rotheln, +measles, and scarlatina will be considered; therefore in this place it +will only be necessary to call attention to certain general facts. +Thus, aside from the marked divergence in clinical +symptoms--incubation, invasion, fever, eruption, complications, and +sequelae--we are at once met by the positive fact that epidemics of +rotheln, while always presenting identical features, prevail without +regard to the existence of similar epidemics of measles and +scarlatina--following or preceding them--and that attacks of rotheln +offer no bar to the reception of their contagions, or vice versa. +Literature is so full of examples of this statement that it need +scarcely be dwelt upon. By way of illustration, however, the accurate +observations of J. Lewis Smith may be quoted in this connection. Of 48 +cases recorded by him prior to May 1st in the New York epidemic of +1874, 19 had had measles. Rotheln in the N.Y. Foundling Hospital in +1873-74 followed an epidemic of measles. During the epidemic of +1880-81 the same fact was observed--namely, that a previous attack of +measles, as well as scarlatina, afforded no protection from rotheln. I +could multiply such examples from my own experience. A single +interesting instance may be noted here. A physician asked the writer +to examine his child, suffering, as he thought, from measles. A +careful investigation revealed a typical rotheln. A number of weeks +later an older child got measles, from which the rotheln patient +acquired a characteristic attack of the same. In the following year +both children were taken with scarlet fever. + +The only escape for those who would deny the autonomy of rotheln is in +the bold assertion that both measles and scarlatina more frequently +recur in the same individual than universal experience and observation +will allow; and this leaves them in the dilemma of determining to +which group rotheln must be relegated. The hypothesis of the hybrid +nature {585} of rotheln cannot be accepted by the pathologist nor the +clinician, if for no other reason than that no one has ever seen +rotheln generate anything but rotheln, and in no case give rise to +either scarlatina or measles. + +SYMPTOMS AND COURSE.--As already stated, the probable average duration +of the incubation period in rotheln is about fourteen days, varying, +however, within the limits of from six to twenty-one days. In this +respect rotheln resembles scarlatina more than measles, the period of +latency in the latter observing considerable uniformity. No deviations +from the general health are to be noted in the incubation stage. + +In most cases prodromal symptoms are entirely absent, the presence of +the eruption being the first thing to show the existence of rotheln in +the system. On the other hand, in a certain proportion of cases there +will be present for a half day, or even longer, the general symptoms +of malaise, such as slight nausea, some sore throat, pain in the +limbs, stiffness of the neck, etc. Vomiting is generally absent. J. L. +Smith records one case of convulsions in the stage of invasion, and I +have notes of a single case in which the prodromal stage was initiated +by mild delirium and fever, the latter anticipating the eruption for +two days and a half, and disappearing when the rash came out. As +Thomas well observes, however, such cases are anomalous, and indicate +either abnormal sensibility on the part of the patient or are due to a +secondary rotheln. + +Most observers (Emminghaus, Thomas, Smith, Squire) describe the rash +as coming out in the order usual in measles--namely, first upon the +face, scalp, and neck, then the trunk and arms, and finally the legs. +Others (Liveing, Morris) have stated that the rash first appears upon +the back and chest. In many cases in my own experience this has seemed +to be true. It is quite probable that the situation of the exanthem in +rotheln, as in measles and scarlatina, may present various +irregularities; but I am inclined to believe that a careful +investigation will in most instances show that the normal course of +the eruption is as first stated. Now, a marked characteristic of the +rash of rotheln is that, unlike that of measles, there is no period, +however short, in which its maximum is simultaneous over the whole +body; on the contrary, the eruption will have reached its full +development upon the face, and will be almost or quite faded again, +before the exanthem, for example, will have blossomed upon the trunk, +and especially upon the lower extremities. The duration of the +eruption upon individual parts of the body is probably from a few +hours to half a day at most (Thomas). A consideration of these facts +explains, according to Emminghaus, how different observers have +described the eruption as having its seat upon this or that region of +the body; in other words, it is probable that in a certain proportion +of the cases in which the rash was supposed to have begun on the chest +it had already run its course upon the face. The eruption usually +continues altogether about four days, sometimes disappearing sooner, +and sometimes being visible, especially as a fine mottling, for some +days longer. So far as the individual lesions of the eruption are +concerned, there is no question that they present, within a certain +range, varying aspects; and this clinical fact has been taken +advantage of by the opponents of the idea of specificity in order to +make it appear that the disease is not sui generis, inasmuch as it +lacks uniformity of expression. Such an argument wants force when we +consider that in making up a given diagnosis we lay stress {586} not +upon special, but upon the ensemble of, symptoms. For example, no one +would deny to measles an independent position because the eruption, as +is well known, may assume this or that form (morbilli laevis, m. +papulosi, etc.); on the contrary, we recognize a particular case or +series of cases to be measles from a due appreciation of all the +symptoms present. So it is to be expected that while the cutaneous +lesions will present a certain similarity of feature, as they do, +there will also exist minor differences in detail. + +In the greatest number of cases in my own experience the exanthem is +composed of ill-defined, roundish, punctate macules, without special +grouping. These are usually discrete, but in certain situations they +may coalesce. The color is of a pale rosy red, quite difficult to +describe, but less purplish than in measles, and not so livid a red as +in scarlatina. I have occasionally observed large irregular spots not +unlike those of measles.[7] + +[Footnote 7: According to Emminghaus (_op. cit._, p. 345), the +eruption generally forms roseolae of pin-head, lentil, or small bean +size. They are mostly round, sometimes oval, and bordered by +well-defined or by blurred edges. The intervening skin is not always +unchanged, for here and there we find upon it small dilated +blood-vessels, and from the spots processes extend with a certain +regularity to other spots in such a way as to give the skin a marbled +appearance.] + +Thomas distinguishes three types of eruption--one with large spots, +which is rare; one with medium-sized spots; and one with small spots. +Emminghaus describes a discrete and a more confluent variety. I have +observed one case where the maculae on the back had undergone a +vesicular transformation. Others have mentioned this occurrence. +Itching of the skin is marked in some cases, and a fine desquamation +is observed after the rash, but by no means invariably. + +The mucous membranes are implicated to a slight degree in rotheln, but +the amount of involvement varies considerably. In some cases that I +have observed the catarrh of the mucous membranes has been barely +appreciable. As a rule, however, the eyes are somewhat suffused, and +there is slight lachrymation and photophobia. Sneezing may be noted, +but there is little discharge from the nose. Sore throat is not +uncommon, perhaps the most constant feature, and, according to +Liveing, is apt to persist after the subsidence of the rash. The +fauces are injected, and the tonsils are red and swollen, but with no +evidence of ulceration. J. Lewis Smith and others state that the +buccal mucous membrane shows a more or less diffuse patchy and spotted +redness. The tongue may be, and usually is, covered by a white fur, +through which protrude a few enlarged red papillae. There may be +slight cough. Loeri[8] describes the mucous membranes of the pharynx, +larynx, and trachea as presenting a spotted or uniform hyperaemia. +There is no marked participation of the intestines in the catarrh. +Some few writers have noted a transient albuminuria, but it is safe to +say that such cases are entirely anomalous, if not, indeed, in some +instances, examples of mistaken diagnosis. + +[Footnote 8: _Jahrb. f. Kinderk._, xix. Bd., 1 Heft.] + +A very constant feature is the swelling of the lymphatic glands of the +neck, especially those back of the sterno-mastoid; the swellings may +come on before the rash appears. In all the cases that have fallen +under my notice this symptom has not been absent in a single instance. +Less constantly, and it would seem in proportion to the development of +the rash, engorgement of the glands may be noted elsewhere. + +{587} There is but slight disturbance of the temperature in rotheln, +and when it does occur it is usually limited to the first few hours of +the eruption. This has been the rule in my observation, and certainly +holds good for the majority of cases. In a minority, varying degrees +of fever may be present; thus, the temperature may reach 102 degrees +F. or 103 degrees F., and then rapidly sink by the second day of the +disease, or, having fallen a degree, it may continue at this point +till the subsidence of the rash, or, it is said, may retain its +initial height till the end of the disease. During the following week +Squire states that the temperature may be readily disturbed--either +elevated by exertion or depressed by fatigue or chill. A relapse or +recrudescence of the rash may be looked for at this time.[9] + +[Footnote 9: Cheadle (_Trans. Internat. Med. Congress_, London, 1881) +has reported an epidemic of rotheln of a very severe type, all the +symptoms of the disease as ordinarily recognized being very much +exaggerated.] + +COMPLICATIONS AND SEQUELAE.--In the vast majority of cases neither +complications nor sequelae have been observed in connection with +rotheln. J. Lewis Smith has recorded instances of diphtheritic +inflammation as a complication, which, however, as he justly remarks, +may, when prevalent, attack any inflamed surface. Pneumonia and +bronchitis have been occasionally reported as complicating or +following rotheln. Liveing and Duckworth mention albuminuria, but, so +far as I know, they are alone in this experience. I have known +otorrhoea and ciliary blepharitis to occur as sequelae. It would not +be a matter of surprise that in weakly children various chronic +ailments should be set up by rotheln, as by any other disturbance of +the general health. + +DIAGNOSIS.--There is no other disease which so much resembles rotheln +as measles. Especially is this true of atypical cases occurring +sporadically. In rotheln the whole course of the disease is much +milder than in measles, the incubation is longer as a rule, and the +fact of a previous attack of rubeola is of much importance, since we +know that recurrences are very rare. In measles there is a prodromic +period, having a characteristic temperature curve, and presenting +pathognomonic catarrhal symptoms, which precedes the eruption for +three or four days; in rotheln the appearance of the rash is often the +first sign of the affection. The sore throat of rotheln resembles that +seen in scarlatina more than the angina of measles, and the general +catarrhal implication of the mucous membranes, so marked a feature of +measles, is either absent in rotheln or exists to a very trivial +extent. Measles is essentially a febrile disease, having a peculiar +type of fever; rotheln may run its whole course without appreciable +rise of temperature. As will be seen in the preceding pages, the +development and progress of the exanthem of measles differs materially +from that witnessed in rotheln. In measles the lesions are larger, +more vivid, more angular and indented, more frequently provided with +processes, and therefore more apt to assume the crescentic +arrangement, than in rotheln. Finally, it must be urged that the tout +ensemble of the case should be taken into consideration, and not some +special feature of the skin eruption. + +The incubation period of scarlet fever is much shorter than in +rotheln, and all of the constitutional symptoms are, as a rule, +infinitely graver. In scarlatina there is a febrile invasion stage of +twenty-four hours; in rotheln, if fever is present at all, it is most +generally simultaneous with {588} the rash, and rapidly disappears, +while in the former it persists for a number of days longer. Vomiting +is common in scarlet fever, rare in rotheln. In scarlet fever the +lymphatic glands are notably involved at the angles of the jaw, in +rotheln at the sides and back of the neck. Sore throat is a feature +common to both scarlet fever and rotheln, but it is very much less +marked in the latter. Thomas[10] says that in scarlatina only the +posterior parts, the uvula, the arches of the palate and their +vicinity are affected, while in rotheln the anterior parts are also +affected, and both in much the same degree. In scarlet fever the rash, +which mostly begins on the neck and chest, is made up of large patches +formed of minute red spots on a bright-red hyperaemic base; in rotheln +the eruption is composed of roundish pea-sized macules, with normal +integument intervening. In cases of doubt--for example, when the rash +of rotheln consists of very small spots which have become +confluent--the further development and persistence of the scarlatinal +efflorescence, the temperature, the pulse, the angina, and the +character of the desquamation must be taken into consideration. The +complications and sequelae are very different in the two diseases. + +[Footnote 10: Article "Scarlatina," _op. cit._] + +The symptomatic eruptions of the skin which pass under the name of +roseola bear no resemblance to rotheln. They usually occur as the +result of some trivial derangement of the system or in the course of +some primary affection. They are not contagious, the lymphatic glands +and the mucous membranes are not involved, and the rash is quite +different in character. + +PROGNOSIS.--The prognosis of simple uncomplicated rotheln is +invariably good. Complications arising in delicate children +necessarily affect the prognosis, as would any other disturbance of +the general health. + +TREATMENT.--Simple cases of rotheln require no treatment, as the +patients are rarely sick enough to be confined to bed. Graver forms of +the disease must be met by such measures as are indicated by the +symptoms present. The after-management must be conducted on general +principles having reference to the previous and present condition of +the person attacked. + + + + +{589} + +MALARIAL FEVERS. + +BY SAMUEL M. BEMISS, M.D. + + +In the medical nomenclature of this country the term malaria is +synonymous with swamp or ague poison. + +Malarial affections, therefore, comprise all those diseases or morbid +manifestations which the swamp poison produces in the human organism. + +This article is not designed to notice in a systematic manner any of +these disorders which are not properly classifiable under the head of +malarial fevers. It will, however, be necessary to make such +references to the pathology of chronic malarial toxaemia as may serve +to explain the influence this condition exerts in occasioning +departures from type in the febrile attacks. + +When a poison generated outside the human system obtains admission to +it, and produces deleterious effects, three questions naturally arise: +What is the essential character and natural history of this noxious +agent? How does it obtain access to the human system? What is its mode +of action when received? + +In reference to the first of these questions, it must be admitted that +the substantive essentiality of the malarial poison remains as yet +undemonstrated. It is true, however, that the attempts at an objective +study of this poison by means of the microscope and the cultivating +retort point to the conclusion that it is an organism. + +Its subjective or analogical study affords quite incontestable +evidence in support of this conclusion. The leading features in the +natural history of malaria are closely coincident with those of +certain known organisms. It requires for its production suitable +conditions of moisture, temperature, and a properly circumstanced +breeding-place. Within certain bounds these conditions are requisite +to the life and perpetuity of all organisms. + +Again, when all the above-enumerated conditions correspond apparently +in the most favorable degree, their continuous concurrence for a lapse +of time is necessary before the poison manifests its presence. It is +not improbable that this period of development may differ in different +climates, but in this country we assume it to be about thirty days. If +these facts related to some noxious organism visible to the eye, no +doubt would be entertained that the presence of its germs in the +places where it appeared was the indispensable condition. It would +then follow that the concurrence of suitable meteorologic and telluric +conditions with sufficient time for its growth and maturity were +merely accessories to its perfect development. According to this +theory, the coincidence of five circumstances is necessary before +malaria can be fully matured--viz.: Its own {590} specific germ; +suitable soil or pabulum; suitable moisture; suitable temperature; +sufficient time for its growth and development. + +Certain physical qualities which pertain to the malarial poison can +also be profitably made points of subjective study. These are very +closely connected with the answer to the second question, or "How the +malarial poison obtains access to the human system." They will +therefore be briefly noticed in relation to the instrumentality of +each in conveying malaria into the system. + +The first to be mentioned is ponderability, which the following facts +prove that malaria possesses: + +Those different atmospheric states which affect the range of diffusion +of known air-borne yet ponderable substances exert similar influences +upon the malarial poison. + +Altitude illustrates the ponderability of malaria by powerfully +retarding its diffusion. + +High readings of the barometer favor its aerial dissemination. + +Fogs, smoke, dust, or floating particles presumably more buoyant than +this poison may exert greater or less influence in overcoming the +obstacle which ponderability attaches to malaria as an air-borne +agent. + +Currents of air passing continuously and steadily in one direction +over the breeding-places of malaria increase the limits and intensity +of toxic range. + +The atmosphere is undoubtedly the medium by means of which malarial +poison is most frequently brought into the human system. Liability to +intoxication is increased in direct ratio to the proximity of points +of exposure to places of development; to similarity of level; to +situation in the line of prevailing winds which have traversed the +breeding-ground; and, lastly, to the extent and fertility of the +locality of production. + +Whether malaria passes through the respiratory apparatus directly into +the circulation, or is lodged upon the fauces and absorbed through +some other surface, is not clearly ascertainable. It is certainly not +deprived of its noxious qualities by stomach digestion, and therefore, +sometimes at least, may reach the blood through the alimentary canal. + +Malaria is miscible with water. It is capable of being carried by +currents of water through distances and periods of time altogether +undetermined, without losing either its toxic effects or, perhaps, the +faculty of reproduction. It is more than likely that this means of +conveyance has effected its distribution to continents and islands too +widely separated to justify a belief that it was wind-wafted. No +observations need be adduced to establish the water-borne habit of the +malarial poison, or the positive liability to its toxic effects when +received into the stomach through this medium. These facts have been +well understood from the time of Hippocrates. + +The matter of communicability of malaria by means of drinking water +should not be dismissed without some allusion to the great probability +that other fluids or solids are open to a similar charge. There is a +widespread popular prejudice, especially notable in the southern part +of the United States, that drinking milk occasions attacks of the +endemic fevers. It is the usual custom to pour the evening supply of +milk into broad uncovered pans, and allow it to remain exposed in the +open air for {591} consumption at the morning meal. This viscid fluid, +so tenacious of ordinary air-borne particles, may well be suspected of +entangling sufficient quantities of swamp poison to produce sickness +if exposed where it is rife during a whole night. + +A similar popular prejudice exists in regard to the muscadine grape, +which flourishes best in swampy localities. The rough skin of this +fruit, frequently covered with its own juice, offers favorable +conditions for the adhesion of air-borne particles. + +The malarial poison is not reproduced within the human system. This +proposition is undeniable, since no intensification of the poison is +produced by any degree of crowding of the sick which can be practised; +neither do any conditions of contact with the sick ever impart +malarial affections. + +Malarial poison is specific. This allegation is sufficiently +established by its specific effects on the human economy. There is no +other agent known which is capable of originating morbid phenomena +characterized by such marked diurnal periodicity. + +It is not interchangeable with other specific poisons. This statement +may be rested upon all fairly collected clinical observations. + +There are no facts which justify the belief that malaria is capable of +becoming mixed in the atmosphere, or outside the system, with any +other specific morbific germ, so as to produce a third something which +may give rise to compound forms of disease. + +The answer to the second question which is best supported is, that the +malarial poison is brought into the system principally by breathing an +atmosphere impregnated with this miasm. + +It is also ingested by being held in suspension in fluids used as +drink or food; perhaps also by eating certain fruits or vegetables in +their natural state whose external surfaces afford favorable +conditions for its lodgment. + +MORBID EFFECTS AND PHENOMENA WHICH FOLLOW ITS INTRODUCTION INTO THE +HUMAN SYSTEM.--The discussion of the morbid process established by the +malarial poison involves some difficult problems. A period of +incubation must be admitted to follow the inception of the ague germs. +But this period has no definitely marked limits. Perhaps it is a +shifting one, according to the quantity or quality of the poison +received, or the sudden or gradual manner in which it is received, or +the state of receptivity of the system. + +Certain facts seem to indicate very clearly that malarial poison is +very slowly removed from a system which has been brought under its +influence. These evidences of long systemic residence of the poison +are principally displayed in those attacks which occur after long +periods of removal from any surrounding where intoxication was +possible. Vernal attacks may be classed in the same connection. In +many instances the subjects of these long-delayed attacks have never +suffered a paroxysmal seizure, and yet when some accidental +derangement of health occurs, as from a fit of indigestion or a sudden +wetting, they fall sick with one or another form of malarial fever. + +It does not appear to me that we are justified in assuming that such +attacks as I refer to are to be ascribed to secondary changes produced +in either the fluids or solids of the system by the malarial poison. +In so {592} far as the clinical phenomena are worth anything in +demonstrating the presence and agency of the specific malarial poison +in these deferred attacks, they are precisely similar to those +observed in paroxysms arising after a few hours' or a few days' +exposure to marsh miasm. + +But we find further proofs of the long-continued and silent manner in +which malaria exerts its pathological influences in those enlargements +of the spleen which occur without specific attacks of sickness. The +alterations of nutrition in this organ are so characteristic of +malaria that they can scarcely be supposed to depend upon those +chances which determine the nature of secondary blood-impurities. + + +Intermittent Fever--Simple Forms. + +The clinical phenomena of intermittent fevers afford strong support to +the opinion that this type of malarial attacks illustrates more +strongly than any other the primary influence of the poison upon the +human system. Fits of ague often occur very shortly after exposure in +infected localities, and the persons thus suddenly attacked may +present little or no evidence of cachexia before or after the +paroxysm. Indeed, they frequently resume their ordinary avocations +after the paroxysms, apparently as well as if they had not occurred. + +It is therefore my opinion that the pathology of an intermittent fever +does not necessarily involve an hypothesis that the attacks are the +results of certain changes which the poison undergoes after its +inception, nor, on the other hand, that certain perversions of +systemic chemistry are required to inaugurate the paroxysms. + +In accordance with these conclusions, it seems likely that the +phenomena of intermittent malarial fever result from the primary +effects of its specific poison exerted directly upon the fluids and +solids of the system, and disturbing their functions, and especially +the nerve-function. + +Those malarial attacks which ensue almost immediately after exposure +are principally manifested in persons exposed at points of unusually +abundant evolution. The rule of malarial attacks in temperate +latitudes is, that they require repeated exposure to infection for +their production. The long residence of the poison in the system may +render additional doses possible, until a point of saturation is +reached which occasions paroxysmal explosions. In these cases the +period of incubation is reckoned from the first date of exposure, thus +forming the most striking contrast with the incubative periods of the +cases occurring almost immediately after exposure. + +Whether the quiescent period after exposure to malaria be long or +short, attacks are seldom abrupt in their announcement. The symptoms +which usually precede pronounced attacks consist, for the most part, +in some derangement of the functions presided over by the organic +nervous system. Derangement of digestion, vitiated taste, coating of +the tongue, loaded urine, and sallow skin are ordinarily found among +the prodromic symptoms. Next in succession come feelings of malaise, +hot and cold flushes, and those neuralgias which precede and attend +malarial paroxysms. + +The symptoms of an ordinary or typical malarial paroxysm are so +characteristic, as to be generally readily interpreted. Creeping, +chilly, {593} sensations over the surface, especially along the spine, +yawning, livid coloration beneath the finger-nails, retreat of blood +from superficial capillaries, and that consequent papillary elevation +which is commonly called goose-skin, comprise the earliest symptoms. +Then decided shiverings with chattering of the teeth come on, and the +patient asks for blankets to be heaped upon him and hot applications +to be made, even though the atmospheric temperature may be decidedly +elevated. + +Nausea and vomiting are frequent symptoms, no doubt due to the fact +that the portal system of blood-vessels is so often the seat of +congestion during a chill. No intelligent practitioner can watch a +patient during the cold stage of a malarial paroxysm without realizing +how important the attendant congestion is as a pathological state. It +should first be considered that every chill necessarily implies a +condition of congestion in some part of the system. The blood driven +from the surface and extremities must be accounted for elsewhere; and +the amount of blood which is lost from one part of the circulatory +tree must correspond with that accumulated elsewhere. But in treating +of the pernicious forms of malarial fevers this question will again +receive notice. + +In our present state of knowledge we are no more able to explain those +perversions of the normal action of the physical forces of the system +which occasion the phenomena of a chill than we are to explain how the +altered circulation in the first steps of an inflammation is brought +about. The theory which Cullen adopted is quite as explanatory and +consistent as any which has been promulgated since his time. According +to this, a state of spasm of the arterioles and capillaries causes the +chill, while the fever is merely the rebound of functions held in +abeyance during the chill. + +After a variable length of time there occurs a change in these +symptoms: the patient begins to remove the blankets which covered him; +the face shows signs of returning circulation; the veins of the whole +surface gradually fill again, apparently beyond their normal state. +But the reaction goes far beyond any normal physiological state. The +face becomes flushed and the eyes injected, and the patient complains +of headache, thirst, dryness and heat of the surface; he will not +permit any covering, and constantly shifts his place in the bed in the +hope that some new position may afford him more comfort. Nausea and +vomiting are commonly present. If the fever runs high, delirium is apt +to occur. The thermometer seldom shows a temperature above 105 +degrees, but I have seen 106.5 degrees recorded in the axilla in the +hot stage of a paroxysm of simple intermittent fever. + +The duration of the hot stage is different in different cases. +According to Aitken, the mean duration is three to eight hours. + +There is a very old and quite well-supported opinion, that the cold +stage is shorter in the quotidian than in the tertian type, and also +that the hot stage is longer in the former than in the latter. It may +certainly be affirmed that in individual cases of either type there is +no fixed relation between the duration of the chill and that of the +hot stage. + +The decline of the hot stage begins by the appearance of a gentle +perspiration, limited at first to the forehead, face, and neck. This +gradually extends itself over the surface and increases in quantity +until the whole body is bathed in a profuse sweat. During this period +the {594} patient's symptoms, both subjective and objective, undergo +wonderful mitigation, and, although this stage is usually short, it +often happens that by the time it is concluded a restoration to +ordinary health seems to have occurred. + +The sweating stage terminates a malarial paroxysm. The intermission +now begins, and lasts until the inauguration of another paroxysm. The +intermission is longer or shorter accordingly, first, as the paroxysm +occupies less or more time; and, second, as the interval may affect +it. The interval is that period of time which reaches from the +beginning of one paroxysm to the beginning of another. It therefore +furnishes the basis of classification of simple intermittents into the +following forms: quotidian, tertian, and quartan. + +Statistics gathered from a great many sources and relating to many +countries and climates indicate that quotidian intermittents are more +common than tertian. It may then be assumed that the natural type of +intermittents is that form characterized by diurnal paroxysms. It must +be remarked, however, that if any natural law does exist establishing +the quotidian as the typical form of intermittent fevers, it is very +often set aside by unknown influences. In certain epidemics the +tertian cases preponderate, and under all circumstances convertibility +may be witnessed between the various forms. + +It is probable that the statistics gathered by the medical staff of +the United States Army during the late Civil War afford the most +valuable data which we possess touching these points, in so far as +they relate to this country. During three years of the war 724,284 +cases of intermittent fever were recorded, tabulated as follows: + +Quotidian, 370,401 cases, 388 deaths--equivalent to 1047 + deaths per +1,000,000 cases. + +Tertian, 318,704 cases, 324 deaths--equivalent to 1007 + deaths per +1,000,000 cases. + +Quartan, 35,179 cases, 79 deaths--equivalent to 2245 + deaths per +1,000,000 cases. + +It has been remarked by several writers that quartan attacks have a +smaller ratio in the Southern States than in other parts of the Union. +My observations on this point have not been sufficiently well recorded +to make them especially authoritative, but they support such a +conclusion. + +The morbid anatomy of malarial fevers is more properly discussed in +treating of the graver forms, since the paroxysms of simple +intermittent do not often occasion death. + +TREATMENT.--This must necessarily vary with the stage of the paroxysm +and condition of the patient at the time of the first visit. + +Let us suppose this to be the incipiency of the paroxysm, or the early +part of the cold stage. However little the danger to life from the +paroxysm of a simple intermittent attack, the practitioner should not +forget that whatever danger does exist is to be ascribed to damages +suffered during or in consequence of the chill. There are few +exceptions to this rule, and those will be noticed presently. With +this fact in view the practitioner's duties are much simplified. He +should first endeavor to remove any complications present which tend +to aggravate the cold stage. If the chill has come on after a full +meal or after eating indigestible food, the stomach should be promptly +emptied; otherwise the cold stage will {595} be prolonged and rendered +more violent. Large draughts of warm water will frequently produce +sufficient emesis. If this should fail, ipecacuanha may be added. The +warm infusion of eupatorium perfoliatum answers well as an emetic, +producing also a laxative effect. But it is disgusting to the palate, +and sometimes prolongs its action beyond desired results. The effect +of an emetic in abridging a chill by revulsive action are uncertain, +and I avoid resorting to them for this purpose alone in simple +intermittents. + +The patient's subjective complaints of suffering should receive a due +degree of attention. Additional blankets and warm applications should +be allowed when solicited. I always discourage hot or heating drinks, +except for the purpose just mentioned. I especially oppose alcoholic +stimulants, because they seldom do any good in mitigating the chill, +oftener aggravating the patient's symptoms during the hot stage, +particularly the headache and vomiting, and sometimes directly +occasioning perplexing perturbations. For example, I have seen +convulsions speedily follow a strong brandy toddy given to shorten a +chill. + +While the removal of complications is imperatively indicated, it is +also important to use promptly those means which are designed to +modify and shorten the chill. It is a remarkable fact that all the +agents found to be useful for this purpose are such as directly +influence nervous function. Opium in some form enters into all +prescriptions which I have found efficient in modifying a chill. It is +quite efficacious when given alone, but I think its therapeutic energy +and certainty are increased by the addition of other agents of the +same class. I have often exhibited twenty to thirty drops of +chloroform with an equal quantity of laudanum with excellent results. +The tincture of opium may be combined with aromatic spirit of ammonia, +or with bromide of potassium, or with chloral hydrate. In combination +with either of the latter medicines it may be given by rectal +injection. If the stomach is intolerant, or by preference because of +facility of dosage and quickness of effect, the opiate may be given +hypodermically. For this purpose one-sixth to one-quarter of a grain +of morphia may be given, together with one-sixtieth to one-fortieth of +a grain of atropia. It is rarely necessary to repeat the dose +whichever form may be adopted. + +After much experience in these methods of mitigating and abridging the +chills of intermittent fever, I feel entitled to say that, whether the +objects be achieved or not, no injurious consequences ensue. + +The conditions of the circulatory and digestive organs are not +favorable for the introduction of quinia or of any preliminary +purgative which may be supposed to be necessary, and I therefore delay +their exhibition. It may be excepted, however, that sometimes a very +obstinately irritable stomach or exceedingly vitiated state of the +fluids can be appropriately met by gr. x to xx of calomel. + +The hot stage of a simple intermittent seldom calls for medical +interference on account of excessive temperature. If the headache is +very violent or the vomiting troublesome, a subcutaneous dose of +morphia will bring speedy relief. The existence of high temperature +does not contra-indicate its use. + +I am in the habit of giving opium in the following combinations: + + Rx. Morphiae Acet. gr. ss; + Liq. Ammon. Acet. fl. oz. iv. M. + +S. Two tablespoonfuls every second hour. + +{596} Or, occasionally, the following: + + Rx. Sodii Bicarb. gr. xx. + Morphiae Sulph. gr. i; + Aquae Lauro-Cerasi, + Aquae Menth. Pip. _aa._ fl. drachm iv. M. + +S. Teaspoonful pro re nata. + +I do not limit the use of opiates in the hot stage to old and infirm +subjects, as Dickson suggests, but give them in all cases where +vomiting, headache, or other neuralgias are excessive, or where +unusual restlessness and jactitation are present. + +The propriety of giving purgatives as a preliminary measure of +treatment during the hot stage must be determined by symptoms +connected with individual cases. In the majority of cases falling +under my care purgatives are avoided. When regarded necessary, gentle +purgation is solicited by administering bitartrate of potassium in +lemonade or by combining mild mercurial doses with antiperiodics when +these latter are resorted to during the fever. In some cases a very +furred tongue, sallow skin, and costive bowels indicate more active +purgatives, which may be exhibited during the febrile stage. + +The most important question which relates to medication during the hot +stage is in respect to the administration of antiperiodics. It may be +safely stated that practitioners of this country were the first to +adopt this method of procedure in malarial fevers. Here it has been +well demonstrated that a competent dose of quinia, given during any +part of the hot stage, is so often followed by the defervescence of +the fever that it would be illogical to attribute the change to any +other cause. Sometimes the remedy fails in producing this result; then +excessive physiological disturbances may follow, and perhaps some +general aggravation of the patient's symptoms. + +There are four different circumstances, each of which, in my opinion, +calls for the exhibition of quinia during the hot stage, whether the +fever has reached its maximum point or not: + +_First._ If the period which has elapsed since the beginning of the +paroxysm is so considerable that further delay might prevent +sufficient cinchonism to intercept the next accession. + +_Second._ When the fever is so excessive that quinia should be given +as an antipyretic. + +_Third._ When apprehensions exist that the fever will occasion some +complication or accident. + +_Fourth._ When the tongue is clean and the state of the system is +favorable to absorption. + +The hot stage is not usually favorable to absorption, and consequently +the economical use of quinia must not be attempted. It should be given +in doses varying from ten to twenty grains, preferably in solution. I +may remark that I have seldom failed in getting good results from the +powder or pills if lemonade or some fluid facile of absorption be +given at the same time. The mixtures previously formulated answer this +purpose very well, and at the same time mitigate the disagreeable +physiological effects of the quinia. + +Allusion has been made to certain symptoms occasionally connected +{597} with the hot stage which involve danger. Convulsions are among +the most important of these. They occur most often among children, but +occasionally with adults. They should be met by chloroform, cold to +the head, hypodermic injection of morphia, and cupping or leeching if +the face is flushed, the eyes injected, and the carotids pulsating +forcibly. + +The sweating stage may be classed with the intermission in respect to +medication. No time should be lost in securing cinchonism. From the +moment the sweating stage announces itself the fluids of the system +begin to resume their normal physiological functions. Absorption from +the intestinal surfaces is again restored, and remedies may be +administered with confidence in their effects. + +The question is now no longer whether antiperiodics should be +administered, but how they shall be given. Many practitioners prefer +exhibiting them in one large dose; others think it better to give them +in repeated small doses. I have usually adopted the latter method. +Beginning with the sweating stage, I give three grains of quinia every +hour or two hours, until eighteen grains have been taken. This would +occupy periods of five to ten hours to complete the doses, ordinarily +quite a sufficient length of time to obtain cinchonism before the +advent of another paroxysm. If the physician elects to give his +antiperiodic in one or two large doses, he should not trust to so +small an amount as eighteen grains. Allowance must be made for the +loss incident to the probable over-taxation of the power to dissolve +and receive a large amount into the circulation. + +Purgation should not be induced to a sufficient degree to hurry the +quinia off before absorption takes place. Some practitioners favor the +employment of adjuvants to the quinia. Very few of these have appeared +to me to be of service except opium. A very convenient formula is a +solution of quinia in peppermint-water by addition of dilute sulphuric +acid, in such proportions that fl. drachm j of the solution shall +represent five grains of quinia and seven and a half drops of +laudanum. + +But, however we may boast of the efficacy of cinchona as the anceps +remedium for malarial diseases, we are forced to admit that it is not +certainly an immediate cure, and very commonly fails in producing a +permanent curative effect. If we could in all cases discern and remove +the impediments to its immediate or temporarily curative action, its +claims to be regarded as a practical specific would be undeniable. It +is probable that these impediments generally rest upon the fact that +either the remedy does not gain admission to the circulation or that +some complication exists not within the range of its therapeutic +action. + +The failure of cinchona to cure a malarial attack in such a permanent +manner that it shall not be liable to return is probably owing to the +incompetent action of the drug because of its transitory stay in the +system as compared with that of the malarial poison. Some objections +apply to this theory, because when the succession of intermittent +attacks is broken by quinia and it is continuously administered +afterward, the paroxysms occasionally recur in spite of its presence +in the system. These objections may be answered by pleading that under +these circumstances secondary blood-poisons precipitate the attacks, +and cinchona should not be expected to cure these conditions. + +The best methods of practice I know of to prevent a recurrence of +{598} intermittent fever after having interrupted the succession of +attacks are, first, to continue the cinchona for at least forty-eight +hours, giving at least three three-grain doses a day. After this no +medicine need be given except such as may be required to correct +chronic toxaemic states of the system or to act as blood-restoratives +until such time as prodromes of another paroxysm may exhibit +themselves. At the instant when these manifest themselves ten to +fifteen grains of quinia in solution should be taken. In order that no +loss of time should occur in applying this method, I always advise +patients to keep a solution of quinia within immediate reach. The +following prescription has sometimes appeared to effect a permanent +exemption from recurrence of paroxysms: + + Rx. Ferri Redacti gr. xl; + Acid. Arseniosi gr. j; + Quiniae Sulph. gr. xl; + Ol. Pip. Nigr. gtt. x. M. + Ft. pil. No. xx. + +S. One pill three times daily. + +It seems sometimes to occur that intermittent attacks so impress the +nervous system that they become, like epilepsy, more liable to recur +because of an established habit. I have known chills to occur when the +ears were ringing with quinia. Strychnia fails to arrest them; arsenic +has more value, but frequently fails. Pure nitric acid, properly +diluted, in doses of six to ten drops, given every four to six hours +without regard to the stage of the paroxysm, succeeds more often than +any medication I have ever resorted to. + +Before dismissing the subject of the treatment of simple intermittent +fever it may be proper to mention that I have made trials of cure by +carbolic acid, administered by mouth and subcutaneously, and also of +the sulphites, with no results worthy of recommendation. + + +Remittent Fever. + +The difference in definition between the words remittent and +intermittent expresses the clinical distinction between these two +forms of fever in a very satisfactory manner. + +Remittent fever exhibits oscillations of temperature regulated as to +hours of recurrence by laws similar to those which govern the periodic +returns of intermittent fever; but there is no complete defervescence +of the fever. While the lowest angles of the fever curve approximate +the normal body heat more or less closely, they never decline to a +standard of apyrexia. + +That remittent fever is a malarial disease, produced by a cause +identical with that which produces intermittent fever, is well proven +by the following facts: + +First. Cases occur in close relation with cases of intermittent fever +in populations similarly exposed to malaria, and at the same periods +of the year. + +Second. The two forms of disease are readily convertible, the one with +the other. + +In non-tropical countries remittent fever cannot be regarded as the +{599} natural type of malarial fevers. At least, it may be affirmed +that the proportion of cases which begin as remittent attacks is so +small that we are warranted in looking upon them as departures from +type. In the United States army during the years 1861-66, inclusive, +there occurred 286,490 cases of remittent fever. The fatal cases were +3853, being a mortality-rate of 13,450 per 1,000,000 cases. By +comparing these statistics with those of intermittent fever recorded +in a previous section it will be found that remittent fever is more +than twelve times as fatal to life as the simple intermittent forms. + +If we accept this view of the pathology of remittent fever, it is of +interest to the sanitarian or practitioner to endeavor to arrive at +the causes which occasion these departures from type. Some of these +are undoubtedly extraneous to the system, and relate wholly to +circumstances affecting the malarial poison as a disease-producing +agent. Increased quantity of malaria is well understood to enlarge the +ratio of remittent cases. There is also strong presumptive evidence +supporting the hypothesis that different annual crops of malaria vary +in respect to the noxious qualities of this agent. The same +presumption relates to all crops produced in certain localities as +contrasted with others. Other causes which determine remittent rather +than intermittent attacks are personal to patients. They may be +classed as follows: + +First. Unusual personal receptivity or impressibility to malaria may +exist, either because of some constitutional idiosyncrasy or of some +state the system at the time of exposure. + +Second. Want of timely medical treatment or of proper medical +treatment may convert intermittents into remittents. + +Third. The rapid occurrence of secondary blood infections, +extraordinary in character or amount, may cause the fever to be +continuous. + +Fourth. The existence of complications, inflammatory in their nature, +may change intermittent into remittent attacks. + +However various or complex the causes may be which operate to convert +intermittent attacks into remittent forms of fever, each one must be +supposed to act by disturbing the functions of those centres which +preside over the normal physiological and chemical changes of the +system. + +SYMPTOMS AND DIAGNOSIS.--Attacks of remittent fever are, as a rule, +more abrupt in their advent than intermittents. When prodromic +symptoms exist, they are similar to those which precede ordinary cases +of ague. + +The chill is seldom attended by such violent symptoms as the cold +stage of intermittents. The duration of the cold stage is also more +brief. In a small proportion of cases severe vomiting with large +bilious ejections complicate the cold stage. The chill is quickly +followed by the hot stage. + +The mildest cases of remittent fever are not readily distinguishable +from the intermittent forms. In these cases the temperature curves are +marked by sharp angles and long tracings between the lowest and +highest records. As cases become more decided in diagnosis, and +consequently represent higher degrees of departure from the +intermittent type, the angles of temperature curves become more obtuse +and exhibit a more or less high average range. The accompanying +temperature diagram (Fig. 23) shows the thermometric record of an +unusually protracted and grave case. The patient was a near relative +of my colleague, Prof. Logan, a leading practitioner of New Orleans, +and the clinical records may be {601} accepted as altogether accurate. +It is somewhat to be regretted that the records of temperature were +not begun at an earlier period, but the gravity of the case was not +manifest until the continued type of fever was found to exist. The +latter part of the diagram illustrates the lapse of the remittent +fever into an intermittent. This is so commonly a mode of cure that +the practitioner watches with solicitude for increasing oscillations +of temperature to announce mitigations of severity in his gravest +cases. + +{600} [Illustration: FIG. 23. Temperature chart showing the lapse of a +remittent fever into an intermittent. NOTE.--From the third to the +fifteenth day after attack a half drachm of quinia was given daily. +Observing no good result, it was omitted until the twenty-ninth day, +on which date two doses of eight grains each were administered. On the +morning of the thirty-fourth day eight grains were again given; on the +thirty-fifth day one scruple was given.] + +The differential diagnosis of intermittent and remittent fevers may be +looked upon as practically unimportant. All cases so near the +borderline as to make differential diagnosis a question should receive +identical treatment. + +There are, however, two other very grave forms of fever which are +liable to give trouble in differentiation from remittent fever. These +are typhoid and yellow fevers. The sanitary protection of communities +exposed to cases of the latter, and also the practical treatment of +the sick, call for early and correct differentiation. + +But it is only in the early stages of the pathological processes of +these affections that difficulties of diagnosis are liable to obtain. +The facial expression of patients suffering with remittent is +sufficiently characteristic to afford some diagnostic inferences. +During the pyrexia the face is flushed and the eyes injected, but the +redness is more vivid and the countenance more animated than in either +typhoid or yellow fever. It would not be inaccurate to say that, +however great may be the flushing or other alterations of the +countenance in remittent fever, the natural facial expression is +better preserved than in either of the fevers under comparison with +it. Sallowness of the skin is an early and almost constant event in +remittent fever. It comes on as a secondary manifestation, and appears +in a large ratio of cases to bear some relation to the high +temperature preceding its occurrence. The icteric hue is seldom +intense, indeed very infrequently equalling the orange-yellow of +jaundice resulting from obstruction. There is an exception to this +statement in those cases in which remittent fever attacks a person +already jaundiced. I have seen many cases in which the jaundice +preceded the remittent fever, and became more strongly marked after +its incursion, particularly in those persons who had remained for some +time in a malarial region and suffered repeated attacks. In all cases +of remittent fever it seems reasonable to ascribe the more or less +jaundiced state to one or both of two factors, viz.--the accumulation +of excrementitious material and bile constituents in the blood from +primary derangement of its chemistry; and that excessive activity of +the liver which the malarial poison appears to induce. Whether the +latter mentioned factor results from some action of malaria directly +affecting the nutritive processes of the liver, as it does those of +the spleen, or whether the altered blood-currents during the paroxysms +cause this supposed hypersecretion of bile, we certainly know that to +malaria only can we ascribe those fevers which are marked by such +peculiar symptoms of biliousness or superabundance of bile as to +justify the prefix bilious fever or bilious remittent fever. + +The state of the alimentary tract may properly receive notice after +these remarks. In the early stages of remittent fever the tongue may +be moist and large, and covered with a white or lead-colored or +yellowish coat. The edges may be indented with imprints of the teeth. +This is {602} Osborne's malarial tongue, and its appearance is worth +something in diagnosis. + +Later in the progress of remittent fever the tongue may become dry, +brown, cracked, and difficult of protrusion, but seldom showing the +tremulousness of a typhoid-fever tongue, and differing also from the +yellow-fever tongue in the fact that in this disease the appearance of +the tongue is usually indifferent as a symptom, except that in +advanced stages it is liable to be smeared with blood. + +The stomach is irritable from the very beginning of an attack, and the +acts of emesis are generally in striking contrast with those of +typhoid or yellow fever, both in respect to their violence and to the +relative amount of bile they eject. + +The bowels are ordinarily costive, and when moved by purgatives the +stools contrast strongly with those of typhoid or yellow fever by +presenting evidences of the bile-coloring principles which attend all +excretions in malarial fever, and are found in the urine, the +perspiration, and occasionally the sputa. + +Some unusually violent cases of malarial fever, which may become +remittent, are inaugurated with convulsions, profuse diarrhoea, and +coma. + +Before closing the remarks concerning the digestive organs in +remittent fever I should mention that in the long array of cases I +have treated I cannot recall one solitary instance of black vomit. It +is, however, true that I have observed hemorrhage from the bowels in +quite a number of cases. These occurred late in protracted cases, and +were sometimes the cause of death. Whether it be merely a coincidence +I am unable to say, but it is true that the majority of these cases +have been in young females just after the establishment of the +catamenia. + +Hemorrhage from the nose is frequent in remittent fever, but I have +never seen a case with general tendency to hemorrhage. + +The pulse in remittent fever differs from that of the typhoid or +yellow fevers by being more synochal in character, firmer, and more +resisting to pressure. The longer the duration of the case the less is +this characteristic discernible. + +The nervous system shows less ataxia. Delirium may occur in any stage +of the disease, but differs from the delirium of typhoid and yellow +fevers in showing a lessened degree of perversion of the reasoning +faculties. The neuralgias have nothing special. + +The urine is acid, high-colored, and scanty. I have never found much +albumen in the urine of a case of remittent fever, unless there was +some other cause to account for its presence. A small amount may be +detected during excessive fever. Blood is a rare constituent. + +Mild cases of remittent fever should terminate in recovery in from +five to seven days. Fatal attacks usually end from the fifth to the +tenth day. Many cases pursue a course which lasts from twenty to forty +days. Under proper treatment the usual termination is in recovery, +either directly or by conversion into the intermittent type. + +POST-MORTEM APPEARANCES.--When death occurs in remittent fever the +post-mortem changes generally consist of those which are principally +due to chronic malarial toxaemia and those ascribable to the acute +attack. + +Under the former division are permanent enlargements of the spleen and +liver, and pigmentary matter in the blood and deposited in various +{603} organs. Under the latter are to be classed hyperaemic or even +inflammatory states of the stomach and intestines, and those +degenerative changes which are the consequence of continuous +hyperpyrexia. The post-mortem changes which are so uniformly found as +to be most often appealed to in the establishment of diagnoses are +enlargements of the liver and spleen. These may be due in part to +hyperplasia and in part to blood-engorgement. The brown or slate color +of an enlarged liver is strongly diagnostic of malarial affections. It +contrasts strongly with the yellow and natural-sized liver of yellow +fever and with the negative liver of typhoid fever. + +The skin is generally yellow, sometimes quite intensely icteric, but +seldom showing the ecchymotic extravasations of yellow fever. In +remittent fever we never find the cadaver oozing blood from the nose +and the mouth, nor are the stomach or intestines ever found to contain +black vomit. + +TREATMENT.--The indications of treatment in remittent fevers differ +from those of intermittents in two leading essentials. + +First. It is a far graver form of fever, and calls for more +promptitude and energy in treatment for its successful management. + +Second. The important pathological condition to be combated is the +hyperpyrexia, and not the cold stage, as in intermittents. + +But even with a clear realization of the practical importance of these +facts in governing the treatment of remittents, the practitioner must +still exercise care and self-control, lest he shall unconsciously +adopt the doctrine that inflammatory lesions must be present to +occasion such violent pyrexia as often exists. The physician who comes +directly from a case of pneumonia or rheumatic fever and finds a +patient suffering from remittent fever, with temperature higher and +pulse more bounding than those of the patient he has just left, is +pardonable for finding it difficult to realize that these furious +symptoms are not also associated with inflammation. + +Attempts to cure remittent fevers by an exclusively antiphlogistic +treatment either result fatally or induce long periods of confinement +and suffering before recovery is reached. The great indication is to +secure cinchonism as promptly and completely as possible. Nothing +should divert our attention from this object. The condition of the +patient as it respects fever, delirium, or state of the tongue, should +form no bar to the administration of quinia. There are no +practitioners who have had much experience in treating these grave +forms of malarial fever after this method who are not able to recall +the numerous instances of most astonishing and gratifying amelioration +of symptoms as soon as saturation with quinia was brought about. The +dry tongue becomes moist, the skin is bathed in gentle perspiration, +the delirium ceases, and the patient sinks into a quiet sleep. + +The amount of quinia necessary to produce cinchonism must be estimated +for each particular case according to the measure of its severity or +to states of the system more or less favorable to its absorption. It +must be borne in mind, however, that questions concerning the +patient's safety are paramount to those of economy. In the mildest +cases I never trust to a smaller amount than from twenty to thirty +grains. In violent attacks I have administered scruple doses every +fourth hour until a {604} sufficient test had been made of its +capability to arrest or modify the febrile paroxysm. I have never met +with any of those exaggerated physiological effects which some +observers teach us to fear from the exhibition of cinchona +preparations during fever. Certainly, I can declare that no permanent +deafness or other lasting lesion of nerve-function has ever occurred +under my observation. I must also add that I know of no reasons why +remissions afford more favorable conditions for the administration of +quinia, beyond the fact that the system is in a better state for its +absorption and assimilation. The quinia is preferably given in +solution, but may be exhibited in the form of pills, or in powder +suspended in black coffee, or in the thick mucilage of the slippery +elm. + +The considerations of treatment which are naturally connected with +those just advocated relate to measures which it may be proper to +associate with the quinia. The answers to the two following questions +comprise all that is necessary to be said on this point--viz.: + +Are conditions of the system present which may interfere with the +specific treatment by quinia, and which are not, in themselves, +curable by it? + +Are any medicines to be given as succedanea to the specific remedy for +the purpose of rendering its action more sure or prompt? + +In regard to the first inquiry, it must be admitted that in quite a +large proportion of cases of remittent fever specific treatment fails +to cure. I suppose that may be a reasonable proposition which holds +that in the majority of these cases the presence of secondary +blood-impurities annuls the ordinary specific effects of cinchona. +These must be gotten rid of by depurative medicines. The intestinal +canal, the skin, and the kidneys are the emunctories through which +elimination must be effected. It is therefore proper for the physician +to endeavor to recognize cases where such impurities exist, and to so +modify his treatment as to remove them. The indications for depurative +treatment are jaundiced skin and eyes, furred tongue, costive bowels, +and scanty, loaded urine. These are more or less positively expressed +symptoms in a large majority of cases. It is therefore proper that in +this large majority of cases of remittent fever depurative treatment +should be conjoined with the specific treatment. In my opinion, no +drugs meet this indication so well as mercurials and saline purges and +diuretics. Calomel or blue mass may be given either simultaneously +with the quinia or in alternate doses. + +There are three very important rules to be observed in regard to +cathartics: They should never be carried to such an extent that +absorption of the quinine is interrupted. They should not be given in +such large or repeated doses as to produce prolonged irritation, or it +may be even inflammation, of the alimentary canal. Purgatives should +be used for their depurative effects, and never as antiphologistics. + +Opium exercises excellent effects in preventing local irritation or +hypercatharsis, and in relieving derangements of nerve-function and +insomnia. It is preferably given in small doses, combined either with +purgatives or with the quinia. + +I have found bitartrate of potassium the most grateful and efficient +saline for depurative action. I have generally given it in lemonade in +such amounts as to secure a gentle aperient and diuretic effect. I +hold strongly to a conviction that all drugs as soluble as this +facilitate the absorption of those less soluble--as, for example, of +quinia. + +{605} If the first efforts to break the febrile paroxysms fail, it is +better to discontinue the quinia and place the patient under +symptomatic treatment, and await conditions of the system more +favorable for its repetition. Of course the high temperature is +generally the symptom requiring most care and attention. + +Vomiting is one of the troublesome symptoms of remittent fever. As +internal medication minute doses of morphia, dry upon the tongue or in +solution in cherry-laurel water, or in combination with eight or ten +drops of chloroform, are generally efficacious. Swallowing pellets of +ice or frequently taking iced effervescing mixtures are good measures +of treatment. Occasionally, a mild emetic, such as warm chamomile +infusion, or warm water alone, will arrest the vomiting temporarily. +It is doubtful, however, whether this relief is secured by the +ejection of any offending matter from the stomach. It is more than +probable that the forced dilatation of the stomach has arrested the +spasms, for filling this viscus with cold drinks to repletion will +often effect the same result. + +Of all applications to the epigastrium, a cold wet towel occasionally +sprinkled with chloroform is the best. + +A tympanitic or tender abdomen requires stupes wrung from warm water. +They may be dashed with turpentine at first, and afterward consist of +warm water with whiskey. I have occasionally given two or three doses +of turpentine emulsion with benefit, but from much observation I am +forced to protest against the turpentine treatment, as it is called, +which is to give twenty drops of turpentine every two to four hours as +a curative agent. + +Hemorrhage from the bowels must be met by haemostatic +treatment--preferably, in my experience, by the use of five grains of +gallic acid in half an ounce of camphor-water every two hours, of +morphia subcutaneously, and of cold cloths over the bowels. As in all +diseases liable to cause death from exhaustion, careful attention must +be paid to the nutriment, and stimulants must be administered as +required. + + +Pernicious Malarial Fever. + +Certain departures from the ordinary types of malarial fever are +termed pernicious, because of their great tendency to inflict more +than usual systemic damage and danger to life upon those who suffer +such attacks. The word pernicious is used in its common English sense +of being hurtful or injurious. + +It is entirely unnecessary to enter upon a discussion respecting the +propriety of employing this adjective to designate a class of cases of +disease which are primarily due to the same poison which produces +simple intermittent attacks. The extreme hurtfulness and danger of the +attacks to be described in this section, and the awful suddenness with +which they often occasion death, form striking contrasts with the more +typical forms of malarial fever, and appear fully to justify the use +of the qualifying adjective pernicious. + +While all these various departures from type to be grouped under the +term pernicious possess the quality ascribed to them, they +nevertheless differ so widely in their modes of inflicting injury that +it seems desirable to arrange them under distinct sub-classifications. + +{606} Some cases of pernicious malarial fever preserve the periodicity +of simple attacks sufficiently well to enable one to classify them as +intermittent or remittent in form. But more commonly it is impossible +to determine this classification, and for practical purposes it is +unimportant to attempt to make any such distinction. + +The classification which appears to me most true to nature is the +following: + + First. The algid or congestive form; + Second. The comatose form; + Third. The hemorrhagic form. + +The algid or congestive form occurs more frequently than either of the +others. Its perniciousness is due to an aggravation or sheer +exaggeration of the cold stage of an intermittent attack. + +The following brief clinical histories of two cases will serve to +illustrate the symptomatic phenomena of this form of pernicious +malarial fever: + +M. S., aged fourteen, had accompanied his father to a malarious +locality in the country, and had remained with him during September +and a portion of October. Shortly after his return I was asked to +visit him because of some unusual symptoms attending a chill. I found +him in a stupor, from which he was with difficulty aroused +sufficiently to be able to swallow a dose of quinia combined with +laudanum. His face was pallid and inexpressive; the skin cool and +moist; extremities shrunken and cold; pulse small, easily obliterated +by pressure, and irregular; tongue large and moist; and pupils rather +dilated. + +My second visit was at 12 M., one hour and a half later than the +first. Patient was found in a deep stupor; surface cold; extremities +and face shrunken and blue; pulse barely perceptible; large liquid and +offensive stools occasionally escaped from the bowels without the +consciousness of the patient. Death at 3 o'clock P.M. + +Miss H., living in a malarious situation, complained about noon of +September 19th of great cerebral fulness and unaccountable sleepiness +and debility. She retired to her room, and after a few hours' sleep +resumed her household occupations. On the 20th similar symptoms +manifested themselves, but earlier in the day. She again slept for +some hours, but complained of great prostration after the sleep. On +the 21st, about 10 A.M., she complained of a return of the stupor, and +while retiring to her room requested that I should be called if she +did not awake in a better condition. At 1 P.M. she was found +profoundly comatose, with cold extremities and surface and bathed in +perspiration. When I reached her residence at 3 P.M. she had expired. + +There is a common belief among non-professional people that the third +congestive chill is necessarily fatal. There is no foundation for this +opinion, except in the fact that when congestive chills are waxing in +their perniciousness the subject is seldom able to survive the third +recurrence if the second or first should not prove fatal. + +It is difficult to account for the pathological dissimilarity between +the simple and congestive types of malarial fevers. If we say that +congestive chills are produced by an intensification of those causes +which produce and govern an ordinary chill, we make an explanation +which, however unsatisfactory, represents very nearly the full extent +of our knowledge on this point. + +{607} It cannot be admitted that alterations of quantity or quality of +the malarial poison exercise the sole influence in determining the +occurrence of congestive cases. All experienced practitioners +understand that certain constitutional conditions may pervert simple +chills into congestive forms by producing prolongation or aggravation +of the states of congestion always present in ordinary chills. +Weakened cardiac function, from whatever cause, may be reckoned among +these conditions. In these cases the feeble vis a tergo yields readily +to those perturbations of vaso-motor influence which occasion passive +blood-accumulations in the small veins and capillaries. I may say +further, in speaking of the influence of the vaso-motor nerves in +governing the phenomena of a chill, that we know that in congestive +chills the cerebro-spinal system is much less the seat of symptomatic +phenomena than in simple attacks. On the other hand, the organic +system is far more profoundly affected. + +However we may account for the perversions of normal circulation +underlying and producing congestive chills, the great degree of injury +they are liable to inflict is so well understood as to awaken the most +serious apprehensions whenever we are called upon to treat them. +Congestion, however occasioned, may destroy life through abolishment +of function by the sheer physical change of infarction, or, again, +through those inevitable consequences which arrested circulation +entails upon the blood. Blood-stasis is followed by separation of its +constituents, and its disqualification as a circulatory fluid in a +degree proportionate to the duration of the stoppage, and probably +also to the actual extent of the passive engorgement. Thence result +the formation of coagula in the congested vessels and deposits of +pigmentary matter. If partial reaction should occur, portions of this +blood-debris may be floated to various parts of the circulatory +system, and give rise to greater or less important alterations of +function. + +Among the white soldiers of the United States army from May 1, 1861, +to June 20, 1866, 13,673 cases were diagnosed as congestive +intermittent fever. Of this number, 3370 died, being a mortality-rate +of 23.91 per cent. The aggregate number of malarial cases returned was +1,255,623. It would therefore appear that 1 case in not quite 372 was +congestive in its type, or 1.08 per cent. The late Dr. Cook of +Washington, La., estimated 2 per cent. of his malarial cases to be of +the congestive type. It can scarcely be doubted that the ratio of +congestive attacks is greater in the more southern belts of latitude +than in the middle or northern parts of the United States. Chronic +malarial toxaemia and the enervating effects of long-continued heat +upon the circulation must occasion an increased proportion of such +attacks, but my own observations show slightly more than 1 per cent. +of the cases treated in the Charity Hospital to have been of the +congestive form. + +The cure of a congestive chill is one of the most difficult problems +the physician can possibly encounter. It is nothing less than the +proposition to remove a perverted state of the blood-vessels which is +dependent upon some influence exerted through a nervous apparatus +whose therapeutics and experimental physiology are imperfectly +understood. While a satisfactory solution of this problem will +probably be a remote achievement in medicine, it was long ago +empirically ascertained that certain {608} agents exercised some +degree of control over the cold stage of febrile attacks. For the most +part, these agents are addressed to those perversions of +nerve-function which constitute so important a part of the pathology +of a chill. They are identically the same remedies whose aid we invoke +to allay many other forms of perturbed nervous action. Opium, +chloroform, belladonna, chloral hydrate, and bromide of potassium have +proved more or less valuable, according to the idiosyncrasy of the +patient or the circumstances under which they have been used. I +consider opium the most valuable of these remedies. It should be given +in moderate doses, and preferably combined with chloroform or ammonia, +or, if more expedient to administer per rectum, combined with +solutions of chloral hydrate or bromide of potassium. One-sixth of a +grain of morphia, combined with one-fortieth or one-fiftieth of a +grain of atropia, is an available and useful prescription when given +hypodermically. Rubbing the extremities or the spine, or indeed the +whole surface, with ice, is a mode of practice well worthy of +attention. In the event of inability to procure ice, douches of cold +water, followed by frictions with coarse towels, may be substituted. I +have used nitrite of amyl by inhalation, but its effects are too +transitory to prove serviceable. + +Some practitioners speak highly of alcoholic stimulants. My own +experience has not been favorable to their use. Perhaps their benefits +are altogether restricted to those cases in which previously weakened +heart-function existed. But it is important that alcohol be added in +all those cases of pernicious malarial fever, whatever the type may +be, where cardiac stimulation and improvement of nutrition are leading +indications. + +I am sure I have often derived benefit from enemas consisting of four +ounces of well-prepared beef essence with a half ounce of whiskey or +brandy and a half ounce of strong infusion of coffee. + +The value of the hypodermic syringe in treating congestive chills must +never be lost sight of. The suspension, or even reversal, of normal +systemic currents is made evident by the serous vomiting and purging +attending congestion of the abdominal cavity. Medicine placed in the +stomach under these circumstances is virtually thrown away. + +The term comatose is applied to certain cases of pernicious malarial +fever because they present coma as a marked symptom. To appreciate the +propriety of this classification, it must be well understood that the +coma present is not due to cerebral congestion. Further than this one +restriction upon the application of the word there is in its +employment no declaration of any pathological views respecting the +cases it is intended to define. While, therefore, the term is +unquestionably liable to criticism, I suppose its use may still be +admitted, provided it is accompanied by a satisfactorily explicit +account of the symptoms and probable pathological conditions of the +cases included under its caption. + +There is a sharp line of distinction between the symptoms and +conjectural pathology of comatose cases and of those of the congestive +form of pernicious fever. The following notes of cases will +sufficiently establish this statement: + +C. L., fisherman, aged forty-four, brought into Ward 20, Charity +Hospital, in an insensible condition, November 18, 1875. Temperature +at time of admission 104.8 degrees, pulse 120, respiration 40; able to +swallow liquids placed far back in his mouth. Ordered scruple ij of +quinia in {609} solution, ten grains to be given every fourth hour. +Nov. 19th, patient has taken and retained all the quinia ordered; is +perspiring profusely; temperature 97.8 degrees, pulse 88; more +conscious; takes food and water when offered him. Ordered blue mass, +comp. extr. colocynth., _aa_ gr. v, to be taken at once. To drink +through the day bitartrate potass. oz. j, dissolved in lemonade, until +bowels are moved. Evening temperature 99.3 degrees. Nov. 20th, +temperature 98 degrees; patient placed under convalescent treatment; +discharged from hospital Nov. 29th. + +Another comatose patient was admitted to Ward 19 on the 29th of +October, entirely insensible. He was treated by large doses of quinia +in solution per rectum, and by calomel gr. xx, sodii bicarb. gr. v, +placed upon base of tongue, and caused to be swallowed by a +tablespoonful of water trickled over the powder. As the patient began +to recover it was noticed that his right arm was paralyzed. A history +subsequently obtained showed that the patient was an engineer, and had +been engaged in making some land surveys in a swampy portion of the +State of Louisiana, and had been often obliged to wade or swim across +the bayous and to sleep at night in the open air, sometimes without +any protection from the weather. He had previously enjoyed good +health, and was altogether unable to account for the paralysis of his +arm. During convalescence he was treated with iron, strychnia, and +preparations of cinchona, and by cold douches and frictions to the +paralyzed arm. Convalescence was slow, but he was discharged, +completely recovered, on November 20th. + +In typical cases the differential diagnosis between the congestive +form and the comatose is made without difficulty. In a congestive +chill the surface is cold, blue, or livid, the pupils dilated, and the +pulse generally slower than natural and irregular. In the comatose +form the surface is preternaturally warm, of a muddy, semi-jaundiced +hue, and the pulse and temperature both indicate the feverish rather +than the algid state. + +The subjects of attacks of the comatose form of malarial fever are for +the most part persons who, having contracted attacks of fever in +malarial regions, continue to reside in the same localities and yet +use no proper medication, either for cure or for prophylaxis. We have +in these cases accumulations of secondary blood-poisons quite +sufficient to greatly impede brain-function, and the additional doses +of the primary toxic agent must exercise more or less influence in +determining the phenomena of the attacks. + +Very little need be said of treatment, beyond a recommendation of the +courses pursued in the cases cited. Hypodermic medication must be +resorted to when necessary. Efforts to nourish the patient must never +be relaxed. One must see many of these cases before he can realize how +often they recover, from conditions apparently utterly hopeless, when +promptly treated and properly nourished. + +The hemorrhagic form of pernicious malarial fever can scarcely be +regarded as an original type. Malaria is not a hemorrhage-inducing +poison. Indeed, it may be positively stated that malaria never +establishes the hemorrhagic diathesis as a primary effect; and it is +only by changes effected in the human economy by its prolonged +influence that it appears to become capable of doing so. The most +experienced and accurate observers of malarial affections concur in +the opinion that this rule is almost without exception. + +{610} The morbid conditions whose concurrence entails upon malarial +fevers a tendency to hemorrhages may be classed together as follows: +First. The blood-changes of chronic malarial toxaemia so alter the +consistency of that fluid as to favor the occurrence of hemorrhage. +Second. The long persistent states of malnutrition in chronic malarial +cachexias produce textural weakening of the vascular walls and +increased liability to their rupture. Third. There should be added to +these one other factor, which is mainly operative during a malarial +paroxysm--namely, the increased blood-pressure put upon the vascular +walls by passive congestions. + +Two of these factors, as above enumerated, are more or less general to +the system, being the consequence of general cachectic states. The +third factor acts in a purely dynamical manner in causing hemorrhages, +and must necessarily have its area of influence confined to some +certain portion or portions of the vascular tree, since the +congestions of malarial paroxysms cannot by any possibility be +general. It is an interesting fact that the influence of this +last-mentioned factor is so frequently paramount in producing malarial +hemorrhages. These hemorrhages occur in such immediate relation to +chills that we are forced to the conclusion that while altered blood +and weakened blood-vessels were previously present, yet some increase +of pressure beyond the normal was required to precipitate the +hemorrhage. + +More than once in the presence of medical classes I have illustrated +the influence of these various factors, respectively, by showing the +arm of a patient suffering with chronic malarial cachexia, with no +extravasation of blood, but upon which the slightest suction with the +lips would produce exaggerated ecchymoses. This explains the fact that +hemorrhages in malarial fevers are never general, but only manifest +themselves upon those surfaces or into those structures which are the +seats of congestion during the cold stage of an intermittent. + +I do most earnestly assert that during a practice of almost half a +century, nearly all of which has been passed in malarious localities, +I have never once seen a malarial-fever patient with a general +hemorrhagic tendency, if yellow fever and other hemorrhage-inducing +diseases could be authoritatively excluded. The medical profession +cannot be too watchful in guarding itself against erroneous entries +upon mortuary records to account for deaths from fevers accompanied by +hemorrhages from multiple surfaces of the body. Such aliases as +hemorrhagic malarial fever, climatic fever, rice fever, haematemesic +paludal fever, and many more of the same character, should receive the +severest examination before approval and adoption. + +When hemorrhage does attend malarial fevers, it may occur from one or +another of a variety of surfaces or into shut cavities or in +parenchymatous structures. Some years ago I visited a gentleman who +was suffering from an attack of malarial fever, with haematuria. He +made a rapid and, apparently, a complete recovery. Disobeying my +injunctions, he returned to the intensely malarious locality where he +had formerly resided. After a few weeks he was seized with a chill, +followed by apoplectic symptoms, hemorrhage, and death on third day. +It is hardly to be doubted that his death was caused by cerebral +hemorrhage. But, however much in consonance with ascertained facts the +foregoing remarks may appear to be, there are certain points of +pathology connected with {611} malarial hemorrhagic fevers not easy of +explanation. Within the last score of years haematuria has been a far +more common form of hemorrhage in malarial fevers than formerly. In +many localities and during certain seasons it has been very prevalent. + +In the present state of our knowledge it is not at all possible to +explain why it is that different epidemics of malarial diseases should +give rise to such a diversity of phenomena, so that one epidemic will +be characterized by a peculiar train of symptoms which shall be absent +in another, being there replaced by different symptoms equally +distinctive of the second epidemic. Whatever may be the cause of these +epidemical peculiarities, it must rest in a something which is capable +of acting as a force upon the human system. We must think of that +unknown agency which exercises this force and gives it some peculiar +direction as possessing at least a conventional essentiality. It is +not satisfactory to say that the renal blood-vessels are the first to +give way, because they are accidentally more weakened than other parts +of the vascular system, or accidentally more often the seat of +congestion. When accidents become as numerous as these cases sometimes +are, they acquire the authority of laws. + +The following notes of two cases of malarial hemorrhagic fever may be +found of interest: + +C. E., aged twenty-six years, was admitted to Ward 19, Charity +Hospital, Nov. 18, 1872. Had been in America more than a year, and for +several months had been working in an intensely malarial district +preparing the bed of a railroad; has had malarial diseases for several +months, and suffered a severe chill the day before admission. A few +hours after admission temp. 103 degrees, pulse 120, respiration 29; +effusion in both thoracic cavities, and very marked in abdominal +cavity; lower lobe of right lung oedematous, legs anasarcous, pitting +greatly on pressure, with several ulcers of long standing. Urine +loaded with albumen and showing under the microscope abundant +blood-corpuscles; considerable jaundice present, which the patient +states to have occurred suddenly. Ordered five grains each of calomel +and bicarbonate of sodium, to be followed after catharsis with ten +grains of quinia in solution every two hours. Nov. 22d, patient has +taken and retained one hundred and eight grains of quinia; secretion +of urine abundant; no blood present, and only a trace of albumen; +ordered twenty drops of tincture of chloride of iron three times +daily. Discharged cured December 12th. The above comprises the whole +treatment in this case, except one important measure, which consisted +in determined and persistent efforts at forced nutrition. Meat +essences, milk, eggs, and milk-punch were given as methodically as +drugs. + +H. K., fifteen years of age, was admitted to Charity Hospital Sept. +15, 1872; has a history of malarial poisoning for several months; was +considerably jaundiced at time of admission, with anasarcous legs. +Under the administration of a mercurial, followed by quinia and iron, +he improved so greatly that he was discharged from my wards and placed +upon some duty in the hospital. Dec. 19th, at 11 A.M., had a chill +which lasted several hours; this was followed by violent fever, with +rapid but compressible pulse; much jactitation; incessant vomiting of +a greenish-black fluid; urine loaded with blood; and sudden +supervention of intense jaundice. Ordered quinia gr. xij by hypodermic +injection; {612} small doses of calomel and soda to be placed upon the +base of the tongue and washed down with ice-water. Secretion of urine +ceased on the morning of the 20th, followed by death at 11 P.M. +Autopsy showed both kidneys dark-colored and swollen from complete +blood-engorgement. + +The treatment of hemorrhagic malarial fevers may be included under the +following indications: + +First, to secure cinchonism as early as possible; + +Second, to arrest the extravasation of blood; + +Third, to sustain the patient's strength, and to preserve the systemic +fluids at as near a healthy standard as may be possible. + +The first-mentioned indication is certainly the first in importance. +If the hemorrhage originates during a chill, or exhibits degrees of +aggravation in such close relation to the cold stage of malarial +paroxysms as to point to a relation of cause and effect, then that +course of treatment which breaks the recurrence of paroxysms will at +the same time mitigate the hemorrhage, if, in truth, it should fail to +stop it entirely. Quinia should be given in large doses by the mouth +or rectum, or both, or subcutaneously if demanded by the urgency of +the symptoms. I have generally used carefully prepared solutions of +the sulphate for hypodermic injections, but many practitioners prefer +solutions of the hydrobromate for this mode of exhibition. I have +never witnessed any symptoms following the administration of cinchona +salts which justified a belief that they increased the hemorrhage. My +rule of practice has invariably been to endeavor to prevent the +occurrence of another paroxysm, without regard to this very +questionable charge. + +In regard to the second indication, it may be stated that patients are +not likely to die from actual loss of blood in any form of hemorrhagic +malarial fever. The blood which is poured out on free surfaces and +escapes by some outlet is seldom so much as to endanger life, but the +hemorrhagic process is likely to involve deeper-seated vessels. This +is especially true in malarial haematuria. Hemorrhages into the stroma +of the kidneys, the Malpighian tufts, and the uriniferous tubules +arrest urinary secretion, and thus entail death. In order to prevent +these results haemostatics should be resorted to as often as attendant +circumstances will permit. Generally these are such as to admit of the +use of haemostatics without prejudicing the effects of other remedies. +In my experience ergot in combination with gallic acid and dilute +sulphuric acid has been very efficient. The following prescription has +been usually given: + + Rx. Ext. Ergot. Fluid. fl. drachm iv; + Acid. Gallic. gr. xl; + Acid. Sulphuric. dil. fl. drachm j; + Syr. Zingiber. fl. drachm iij; + Aquae q. s ad fl. oz. ij. M. + +S. Dessertspoonful every four hours, diluted with water. + +Some practitioners place a very high estimate upon the haemostatic +effects of turpentine. This is undoubtedly a most valuable and +accessible remedy. Dr. Schnell of Plaquemine Parish, La., has found +the tincture of chloride of iron the best haemostatic. He places fl. +drachm ij in fl. oz. iv of water, and directs a dessertspoonful every +hour as long as the hemorrhage continues. In a great majority of cases +of malarial haematuria occurring under my observation solutions of +bitartrate of potassium have {613} been given with great apparent +benefit. Its action is certainly not that of a direct haemostatic, but +by setting up currents through the kidneys, and perhaps by some +solvent power over exudations in the uriniferous tubules, it has acted +as a renal deobstructive. + +In the arrest of renal secretion diuretics, cupping over the lumbar +region, and large injections of warm water into the bowels may be +resorted to. Some practitioners state that they have found buchu +beneficial. + +The third indication involves a twofold duty. One relates to judicious +and vigilant attention to the patient's nutrition; the other relates +to such measures for depuration as may be called for in each +particular case. + +It must be admitted that there is a degree of antagonism in the +measures of practice proper to effect these two purposes, which +renders their coincident exercise a difficult practical question. In +many cases of hemorrhagic malarial fever a competent supply of +properly prepared foods is sufficient. In other cases--and this is +especially true of malarial haematuria--depurative medication becomes +paramount. A person suffering under the effects of chronic malarial +poisoning is seized with a chill; this is followed by bloody urine, +and in the course of four or five hours intense jaundice appears. +Incessant vomiting, delirium, and jactitation also occur. The +experienced physician is at once brought to the conclusion that he has +to deal with a case of blood-poisoning bearing a close resemblance in +symptoms to uraemia. To render this conclusion still more absolute, he +has only to recall the suddenness of the occurrence of the jaundice +and to inquire what has occasioned it. Its appearance is too rapid to +permit us to ascribe it to obstruction. It is altogether improbable +that it is due to sudden hypersecretion in such pathological states of +the system as are present. If, however, we account for it by saying +that the addition of a new toxic constituent, urea and its congeners, +to an already profoundly poisoned fluid suddenly arrests those +processes which dispose of bile in physiological conditions of the +system, it seems to me that we adopt the most rational theory. It is +then jaundice from lack of consumption. The mere probability of truth +in this theory will impress the practitioner with the great importance +of eliminant practice in these conditions. + +Calomel has been the medicine to which I have principally trusted. I +give it merely as a depurative, and not as an alterative. Doses of +from two to ten grains may be repeated at suitable intervals until +catharsis has been produced. Bitartrate of potassium, Seidlitz +powders, or solutions of citrate of magnesia may be also administered +if indicated. After purgation the vomiting is mitigated, if not +altogether relieved. On this account, and because of bettered states +of the system for absorption and assimilation, the way is now clear to +the physician. He can ply his antiperiodics, his properly prepared +sustenance, and his alcoholic stimulants according to the exigencies +of each particular case. + +The following propositions may seem not inappropriate in closing this +section: + +1st. Attacks of pernicious malarial fever are attended by more danger +to life or subsequent health than simple attacks; therefore more +prompt and energetic efforts should be made to cut them short by +cinchonism. + +2d. The blood depravations of pernicious malarial fevers far exceed +those of simple cases; and therefore it becomes a leading indication +of treatment to correct faulty conditions of this fluid as early as +possible. {614} In endeavoring to secure this end assimilable foods, +stimulants, and depurants must have a shifting scale of value +according to the exigencies of each particular case. + +3d. The complications of attacks of pernicious fever are far more +important than those of simple forms; and therefore symptomatic +treatment is often urgently required. + +4th. Attacks of pernicious fever may be greatly diminished in number +by properly directed treatment of chronic malarial toxaemia, and +especially also by the removal of persons suffering under this +cachexia to non-malarious localities. + + +Typho-Malarial Fever. + +The prefix typho- is properly applicable to a class of malarial fevers +which are complicated by the specific poison which produces typhoid +fever. + +This term was introduced into medical nomenclature by Surgeon J. J. +Woodward of the United States Army. His classical paper on this +subject has been published in the _Transactions_ of the International +Medical Congress at Philadelphia in 1876. The following extract from +the proceedings of this congress will show the interpretation of this +term by Woodward: + +"On motion of Dr. Woodward, seconded by Dr. Pepper, the following was +adopted as expressing the opinion of the section: Typho-malarial fever +is not a specific or distinct type of disease, but the term may be +conveniently applied to the compound forms of fever which result from +the combined influence of the causes of the malarious fevers and of +typhoid fever." + +It follows, therefore, that the term should be so restricted as to +define a disease compounded of the two pathological factors which when +acting separately produce either typhoid or malarial fever. + +When understood in this sense, and carefully employed, the term +appears to me unobjectionable. Perhaps, indeed, it may be a convenient +addition to medical nomenclature. If such a name had not been +introduced, we would be forced to speak of these cases of compound +disease as complications. As it is customary to regard the minor or +less important affection as the complicating disorder, we would often +have confusion in determining whether the case should be typhoid fever +complicated by malaria or malarial fever complicated by typhoid. This +term leaves all questions of precedence or predominance in abeyance. + +There are no facts, however, which support a conclusion that the +malarial poison is capable of forming combinations with the particular +poisons of other specific fevers and give birth to a new special +poison, which may be perpetuated by successive generations, and thus +produce epidemics of a new but compound disease. + +The importance of a proper use of the term typho-malarial implies +co-ordinate care in diagnosing the true nature of the malady it should +define. + +It may be said, in brief, that the diagnosis of typho-malarial fever +must rest upon the blending of the symptomatic phenomena peculiar +{615} to each one of the two fevers which enter into combination. In +other words, if the differential diagnosis between the two diseases +when they are distinct is made by contrasting the symptoms peculiar to +each, the compound disease is to be recognized by more or less +positive combinations of these symptoms. + +These blended symptoms should not be expected to exhibit the results +of a copartnership in which each member exerts equal influence. It is +well understood that when two diseases coincide, that one which is +more violent or excessive in its morbid process holds so much sway as +in some cases almost to extinguish the symptoms of the weaker member +of the combination. Consequently, in typho-malarial fever, the +typhoid, being the graver of the two forms of disease, ordinarily +rules the pathology. + +The following notes, accompanied by a temperature chart, will +illustrate the clinical course of a case of typho-malarial fever: + +J. L., aged thirty years, of French nativity, but a resident of New +Orleans for three years, was admitted to Ward 21, Bed 311, Charity +Hospital, on the night of December 10, 1881. Had been ill some days +with ague. The house-surgeon administered gr. x. of quinia in solution +and gtt. xv. of tincture of opium. + +The records and temperature date from the 12th of December. During the +11th he took drachm ij sulph. cinch. in solution. + +{617} [Illustration: FIG. 24. PART I., showing the temperature-curve +from December 12th to 31st, inclusive, during which time the more +characteristic typhoid symptoms predominated. PART II., showing the +temperature-curve in same case from January 1st to 20th, inclusive, +during which the influence of the associated malarial poison was +prominent.] + +Dec. 13th, tenderness and gurgling in ileo-caecal region; epistaxis; +rose spots on abdomen; deafness and ataxia; no stools since 11th. +Ordered + + Rx. Acid. Sulphuric. dil., + Syr. Aurantii Cort. _aa._ fl. drachm ij; + Tinct. Cinchonae Co. fl. oz. j. M. + +S. Teaspoonful in water every four hours. + +Also ordered beef-essence, milk-punch, and milk. + +Dec. 13th, two very offensive liquid stools; ataxia greater; skin +yellow and countenance dull and listless. Dec. 14th, fresh rose spots; +tongue brown and dry; three stools; much jactitation. Dec. 15th, more +ataxia; some delirium; pulse 100, weak. Gave gr. iiss quinia in +solution, with tincture opium gtt. iii, every two hours. Dec. 16th, +pulse 128, weak; delirious. Dec. 17, new rose spots; belly tympanitic; +tongue brown, dry; sordes on teeth and lips; eyes injected; very +delirious. Treatment continued; nutrition and stimulants given +methodically. From 17th to 22d but little change in condition or +treatment. Diet and stimulants administered regularly. Dec. 22d, coma +vigil; completely delirious. Ordered + + Rx. Liq. Morphiae Sulph., + Tinct. Digitalis _aa._ fl. drachm iij; + Spts. Aether. Nitrosi fl. drachm ij; + Liq. Potass. Citrat. fl. oz. iij. M. + +S. Tablespoonful every three hours. + +As the oscillations of temperature became more marked, quinia was +resorted to, apparently with good effect. The patient was discharged +from the hospital Feb. 8, 1882. + +It should be observed that after the 14th of December the patient's +bowels were rather costive, and the stools occasionally moulded and +very {616} dark in color. On the forty-fifth day after admission the +patient had a severe chill, followed by a rise of temperature to 104 +degrees. This yielded to competent doses of sulphate of cinchonidia. + +This was a typical case of typho-malarial fever. The blended symptoms, +as well as those special to each disease, are sufficiently exhibited +in the clinical account. The presence of typhoid fever was established +by the rose spots and the marked nervous symptoms. The typhoid process +seems to have been unusually mild in so far as evidence of bowel +lesions were made manifest. + +The history of the patient before admission, the color of his skin and +stools, and the temperature curves gave abundant proofs of the +malarial element in the pathology of the case. + +Perhaps nothing need be added on the subject of diagnosis. I may, +however, remark that I am very cautious in asserting the diagnosis of +typho-malarial cases unless the nervous symptoms, positively-marked +bowel symptoms, or rose spots are present to vindicate such a +decision. The presence of malarial poison may be determined with less +difficulty from the previous history of the case and its special +symptoms in the early stages of an attack. But if the morbid processes +of the typhoid poison are violent, there are likely to be stages of +the disease when it is not possible to detect symptoms which indicate +the presence of malaria. On the other hand, it is unquestionably true +that the typhoid condition, as it is termed, which so often +complicates malarial fevers, can very generally be differentiated from +true typhoid fever. While certain cases, or even epidemics, of +malarial fevers are attended by remarkable adynamia, often manifesting +itself from the very incipiency of attacks, it differs widely from +that utter nervous ataxia which characterizes typhoid fever. Again, +the adynamia of malarial attacks is generally ascribable to some cause +not essential to those affections. Imperfect reaction from a chill, +long persistent hyperpyrexia, diarrhoea or vomiting, or chronic +paludal cachexia, or, it may be, some epidemic influence, may produce +it. The ataxia of typhoid fever is part of its morbid process. + +Woodward's statistics show that 49,871 cases of fever diagnosed as +typho-malarial occurred among the white forces of the United States +during the late Civil War. Of this number, 4059 proved fatal, a +mortality-rate of 8.13 + per cent. Among the colored troops 7529 cases +occurred, with 1301 deaths, a mortality-rate of 17.27. Statistics +borrowed from the same excellent authority give the number of cases of +unmixed typhoid fever (or fever classed as typhoid without reference +to any complication) as 75,368 among the white troops, with 27,056 +deaths, a mortality-rate of 35.89. Among the colored troops 4094 cases +occurred, and 2280 died, a mortality-rate of 55.68. These figures show +very singular comparative results. They prove that typhoid fever as an +uncomplicated malady, was four and a half times as fatal among the +whites as the same disease when in combination with malarial poison. +Among the colored troops typhoid fever was three and a half times more +fatal than typho-malarial fever. + +It is highly probable that inaccuracies exist in statistics gathered +in the confusion of a great civil war, but I am not prepared to say +that the conclusions they point to are incorrect. When an acute +inflammation is complicated by malaria, its prognosis is rendered more +grave. This, no doubt, {618} is due in part to degradations of the +fluids of the system by the malarial poison, and in part to the +revulsions of circulation during paroxysms. But it does not follow +from this fact that the presence of malaria in the blood, or its +effects upon that fluid, exercise an unhappy influence upon diseases +due to other specific poisons. It may, on the contrary, be ascertained +in the future that it modifies the typhoid process, so as to deprive +it of some of its most dangerous features. + +Further investigations are required to determine the facts in regard +to these questions. But it may be premised that if such a conclusion +shall ever be reached, it will influence our expectations of cure +rather than our practice. If the malarial poison is capable of +modifying the toxic effects of the typhoid poison, it must do so in +the very formative stages of that affection, if not in its incubative +period, so that, having accomplished all the good it is capable of +effecting, we may proceed at once to rid ourselves of its presence. + +In entering upon the treatment of two diseases compounded in the same +patient, if one should ordinarily be amenable to specific treatment, +it must certainly be wise practice to endeavor to simplify the case by +subtracting that one from its composition. This is more especially +true if the treatment does not affect the course of the other disease +in any injurious manner. It is therefore proper to begin the treatment +of a case of typho-malarial fever by administering large doses of +quinia. A scruple may be given every fourth hour, until its effects in +eliminating symptoms ascribable to malaria, and also as an +antipyretic, have been sufficiently tested. In the early stages of +typho-malarial attacks the febrile exacerbations conform to those laws +of periodicity which govern uncomplicated malarial fevers. After the +first week, or when the typhoid process has become well established, +periodic returns of the fever are less plainly observable. It is +possible that in some cases in which the typhoid process manifests +itself with great severity the temperature curves may be very +characteristic of that disease. I am satisfied that the indications +for giving quinia to eliminate the malarial element must be based upon +the fever curves which mark the case. Perhaps a more frequent +application of the thermometer would often exhibit malarial +periodicity where it may otherwise remain unsuspected. I know this to +be very often the case in pneumonia complicated by a malarial fever. + +Whether thorough cinchonism in the early progress of the attack rids +the case of symptoms due to malaria or not, only a very few days are +likely to elapse before oscillations of temperature call for its +repetition. + +The typhoid processes require very much the same measures which are +applicable in uncomplicated cases of that disease. The stools of the +early stages of attacks should not be checked unless excessive, and +mercurials and laxatives should be more freely used than in simple +typhoid fever. The effects of the malarial fever and of the +hyperpyrexia of typhoid fever, when combined, must almost necessarily +entail more accumulation of excrementitious material in the blood than +would occur either disease existing separately. On this account +eliminating treatment is an important indication. When it becomes +necessary to check the diarrhoea because excessive or on account of +failing strength, diuretics subsequently prove serviceable. +Effervescing solutions of potassium or ammonium, lemonade, Apollinaris +water, iced tea, strawberry, mulberry, or raspberry juice, are {619} +grateful beverages and increase renal activity. The mineral acids may +be given during the ulcerative periods of the disease. Insomnia must +be relieved by opiates, chloral hydrate, or other hypnotics. + +Tympanites should be met by warm stupes, large enemas of warm water +with fl. drachm j tincture of asafoetida or fl. oz. j of whiskey. +Small doses of turpentine in emulsion are often beneficial. + +In the early progress of cases the diet should consist of farinaceous +foods, with milk and the pulps or juices of fresh fruits, given either +cooked or in their natural state as the physician may determine for +each patient. Methodical and forced nutrition becomes necessary at +more or less early periods in different cases. + +The stools and all ejecta of the sick should be disinfected and +disposed of with the same care and for the same purpose as those of +unmixed typhoid fever. + + + + +{620} + +PAROTITIS. + +BY JOHN M. KEATING, M.D. + + +The term parotitis is applied to a condition of painful enlargement of +one or both parotid glands, inflammatory in nature, acute in its +course, and usually subsiding by resolution, but sometimes ending in +suppuration. The different methods of termination, together with +certain etiological distinctions, form the basis of a division of the +affection into two sub-classes--namely, 1, idiopathic parotitis; and +2, symptomatic or metastatic parotitis. These demand separate +consideration. + + +I. Idiopathic Parotitis. + +Idiopathic parotitis, parotitis epidemica, or mumps, as it is +variously named, is an acute contagious inflammation of one or both +parotid glands, which usually appears but once in a lifetime, and +which, although by no means limited to children, is commonly met with +between the second year and the age of puberty. In certain exceptional +cases the disease affects the submaxillary glands alone. + +NATURE.--The undoubted contagiousness of mumps, with the fact of its +frequently occurring in extended epidemics, entitles it to a place +among the zymotic diseases, from which it differs, however, in the +marked disproportion between the local and constitutional symptoms, +the former being well developed, the latter but slight or altogether +absent. + +ETIOLOGY.--While it is more than probable that, like the other +diseases of the zymotic class, mumps is due to a contagium that finds +its way into the body in the inspired air or with the food or drink, +nothing is known of the nature of this infecting principle. + +The predisposing agencies are better understood. Age is one of these, +the greater number of cases occurring, as already stated, between the +second and the fifteenth year. Infants at the breast are almost +entirely exempt, and so, too, are individuals advanced in years. In +extended epidemics it is not unusual to meet with cases in adults, but +it will generally be found on careful examination that these patients +have escaped the disease during childhood. Sex exerts some influence, +a much larger percentage of males being attacked than females. +Epidemics appear more frequently in the spring and fall than at the +other seasons of the year, so that cold and dampness of the atmosphere +must be looked upon as predisposing causes. Mumps bears a peculiar +relation to measles, scarlet fever, and diphtheria, epidemics being +apt to occur directly before, during, or immediately after the +prevalence of either of these affections, especially {621} the first. +The popular idea of mutual protection is entirely without foundation. + +Certain peculiarities are presented by the disease in its mode of +occurrence and in the duration and intensity of its epidemics. Thus, +some localities are visited annually, others only at intervals of +thirty years or more; again, one epidemic may last but a few weeks and +affect a small number of individuals, while another extends over +months and attacks all the children and many of the adults in the +affected region. + +ANATOMICAL APPEARANCES.--The exact pathological lesion in mumps is +obscure, since the trifling nature of the disease and the almost +invariable termination in recovery afford no opportunity for +post-mortem investigation. According to Foerster, who seems to have +made examinations in cases where mumps occurred as one of the +accidental complications of other and fatal diseases, the affected +gland at first becomes hyperaemic, and is then the seat of serous +exudation. It is reddened, swollen, and on section presents a uniform +flesh-like, moist appearance, in place of the ordinary granular +aspect. The tumor is often greatly increased in size by a simultaneous +serous infiltration of the periglandular connective tissue, and +occasionally this tissue alone is involved, the gland itself being +entirely free from lesion. The great point in favor of this view of +the pathology is the rapid and complete subsidence of the parotid +swelling by resolution--a termination to be expected only when the +inflammatory process stops short of suppuration or fibrinous +exudation. + +Virchow regards all cases of parotitis as the result of an extension +of a more or less malignant catarrh originally affecting the +gland-ducts. This is undoubtedly true in some cases, but that it is +far from being the rule is proved by the infrequency of parotitis as a +secondary complication of catarrhal affections of the mucous membrane +of the mouth. + +COURSE AND SYMPTOMS.--The course of the disease is susceptible of a +division into three stages--a period of incubation, of invasion, and +of actual attack. + +The stage of incubation extends over a period variously estimated as +from seven to fourteen days. It is marked by no symptoms, though +sometimes a history of impaired appetite and digestion, irregular +bowels, and languor during the last two or three days may be obtained. + +The period of invasion is short, lasting only twelve, or at the most +twenty-four, hours. The patient is pale and languid, has slight +rigors, pains in the breast and head, and loss of appetite; later, +local pain in the parotid region on moving the jaws or on taking acid +liquids into the mouth. The surface temperature increases from hour to +hour, and just before the glandular swelling appears it reaches 100 +degrees or 101 degrees F. In some cases the invasion is characterized +by the same train of symptoms that ushers in the acute exanthemata, +such as repeated vomiting, diarrhoea, restlessness and anxiety, a +disposition to syncope, and, in very irritable children, convulsions. +Contrasted with this violent invasion other cases are met with, in +which there are no prodromes whatever except a gradual rise in +temperature, imperceptible without the use of the thermometer. + +The first symptom of actual attack is a peculiar slight stitch-like +pain in one parotid region, usually the left. This radiates toward the +ear of the affected side, and is increased by movements of the jaw, as +in {622} chewing or talking, and by external pressure. The pain +rapidly grows more intense, and soon becomes associated with swelling. +The tumor first appears in the depression between the mastoid process +and the ramus of the jaw, which it fills up, and at the same time +thrusts outward the lobe of the ear. As the gland alone is swollen at +first, the tumor has the outline of a triangle, with the apex directed +downward and forward; soon, however, the connective tissue becomes +oedematous and the swelling is greatly extended, involving the cheeks +and neck, in the latter region, in severe cases, running forward as +far as the median line, downward nearly to the shoulder and backward +toward the spine. The most prominent point is directly in front of the +ear. The oedema also extends internally, involving the pharynx, the +tonsils, and sometimes even the larynx. The skin covering the tumor is +either perfectly natural in color or slightly reddened. The central +portion is firm and elastic to the touch, the periphery doughy, and +pressure here often produces pitting. There is but moderate +tenderness. The swelling reaches its height in three days, remains +stationary for two days longer, and then rapidly declines, the oedema +first disappearing and afterward the glandular swelling, the process +of resolution occupying four or five days and being attended with a +slight desquamation of the cuticle. + +While mumps almost uniformly begins on one side, both glands are, as a +rule, affected during the attack. The second tumor begins to develop +twenty-four to forty-eight hours after the first, though its +appearance may be delayed much longer, even until resolution has begun +on the side primarily affected. As the course of the inflammation is +similar in both parotids, the whole duration of the attack will depend +on the time of involvement of the second gland. + +Among the other symptoms an alteration of expression is prominent. At +first, the head is inclined toward the affected side; later, when both +glands are involved, it is held perfectly erect, and, as the slightest +movement increases the pain, it is maintained stiffly in this +position. The swelling of the cheeks prevents all play of the +features, and this, combined with widely-open, staring eyes and +increased thickness of the neck, gives the patient a stupid, almost +idiotic, expression. The swelling of the neck is sometimes so great +that its diameter exceeds that of the head, and the shoulders, neck, +and head, viewed together, have the outline of a truncated pyramid. + +As any movement of the lower jaw greatly augments the suffering, the +mouth is kept closed, often so tightly that it is impossible to see +more than the tip of the tongue. All efforts at mastication are +suspended, and deglutition is so painful, especially when the tonsils +become enlarged, that the sufferer bears the pangs of hunger and +thirst rather than endure the agony entailed in satisfying his wants. +The act of speaking even augments the pain; the voice, when heard, has +a nasal tone. The acuteness of hearing is impaired, there are singing +noises and shooting pains in the ears, headache, and sometimes, in +extreme cases, symptoms of cerebral hyperaemia due to pressure upon +the cervical veins. + +The tongue is heavily coated, the mouth is either dry or there is an +increased flow of saliva, and the fluid dribbling from the mouth adds +another element to the idiotic expression already referred to. There +is loss of appetite, increased thirst, occasionally vomiting, and +commonly {623} constipation. The temperature is elevated and the pulse +increased in frequency, both to a moderate degree. The respiration is +unaffected, except when the oedema has invaded the submucous +connective tissue of the larynx; then the movements are increased in +frequency and difficult. + +Throughout the attack the pain, unless intensified by some extraneous +influence, as pressure or the act of speaking or swallowing, is only +moderately severe. In ordinary cases the patient rests quietly and +sleep is undisturbed, unless the tonsils are enlarged, when it is +liable to interruption from loud snoring. When the attack is severe +and in nervous, excitable children there is restlessness, +sleeplessness, and slight delirium at night. + +The general symptoms keep pace with the local in their increase, but +they commence to subside before, beginning to disappear while the +swelling remains stationary. As soon as resolution sets in the general +and local improvement are both rapid, and by the end of the week +nothing is left but a trifling weakness and pallor, which disappear in +a few days more, leaving the patient perfectly well. + +Besides the ordinary symptoms, mumps in certain instances shows a +peculiar tendency to metastasis, or secondary involvement, of the +testicle and scrotum in males, and the mammae, vulva, and ovaries in +females. This metastasis occurs much more frequently in males than in +females, and is usually met with in pubescents and adults, being very +rare either in childhood or old age. It generally begins six or eight +days after the appearance of the parotid tumor. The latter, as a rule, +subsides on the occurrence of any of these metastatic affections, +though occasionally the two run a simultaneous course. This +occurrence, together with the fact of the secondary inflammation +appearing at the date on which the parotitis naturally begins to +disappear, tends to support Niemeyer's view, that the two affections +are in reality due to the same cause, and that no true transference of +inflammation takes place from one point to the other. Occasionally, +the parotitis disappears a variable time before the onset of the +metastatic affection; then the interval is marked by grave symptoms of +depression and cerebral disturbance, but there are no proofs of actual +meningeal involvement. In these cases there is, at times, an excessive +elevation of temperature, which may account for the brain symptoms. + +The most constant secondary manifestation is swelling of the testicle +proper, or true orchitis; less frequently there is epididymitis, and +with it acute hydrocele and oedema of the scrotum. The orchitis in +most cases is unilateral, the right testicle being affected, just the +opposite to the parotids, of which the left is the one first involved. +When the orchitis is double, both testicles do not become swollen at +once, the one preceding the other by an interval of several days. + +The course of the orchitis is very similar to that of the mumps, the +inflammation increasing gradually for from three to six days, then +undergoing rapid resolution, the gland returning to its normal +condition by the end of two weeks. + +The local symptoms are swelling, the testicle being enlarged to two or +three times its natural size, dull pain, and moderate tenderness, +while in very severe cases there is burning on micturition and a +purulent discharge from the urethra. The spermatic cord does not +sympathize in the {624} inflammation, and neither the swelling, pain, +nor tenderness is so great as in specific orchitis. + +The general symptoms are confined to a moderate elevation of +temperature and increase in the frequency of the pulse, thirst, and +loss of appetite. This fever is separated from that of the parotitis +by an interval of two or three days. + +The course of bilateral orchitis is longer by forty-eight hours than +that of the unilateral form, and the attending fever is more intense. + +The rapid return of the testicle to its natural size and shape shows +that, as in the parotid glands, the inflammation does not extend +beyond the stage of serous exudation. + +THE DIAGNOSIS of mumps is easy after the disease is sufficiently +developed to produce the characteristic alterations in the facial +expression. In the earlier stages the position of the swelling, +immediately beneath and in front of the ear, its triangular shape, and +the elevation and outward displacement of the lobe of the ear of the +affected side, distinguish it from the enlargement of the cervical +lymph-glands so liable to occur in strumous subjects. The acute onset +and course of mumps are the points of distinction between it and +morbid growths, or the very rare condition of chronic hypertrophy of +the parotid gland. The metastatic orchitis cannot be mistaken for +gonorrhoeal orchitis if the least care is taken to investigate the +history in either case. + +THE PROGNOSIS is extremely favorable, there being no record of a fatal +case of uncomplicated mumps. Suppuration may occur, but it is an +exceedingly rare event. In scrofulous children the course may be +protracted for several weeks, and in them resolution is occasionally +imperfect, a degree of enlargement and induration of one or both +parotids remaining for some time. + +Metastatic orchitis, as a rule, leaves the testicle in a normal +condition, but, according to Vogel, in some epidemics complete atrophy +results. + +Dogmy reports an epidemic which raged in a garrison of Mount Louis in +January, 1828. Of sixty-nine bilateral and eighteen unilateral cases +of parotitis, metastasis to both testicles occurred in four cases, all +of which resulted in atrophy of the affected testicle. + +THE TREATMENT is simple. The patient should be kept in a uniform +temperature, confined to one room, or, better still, to bed, until +resolution is well established. While the difficulty in swallowing and +fever continue the food should consist of milk and beef-tea; later, +other nutritious articles of diet may be added as the appetite +demands. Water, iced carbonic acid water, or lemonade may be allowed +as freely as the patient will take them, to allay the thirst. A daily +evacuation of the bowels must be secured by the use of saline +laxatives. During the early stage, if the fever be high, tincture of +aconite-root should be cautiously administered; afterward liquor +potassii citratis will sufficiently fill the indications for a +febrifuge. Tonics are required during the decline of the disease; of +this class of remedies, syrup of the iodide of iron, bitter wine of +iron, and ferrated elixir of cinchona are most useful. + +Special symptoms may demand attention. For example, headache and +delirium should be relieved by hot mustard foot-baths and moist cold +to the forehead; difficult deglutition from enlargement of the +tonsils, by the frequent swallowing of bits of ice, or, if possible, +by the application of {625} astringent lotions, as tannic acid and +glycerine (one drachm to the ounce); sleeplessness, by the +administration of bromide of potassium, with or without small doses of +hydrate of chloral in children and of some preparation of opium in +adults. + +In the way of local treatment the best results and greatest relief to +suffering will be obtained by gently rubbing the swollen glands with a +mixture of tincture of opium and sweet oil (one drachm to the ounce), +three times daily, and in the mean while keeping the parts enveloped +with a moderately thick layer of cotton wadding covered by oiled silk. +Water dressings or light poultices may be used with advantage. When +resolution begins a more stimulating lotion will hasten the +disappearance of the swelling. + +In the exceptional instances in which the skin covering the tumor +becomes tense and red, and suppuration is threatened, two or three +leeches may be applied behind the ear of the affected side. When +suppuration has actually taken place the abscess should be immediately +opened to prevent further destruction of the gland-tissue and +perforation into the external auditory meatus. + +If, particularly in strumous subjects, resolution be incomplete and +glandular enlargement and induration remain after the cessation of the +acute symptoms, cod-liver oil and iodide of iron are demanded for +internal administration and the compound ointment of iodine for +external application. It is well to dilute the latter sufficiently to +prevent its causing irritation of the skin, and to apply it twice +daily. + +When metastasis occurs, the return of fever calls for the same general +treatment as in the early stage of parotitis. In addition, an emetic +should be given, as this often cuts short the fever or causes it to +disappear more rapidly. The patient must be kept at perfect rest in +bed, with the scrotum elevated by a cushion and covered with warm +anodyne lotions. Salines must be administered sufficiently often to +secure regular and free action of the bowels. + +When the mammae or ovaries are secondarily attacked, the seat for +local treatment is of course different, but in all other respects the +management must be the same. + +For the uncommon cases in which the transference of the inflammation +is attended with depression stimulants are required, and for those in +which meningitis is threatened cutting off the hair and the +application of cold to the head, hot mustard foot-baths, local and +general venesection, drastics, and irritants to the cutaneous surface, +are necessary. + + +II. Symptomatic or Metastatic Parotitis. + +Symptomatic, metastatic, malignant, or suppurative parotitis, as the +condition is variously designated, is an inflammation of the parotid +gland which occurs during the course of different grave acute +diseases, is usually unilateral, and terminates in suppuration, or +much more rarely in gangrene, of the gland involved. + +ETIOLOGY.--It may occur in association with typhus, typhoid, +relapsing, puerperal, and scarlet fevers, or with the plague, measles, +dysentery, cholera, and pyaemia, springing into notice at different +periods of the {626} course of these affections, which may be regarded +as predisposing causes. The exciting cause is perhaps mechanical in +nature--namely, the excessive dryness of the mucous membrane of the +mouth so common in the severe fevers. This dryness may lead to an +occlusion of the orifice of the parotid duct, with retention of the +saliva, which fluid, undergoing decomposition, may act as an irritant, +producing inflammation, and finally suppuration, of the glandular +tissue. This is a likely enough explanation of the causation in some +cases, but dryness of the mouth is such a uniform symptom in fever, +and suppurative parotitis such a comparatively rare complication, that +it cannot be a very active or common cause. Nevertheless, it is +impossible to fix upon any other direct cause, though the altered +condition of the blood in the conditions mentioned must not be lost +sight of as an important etiological factor. + +ANATOMICAL APPEARANCES.--The character of the pathological lesions +have been well established, owing to the frequent opportunities that +arise of examining the diseased gland at different stages of the +inflammatory process. When the inflammation has lasted a short time, a +day or two, the tubes and acini of the gland are seen on section to be +swollen and reddened, and the connective tissue infiltrated with serum +and yellowish-red in color; a fluid, either viscid, ropy, grayish in +color, or more purulent in character, fills the duct, and may be +forced out into the mouth by stroking it in the direction of the +orifice. If of several days' longer duration, purulent softening will +be noticed in the centre of the acini; this gradually extends until +each acinus is converted into a little sac of pus. Then the +inter-acinous connective tissue breaks down, and the multiple, minute, +purulent collections become converted into a single large abscess or +into two or more smaller ones. Next, the pus seeks an outlet. The +position of pointing may be on the cheek or in the external auditory +meatus--a very common location; again, the abscess may break into the +mouth, the pharynx, the oesophagus, or into the anterior mediastinum, +the pus burrowing its way along the sheath of the +sterno-cleido-mastoid muscle. + +While the parotid abscess is forming, suppurative inflammation is apt +to be set up in the masseter, pterygoid, and temporal muscles, and +from these positions the pus forces its way upward to the temporal or +zygomatic fossae. The periosteum of the neighboring bones, and even +the bones themselves, may become involved, and sometimes the cranial +bones are partially destroyed, and there is an extension of the +inflammation to the brain or its membranes. The middle ear may +participate in the general destruction, and the patient is left +permanently deaf, if indeed he escape with his life. + +The lymphatics, veins, and nerves traversing the parotid are affected +by the suppuration in the gland. Irritation of the lymph-vessels +results in swelling, tenderness, and suppuration of the lymph-glands. +Thrombi form in the jugular vein and its branches, and by breaking +down lead to septicaemia and ichorization of the sinuses of the dura +mater. The nerves resist for a long time, but seem to act as paths of +conduction of the inflammation, the facial nerve leading it to the +ear, and the branches of the trifacial to the brain. When gangrene of +the gland takes place, the traversing nerves as well as the gland +elements are rapidly destroyed. + +SYMPTOMS.--Symptomatic parotitis, occurring during the course of {627} +any of the diseases already named, produces no change in the general +symptoms; if, on the other hand, it occurs during convalescence, the +onset is marked by a moderate elevation of temperature and increase in +the frequency of the pulse, by thirst, loss of appetite, and sluggish +bowels. The tumor, which occupies the same position and thrusts +outward the ear-lobe as in mumps, is hard, dense, well defined, and +the seat of considerable pain until suppuration takes place, when the +latter subsides greatly. The skin over it is red, hot, and tense, and +there is much tenderness and little or no pitting on pressure. After +the abscess has formed there is well-defined fluctuation on palpation, +and at the position of pointing the skin becomes very thin and assumes +a bluish-red hue. Gangrene of the gland is manifested by the +cadaverous odor, blackening of the skin, the formation of a cavity, +and the discharge of ichor and shreds of tissue. The alteration in the +expression, the pain in the ear, the difficulty in moving the jaw and +in swallowing, are as constantly present here as in idiopathic mumps. +It must not be forgotten, though, that when the disease arises during +the course of any of the severe infectious diseases, the brain may be +so overcome that the subjective symptoms are frequently not complained +of. + +The course is usually rapid, the abscess pointing on the fourth or +fifth day after the appearance of the parotid tumor; occasionally, +however, the inflammatory process is much slower, extending over a +period of several weeks. The course is also much protracted when +secondary abscesses form in other parts of the gland or in the +surrounding tissues, when the abscess is transformed into an ichorous +cavity, and when gangrene sets in. Ordinarily, where the pus is +evacuated by spontaneous rupture or by incision the abscess heals +quickly by granulation, leaving the gland enlarged and indurated for +some time. + +THE PROGNOSIS depends upon the gravity of the original disease, the +period of the disease at which the complication occurs, and whether or +no mortification sets in. When the vital processes are greatly +impaired by the primary disease, the onset of the parotitis, trifling +in itself, may prove sufficient to determine a fatal result. The +danger of such a result is much increased, too, if the inflammation +begins in the earlier stages or during the height of the disease which +it complicates, while if it commences during convalescence by far the +most frequent result is recovery. Gangrene of the gland involves great +risk of life--a risk which increases in proportion to the early date +of its onset in the course of the original disease. Even when the +gangrenous process ends in recovery, the face is much distorted, the +hearing is lost in the ear, and the facial muscles are paralyzed on +the affected side. Bilateral symptomatic parotitis has naturally a +graver prognosis than the unilateral form. + +DIAGNOSIS.--The disease is readily distinguished from idiopathic mumps +by the history, the less marked degree of the enlargement and +surrounding oedema, the greater degree of pain and tenderness, the +hardness of the tumor, the red discoloration of the skin covering it, +and the termination in suppuration. Further, it never displays an +epidemic tendency. + +TREATMENT.--The general treatment of this form does not differ from +that of the disease it complicates, though the employment of +stimulants in increased quantities may be indicated. + +{628} Before the first appearance of tumefaction of the parotid the +introduction of a probe or canula into the duct of Steno, associated +with pressure on the gland from the outside, may, by forcing from the +duct a collection of mucus or muco-pus, abort the inflammation. If +this is unsuccessful, a poultice should be applied over the gland to +encourage suppuration and pointing externally. As soon as the abscess +points the pus must be evacuated by an incision, and, as this has a +tendency to close again, a piece of lint must be kept between the lips +of the wound. + +The enlargement and induration left after the healing of the abscess +require the application of tincture of iodine or of compound iodine +ointment to the surface. + +When gangrene occurs it demands the same treatment, both local and +general, as when it is seated elsewhere. + + + + +{629} + +ERYSIPELAS. + +BY JAMES NEVINS HYDE, M.D. + + +DEFINITION.--Erysipelas is an acute disorder, characterized by the +systemic symptoms common to the febrile state, and by an involvement +of the integument and deeper parts, the affected surface being tumid, +hot, reddened, painful, and often the seat of well-defined bullae, the +process terminating either in complete resolution after cutaneous +desquamation or in a fatal result commonly due to complications of the +malady. + +SYNONYMS.--_Eng._ St. Anthony's Fire; _Fr._ Erysipele; _Germ._ +Rothlauf; _Ital._ Risipolo. + +CLASSIFICATION.--Erysipelas is properly recognized as one of the acute +infectious diseases. Though by its symptoms and career it would seem +to be properly assigned to the category of the exanthemata, it is yet +by most authors set apart from the latter--first, because its career +is less specifically defined; second, because its contagiousness is +less demonstrable in every case; third, because one attack is not +known to confer upon its victims immunity against a second; fourth, +because the occasional prevalence of the disease in apparently +epidemic form is evidently due to extrinsic causes, and does not +depend exclusively upon its sudden appearance among the unprotected; +fifth, because no definite period of incubation precedes its earliest +manifestations; and, sixth, because at times it appears in local +manifestations apparently unaccompanied by systemic phenomena. + +HISTORY.--The earliest writers on medicine bear witness to the fact +that the disease was recognized at the date when men first made record +of human ailments. It has occurred in all parts of the world and at +all seasons of the year, sparing neither age nor sex in its +development. Zuelzer[1] refers to epidemic occurrences of the +disorder, described by Rayer, as visiting the Paris hospitals in 1828; +by Schonlein, as existing in Zurich in 1836; by Gintrac, as spreading +in Bordeaux in 1844-45; and by Trousseau, as prevailing in the +Maternite in Paris in 1858. + +[Footnote 1: _Cyclop, of the Prac. of Med., Ziemssen_, vol. iv. p. +424.] + +ETIOLOGY.--Authors have in general assigned different causes to the +forms of erysipelas hitherto regarded as either idiopathic (or +medical) or traumatic (or surgical). The modern view, however, is that +which regards all cases as alike produced by the absorption of the +toxic agent capable of exciting this peculiar inflammation of the +skin. The peculiarly well-characterized symptoms of the disease--for +example, when it affects the head and face--were long regarded as +etiologically distinct from the affection which complicates surgical +injuries and wounds. But {630} a closer study of many of the cases +first named has again and again disclosed the fact that they +originated in such traumatism, for example, as the piercing of the +lobule of the ear for the insertion of an ear-ring, a carious tooth, +an alveolar abscess, or a pathological product in the antrum of +Highmore. + +The disease is equally common--apart from the puerperal state--in both +sexes and at all ages, and occurs under favorable circumstances in all +seasons of the year. It is unquestionably at times spread by direct +contagion, either from the living or dead body affected with the +disease. Such contagion may occur mediately or immediately. It is, +however, not readily shown to be producible by the media of clothing +and other articles which have been in contact with a diseased surface. +The contents of the bullous lesions which appear upon the +erysipelatous surface are inoculable; and the disease has in this way +been transferred not only to men, but also, by Orth and others, to the +lower animals, and even from one of the latter to another of the same +species. + +Certain it is, however, that the disease does occur, characterized by +symptoms indistinguishable from those to be recognized in the +contagious type of the malady, where the most careful investigation +wholly fails to reveal the cause, and where the disorder rapidly +spreads if the conditions for its extension are favorable. Under these +circumstances it is wisest at present to admit that the exact etiology +of erysipelas is unknown. Its relative frequency in the puerperal +state is unquestionably to be explained by the favorable local +conditions which at such times exist in the female for the development +of all septic disorders. + +As regards the circumstances which might be supposed to specially +favor its development, these the capriciousness of the disease, which +is its striking characteristic, often quite disregards. Thus, on the +one hand, it may and often does prevail, year after year, in certain +hospitals, and even in certain wards of a single hospital, especially +where these are crowded with patients. But it may also repeatedly +spare masses of men affected with disease of a different type when the +latter are gathered together in prisons or camps, and indeed even may +appear among such individuals and fail to spread to others who are in +close proximity to them. + +With respect to the propagation of erysipelas from infected to sound +individuals, a contrast is exhibited when the transmission of variola, +for example, is compared with it. Thus, it is well known that the +mildest cases of varioloid may be sources of malignant forms of +variola to the unprotected, while those who are partially protected +and exposed to the virus of confluent forms of the disease may exhibit +the mildest symptoms of varioloid. In erysipelas, however, it is +tolerably certain that there are different degrees of virulence to be +recognized in different cases, and that the disease at times is +transmitted in its different types. Thus, traumatic erysipelas is much +more closely related to childbed fever than the varieties of the +disease appearing upon the head and face, which cannot be attributed +to traumatism, surgical accidents, dental abscesses, or local injuries +of the antrum of Highmore. Parturient women frequently escape +infection when the erysipelatous disorder is of the so-called medical +type. Per contra, it is to be noted that women who are prone to the +relapsing and so-called chronic forms of erysipelas are {631} +particularly apt to suffer from that involvement of the genital +organs, peritoneum, spleen, and febrile movement whose sudden +occurrence after confinement is so portentous. + +SYMPTOMATOLOGY.--The disease is usually announced by the occurrence of +a chill, which may precede by a day or but a few hours the appearance +of the cutaneous disorder. The rigor may be severe or mild in grade, +so that it may even be forgotten by the patient till his attention +reverts to it in connection with the resulting symptoms. There may be +simultaneously some gastric distress, rarely of severe character. +These symptoms are commonly followed by a febrile reaction. In other +cases the first recognized symptoms of the malady occur in the skin, +the patient scarcely recalling the fact of a slight preceding malaise. + +The cutaneous lesions appear in the form of a circumscribed oedema and +redness of the surface, often preceded and usually accompanied by a +sensation of tension, heat, and burning pain. This macule, plaque, or +patch of diseased integument is in its typical features +characteristic. It is distinctly or irregularly circumscribed; its +oedematous condition elevates its level decidedly above that of the +adjacent integument, so that there is a somewhat sudden descent from +the former to the latter for a space of from one to two or more lines. +The redness is also of a bright crimson hue, and the reddened surface +has a sheen or glossy appearance uniformly displayed over its area. It +disappears under the pressure of the finger, leaving a yellowish-white +color in the region of impact, the erysipelatous blush rapidly +returning when the circulation at the surface is restored. This smooth +and shining condition of the reddened patch is so characteristic of +erysipelas that it arrests the attention of the diagnostician as soon +as he observes it. According to Zuelzer, it is caused simply by the +tension of the epidermis. When first observed it may occur in the form +of circular, small or large coin-sized patches, or in streaks, striae, +and radiations, or as very irregularly disposed, rosy, and shining +marblings or mottlings of an oedematous surface. + +The skin thus affected is hot to the touch, tender, firm, and smooth. +It is occasionally the seat of pruritic sensations, more commonly of a +peculiar sensation of heat and burning. + +In the course of two or three days the involved area spreads uniformly +or irregularly and centrifugally from the point first involved, after +which time, in mild cases, the disease persists without apparent +change for a few days more, prior to its decadence by resolution. This +final stage of the malady is characterized by a progressively +diminishing fever, moderate desquamation, gradual disappearance of the +oedema, and a color-change to the darker shades of bluish-red or to a +light brown. In this form of the disease the erysipelatous patch, +after being fully developed, does not tend to spread from the affected +to the unaffected surfaces; and, as a consequence, the affection may +complete its entire career in less than a fortnight. + +In other cases, however, a remarkable tendency is developed to the +progressive spreading of the inflammation from one point or surface of +the body to another, the parts first affected paling as the disease +passes on to involve those in the vicinity, or being yet deeply +involved while the process of peripheral extension is in progress. In +yet other cases the red blush sweeps away from its first position in +tongue-like projections over a {632} tumid and painful skin, while the +region first invaded becomes paler, though still preserving its +oedematous features. In still another class of cases the advancing +ribbon or band of elevated and reddened integument passes over to a +new area, leaving the regions it has traversed tumid, painful, and +here and there streaked with rosy lines, patches, or irregular +gyrations. + +In yet severer types of the malady the intensity of the inflammatory +process is such that the epidermis is raised from the tissues below by +the free exudation of the serum of the blood. In this way vesicles, +or, more commonly, bullae, develop upon the surface. Bullae thus +formed may be typically perfect, but are often exceedingly irregular +in contour, having an appearance which is suggestive of the blistering +of a surface by boiling water. The bullae may be well distended and +filled with a perfectly limpid serum. This fluid may, however, in the +course of a few days become purulent, the contents in such case drying +into crusts. In the severest types of the disease gangrene results +from the intensity of the dermatitis, and the loss of tissue which +thus occurs is repaired by the processes of granulation and +cicatrization. + +The migration of erysipelas from one part to another of the surface is +sometimes so extensive as to invade from time to time the larger part +of the superficies of the body. Erysipelas of this ambulant character +may also, after invading the entire surface of the body, be relighted +at the point where it first appeared. In other cases this phenomenon +of recurrence or reawakening on patches of skin traversed by the +disease may be noticed only after moderate extension from a given +point. Reddish or rosy-colored islets then appear as new centres of a +fresh extension-process upon an integument whose swollen tissues still +exhibit the evidences of the prior invasion. In still other cases +similar islands of fresh disease are recognized in advance of the +elevated edge and tongue-like prolongations which mark the onward +progress of the erysipelatous inflammation over areas previously +unaffected. + +The swelling of the involved tissues is one of the most characteristic +features of erysipelas. By this is meant not the tumefaction simply of +the superficial portions of the integument, nor the tumefaction which +may be measured by the height of the affected above the level of the +unaffected skin at the edge of the involved area, but a swelling much +more than this, involving the entire skin, and often indeed the +subcutaneous tissues, differing, of course, in the extent to which it +advances in different cases. In those of severe grade the swelling is +enormous, an affected limb assuming the elephantiasic aspect, while +the deformity thus induced in the head is fully as great as that seen +in the height of confluent variola. In such cases the neighboring +ganglia are, as a rule, enlarged and often painful. + +It is indeed this swelling which gives to erysipelas of the head and +face its peculiar physiognomy. The disorder is apt to find its +starting-point in the ear, the side or point of the nose, or one +cheek. At this moment it may be possible to recognize the fact that +the adjacent mucous membrane is also involved. Thence the disease +progresses over the face, and possibly over the scalp also, the +resulting tumefaction being occasionally, as already stated, enormous. +Thus the eyes are usually closed and sealed by the swollen lids and +the orbital depressions are effaced. The lips, enormously pouting and +reddened, project from the swollen visage to as {633} great an extent +as the tumid ears, which, for similar reasons, depart from the usual +plane. The mouth, nares, and eyes alike are covered with mucous +secretions, possibly commingled with the contents of bullae which have +formed and broken. Crusts may thus collect near the mucous outlets. +The tongue is dry, parched, and cracked, and exhibits a reddish-brown +hue. In less severe cases it may be seen to be covered uniformly with +a thick yellowish or yellowish-white paste. The fauces and buccal +membrane are reddish in color, glazed, and dry. + +The patient having this serious form of the malady is indeed in a +critical condition. There is usually a coincident coma or delirium. +The pulse is either greatly accelerated and full, or thready, +fluttering, and destitute of rhythm. The temperature rises to 105 +degrees F., and even higher. In this condition a fatal issue may be +heralded by collapse, with decadence of the external evidences of the +disease, or by the occurrence of blood-filled blebs, or indeed by +larger or smaller areas of the surface falling into gangrene. This +latter accident may also involve the mucous surfaces, large patches of +the buccal membrane, the gums, and even the palate, losing their +vitality and showing as greenish-black, insensitive tracts, quite +firmly attached to the healthy tissue. These accidents may be of very +rapid occurrence, more particularly in the case of individuals prone +to exhibit the severest forms of the malady, such as very young +infants and those enfeebled by advanced age, by alcoholism, or by any +of the cachexiae. + +Other types of erysipelas, chiefly noticeable by reason of their +location, are those spreading from the umbilicus, the genital region, +the sites of vaccination, of varices of the lower extremities, and the +surfaces near the seat of surgical accidents and operations. + +The various names which have been, especially by older writers, given +to the several expressions of this disorder relate almost exclusively +to their external characteristics. Among these may be mentioned--E. +ambulans, e. erythematosum, e. bullosum, e. glabrum, e. levigatum, e. +miliare, e. oedematosum, e. pemphigoides, e. phlyctenulosum, e. +puerperale, e. vaccinale, e. variegatum, e. verrucosum, and e. +vesiculosum. + +The resolution of erysipelas in favorably terminating cases is +accomplished by very gradual amelioration of symptoms. The swelling +begins to subside, usually between the third and sixth days. The blebs +that have formed then disappear by absorption, bursting, desiccation, +or crusting, and subsequent exfoliation. Desquamation of the involved +surface may be a prominent or a very insignificant feature. When the +patient with erysipelas capitis enjoys a favorable crisis in his +disease, there is occasionally noted a very rapid amelioration of the +symptoms. The tumefaction speedily subsides, the features become +recognizable, and defervescence is complete. Throughout the course of +all attacks the febrile process and the erysipelatous blush proceed +pari passu with but little deviation of the severity of the one from +the intensity of the other. + +The complications and sequelae of the disease are less numerous than +they are grave. In erysipelas of the head there is usually a rapid +shedding of the hair, though in convalescence the growth of the hair +may be restored. An obstinate seborrhoea sicca may, as after variola, +linger long afterward upon the scalp; here also, as in other {634} +portions of the body, one or many abscesses may form in the +subcutaneous tissue after the resolution of the dermatitis; while in +phlegmonous erysipelas these abscesses may accompany the disease at +its height. + +Lymphangitis and adenopathy are common complications of erysipelas, +the former betrayed in thickened and often knotted cords, which may be +felt radiating from involved areas to neighboring glands. A singular +modification is often undergone by the integument affected with +erysipelas which has also been the seat of other cutaneous disorders. +In this way lupus, psoriasis, chronic eczema, and some of the +syphilodermata have been relieved. + +Besides the surfaces of the nasal, pharyngeal, and buccal mucous +membranes which have been indicated as at times involved by the +disease, the inflammatory redness and swelling may extend to the +epiglottis, the larynx, and the trachea. Croupous and other forms of +pneumonia, pulmonary oedema, and pleuritis have been not rarely noted. +In erysipelas of the head the membranes of the brain may inflame and +serous effusions distend the ventricles. + +The joints may be inflamed either by sympathy or by direct extension +of the erysipelatous inflammation to the periarticular tissues, or yet +by the occurrence, in or about them, of metastatic abscesses in +septicaemic conditions. + +The peritoneum may be also acutely or subacutely inflamed in +erysipelas, though it is doubtful whether the accident occurs in +consequence of the extension of the disease to this membrane from the +skin of the abdominal wall. The same may be said of the endocarditis +and pericarditis noted by several authors. Of all other complications, +it may be said that they can usually be assigned to the occurrence of +either septicaemia, or pyaemia, or to the development of metastatic +abscesses. + +With respect to the eyes, a distinction should be drawn between those +attacks originating in deep or superficial affections of the globes +and those in which the visual organs are merely involved as by +accident in the extension of the disease. In the former case deep +orbital abscesses or inflammatory affections of the iris and retina +may be followed by erysipelas of the lids or neighboring parts, while +in the latter event the issue is more commonly a transitory +conjunctivitis, lachrymation, and photophobia, which soon disappear +when the disease has declined. The cornea, being unmacerated with pus +as in severe variola, commonly escapes perforation. + +Erysipelas is a disorder which, without question, produces in a +certain proportion of patients a susceptibility to recurrent attacks. +This susceptibility, however, is less a systemic tendency to the +development of the disease than a peculiar liability to recrudescence +originated by chronic local ailments. Thus catarrhal, ulcerative, and +other affections of the nasal mucous membrane are particularly apt to +originate repeated erysipelatous attacks in the integument covering +the nose, and the same is true of the skin in the vicinity of the +orifices of fistulous sinuses and varicose veins. + +The forms of disease which are often described as instances of chronic +erysipelas belong to several classes. There are, first, those in which +are observed recurrent attacks of true erysipelas. Second, those in +which a chronic eczema or dermatitis produces a circumscribed patch of +infiltration {635} in a skin having a lurid reddish hue, which is also +the seat of marked subjective sensations, chiefly itching. The +well-known forms of chronic eczema erythematosum of the face in middle +years or advanced life are commonly, and erroneously, regarded as +erysipelatous in character. Third, there is a peculiar dermatitis, of +the cheeks chiefly, with regard to whose identity as an erysipelatous +affection there is much doubt. The skin is infiltrated in a +circumscribed patch, and has a peculiarly glossy red hue. It is +essentially a chronic disorder, the affected patch remaining unchanged +for months at a time, and then exhibiting aggravation in consequence +of accidental exposure to heat or traumatism. These patches may be +relics of relapsing forms of erysipelas; and in my experience are more +commonly encountered in the subjects of chronic alcoholism. + +PATHOLOGY AND MORBID ANATOMY.--The pathological changes exhibited in +the erysipelatous skin are those of an exudative process involving the +cutaneous and subcutaneous tissues. Nothing specially different from +the phenomena observed in a simple dermatitis can be recognized by the +microscope alone. Biesiadecki's careful investigations[2] certainly do +not disclose any such specificity. The epithelia are swollen with +serous fluid, and the exudate, though largely serous, contains also +the corpuscles recognized in plastic lymph. It is this serum, rapidly +invited to the surface by the acuity of the exudative process, which +raises the epidermis into the bullae described above. The nuclei of +the bodies recognized in the exudate are evidently in a state of +division and consequent multiplication. The epithelia of the rete +mucosum are swollen and stretched. The connective-tissue elements in +the derma are also swollen, and exhibit reversion to the embryonal +state. There is within each a relative increase of protoplasm, as a +consequence of which they undergo a species of liquefaction. The +blood- and lymph-vessels enlarge and are crowded with corpuscles. The +subcutaneous tissue participates in this process, its elements being +filled with finely granular cells disseminated or in aggregated +masses. The chief peculiarity of this exudation, and of these changes +in the tissue-elements where it recurs, is the rapidity with which, +when involution is in progress, the fluid is absorbed and the +inflammatory elements disappear. When abscess or gangrene complicates +the erysipelatous inflammation the changes are not different from +those recognized in dermatitis calorica. + +[Footnote 2: _Sitzungsber. d. k. Acad. der Wissen._, Wien, ii., 1867.] + +The changes noted in the viscera are also of a congestive and +inflammatory type. According to Ponfick,[3] there is at times a +parenchymatous degeneration of the muscular tissues of the large +vessels, and of the extremities, as well as of the kidneys, liver, and +spleen, the latter organ occasionally undergoing softening. The mucous +surfaces of the mouth, larynx, lungs, and alimentary canal have also +been found affected with oedema, congestion, and infiltration, rarely +terminating in ulcerative changes. + +[Footnote 3: _Deutsch. klin._, No. 20, 1868.] + +DIAGNOSIS.--The diagnosis of a typical case of erysipelas is so simple +that the nature of the malady is often recognized by those unskilled +in such matters. It is difficult to mistake for any other affection +the circumscribed, swollen, shining, and rosy-reddish patch of skin, +accompanied by fever or marked malaise, with adenopathy of near +glands, and often with a history of traumatism to which the origin of +the disorder may be readily referred. + +{636} It is to be distinguished from dermatitis in its various forms +(venenata, medicamentosa, phlegmonosa, suppurativa) by its +characteristic features, and by the frequent absence in these +inflammations of a febrile reaction and of a shining, rosy-red hue of +the skin, and by the peculiarities described above of the elevated +margin of the erysipelatous area. + +Eczema, especially in its chronic erythematous forms, exhibited in the +face of adults in middle and later life, is of much slower +development, is productive of itching, is ill-defined in contour, and +is not accompanied by fever. + +Erythema in all its varieties is a purely hyperaemic affection and +unaccompanied by fever. In erythema multiforme there is an exudative +process by reason of which various papules, nodosities, and at times +even bullae, appear upon the surface. None of them, however, are +accompanied by a diffused area of redness spreading at the periphery. +All of its lesions are circumscribed, and rarely affect the face. + +Pemphigus could only be mistaken for the form of erysipelas bullae, +but its lesions do not rise from a broadly inflamed area; they rather +have attended with each a distinct individual halo when the integument +from which they spring is at all congested. They are also rarely +accompanied by a febrile process. + +Scarlatina, though a febrile affection, is readily distinguished from +erysipelas by the appearance of its exanthem, symmetrically and +generally developed over the entire surface of the body, or +progressively and symmetrically from the upper to the lower segment of +it. The exanthem has also a dull scarlet color or the boiled lobster +hue, differing thus from the rosy-red and shining patch of erysipelas. + +Urticaria also is often of symmetrical development, is rarely +accompanied by fever, and is characterized by typical wheals, which, +however closely packed together, never have the smoothness of the +surface affected with erysipelas. + +PROGNOSIS.--The prognosis of a simple case of uncomplicated erysipelas +occurring in an individual in fair health and possessed of a +reasonable degree of vigor may be regarded as favorable. Even in the +weakness of infancy a large area may be involved in the disease and a +high degree of fever be aroused without alarming results. + +Erysipelas should, however, always be regarded as a serious disease or +a serious complication of any existing malady. It is often a grave +feature in surgical injuries. Erysipelas involving the entire surface +of the face and head is always a formidable affection. In the +puerperal state it is dreaded by every accoucheur. + +All these circumstances are rendered more portentous by the existence +of the disorder as a complication of any other grave malady, or by its +occurrence among the subjects of alcoholism, struma, phthisis, or +various other cachexias, and among the aged. Occurring in epidemic +form among the inmates of prisons, camps, and hospitals, the mortality +of the disease may be increased tenfold. + +TREATMENT.--The prophylaxis of erysipelas is that of all contagious +diseases. It involves isolation of the affected individual, +disinfection of body- and bed-clothing before the latter are again +employed upon the persons of others, and destruction by fire of all +dressings which have been in contact with the integument. + +{637} The hygienic management of the patient is not to be neglected. +The complete ventilation of the sick chamber is to be secured, and its +temperature uniformly sustained at a point between 65 degrees and 70 +degrees F. + +The general treatment of the sufferer need not greatly differ from +that commonly pursued in the febrile state by modern therapeutists. +There is but little confidence to-day in the methods by venesection +and purgation, upon which at one time reliance was placed. Cool or +cold water may be freely employed when there is hyperpyrexia, either +by general bathing or by wrapping the patient in sheets dipped in and +wrung out of the same fluid. The results are favorable as regards the +bodily temperature, and are not productive of danger, though water +thus applied has no effect upon the local disorder of the skin. Iced +or cool water, by the ice-bag or compresses, is specially indicated as +a topical application for the head when there is delirium or other +indication of disturbance of the cephalic centres, irrespective of the +invasion of the scalp and face by the erysipelatous inflammation. The +sulphate of quinia in full doses is indicated especially when there is +any tendency to remittence in the febrile accessions, but is not known +to possess any power to cut short the disease. In many cases of +erysipelas the febrile condition is readily managed by the +administration of the simpler remedies found grateful to the palate of +the sufferer, such as iced, acidulated, and effervescing draughts, +with perhaps the employment of the spiritus Mindereri or the spirit of +nitrous ether. In other cases the mineral acids can be substituted +with advantage for the latter. With many American physicians it is +customary to add to these remedies the tincture of the root of +aconite, with a view to its effect upon the pulse. + +Few internal remedies, however, have in this country enjoyed as much +popularity with the profession in the treatment of erysipelas as the +muriated tincture of iron in full doses. Its use, first suggested for +this purpose by Bell in 1851, has here steadily gained in favor since +its general adoption. It is well to give it in doses of not less than +20 or 30 drops, repeated every two or three hours, diluted with water. +When there is high fever, and especially if the secretion of urine is +scanty, the following formula will be found valuable: + + Rx. Tr. Ferri Chloridi; + Sp. Aetheris Nitrosi; + Glycerinae _aa._ fl. drachm i. M. + +S. A teaspoonful in water every three hours. + +This preparation of iron certainly seems, in many cases, to shorten +the disease, but, per contra, it is to be remembered--first, that in +many other cases it has been found to exercise no control whatever +over the severest manifestations of the disease; second, that in other +countries, especially in Germany, where it is rarely employed, the +mortality from the disease is no greater than elsewhere. + +The widest difference in practice has obtained relative to the local +treatment of the affection. They who have had the fortitude to content +themselves with watching the evolution of the specific dermatitis, +merely protecting the skin by dusting over it a simple powder or +leaving it covered with a cold compress, have certainly no worse +results to tabulate than those who entertain a belief in the efficacy +of the abortive treatment of the local disorder. + +{638} No remedies, locally applied, can be recognized as certainly +possessing the power to cut short the inflammation. Those which enjoy +the highest reputation for topical employment are saturated solutions, +hot and cold, of the hyposulphite of sodium, of boracic acid, and of +the bicarbonate of sodium; salicylic acid; iodoform in powder; and, +quite lately, resorcin. Hot fomentations of the erysipelatous patch +are in general most grateful to the patient, and with these an opiate +and astringent effect can be obtained, as by a hot lead and opium wash +or by solutions of the sulphate of iron or of alum and tannin. Useful +methods of applying these are by the medium of borated cotton, oakum, +tow, or spongiopiline, covered with oiled silk or the Lister +protective material. + +Other medicaments which have enjoyed favor in the topical treatment of +the disease are lime-water and linseed oil (carron oil), sulphur in +powder, carbolic acid, camphor, the oil of turpentine, collodium, +cataplasms and ointments containing mercury, lead, zinc, tar, and +tannin. + +Respecting the measures adopted with a view to checking the extension +of the disease at the periphery of the patch, the belief in such a +possibility has been wellnigh abandoned. For this purpose the nitrate +of silver, caustic potash, tincture of iodine, and similar substances +have been boldly and broadly applied, alike over the sound and +affected integument, with the production of an artificial dermatitis +intended to supplant that which was previously in progress. Again and +again has the local inflammation transgressed these artificial limits; +and when they have been by it apparently respected there has been +little ground for believing that the result was due to the treatment +pursued. Inasmuch as the disease is often self-limited and distinctly +limited in its progression over the surface, it is manifestly +difficult to determine that its limitation in any given case is the +result of topical agencies. These agencies have, moreover, the marked +disadvantage of adding their irritative effects to those incidental to +the dermatitis. + +The surgical treatment of erysipelas invading special regions of the +body or the deeper tissues is a matter of importance. Free incisions +are requisite for the liberation of pus, and all abscess cavities +should be treated antiseptically and stuffed with iodoform or +resorcin. Great tension of the lids demands free incisions in the long +diameter of either, and the same surgical procedures are often +demanded in erysipelas of the scrotum or of the labia in the female. +Gangrene and sloughing are to be treated in accordance with the +principles recognized as important in the management of these +accidents in general. + +The mouth when involved may be benefited by gargles containing the +chlorate of potassium, alum, tannin, the compound tincture of +cinchona, or by the use of the spray with a saturated solution of +boracic acid in rosewater. Kaposi lays stress, in all cases of +erysipelas of the face, upon the importance of searching for and +evacuating all dental abscesses and pustules seated upon the +Schneiderian membrane. Crusts in the nasal cavity are to be soaked +with vaseline and removed by washing, their re-formation being +prevented by the insertion of small tampons smeared with a bland +ointment or oily fluid. Abscesses in other portions of the body, not +suspected as being etiologically significant, are to be carefully +searched for and emptied, whether occurring about the anus, the +genitals, or the legs. + +{639} Subcutaneous injections of carbolic acid and other antiseptic +solutions have not been rewarded by such results as to establish in +any degree their special efficacy. + +In all ordinary cases the expectant treatment recommended by Zuelzer +is abundantly to be commended. The inflamed tissue is to be dusted +with finely-powdered starch, and protected by a layer of soft +cotton-wool which exercises a moderate degree of pressure upon it. +Antiseptically, the highest ends are thus reached. + +The diet of the patient should consist of animal broths, soups, milk, +and eggs, with a view to the reparation of the waste incidental to the +febrile process. Stimulants are to be freely used in all asthenic +conditions. In convalescence the warm water and soap bath is to be +employed, followed by dusting of the surface with starch powder or by +inunction with vaseline. + + + + +{640} + +YELLOW FEVER. + +BY S. M. BEMISS, M.D. + + +Yellow fever is a specific, infectious, and communicable disease of +one febrile paroxysm. + +This definition includes some of the most prominent characteristics of +the disease. The malady, however, derives its name from a symptom not +mentioned in the definition. The yellow color of the skin and +scleroticae which appears in advanced stages of grave cases of yellow +fever, and which becomes especially marked in the cadaver, has ruled +its nomenclature. Whatever objections may be urged against the term +"yellow fever" as being founded upon a symptom of the disease not +always present, it is too strongly fixed in both medical literature +and popular usage to justify efforts to change it. + +Neither is it liable to beget confusion as long as it is understood +that it is to be restricted in its application to a specific fever +induced by a specific poison, and that as an incident of its morbid +process it produces yellow coloration of the surface so frequently as +to suggest the prefix yellow to its title. + +ETIOLOGY AND SYMPTOMATOLOGY.--In this day of almost general belief in +the theory which holds that each specific disease has its own specific +poison or morbific germ, it is scarcely expedient to occupy much space +in discussing the propriety of classing yellow fever among the +specific maladies. + +Whether we rest the decision of this question upon the uniformity of +those circumstances and conditions which originate and develop +epidemics of yellow fever, or upon the sameness of its symptomatic +phenomena wherever observed, we find very nearly as substantial claims +to a specific individualization of the disease as any one of the +eruptive fevers possesses. Not only are its morbid phenomena so +characteristic that even non-professional observers designate it by +such epithets as Bronze John, Yellow Jack, Vomito Prieto, etc., but it +is inconvertible with other specific affections. This inconvertibility +of yellow fever with other diseases is absolute, and affords +irrefrangible evidence of the specificity of that germ or poisonous +principle which produces it. + +The study of yellow-fever poison after the objective method has +hitherto been unproductive of definite results. When such experienced +and truthful observers as Sternberg, Woodward, and Schmidt, working +with the most approved microscopes, have failed to identify any +organism or object peculiar to the products from the bodies of +yellow-fever subjects or to the circumfusa of the sick, this +declaration is sufficiently supported. + +{641} But when we turn to a subjective method of investigating that +toxic agent which causes yellow fever, it is found to possess +sufficiently well-marked characteristics to justify practically +valuable conclusions. Some of these characteristics or modes of +behavior merit notice. + +1st. The human system is a field of reproduction and multiplication of +yellow-fever poison. This is sufficiently established by two facts: + +(_a_) A person in the incubative stage of yellow-fever intoxication +may be divested of all fomites and yet originate other cases after a +developed attack. + +(_b_) The infection is intensified by aggregation of the sick. + +These propositions are indisputably true. + +2d. The poison or infection undergoes some change after leaving the +human system. This appears to be susceptible of proof, because +communication of the disease from person to person is not a common +event. When this does apparently occur, there is often very strong +reason for a belief that the contagion was resident in some fomites +connected with the patient's bed or clothing. + +3d. There are no sustained observations which prove that yellow-fever +poison is ever created de novo. + +The autochthonous birthplace of the poison is unknown. The suggestion +of Niebuhr, that yellow fever may have been one of the causes of death +during the plagues of Athens, can not be authoritatively denied. It +may have been called into existence at the moment when all things else +were created which were to perpetuate each its kind. + +4th. Some of those conditions and circumstances which favor or retard +the development or maturation of yellow-fever poison outside the human +body are quite well understood. Warm, damp weather is most prominent +among those climatic conditions which are favorable to the growth of +yellow-fever epidemics. + +5th. A freezing temperature ordinarily destroys the contagium of +yellow fever. A high degree of artificial heat produces a similar +result. It is highly probable that certain chemical agents would also +effect its destruction if brought in contact with it. + +6th. If yellow-fever fomites are hermetically enclosed in situations +protected from cold or other agents which are destructive to their +infection, its vitality may be preserved for an undetermined length of +time, and its toxic qualities again made manifest when unacclimated +persons are exposed to it. + +7th. Yellow-fever poison possesses ponderability. This characteristic +is so distinctly marked that it has been frequently termed a +"low-lying poison." + +8th. It is incapable of being air-borne through any great distance, at +least without being deprived of its toxic effects. + +9th. It is transportable in fomites through great distances, either on +sea or land, and as often as its toxic effects are manifested after +these portations they are so uniform as to be promptly recognizable. + +A great number of different materials in common use may act as +fomites, such as loose wool, cotton, or hair, or textile fabrics of +various descriptions. + +The following facts, which illustrate how yellow-fever infection may +be conveyed in the most unsuspecting and innocent manner, are well +{642} authenticated. There can be no ground for accusation of error +except in the hypothesis that the infection was encountered +simultaneously in some unexplained manner. The facts are furnished by +Dr. Shannon of Ocean Springs, Mississippi: "On the 14th of October, +1883, Maj. J. B. B. died of yellow fever in Ocean Springs, Miss. I +moved the family at once to the healthy locality where you saw Miss +B., not allowing them to take any article from the room where the +husband and father had died. The children applied to me for a lock of +their father's hair, which I refused, but the oldest daughter, now +dead, prevailed upon the nurse to give it her. She placed it in an old +envelope that had been torn open at the end and carefully folded the +torn end down, thus practically sealing it, and laid it away among +other old letters. On Sunday, the 4th of November, at 12.30 P.M., she +brought this envelope out upon the open gallery, and opened it for the +first time to examine the lock of hair and show it to her aunt, Miss +S., who was visiting her, and upon inhaling the concentrated poison +confined in the envelope and emanating from the hair, exclaimed, 'Oh, +what a peculiar smell!' She then handed the envelope to her aunt, Miss +S., who, unconscious of danger, also inhaled the 'messenger of death' +with a similar exclamation, when Mrs. B., who was standing near, +reached out her hand for the envelope, but was prevented from getting +it by the entreaties of a fretful child to be taken up in her arms. +This gave time for sufficient reflection, and she admonished the young +ladies of the possible danger. The envelope was then carefully folded, +and with its fatal contents replaced in the drawer where it had been +since the 14th of October. This drawer had been almost daily opened. +On the following Saturday night, Nov. 10th, at 9 P.M., Miss S. was +taken sick with a chill, and Miss B. at about 2 A.M., some five hours +later, the period of incubation being less than seven days in both +cases. No other person handled the fatal envelope or in any way came +in contact with it, and there is, after the most careful inquiry, no +suspicion of any other source of infection in these two cases. Miss S. +died on Oct. 14th, Miss B. on Oct. 16th." + +10th. These qualities of yellow-fever infection, and especially its +faculty of reproduction (which only organisms possess), furnish almost +conclusive evidence that yellow fever is a germ disease produced by a +specific contagium vivum. + +Many facts are patent which sustain the generally accepted opinion +that yellow-fever poison gains admission to the system through the +medium of atmospheric air. On the other hand, I know of no +observations which prove that the disease is ever communicated by food +or drinks, or through any other vehicle than atmospheric air. + +In respect to atmospheric infection by yellow fever, localizations of +aerial impregnation are often observable, not common in other +air-infecting diseases. A certain district of a large and populous +city may become the seat of a sweeping and fatal epidemic, and yet no +case occur outside of this area of prevalence. It is customary to +speak of these points of epidemic prevalence as infected localities. +If unprotected persons visit such infected places, even for a short +period of time, they are liable to attacks of yellow fever, although +they may take neither food nor drink within the limits of infection +and bring no fomites away with them. Under these circumstances +atmospheric impregnation is conclusive. + +{643} But it is difficult to determine how this infection of a +locality has been produced in the first place, and how, in the second +place, it is maintained sometimes for periods of from one to three +months, with so little apparent diminution or change in the liability +to communicate yellow fever to unprotected visitors within the limits +of infection. + +It seems highly probable that yellow-fever poison, after its exit from +the human body, attaches itself to various solid surfaces in proximity +to the sick, where, under suitable climatic conditions, it undergoes +more or less speedy processes of maturation in toxic qualities. The +poison thus matured is capable of being preserved with but little +change for the periods indicated above, and is communicable through +the atmosphere for short distances. It is also capable, by virtue of +some unexplained process or quality, of spontaneously extending its +area of infection. But this is at all times slow, and is readily +interrupted by streams of water, high walls, or even by much-travelled +thoroughfares. + +There are no instances in which the water-supply of cities has been +shown to have distributed yellow fever. + +The periods of time which may intervene between exposure to +yellow-fever poison and attacks of the disease are extremely variable. +The shortest period of incubation which has come under my observation +was about twenty hours. In three cases in which I was able to fix the +hours of first exposure with precision attacks followed in 72 hours, +83 hours, and 101 hours, respectively. Of 55 unacclimated physicians +who exposed themselves at Memphis during the epidemic of 1878, 54 +suffered attacks of yellow fever. In these cases the periods of +incubation varied from one to twenty-five days, the average duration +being ten days. These physicians all remained steadfastly at their +posts of duty; consequently, the attack which occurred on the +twenty-fifth day was postponed for that length of time during constant +exposure in a locality most intensely infected. + +It must be true that many cases of individual resistance to the +effects of yellow-fever infection depend upon states of the system or +idiosyncrasies which diminish liability to the action of the poison. +In other words, their personal receptivity to it is lessened by +certain constitutional states. + +That this position is correctly taken is proved by the fact that many +circumstances which violently disturb the system determine attacks in +persons who may have for a long time enjoyed immunity from them. +Anxiety, grief, fright, fatigue, or exposure to sudden wettings or +cold may precipitate attacks, either by disturbing vital processes by +which the system is ridding itself of the poison--so far, at least, as +to prevent an accumulation great enough to occasion attacks--or by +lowering powers of resistance through enfeeblement of nerve-force. + +But it can be affirmed in regard to yellow-fever poison that it is not +more capricious or eccentric in its behavior as an infection than that +of scarlet fever. Each of these diseases may appear in a large family +of unprotected persons with a degree of violence which results in +death in every instance, and suddenly cease, leaving a greater or less +number of the household without attacks, though equally exposed with +those who have died. + +One attack of yellow fever confers immunity from the disease during +after life. A person who has suffered an attack is said to be +acclimated {644} or protected. Neither of these terms should be +applied to those who have not suffered attacks, however long they may +have withstood exposure during epidemics. It often occurs that persons +who have escaped attacks through many years of renewed exposure at +last succumb to the disease. On the other hand, I know of three +well-authenticated instances of immunity in a sweeping epidemic of +persons whose mothers had suffered attacks during the gestations which +respectively resulted in their births. + +While negroes are susceptible to yellow-fever infection, attacks are +far less fatal than among whites. + +SYMPTOMS IN MILD OR SIMPLE CASES.--Yellow fever is usually sudden in +its onset. Persons are liable to be seized while pursuing their +ordinary avocations, or, as often occurs, the attack may begin during +the night. The initial symptoms are chilliness or cold sensations, +seldom amounting to a decided rigor. Reaction is usually prompt and +decided, the temperature reaching within a few hours 102 degrees to +105 degrees F. Yellow fever is not a disease in which it is very +common to observe excessive body heat. + +As the fever is established, the countenance becomes flushed and the +eyes injected and glistening. Frontal headache and lumbar pain are +experienced very early in the attack, and are liable to become more +intense during the progress of the fever. Muscular neuralgias, +especially in the lower extremities, are not uncommon. + +During the early period of the attack the tongue is indifferent as a +symptom. It is generally moist and free from any coating. In cases +attended by much furring of the tongue careful investigation is pretty +sure to disclose the fact that it has been brought about by some +pre-existing state of disease. + +The bowels are generally inactive, though naturally impressible to +cathartic drugs. The stomach is querulous from the inception of the +attack to its conclusion. Vomiting may not occur spontaneously, but it +is easily provoked by repletion of the stomach with any description of +ingesta or by harsh or disgusting medicines. The acts of emesis are +sudden and short in duration. Bile is a very uncommon constituent of +the matters ejected. Whether vomiting has occurred or not, patients +nearly always express repugnance to the weight of the physician's hand +over the epigastrium. In the very mildest cases it seems to excite +gastric distress and a tendency to emesis. The stomach and bowels are +liable to distension by flatus, sometimes to the extent of producing +colicky pains. Gaseous eructations are common. + +During and shortly succeeding the cold stage the urine may be somewhat +increased in amount, but after the fever is established both the +quantity and the specific gravity are notably lessened. Albumen seldom +appears in the urine during the first twenty-four hours of an attack. +In very mild cases it is altogether absent throughout. + +Delirium is not unusual during the fever. Among children attacks are +often ushered in by convulsions. In such cases delirium may be +persistent and alarming in violence. + +The pulse in the early stage of yellow fever is slower in proportion +to the temperature than in most other acute diseases. This is more +especially true in respect to mild cases. Another characteristic +feature of the pulse in {645} yellow fever is that it declines in +frequency before the fever has reached its maximum. In the mildest +forms of the disease the temperature will attain its highest record +within twelve hours. It then rapidly defervesces, never to return +again. But in some cases of a moderately mild form the body heat does +not reach its acme of intensity until the second day, occasionally not +until the third or fourth day. In these cases also the pulse is apt to +decline in frequency before the fever has culminated. There are +therefore no fixed laws which govern the duration of the hot stage of +yellow fever. Those which relate to the pulse are more uniform. + +The following clinical reports of two cases support this statement. +The detailed account of the symptoms establishing their diagnosis as +mild cases of yellow fever is omitted. + +Susie W----, white, aged seventeen years, was admitted to Charity +Hospital on August 28, 1878. First observation, nine hours after the +beginning of the attack, pulse 100, temperature 104.6 degrees. Morning +of 29th, pulse 94, temperature 102.8 degrees; evening, pulse 80, +temperature 101.5 degrees. Sanguineous discharge from vagina began on +29th; patient supposed it to be her proper period. Aug. 30th, pulse +80, temperature 99.2 degrees; convalescent and dismissed from further +observations. In this case the urine presented a trace of albumen +early on the second day, but as the menses appeared shortly after the +urine was obtained, the presence of albumen may be in that manner +accounted for. + +Bessie L----, white, age twenty-seven years, admitted to Charity +Hospital on August 28, 1878. First observation, twelve hours after +beginning of attack, pulse 100, temperature 100.6 degrees. 29th, pulse +76, temperature 102.3 degrees. 30th, pulse 64, temperature 101.5 +degrees. Sanguineous discharge from vagina began on 30th and continued +until Sept. 4th; this was two weeks before the patient's regular +period. The urine showed traces of albumen at date of admission. +Discharged, cured, Aug. 31st. + +It may also be stated of the pulse of yellow fever that it is easily +compressible and often gaseous in character. + +Perspiration is probably an incident in the natural clinical history +of a case of yellow fever. It occurs spontaneously if the patient's +surface is protected from those influences which conflict with its +appearance. It is not critical in any sense of the word, and may +coexist with high temperature. + +Yellow fever is considered to have two clinical stages. The first is +the paroxysm. This is made to include the cold stage and succeeding +fever. The cold stage is often almost or quite inappreciable, and when +this is not the fact it is in simple cases a very unimportant event. +It is therefore quite convenient to include it with the fever under +the term paroxysm. The paroxysm of a simple case is terminated by a +subsidence of the fever to nearly or quite a normal temperature. +Sometimes the temperature falls below the normal standard. + +The neuralgias and subjective sufferings are greatly mitigated or +cease altogether. Thirst and restlessness are relieved, and the +patient sees before him a delicious, but too often treacherous, mirage +of restoration to perfect health. This is termed the stage of calm, +perhaps because it often precedes a tempest of fatal symptoms. + +In mild cases convalescence begins at the termination of the paroxysm, +and may proceed without interruption until complete re-establishment +of {646} health has been accomplished. But in the very mildest cases +the process of recovery is easily interrupted. + +In these simple forms the tendency to hemorrhage first manifests +itself in the calm stage. The gums become red, tumid, and spongy, the +tongue pointed and red at the tip. Epistaxis is liable to occur. The +eyes and skin may be slightly yellow, and the urine may show traces of +albumen. However mild the other symptoms may appear, the tendency to +hemorrhage, to albuminous urine, and to jaundice in the calm stage +bears a direct relation in frequency of occurrence and in degree to +the blood-stasis, or sluggish capillary circulation, of the first +stage. + +The foregoing is a recital of the clinical phenomena of typical and +simple forms of yellow fever. The departures from type have been +divided by different writers into a variety of forms. The most +important of these will be referred to in connection with suggestions +as to treatment. + +PROGNOSIS.--Prognosis is variable in different epidemics, this +observation being understood to apply to the same localities. Some of +those circumstances which affect epidemic force, so as to increase the +mortality-rate, are appreciable. If an epidemic invades a population +after an interval of exemption sufficiently long to allow a large +number of unprotected persons to have accumulated in its midst, the +crowding of the sick will increase the death-rate. We may naturally +assume that this is attributable, first, to sheer multiplication of +the infection; second, to lack of proper attention to the sick, and to +fright, grief, exhaustion, etc. + +_Tabulated Abstract of Practice in Yellow-Fever Epidemic of 1878, New +Orleans Charity Hospital._ + + + ---------+---------+-----------+-----------+---------+-----------+----- + AGES. | July. | August. | September.| October.| Total. | + ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ + | N | N | N | N | N | N | N | N | N | N | P + | o | o | o | o | o | o | o | o | o | o | e + | . | . | . | . | . | . | . | . | . | . | r + | | | | | | | | | | | + | t | f | t | f | t | f | t | f | t | f | c + | r | a | r | a | r | a | r | a | r | a | e + | e | t | e | t | e | t | e | t | e | t | n + | a | a | a | a | a | a | a | a | a | a | t + | t | l | t | l | t | l | t | l | t | l | . + | e | . | e | . | e | . | e | . | e | . | + White. | d | | d | | d | | d | | d | | + | . | | . | | . | | . | | . | | + ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ + Under 5 | .. | .. | 7 | 3 | 3 | 1 | .. | .. | 10 | 4 | 40.0 + 5 to 10 | .. | .. | 2 | 1 | 1 | 1 | .. | .. | 3 | 2 | 66.66 + 10 to 20 | 8 | 3 | 26 | 7 | 25 | 6 | 7 | .. | 66 | 16 | 24.2 + 20 to 40 | 18 | 9 | 246 | 141 | 175 | 91 | 61 | 24 | 500 | 265 | 53.0 + 40 to 60 | 9 | 6 | 75 | 45 | 83 | 45 | 18 | 10 | 185 | 106 | 57.3 + 60 to 80 | 2 | 2 | 7 | 6 | 5 | 1 | 1 | 1 | 15 | 10 | 66.66 + ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ + Total. | 37 | 20 | 363 | 203 | 292 | 145 | 87 | 35 | 779 | 403 | 51.7 + ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ + Black. | | | | | | | | | | | + ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ + 10 to 20 | .. | .. | 2 | ... | 5 | ... | 1 | .. | 8 | ... | ... + 20 to 40 | .. | .. | 11 | 3 | 8 | 1 | 5 | 1 | 24 | 5 | 20.8 + 40 to 60 | .. | .. | 2 | 1 | 1 | 1 | 3 | 1 | 6 | 3 | 50.0 + ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ + Total. | .. | .. | 15 | 4 | 14 | 2 | 9 | 2 | 38 | 8 | 21.0 + ---------+----+----+-----+-----+-----+-----+----+----+-----+-----+------ + Grand total. | 817 | 411 | 50.3 + -----------------------------------------------------+-----+-----+------ + + + +{647} Prognosis is especially bad in hospital practice. The foregoing +statistics of cases admitted to the Charity Hospital of New Orleans +during the greater part of the epidemic of 1878 illustrate the usual +results of hospital practice. + +Many of these patients were conveyed to the hospital in extreme +conditions; occasionally they were moribund on admission. It is +hazardous to the life of a yellow-fever patient to transfer him over +the rough streets of a city, often for two or three miles, unless this +is done in the very earliest hours of the attack. + +Prognosis is seriously influenced by the condition of the patient at +the moment of attack. If pregnancy exists or delivery has just +occurred, it is, under most circumstances, extremely unfavorable. +Fatigue, anxiety, despair, or grief, all render prognosis more gloomy. + +The march of temperature is also important in determining fatal +results. + +The following statistics show the influence of temperature in relation +to mortality from yellow fever: + + Deg- |First| |Second| |Third| |Fourth| |Fifth| + rees.| day.|Died.| day. |Died.| day.|Died.| day. |Died.| day.|Died. + -----+-----+-----+------+-----+-----+-----+------+-----+-----+----- + 106 | ... | ... | 3 | 2 | 1 | 1 | 2 | 2 | ... | ... + 105 | 9 | 3 | 5 | 4 | 2 | 5 | 2 | 2 | 2 | 2 + 104 | 18 | 10 | 23 | 13 | 8 | 3 | 2 | 2 | 3 | 2 + 103 | 14 | 4 | 11 | 8 | 2 | 2 | 3 | 1 | 2 | ... + -----+-----+-----+------+-----+-----+-----+------+-----+-----+----- + +It will be seen from this table that the danger line of temperature in +yellow fever descends as the case progresses. + +It may again be stated that yellow fever, like scarlet fever, exhibits +such striking contrasts in its mortality-rate that it is hardly +possible to assert any average standard. It is true that in this +disease, as in all others, statistical accumulations tend to correct +their own errors in exact proportion to the magnitude of the +collections. + +In 1878 some 36,000 cases occurred in Louisiana, of which number not +less than 6000 were fatal, a percentage of 16.66. The results of +private practice in New Orleans are exhibited in the following +statistics: Four of the principal practitioners in the city treated in +private practice 975 patients--909 white and 66 colored. Of the +former, 92, or 10.11 per cent., died; of the colored only 2 died. The +cases and deaths among the whites, classified by age, were as follows: + + AGE. | Cases. | Deaths. | Per Cent. + ---------------------------+---------+----------|---------- + Under 5 years of age | 206 | 26 | 12.67 + From 5 to 10 years of age | 233 | 20 | 8.61 + " 10 to 20 " " " | 183 | 9 | 4.9 + " 20 to 40 " " " | 232 | 39 | 16.7 + " 40 to 60 " " " | 47 | 6 | 12.7 + " 60 to 80 " " " | 4 | 2 | 50 + ---------------------------+---------+----------+---------- + +The physicians above quoted lived in different parts of the city. All +of them extended their visits and professional services to the sick to +the {648} very limits of physical endurance, and consequently included +in the above lists some patients who were not able to procure the +comforts and attention necessary to the sick. Some cases also were +included to which the physician was only brought that he might sign +the death-certificate and so avoid the coroner's inquest. After making +allowance for increase of mortality on these scores, I think it safe +to assert that the best results obtained in private practice varied +from 7 to 10 per cent. of mortality-rate. + +DIAGNOSIS.--While there is no one symptom pathognomonic of yellow +fever in every stage of the disease, its differential diagnosis is +nearly always possible. The morbid action of its special poison +produces phenomena sufficiently characteristic to prove its presence. +The sudden attack, the slight cold stage, the frontal and lumbar pain, +and the capillary congestion are important diagnostic symptoms. + +Even in mild attacks this capillary blood-stasis is usually sufficient +to alter the patient's countenance to such a degree as to attract +attention. A great many different adjectives are used in description +of the countenances of yellow-fever patients. While no one among them +is constantly applicable, the presence of a changed facial expression +should enlist the physician's attention and incite investigation. If +this altered countenance be associated with watery or glistening +injected eyes, the probability of yellow fever is increased. + +The slow pulse which coexists with elevated temperature is a point of +much diagnostic value. But it must be remembered that this symptom is +not peculiar to yellow fever. I have noted this lack of correlation of +pulse and temperature in several cases of dengue. It is also not +infrequently found in ordinary cases of jaundice. The slow pulse of +yellow fever must be attributable to the special action of the poison +upon the nervous system. The heart's action may be slowed by +influences exerted directly or through the retrograde effects of the +delay of blood-currents in the capillary distribution. + +Albuminous urine is a symptom of much diagnostic importance. + +A tendency to hemorrhage may be safely stated to exist in all cases of +yellow fever. In the mildest cases hemorrhage may not actually take +place unless the patients be non-gravid females within the ovulating +limits of life. These patients seldom pass through yellow-fever +attacks without sanguineous vaginal discharges. But even in the +mildest cases yellow fever establishes the hemorrhagic diathesis to an +extent sufficient to render the occurrence of hemorrhage an imminent +event. This fact is shown first, by the congested and tumid gums, from +which blood can be readily pressed, and also by the still more +important circumstance that medical or hygienic mismanagement is so +quickly and certainly followed by black vomit or by hemorrhages from +other parts of the system. Capillary congestion is undoubtedly an +important factor in the production of hemorrhages in yellow fever, +since we cannot otherwise account for the liability to hemorrhage +which is so general in this disease. + +The yellow color of the skin and eyes during life, and of the tissues +and serum of the cadaver, is probably due to the coincident influence +of two causes: first, to the coloring matter of the red corpuscles +diffused in the serum of the blood; second, to an accumulation of +secondary blood-poisons. The occurrence of the yellow color and its +intensity bear a {649} direct relation to the sluggishness of +capillary circulation during the paroxysm. It appears likely, +therefore, that the yellowness is principally ascribable to coloring +principles derived from dissolution of the blood, to which capillary +obstruction would so strongly predispose this fluid. + +Schmidt has made a very careful resume of the pathological changes +found after death from yellow fever. The most important and uniform of +these affected the nervous system, liver, and kidneys. They consisted +for the most part of hyperaemic conditions, not infrequently attended +by points of extravasation and of degenerative changes. The latter are +principally found in the liver, and bear some relation to the duration +of the case, and it may be also to the degree and persistence of the +pyrexia. When the liver is the seat of fatty degeneration, it is +yellowish in color in whole or in parts. It is then sometimes spoken +of as the cafe au lait or the box-wood liver. + +In cases which run a very rapid course these changes are not observed, +but only those which indicate congestion are found, and often +hemorrhagic puncta. In these instances the depending portions of the +body have dark or livid ecchymoses. + +TREATMENT.--There are two propositions to which due attention should +be given before formulating rules for the treatment of yellow fever. +The first of these is, that yellow fever is strictly a self-limited +disease, and therefore is insusceptible of jugulation. Both clauses of +this proposition are indisputably true. Cases have been observed in +which mitigation of symptoms and abridgment in duration appeared to +follow spontaneous diarrhoea. Such events must be extremely uncommon, +since in my large experience I know of but one such instance supported +by good testimony. + +Efforts to abort the disease by purgatives, bleedings, cold baths, +quinia, etc. have all signally failed. Among the possibilities of the +future is the discovery that some drug or combination of drugs is +capable of meeting yellow-fever poison in the field of the circulation +and antagonizing it sufficiently to rescue the victim from its fatal +toxic effects. + +The second proposition is, that the formative stages of the +disease--that is, the early hours of the paroxysm--afford the most +precious moments for instituting such medication as may be considered +proper. This proposition applies no doubt to a number of other acute +affections, but in no one among them all is it so important to be +regarded as in yellow fever. The primary effects of the poison are so +boldly outlined that it appears highly probable that the damage it +exerts upon the economy is chiefly inflicted during the paroxysm. This +affords an additional reason why efforts at medication should be +principally restricted to the paroxysm and to the earliest periods of +that stage. + +It is probable that during an attack of yellow fever the patient's +hold upon life is more or less secure in direct ratio to the number of +functions which retain their physiological integrity fairly well. The +suggestion of such a fact should exclude all scholastic or routine +rules of treatment. + +In simple forms of yellow fever the first desideratum of the +practitioner is to become acquainted with the patient's condition at +the moment of attack. If this has occurred after eating indigestible +food or after a hearty meal of any description, the stomach should be +emptied. Ipecacuanha may be given in warm water or chamomile infusion +until this result {650} has been accomplished. After emesis, provided +this should have been considered necessary or as a first step of +treatment under other circumstances, a purgative is usually given. The +benefits of purgation are, in my opinion, limited to the act of +ridding the bowels of any fecal accumulations present. For this +purpose those purgatives which combine a due degree of efficiency with +inoffensiveness in operation have appeared to me to be the best. +Castor oil is at the head of this class. An ounce may be given to an +adult in some acceptable vehicle. This may be followed by an enema of +tepid water when required. Salines are more agreeable to the palate, +but far too unmanageable in their cathartic effects to be adopted +generally. + +Some very good practitioners believe that a mercurial purge at the +onset of the attack impresses the subsequent career of the case in +some favorable manner. I do not share in this opinion, but I do select +calomel as the preliminary purgative in cases where much gastric +irritability attends the early periods of the attack. I exhibit it +also in those cases in which previous indisposition had occasioned +coating of the tongue, or in which other conditions of systemic +derangement existed for which calomel is usually prescribed. + +In many cases it is desirable to avoid the disgust at taking a +purgative or the perturbation it may occasion by its action. Enemas of +tepid infusion of linseed or of milk and water may be substituted, +with the addition of castor oil when necessary. + +In the early hours of the attack warm pediluvia are always grateful +and proper. They are to be given by placing a basin of warm water near +the foot of the bed, beneath the covering of a light blanket or sheet, +and allowing the patient's feet to remain immersed for ten or fifteen +minutes. If the feet are cold, mustard should be added. During the +foot-bath the patient usually falls into a perspiration which is +sometimes profuse and general. + +Perspiration is a desirable event during the paroxysm, although it is +not, like the sweatings of the malarial fevers, critical, in the sense +of being accompanied by a marked decline in temperature. The idea that +sweating is beneficial is so strongly and generally prevalent as to +give countenance to the erroneous practice of resting the cure of the +disease upon its production and maintenance. I have seen valuable +lives sacrificed by obstinate persistence in measures to promote +diaphoresis, more especially in the later hours of the paroxysm or in +the succeeding or calm stage. It is quite sufficient to encourage the +perspiration by the pediluvia and by a moderate allowance of cool, +palatable drinks. Much value is attached by non-professional persons +to a warm infusion of orange-leaves or some other warm and grateful +beverage. When agreeable to patients I permit them in moderate +amounts, but do not regard them as especially valuable. + +Jaborandi has been used in yellow fever. Strong hopes were quite +naturally based upon the action of this drug in exciting excretory +functions, especially diaphoresis, but the observations of my friend +Dr. Thomas Layton and of others show that it possesses no special +value, while it frequently increases the vomiting and has to be +discontinued. + +After the bowels have been relieved of fecal accumulations it is good +practice to exhibit a scruple of quinia in solution with ten to thirty +{651} drops of tincture of opium, by rectal injection. Infusion of +linseed or mucilage of elm-bark or gum-arabic are the best vehicles. + +The combined action of the quinia and opium mitigates the patient's +headache and lumbar pains. But the influence of these drugs is not +limited to their effect on the nerves of sensation. In quite a +proportion of cases reaction is not so prompt or complete as usual; or +reaction may be quite pronounced, and still the surface may alternate +between a dry and a perspiring state. These oscillations of function +of the organic nerves are also often corrected by this prescription. +In the great majority of simple cases no other medication than this is +requisite or proper, for no medication is proper in yellow fever +unless it is requisite. + +When the neuralgias are excessively violent, opium may be again +administered, preferably by enema, and in combination with bromide of +potassium or chloral hydrate. But the effects of opium in limiting +excretory function must always be borne in mind and carefully avoided. + +External applications are very efficacious in relieving the +neuralgias. In the southern part of this country the "eau sedative" of +Raspail is greatly used. This is a mixture of ammonia, camphor, and +common salt in solution, and may be prepared extemporaneously. The +applications may be made hot or cold, but if used cold they must be +continuously kept up. It is therefore better to use them warm if +sufficiently effective. Stimulating embrocations of turpentine or +mustard, or dry or wet cups, are sometimes resorted to for relief of +pain. + +Excessive temperature demands attention and antagonistic treatment in +direct measure with its persistence, its degree, and its occurrence in +advanced periods of an attack. + +In the epidemic of 1867, I used gelsemium as an antipyretic in fifty +cases or more, but the results were so unsatisfactory that I have +quite abandoned its exhibition. I have given quinia as an antipyretic, +but never in doses of more than a scruple. In these doses it has +failed to accomplish the desired result in the great majority of the +cases. Perhaps its antipyretic effects are limited to those cases in +which malaria is a known or an unknown complication. + +I have exhibited small doses of digitalis with apparent benefit, but +aconite and veratrum viride I have long since discarded. The physician +cannot afford to sacrifice gastric quietude and competency of function +to the use of remedies whose value as antipyretics is, to say the +most, quite doubtful. + +Cold has for a long period of time been brought into use as an +antipyretic in yellow fever. Its positive value and instantaneous +action should be constantly borne in mind, and in the hyperpyrexia of +yellow fever it constitutes by far the most reliable remedy, though +its mode of application must be carefully adapted to the degree of +fever present and to the susceptibilities of the patient. Cold drinks +in limited quantities, but frequently repeated; cold spongings of the +surface, or the use of the cold pack, especially in very high degrees +of body heat; large injections of cold water per rectum, which may be +passed off and repeated once in two to four hours,--form safe and +effective modes of treatment. + +Hemorrhages are a constant source of anxiety in yellow fever. It is +very true that persons do not often die from actual loss of blood. I +do not know that I have ever witnessed such an event except when the +{652} blood was poured out from a recently-emptied uterus. But the +chances of recovery are lessened, because the hemorrhagic state +indicates a degree of spoliation of both the fluids and solids of the +system incompatible with maintenance of life. When this condition of +constitution is once established, the stomach rarely escapes, and in a +majority of instances it is the first, and sometimes the only, +bleeding surface. The treatment should be directed, first, to the +great indication of correcting the hemorrhagic diathesis; secondly, to +quiet gastric irritability, in order that vomiting shall not cause +rupture of capillaries. To meet the first indication I regard +nutrition and stimulants as the most important measures of treatment. +The mode of administration will be specially referred to under the +head of alimentation. + +Haemostatic remedies, given as specific treatment, generally fail in +accomplishing the purpose for which they are administered. It has +always appeared to me that those therapeutic agents which are capable +of controlling hemorrhage where yellow fever is not present are +completely neutralized by the effects of its toxic agent upon the +vaso-motor nerves. Consequently, while ergot, turpentine, gallic acid, +and other like remedies may be resorted to, too much hope should not +be entertained as to their good effects. + +Some excellent practitioners rely greatly on preparations of iron. The +tincture of the chloride is undoubtedly the best. This may be given in +water or upon shaved ice in doses of five or ten drops every half +hour. To allay the gastric irritability pellets of ice should be +swallowed. Effervescing drinks may be given with benefit. + +I have often used with good results the following prescription: + + Rx. Sodii Bicarb. gr. xx; + Morphiae Sulph. gr. ss. + Aquae Lauro-Cerasi, + Aquae Menth. Pip. _aa._ fl. drachm iv. M. + +S. Teaspoonful after every act of emesis. + +Occasionally I have given the following prescription: + + Rx. Creasoti gtt. viij; + Tinct. Opii Deodorat. gtt. xl. + Aquae Menth. Pip., + Muc. Acaciae _aa._ fl. drachm iv. M. + +S. Teaspoonful after every act of emesis in iced Seltzer or +Apollinaris water, or in champagne. + +Sometimes a few drops of chloroform in a spoonful of iced mucilage of +acacia act favorably. + +In cases which appear utterly hopeless the physician, acting +desperately, is sometimes able to save life by treatment which could +scarcely be safely recommended. I once administered a fourth of a +grain of morphia to a child of seven years, who, after a sleep of ten +hours, ceased to throw up black vomit and recovered. + +External applications to the epigastrium usually afford some relief to +nausea at any stage of yellow fever. Mustard or aromatic cataplasms +may at all times be used with hopes of favorable effects. Towels wrung +from cold water are very efficacious. Sometimes a drachm or two of +chloroform dashed over them increases their anti-emetic action. + +Suppression of urine is generally a symptom of fatal import. {653} +Attempts may be made to establish the secretion by dry or wet cups in +the lumbar region, by warm applications around the loins, or by +mustard cataplasms or blisters. If the condition of the patient's +stomach is such as to permit this practice, copious diluent drinks and +diuretics should be given. Lemonade holding bitartrate of potassium in +solution is generally the most acceptable, and probably the most +efficient. Some physicians think they oftener obtain good results from +small and frequently repeated doses of turpentine. I can bear +testimony to the good results which sometimes follow large rectal +injections of warm or cold water, the latter being preferable when +there is high fever. + +In certain cases of yellow fever reaction from the cold stage is +feeble and imperfect, or perhaps may not occur at all. This departure +from type is very fatal. The patients are stupid, sometimes +semi-comatose and incoherent, from the earliest hours of the attack. +The face is listless, drunken, or idiotic in expression. The color of +the skin is dark olive and almost livid. The print of a hand on the +chest is very slowly effaced. Sometimes the surface is covered with a +peculiarly unctuous perspiration. The pulse is feeble and +compressible; the temperature seldom more than one or two degrees +above the normal standard. Albuminous urine is found during the first +day. Death, attended by convulsive rigors, generally closes the scene +within seventy-two hours from the moment of seizure. + +Hot mustard-baths should be resorted to. Blood may be drawn by cups or +leeches from the back of the neck or temples, and this may be followed +by the application of a blister. Morphia and atropia may be exhibited +subcutaneously in small doses, to be repeated as often as proper. +Quinia may be administered per rectum or by the hypodermic method. +Lastly, pilocarpine may be thrown into the tissues in sufficient doses +to procure its vigorous physiological action. + +Almost in precise symptomatic contrast with these cases of failure in +reaction is another form of attack, in which violent disturbances of +nerve-function occurs; such cases often being characterized as +congestive in type. The most typical of these attacks are among +children or adolescents. If attended by noticeable chill, it is +ordinarily slight. Reaction is quick and excessively violent. The face +is flushed, the eyes injected, and convulsions with delirium are +liable to occur as early symptoms. I have watched with much interest +the alternate flushings and pallor of the countenance occurring in +these cases, such as are often observed in basilar meningitis. + +The treatment in this type of attacks should include chloroform by +inhalation in sufficient amount to control convulsions. Chloral +hydrate may be administered by enema, or morphia hypodermically. +Cathartic doses of calomel often exert a beneficial effect. Leeches or +cups, to be followed by cold applications or by blisters, may be +applied about the head or neck. But cupping and leeching should only +be resorted to in the treatment of grave symptoms, since obstinate +hemorrhage is liable to occur from any and every point from which the +cuticle has been removed. + +Yellow fever is often masked during the paroxysm by some pre-existing +disease. Malarial fevers, the febrile states of pulmonary consumption +or of the recently-delivered female, may all mask the early clinical +{654} phenomena to such a degree that the most experienced and +vigilant practitioners are sometimes astonished to find black vomit, +suppression of urine, and all those symptoms which mark the last +stages of the disease, suddenly developed. + +Walking cases should be classed in the same category as masked forms. +In these instances the early symptoms are so slight as to be +overlooked or neglected by their subjects. They continue to prosecute +their usual pursuits until, by sheer exhaustion, they are driven to +beds from which they seldom arise. + +The hygienic and dietetic management of yellow-fever patients is +extremely important, and the strictest attention must be paid to the +condition and discipline of the sick chamber. In this disease those +occurrences and circumstances which in other affections would be +reckoned as unimportant and trivial become matters of serious +magnitude. + +The physician, by a composed and cheerful demeanor, often decides +which end of the balance shall go down. But an intelligent, +experienced, and faithful nurse is equally as important as the +excellent physician. + +The patient should be confined in strictly recumbent positions, and +all drinks and foods must be given through tubes or from pap-cups. It +frequently occurs that patients are unable to void the bladder in such +positions. In these cases the catheter should be used, rather than +suffer any violation of the rule which demands a maintenance of +unbroken decubitus. + +The sick room should be kept freely ventilated, and the patient's +bedding should be changed, when requisite, by removing him to one side +of the bed while the other is renovated. If the patient's night-shirt +becomes soiled and disagreeable, it may be cut so as to remove it, and +another, cut in the same manner, may be substituted and stitched +together. The room must be kept quiet, and useless visiting entirely +forbidden. + +Cool and grateful drinks may be given in any stage or state of yellow +fever if demanded by patients. The quantity allowed at one time should +be small, since over-distension of the stomach almost certainly causes +vomiting. Effervescing drinks are nearly always grateful, and are +better tolerated than others. Seltzer-water and lemonade, or Seltzer +or Apollinaris on shaved ice, are to be recommended. Sometimes +patients call for sparkling wines or beers. I never refuse them or any +other alcoholic drink asked for in any stage of the disease. Wine +surely possesses valuable therapeutic effects in yellow fever. + +Alimentation must be severely controlled by the physician, and the +tolerance and effects constantly watched. Even to the most experienced +physician the kind of food to be selected, and the time and manner of +administration, constitute difficult problems. In simple forms of the +disease food had better be strictly withheld during the continuance of +the paroxysm. Even after the stage of calm has been reached, +sufficient time should be allowed to elapse to enable the physician to +form some estimate of the degree of damage his patient has suffered +and his competency to retain foods and be nourished by them. This +question can seldom be answered in a decided manner, except through a +cautious trial of some bland and inoffensive food. + +{655} On the third or fourth day of sickness a single tablespoonful of +iced milk may be given, and the immediate consequences closely +watched. If no retching or gastric uneasiness should ensue, it may be +repeated at the end of thirty minutes. Some physicians prefer to begin +with spoonful doses of equal parts of sweet milk and thin +barley-water. In my own experience chicken-water has proved to be the +most universally acceptable, as well as the most beneficial, of all +the various forms of nutriment to be chosen as a first venture. I have +frequently combined this with barley-water when first given. In this +cautious and tentative manner even the most experienced physician +prefers to proceed, rather than to attempt to prescribe rules of diet +in an abstract and arbitrary manner. + +If these light articles of diet are well borne, they are to be +gradually and watchfully exchanged for beef-essences, the blood of a +rare beefsteak, and the more substantial broths. Solid articles of +food should not be allowed during the first ten days after an attack, +and for still longer periods patients should be admonished against +excesses in eating, and especially in respect to indigestible +articles. Those lesions of the blood and of the stomach, and those +grave disorders of nerve-function which occasion haematemesis in +yellow fever, are slowly repaired. Instances are reported in which +black vomit and death have followed excessive eating and drinking ten +or twenty days after dismissal from treatment. + +There are, however, certain conditions which are liable to complicate +yellow fever which demand a course of dietetic procedure different +from that which I have recommended. Thus, children cannot bear +privation of food until the paroxysm is over if its duration is long. +In like manner, a more supporting course is required in most of those +cases in which yellow fever occurs as an intercurrent affection, in +all those cases which are termed typhoid or adynamic per se, and, more +emphatically still, in every case in which hemorrhages are occurring. +A failing pulse should in all instances admonish us to resort to +nourishment and stimulants. + +It is a fortunate circumstance that in yellow fever the lower bowel is +generally in a state favorable for the retention of nutritious enemas. +In the most trying and critical hours of desperate cases I have seen +patients tided through by the use of skilfully prepared and skilfully +administered injections of some suitable meat-essence. When insomnia +exists, chloral hydrate or bromide of potassium may be conveniently +given in these vehicles. + +It is evident that the discussion of the vastly important sanitary +questions pertaining to the prevention of yellow fever cannot be +appropriately discussed in the present article. + + + + +{656} + +DIPHTHERIA. + +BY A. JACOBI, M.D. + + +DEFINITION; SYNONYMS; HISTORY.--Diphtheria is a specific, infectious, +and contagious disease, characterized principally by epithelial +changes in, and the exudation of fibrin on and into mucous membranes, +the surface of wounds, and the rete Malpighii, thereby constituting +the so-called pseudo-membrane. Under the names ulcus syriacum, ulcus +aegyptiacum, garotillo, morbus suffocans, morbus suffocatorius, +affectus suffocatorius, pestilentis gutturis affectio, pedancho +maligna, angina maligna, angina passio, mal de gorge gangreneux, +ulcere gangreneux, angina polyposa, angine couenneuse, cynanche, +croup, diphtheritis, and diphtheria, the disease has been known and +described at different periods by the writers of different nations. +The Hippocratic writings and some remarks in the Talmud allow of some +doubt in regard to their explanation. Whether their authors observed +or recognized diphtheria cannot be proven. There is less doubt in +regard to Archigenes, quoted by Oribasius. Aretaeus of Cappadocia is +notably the first, if we except Asclepiades only, who is said to have +performed laryngotomy. The description of the pharyngeal and laryngeal +manifestations furnished by the former, however, can leave no doubt in +our minds that he knew diphtheria and recognized it. Galen, in his +remarks on the Chironian ulcer, tells us that the pseudo-membrane was +gotten rid of by coughing when the respiratory passages were affected +by the disease, and by hawking when the disease was in the pharynx. +Caelius Aurelianus recognized diphtheria of the pharynx and larynx, as +well as the diphtheritic paralysis of the soft palate; it is to him we +are indebted for the information that Asclepiades resorted to +scarification of the tonsils, and even to laryngotomy. Aetius in the +fifth century distinguished white and grayish patches and gangrenous +degeneration, observed paralysis of the soft palate, and advised +against energetic local treatment and the forcible removal of the +deposits before they were in a condition to fall off spontaneously. +The Arabs and Arabists contain no allusions to the subject, but early +chronicles tell of an epidemic raging in St. Denis in 580, subsequent +to a great inundation. There appear to have been memorable epidemics +in Rome in 856 and 1005, in Byzantium in 1004. The former are +mentioned by Baronius, the latter by Cedrenus.[1] + +[Footnote 1: Haeser, _Lehrb. a. Gesch. du Med. u. d. Epidem. Krankh._, +3d ed., vol. iii., p. 434.] + +According to Morejon, Gutierrez wrote his _Tradado del enfermedad del +garrotillo_ in the second half of the fifteenth century. A malignant +form of angina raged in 1517 in Switzerland, along the Rhine, and in +the Netherlands; in 1544 and 1545 in Northern Germany and on the +Rhine; {657} in 1557 in France, Germany, and Holland; to the latter +refer the reports of Tetrus Fosterus. Antonio Soglia, quoted by +Chomel, describes an epidemic in Naples and Sicily (1563), which +spread in the following year as far as Constantinople; Joannes Wierus, +epidemics in Dantzic, Cologne, and Augsburg (1565); Ballonius +(Baillon), in Paris (1576). At the same time this disease was frequent +in Denmark. From Spain there are reports on severe epidemics between +the years 1583 and 1618; the year 1613 was long known as the year of +diphtheria (anno de los garrotillos). + +Mercado (1608) speaks of a child that had communicated the disease to +his father by biting his finger. Casealez advised gargles containing +alum and sulphate of copper. Herrera described diphtheria of the skin +and of wounds, and looked upon the pseudo-membrane as the essential +characteristic of the disease. Heredia, in 1690, recognized the +suffocative and asthenic forms, as well as the paralysis of the soft +palate, the pharynx, and the limbs; he also called attention to the +occurrence of relapses, which he attributed to the absorption of the +morbid products, and endeavored to prevent by cauterization. + +Naples had diphtheria 1610-45, in its worse form 1618-20, together +with erysipelas, and diphtheritic affection amongst cattle. About +those times tracheotomy was often performed by Severino, the same who +found pseudo-membrane in the larynx at a post-mortem examination made +in 1642. In 1620 the disease was in Portugal, Sicily, and Malta; in +1630 in Spain, according to Fontechu, Villa Real, and Herrera. It was +remarked that in some instances no membranes were perceived in the +throat, but the cases were liable to terminate fatally with large +glandular swellings round the neck and general symptoms of adynamia. +Sicily was again invaded in 1632, Rome in 1634, Italy from 1642 to +1650, Spain in 1666. The Italian reports emphasize the marked +contagiousness of the disease and its tendency to depress the vital +powers, also the weakness of the mental faculties left behind. In +Germany the disease was described by Wedel in 1718. The epidemics +observed by him were not very instructive, yet they sufficed to teach +the importance of isolating the sick. + +In the New England States diphtheria appeared in the seventeenth +century. Samuel Danforth lost the four youngest of his twelve children +by the "malady of bladders in the windpipe" within a fortnight in +December, 1659, in Roxbury, Mass. John Josselyn mentions an epidemic +in New England, mainly in Maine, which lasted at least until the year +1671. Mr. Douglass reports another, which commenced on the 20th of +March, 1735, in Kingston township, about fifty miles east of Boston, +and extended all over, and also to Boston, where it was mild at first. +But in 1738 it was very severe, and remained so for some time. Indeed, +it did not abate for a long time, to judge from a letter of Cadwalader +Colden written in 1753 to Dr. Fothergill, and the two letters of Dr. +Jacob Ogden, written in 1769 and 1774 to Mr. Hugh Gaine of New York; +as also from John Archer's "Inaugural Dissertation on Cynanche +Trachealis, commonly called Croup or Hives," published in 1798.[2] In +1809 there was a severe epidemic in Philadelphia;[3] in 1816 in Crete. + +[Footnote 2: For extensive quotations from these and other writers on +diphtheria at a very interesting period of our medical literature, see +A. Jacobi, _A Treatise on Diphtheria_, New York, 1880.] + +[Footnote 3: Caldwell, in ed. of Cullen's _First Lines of the Practice +of Physic_, Philadelphia, 1816, 1, p. 260.] + +{658} The reports of Le Cat concerning epidemics in Rouen in 1736 and +1737 being doubtful, the first great epidemic must be set down, in +France, for 1745. It commenced in Paris, and invaded the provinces +afterward. Chomel gave an accurate description of the diphtheritic +paralysis of the soft palate, and reports a case of strabismus. +Epidemics are reported from the Netherlands in 1745, 1746, 1769, 1770, +1778-86; from Spain in 1764-71; from England in 1744-48 (by Starr), +from Plymouth, England, in 1751-53 (Thurham) and 1776. Dropsy and +glandular swellings were frequent; emetics and pure air were the +sheet-anchors of treatment. The Netherlands, France, and the West +Indies were invaded from 1770-80 by the disease, which was found often +complicated with scarlatina; Portugal in 1786 and 1787; France again +in 1787 and 1788; Northern Germany in 1790. At that time, particularly +in France, the main reliance was had on the internal administration of +cinchona and the insufflation into the throat of alum. + +Epidemics have been described since from different localities in +different years: in Glasgow, 1812 and 1819; Switzerland, 1823-26; +Norway and St. Helena, 1824; New York and Kentucky, 1826 and 1828; +French provinces, 1834; Paris, 1841; several parts of Europe and North +America, 1845-56; Paris, 1853-55; England, 1854 and 1859, when 95 per +cent. of all the cases of nasal diphtheria proved fatal; Netherlands +and Sweden, 1855; all Western Europe, 1855-65, up to the present time, +and all Europe since; California, 1856 and 1857; Portugal and France, +1856; Eastern Prussia, 1850, 1852, 1856, 1857; and all the countries +with a cold or moderate climate to this very day. + +During the second half of the eighteenth century but two writers are +worthy of especial notice--Home, a Scotchman, 1765, and Samuel Bard, +an American, 1771. + +Home deserves credit for having distinctly drawn the line between the +pseudo-membranous and the gangrenous affections. He also endeavored to +prove that croup and angina maligna were two distinct diseases, +notwithstanding all that had been said since the time of Aretaeus in +favor of their identity. The false membrane of croup he looked upon as +an aggregation of mucus. He sought for it exclusively in the +respiratory tract, and disregarded any connection between it and the +false membrane found in the pharynx. + +Bard's experience was very extensive; he saw membranous pharyngitis, +laryngitis, and pharyngo-laryngitis; he speaks of the membrane as met +upon the skin, of paralysis of the muscles of deglutition and of the +larynx, and likewise of paralysis of the lower extremities, as +sequelae. He looked upon the morbific process as the same whichever +were the mucous membranes attacked, and made a distinction only +according to the localization of the disease. The influence which he +might have exercised in shaping the professional opinion on the nature +of the disease did not make itself felt, partly because of his +classical modesty, and partly because of his remoteness from the +centres of European learning. Not before 1810 was his book translated +into French (by Ruette). While his style is classical in its +simplicity, his observation is astonishingly correct, and his +conclusions as to the actual identity of all the diphtheritic +processes in the most various clinical symptoms unimpeachable this +very day. His description of the various forms of pharyngeal +diphtheria is painfully {659} good, his observations on cutaneous +diphtheria very accurate, his few dissections well recorded, +particularly when he speaks of tracheal and tracheo-laryngeal +diphtheria, and his historical reviews very judicious indeed. "Upon +the whole, I am led to conclude that the morbus strangulatorius of the +Italians, the croup of Home, the malignant ulcerous sore throat of +Huxham and Fothergill, and the disease I have described and that first +described by Douglas of Boston, however they may differ in symptoms, +do all bear an essential affinity and relation to each other, or are +apt to run into each other, and, in fact, arise from the same leaven. +The disease I have described appeared evidently to be of an infectious +nature, and, being drawn in by the breath of a healthy child, +irritated the glands of the throat and windpipe. The infection did not +seem to depend so much on any prevailing disposition of the air as +upon effluvia received from the breath of infected persons. This will +account why the disorder sometimes went through a whole family, and +yet did not affect the next-door neighbors. Here we learn a useful +lesson--viz. to remove young children as soon as any one of them is +taken with the disease, by which many lives have been saved and may +again be preserved." + +Jurine, in his prize essay of 1807, denies the gangrenous nature of +angina maligna and emphasizes the frequent complication of membranous +croup with membranous pharyngitis. It was reserved for Bretonneau to +enforce attention to the ideas of Bard by asserting (though he did not +mention either his monograph or its French translation of 1810) the +identity of angina maligna, or by whatever other title it may be +known, with membranous laryngitis, and by inaugurating his theory with +a new name for the disease to perpetuate the views expressed therein. +First and foremost, he called attention to the continuity of the +membrane (according to him, composed of coagulated mucus and fibrin) +of the nose, pharynx, and respiratory tract, its identity with certain +morbid conditions of the skin, and promulgated the theory that +"diphtherite"--the name dates from that time--is a specific disease, +an affection sui generis, and differs both from a catarrhal and a +scarlatinous inflammation. + +The modern history of diphtheria may be dated from June 26, 1821, when +Bretonneau read his first essay on that subject before the French +Academy of Medicine, and gave to the disease the name it now bears. +His second and third (Nov. 25th) papers belong to the same year; his +fourth was read in March, 1826; his fifth appeared in the _Archives +gen._ of January and September, 1855. It was only in 1826 that the +material, previously gathered, was summed up in his celebrated +monograph.[4] Before this time, however, the separate essays had +received prominence from the reports and commentaries of Guersant, who +laid particular stress on the statement that diphtheria was a +non-gangrenous affection, identical, and even synchronous, with croup +in the majority of epidemics. Since that epoch the literature on the +subject has assumed enormous proportions. It is a matter of regret +that the limited space allotted to this subject should exclude much +historical detail of the etiology, pathology, and therapeutics of +diphtheria. If the history of any disease is interesting, and the +neglect of its study has ever punished itself, it is diphtheria. {660} +Particularly would the treatment have been more successful if the +knowledge of former times had been available and more heeded. As long +ago as in the seventeenth century depletion in diphtheria was +condemned, and in the seventeenth and eighteenth centuries the local +treatment with muriatic acid and the internal administration of +cinchona, camphor, and roborant diet were held to be the only +admissible ones. Bretonneau urged the same principles, and still in +our own times, for want of historical knowledge, we had to learn the +old lesson over again.[5] + +[Footnote 4: P. Bretonneau, _Des Inflammations speciales du tissu +muqueux, et en particulier de la Diphtherite, etc._, Paris, 1826.] + +[Footnote 5: See history and bibliography of diphtheria in Chatto; +Sanne, _Traite de la Diphtherie_, Paris, 1874; Jacobi, in _Gerhardt's +Handb. d. Kinderk._, vol. ii., 1877; Seitz, _Diphtheric und Croup +gesch. u. Klin. dargest_, Berlin, 1879; _Index-Catalogue of the +Library of the Surgeon-General's Office, U.S.A._, vol. iii., +Washington, 1882.] + +The following is a brief review of the main points of discussion upon +subjects connected with the symptomatology and pathology of diphtheria +since Bretonneau's first paper: + +Bourquoise and Brunet express their belief (1823) in the contagious +character of this disease. Desruelles (1824) sees a diagnostic +difference between the sporadic and the epidemic forms in the +participation of the brain in the latter. Louis referred a number of +cases of croup in adults to pharyngeal diphtheria as their source. +Mackenzie considers that croup has its origin in the fauces, and urges +the employment of lunar caustic. Billard (1826) denies the specific +character of diphtheritic inflammation. Hamilton describes cases that +terminated in suppuration, and which he therefore distinguishes from +Bretonneau's cases. He describes two modes of termination of the +disease--one in croup, the other in a state of debility arising from +the effect of the absorbed secretion on the respiratory nerves. Pretty +looks upon those cases of croup that have their original seat in the +tonsils as contagious. Bland (1827) explains the difference between +croup and diphtheria. Deslandes declares them to be identical. +Bretonneau publishes a work in which he compares diphtheria with +scarlatina anginosa, and recommends the use of alum. Emmangard is the +first one of the physiological school who, likening diphtheria to +typhoid and claiming its origin in a malarial infection, calls it +angina gastro-enterica. Abercrombie is in favor of distinguishing +diphtheria from croup, but reports a number of cases of diphtheria of +the pharynx that terminated fatally by stenosis of the larynx. Ribes, +who encountered the disease in nine members of a single family, +asserts that croup rarely occurred without a preceding diphtheria in +his experience; he advises an examination of the throats of apparently +healthy individuals. Fuchs relates the history of epidemics of angina +maligna, and declares croup to be a genuine angina maligna trachealis, +which only does not run through all the stages. Broussais opposes the +identity of croup and diphtheria (1829), and gives a report of cures +by means of antiphlogistic regimen and laryngotomy. Diphtheria and +gangrenous angina are synonymous with him. Gendron expresses a belief +in the identity of diphtheria and gangrenous angina. Roche considers +the membrane rather of hemorrhagic than of inflammatory origin, and +consisting of discolored fibrin. About the same time Trousseau is +endeavoring to clearly establish the diagnosis between diphtheria and +scarlatinous angina. Shortly after (1830), he reports cases of +diphtheria which originated in blistering wounds, and of diphtheria of +the skin giving rise to throat affections, and {661} diphtheria of the +throat followed by skin disease. T. F. Hoffmann cites a severe case, +that ultimately recovered, with consecutive paralysis of certain +cranial nerves. Cheyne (1833) makes a stand against the "confounding +of croup and cynanche maligna under the name of diphtheritis." +Bourgeois witnessed an epidemic succeeding mumps. + +Fricout and Burley (1836) declare their belief in the contagiousness +of the disease. Bouillaud attacks the theory of its specific character +on the ground that abstraction of blood produced favorable results. +Stokes makes a distinction between primary and secondary croup +according to the original seat of the affection (1837). Kessler +advocates (1841) the view of its contagious nature, and Rilliet and +Barthez adduce evidence of the occurrence of ulceration and gangrene +in the course of the disease. Taupin, like Ribes, enjoins a methodical +examination of the throat of every patient during the prevalence of an +epidemic of diphtheria, whatsoever be the disease from which the child +suffers. Boudet (1842) opposes Bretonneau's hypothesis that croup is a +descending diphtheria, and holds to the identity of diphtheria and +gangrenous angina. In this contest Durand (1843) also takes sides +against Bretonneau, and lays particular stress on the point that the +diphtheritic patient succumbs rather from the severity of the +constitutional symptoms than from suffocation. Rilliet and Barthez, on +the other hand, rally to the support of the attacked master, asserting +that the usual form of croup and that resulting from a descending +diphtheritis are one and the same, while they claim that diphtheritis +and gangrenous angina are distinct affections. + +Meanwhile, the strife regarding the nature of the disease continued. +Guersant and Blache (1844) describe the stomatite couenneuse (noma, +stomacace, according to them, the rarest kind of gangrenous angina) as +a form of Bretonneau's diphtheritis, and Landsberg raises the question +whether a nerve-inflammation, present in a certain case, was to be +looked upon as an accidental or an essential feature of the disease, +and finally comes to the conclusion, with Schonlein, that it was a +neurophlogosis dependent on the disease. Bouisson (1847) reports a +case of diphtheritic conjunctivitis resulting in loss of the eye. +Robert publishes his observations on diphtheria of the skin and of +wounds, which he attributes to an atmospheric contamination in crowded +wards of hospitals, and looks upon it, with Delpech and Eisenmann, as +a form of hospital gangrene. Virchow, in the same year, distinguished +the catarrhal, croupous, and diphtheritic varieties of the disease. +Meanwhile, reports of paralysis of the soft palate after diphtheria +came from Morisseau, from Trousseau and Lasegue, and lastly (1854-59) +from Maingault. The subject of diphtheritic conjunctivitis was studied +by A. v. Graefe (1854), who encountered the disease as a complication +of diphtheria of the pharynx, nose, and skin, and hence considered it +a part of the general disease rather than an independent local +affection. Diphtheria, in its effects on the system, had at the same +time been investigated by Trousseau, who sums up with the statement +that the principal source of danger lies in the invasion of the +larynx, and that the large majority of cases of croup began as a +diphtheria of the pharynx, but that, even without the occurrence of a +laryngeal localization, many cases terminate fatally owing to +adynamia. + +Outside of France, too, the subject had attracted attention. West, who +had never seen the disease occur primarily, describes diphtheria as a +{662} complication of measles. Bamberger (1855) divides the +inflammations of the mouth and pharynx into the catarrhal and croupous +forms, and considers croup and diphtheria to be subdivisions of the +latter form, differing only in degree. The paralysis of the muscles of +deglutition is discussed by Dehaenne (1857) who had contracted the +disease, and the paralysis of other muscles by Faure. A case of +diphtheria of the tonsils, nipples, and vagina in a woman recently +confined, followed by infection of the new-born and the death of both, +is reported by Mathieux; and cases of diphtheritic conjunctivitis by +Grichard, Warlomont, and Testelin. The same year Isambert published a +work in which he divided the diphtheritic affections into three +forms--viz. angine couenneuse, scarlatinous angina, and diphtheritic +angina. The last-mentioned is further subdivided into a +croupous-diphtheritic angina, in which croup of the larynx plays an +important part, and into that form in which death results from +adynamia; in the latter form there is a marked swelling of the +lymphatic glands. Apparently, at this time the epidemic in Paris +underwent a considerable change, for the croupous form does not occur +by far so frequently as Bretonneau had asserted, and croup of the +larynx without a preceding diphtheria of the pharynx was observed more +frequently than he would lead us to believe. + +The various changes in the symptoms of the epidemics of diphtheria +which were observed in different places and countries, and at +different times, explain many of the differences of opinions in regard +to the nature of the disease. The literature of that subject is in the +last twenty-five years simply stupendous, and a few more notes must +suffice for the elucidation of the drift of theories and observations. +Beale was the first to look for organic beings as the cause of the +disease, without finding any. Laycock sees it in the bacilli and +spores of oidium albicans; Wilks, however, found the same parasite in +other affections. Cammack declares the diphtheritic membrane to be +herpetic. Feron also calls Bretonneau's mild form of the disease a +herpetic angina with pseudo-membrane; so does Gubler. Bouchut writes +against the identity of diphtheria, croup, and gangrene. Condie +describes the disease as occurring with scarlatina. Litchfield claims +that it is a concealed scarlatina, and Hillier that it has some +connection with it. Millard cites one case in the course of which +gangrene occurred, and another in which skin, mouth, pharynx, +respiratory passages, oesophagus, and vulva were affected at the same +time. Harley vainly endeavored to inoculate the disease in animals. +Stephens declares the disease to be infectious. Sanderson looks upon +it as identical with the angina maligna of the aged. Farr considered +the exhalations from sewers an important etiological factor. +Sellerier, Kingsford, and Harley (1859) report paralyses as sequelae. +Maugin speaks of a specific eruption; Ward, of an accompanying +purpura. Bouchut and Empis remarked the frequent presence of and +danger from albuminuria; so did Wade. Maugin calls attention to the +fact that, when present in diphtheria, it occurs early, whereas in +scarlatina it is seen during the period of desquamation, and is not of +frequent occurrence even then. Gull gives an account of cases in which +death resulted from asthenia, and speaks of a nerve-lesion which he +attributes to the severity of the local inflammation. Hildige +describes diphtheritic conjunctivitis as seen in Graefe's practice, +and looks upon it as contagious. Magne denies its contagious or {663} +infectious character. Mackenzie, while probably having seen false +membrane appear on the conjunctiva when in a state of inflammation, +yet refuses to recognize diphtheritic conjunctivitis as a distinct +disease. + +In the same degree that observations of cases and epidemics increased +in number, the nature of the disease and its cause commenced to be +studied. The assumption that the latter was a chemical poison was soon +doubted, and the parasitic nature of diphtheria considered by many as +proven. + +After Henle had (1840) expressed his belief in the existence of a +contagium animatum, and morbid processes had for some time been +compared with the phenomena of fermentation, Schwann demonstrated the +presence of lower organisms in fermentation and putrefaction. The +discovery of the cause of the silk-worm disease by Bassis, of the +achorion by Schonlein, of the acarus by Simon, of bacteria in +malignant pustule by Pollender, Brauell, and, above all, by Davaine, +in relapsing fever by Obermeier, the teachings of Pasteur concerning +the conditions under which putrefaction occurs,--all tended to explain +the various infectious and contagious diseases by analogy also, and to +stimulate the search for a vegetable organism in diphtheria. Buhl was +the first to discover schizomycetae in diphtheritic membrane, but +expressed no opinion as to the part they played in the process. Huter +found them in the gray diphtheritic covering of wounds, in the +surrounding apparently healthy tissues, and in the blood. Huter and +Tomasi found them in the diphtheritic membranes of the pharynx and +larynx, inoculated them on the mucous membranes of animals, and +described them as small, round or oval, dark-colored, active little +bodies. The latter observers look upon these organisms as a part of +the infectious element. Oertel found them in diphtheritic membrane and +in inflamed mucous membranes in the lymphatic vessels, lymphatic +glands, kidneys, and other organs; he considers them as the contagious +element of diphtheria. Nassiloff, too, after inoculations in the +cornea resulted in an enormous multiplication of the microscopic +organisms and their appearance with pus-cells in the lacteals and in +the lymphatics of the palate, and even in the bones and cartilages, +asserts that the development of organisms is the primary step in the +diphtheritic process. Eberth made successful inoculations in living +tissues; the micro-organisms, introduced into the cornea, proliferated +actively and caused an inflammation of irritative character in the +surrounding tissue. He asserts, with the positiveness of an +evangelist, that diphtheria cannot occur without bacteria. Klebs +inoculated the micrococci in pigeons and dogs, and found them in the +blood of the animals after death. Orth found them in the pleura, +lungs, kidneys, and urinary bladder. But what their action is, whether +they are directly pernicious, or deprive the body of certain elements +(as of oxygen in malignant pustule, according to Bollinger), or injure +mechanically by acting on the coats of the blood-vessels (either +directly or by means of altering the blood), thus depriving whole +territories of their blood-vessels, is a question upon which the +principal advocates of the parasitic theory have not yet agreed. Even +Oertel acknowledges the impossibility of explaining the manner in +which bacteria act (Ziemssen, _Handbuch_, ii., 1, p. 581, 2d ed.). +This much is positive, at any rate: that no one has yet proven that +the vegetable organisms alone, and not other, free or fixed, parts of +the {664} diphtheritic membrane, are the vehicles of the infecting +elements (Steudener); and even now the question has not been decided +whether the bacteria met with in diphtheria constitute the cause of +the disease, or are a part of the process, or co-effects of the +poisonous action--whether they are the carriers of the poison or +entirely indifferent entities. + +The most important observations made by those who deny a direct +etiological connection between micro-organisms and septic diseases in +general, and diphtheria in particular, are those of Hiller and +Billroth. The latter has proven the morphological identity of the +various kinds of bacteria, although it cannot be denied that the +apparent similarity may mask a yet unknown difference. Hiller calls +attention to the fact that large numbers of micrococci have been found +in the cadaver where death has not been the result of septic disease, +and also that septic infection is not always severest where the +bacteria most abound, but where an extensive chemical decomposition or +a mass of putrefying tissue is found. This would indicate that the +septic process is rather dependent on chemical decomposition than on +the presence of bacteria. + +Panum, Bergmann, and Schmiedeberg have isolated poisons that contained +no bacteria. Rawitsch and many others prove that septic infection is +not dependent on the existence of bacteria. Davaine has shown that an +infinitely small amount of a chemical poison, free from bacteria, can +kill quickly. + +The presence of cocco-bacteria (Billroth) in the blood during life has +not once been proven, not even in pyaemia or septicaemia. Yet their +being swept into the lungs with the atmospheric air is indisputable. +It would therefore seem as though living blood had a greater tendency +to destroy bacteria than to allow itself to be decomposed by them. Not +only, however, would it seem so, but P. Grawitz (_Virch. Arch._, vol. +lxx., p. 546) proves that sporules do not grow in the (tissue and) +blood, but that they are in part dissolved, in part eliminated through +the kidneys, and that this result is accomplished through the +combination of the following four factors--viz. the elasticity of the +blood, its constant motion, the absence of oxygen in sufficient +quantity in the circulating blood, and the presence of living animal +cells. All of these factors appear to be of great importance. Thus it +is that, where the constant motion of the blood and the animal living +cells are not present (as in the anterior chamber of the eye or in the +humor vitreous) a rapid proliferation and accumulation of bacteria can +take place. They are also known to increase rapidly and emigrate into +the liver when deposited in the abdominal cavity. + +The destruction of bacteria in the circulating blood, into which they +may have penetrated, accounts for some microscopical facts in +connection with (actually or apparently morbid) blood. Their remnants +are probably the pale and dark particles which are discovered in the +blood alongside the red and white blood-corpuscles. They could not be +identified as micrococci, while in the tissue they are more +recognizable. In autopsies they have been found in the urinary +tubules, pressing forward and piercing the walls, not occupying a +nidus of inflammation, however, and probably are even here a +post-mortem phenomenon. A direct necrosis or inflammation by the +inoculation of diphtheritic elements can only be produced in the +cornea, as was shown by Recklinghausen, and particularly Eberth. +Besides, there is nothing characteristic in the cocco-bacteria of +{665} diphtheria, with the exception, perhaps, of their browner color, +to justify their being looked upon as a distinct variety, certainly +not as another species. It is more likely that a difference of action +is not so much to be sought for in a different parasite as in the +peculiarity of the corneal tissue. When fluid containing +cocco-bacteria was injected into the eye of a rabbit, in twenty-four +hours the eye was destroyed. If injected into the eye of a dog or +guinea-pig, only a slight inflammation resulted (Billroth and +Ehrlich). If these experiments were continued on a larger scale, we +might eventually, by analogy, infer, and even prove, that the immunity +against certain diseases enjoyed by some animals is owing to +peculiarities in the very structure of their own tissues. In a similar +manner I shall prove hereafter that even peculiarities and variations +in the tissue and epithelium of the human body give rise to different +shades and variable clinical symptoms in the diphtheritic processes. + +The views of Curtis, Satterthwaite, and Charlton Bastian fully agree +with those of the above observers. The latter is rather inclined to +look upon bacteria as an effect of the disease than as a cause. +Similar views were expressed by Burdon Sanderson. + +Nor are the researches of Weissgerber and Terls, Lukomsky, Weigert, +Lucke, any more conclusive; and, finally, Furbringer, in his most +recent and careful studies of diphtheritic nephritis, insists upon +this, that it is not caused by immigration of fungi into the kidneys, +that the very best methods employed for the finding of parasites +result in the absence of micrococci from the inflamed organ, and that +the renal inflammation following diphtheria is the result of a +chemical process. + +H. C. Wood and Henry F. Formad, in Supplement 7 of the _National Board +of Health Bulletin_ (1880), declare it altogether improbable that +bacteria have any direct function in diphtheria--_i.e._ that they +enter the system as bacteria and develop as such in the system, and +cause the symptoms. It is, however, possible that they may act upon +the exudations of the trachea as the yeast-plant acts upon sugar, and +cause the production of a septic poison which differs from that of +ordinary putrefaction, and bears such relations to the system as to, +when absorbed, cause the systemic symptoms of diphtheria. Now, these +bacteria may be always in the air, but not in sufficient quantities to +cause tracheitis, but enough when lodged in the membrane to set up the +peculiar fermentation; whilst during an epidemic they may be +sufficiently numerous to incite an inflammation in a previously +healthy throat. + +The same authors publish a number of other experiments and conclusions +in Suppl. 17 (Jan., 1882): "There is no proof as yet that the +micrococci are the cause of the disease. Their presence in the exposed +dead tissue is no evidence, for the membrane represents but the +necrotic mucous lining.... Indeed, when the healthy mucous membrane of +the mouth or trachea is destroyed by caustics--for instance, +ammonia--the eschar into which it is converted--really a +pseudo-membrane--contains the same micrococci as are found in true +diphtheria, as Wood and Formad have learned. Moreover, in the +scrapings of the healthy tongue the same micrococci can be seen. Of +more significance is the detection of the same or similar micrococci +in the blood of the living patients during severe attacks. But since +these parasites were found only in the more severe cases, and not in +all instances of the disease, were seen also {666} in the blood of +other septic disorders, and since no cultures have been made with the +fresh blood, there is not yet enough evidence for any decision. In the +internal organs bacteria are not found with any regularity in +diphtheria."[6] + +[Footnote 6: H. Gradle, _Bacteria and the Germ Theory of Disease_, +Chicago, 1883, p. 186.] + +O. Heubner, while studying both the local affection and the general +infection of diphtheria, availed himself of the methods of Cohnheim +and Litten, who produced diphtheritic deposits by cutting off the +circulation of the blood. He ligated the neck of the bladder in +rabbits for two hours. On the first day he noticed a hemorrhagic +oedema of the mucous membrane, with loosened and tumefied epithelium; +on the second a firm and coagulated exudation took the place of the +normal tissue; on the third there were genuine diphtheritic spots in +the mucous membrane. The newly-formed pseudo-membrane exhibited all +the morphological elements of human diphtheria (genuine or +scarlatinous) and epidemic dysentery.[7] Thus Heubner's results agree +with the definition of diphtheria as the compound of severe +inflammation and necrosis. The inoculation of his diphtheritic +artefacts he found sterile. Animals, however, which were inoculated +with diphtheritic masses taken from the diseased human patient fell +sick with tumor of the spleen, hemorrhages, and general sepsis, +besides a local diphtheritic affection. Scarlatinal diphtheria used +for the same purpose had the same effect. Bacilli were developed, but +they were not found in the blood-vessels (differing in that respect +from the bacilli of anthrax), in spite of continued examination. Thus, +Heubner refuses to accept the bacilli as the diphtheritic poison; they +are, in his opinion, the result of the morbid process, and not its +cause. Thus, though he believes the diphtheria poison to be organic, +he concludes that its nature is not yet explained; contrary to the +assertions of many prolific prophets of the bacteria literature, who +now and then claim for this year's microscopic revelations the same +infallibility which was claimed for last year's opposite views.[8] + +[Footnote 7: _Die Experimentelle Diphtherie_, Leipzig, 1883.] + +[Footnote 8: L. Letzerich recognized in former years the specific +parasites of diphtheria, whooping cough, and typhoid fever as if they +were labelled. Then, again (_Arch. f. Experim. Pathol. u. +Pharmacol._), he admitted the great difficulty in discriminating the +specific schizomycetae of diphtheria, croupous pneumonia, epidemic +influenza, and typhoid fever.] + +E. Rindfleisch[9] expresses himself as follows: "The microphytes of +diphtheria, septicaemia, and pyaemia have not been isolated and +cultivated as yet. But experimenters are convinced that there are a +great many species of microphytes underlying genuine putrefaction. In +producing septicaemic conditions in animals their efficacy differs. +Not every animal is influenced by the same microphyte. Thus it becomes +probable that the human organism is endangered by a certain number of +the putrefaction microphytes. Some one may have a particular +predilection for granulating wounds and mucous membranes, and thereby +produce a diphtheritic inflammation. Another may enter the blood from +a recent wound and give rise to a septicaemic fever with rapidly fatal +termination. The third may invade the body by means of a phlegmonous +inflammation, purulent infiltration, thrombosis, embolism, and +metastatic abscesses, accompanied with a pyaemic fever of a remittent +type." + +[Footnote 9: _Die Elemente der Pathologie_, Leipzig, 1883, p. 301.] + +After all, it does not appear to me that the bacteria question has +come {667} any nearer its solution in the last few years, in spite of +the most eager researches and the fact that some of the best medical +names in the world of medicine take the parasitic nature of diphtheria +for granted. For instance, in the second Congress for Internal +Medicine (Wiesbaden, 1883) C. Gerhardt rises in its favor. He makes +the statement, or rather admits, that several parasites have been +found by different men, that every one considers his the genuine one, +that several writers assume that there are several diphtheria +parasites, and suggests that, in his opinion, the disease may be +produced by different varieties of bacteria. At the same time, he +contends that the essence of the disease consists in the erosion (and +change) of the epithelium and the emigration of leucocytes. If that be +the case, I understand less than ever why diphtheria is, or is to be +called, a parasitic disease. + +Panum's words seem still to be the soundest expression of all our +knowledge on the subject when he says: "It is a matter of rejoicing +that physicians have come to the conclusion that certain microscopic +organisms, be they considered vegetable or animal, and designated as +bacteria, fungi, monads, micrococci, or vibriones, do not exist merely +in the minds of theorists as causes of disease, but are in reality +enemies that must be combated with all the known efficient weapons in +our possession. But, while thus rejoicing, it must be borne in mind +that we have but a feeble insight into the relation between these +organisms and diseases, and in order to effect that much-desired +advance in scientific knowledge--a matter of considerable importance +in the practice of medicine--it is necessary not only to grasp at +isolated data, but carefully and deliberately to observe and study all +the facts before us, and even to devote some attention to those which +would tend to prove that there are bacteria and fungi which, under +certain circumstances, are perfectly harmless, and that even some of +the malignant ones among them do not commit all those outrages with +which they are charged, directly and personally." + +SYMPTOMS.--In the majority of cases the disease has a prodromal stage, +which usually lasts a day or two, and may run a similar course to that +of a catarrhal pharyngitis. The patient feels somewhat indisposed, has +slight fever, is dejected, complains of painful deglutition, more +marked when swallowing fluids than solids or semi-solids, has headache +and occasionally vomiting. The occurrence of the latter, however, is +very much less frequent than in the outbreak of scarlatina. In very +severe cases convulsions have been observed, chills very rarely; +elevations of temperature of from 102.5 degrees to 104 degrees F. are +frequent; higher ones, from 105 degrees to 107 degrees, rare. At this +time it is often difficult or impossible to distinguish a catarrhal +angina from a diphtheritic by the subjective symptoms. Slight +glandular swellings under the jaw may occur in either. The +characteristic objective symptom of the latter disease is the presence +of membrane on the reddened mucous membrane of the fauces, which, +usually, is markedly injected over all or part of the surface. The +arches of the palate and the tonsils, less frequently the posterior +wall of the pharynx, are so affected. A distinctly localized redness +cannot be but either traumatic or diphtheritic. Larger or smaller +deposits are found thereon, lying loose on the surface or deeply +imbedded according to the locality. At times the first examination +reveals their presence in large numbers; at other times but a single +one can be {668} detected, which is soon followed by others, however. +Within a certain period of time, as a rule twenty to twenty-four +hours, the single deposits coalesce and form a membrane of greater or +less extent. Mostly in the same proportion to its increase in size it +increases in thickness. On the uvula, soft palate, and the posterior +wall of the pharynx the membrane is located superficially, and at +times can be easily removed; on the tonsils it has a firmer hold, and +is usually amalgamated with their uppermost tissues. On the other +hand, there are cases in which no actual membranous formation is +observed; in such cases the tissues are more or less swollen, the +surrounding portions more or less reddened, and the grayish-white +discoloration is the result of an infiltration of the tissues +themselves, and cannot be removed. + +There are still other cases in which deposits of membrane and tissue +infiltration are found at the same time, and where both history and +evidence indicate that these two phenomena are the result of one and +the same process. When the uvula takes part in the process the +swelling is, as a rule, more marked than when the remaining parts of +the fauces only are implicated. Its circumference is very +considerable, and amounts sometimes to the treble or quadruple of the +normal, in consequence of the oedematous condition of the entire +tissue. + +We have to deal, then, with three different manifestations of the +diphtheritic process: first, with a membrane lying on the mucous +membrane, and removable without causing much injury to the epithelium +or any to the basement membrane; such membranes were given by some the +name of croupous deposits; secondly, with a membrane implicating the +epithelium and upper layers of the mucous membrane; to this the title +of diphtheritic membrane has been given by preference; thirdly, with a +whitish or grayish infiltration of the surface and the deeper tissue, +which, if abundant, may give rise to a necrotic destruction of the +tissue. + +The severity of the disease does not always depend on the predominance +of one of these three forms, for any of them may accompany a mild or a +severe attack. By a severe attack we understand one attended with +chills, temperatures as high as 105 degrees and 107 degrees F., and +marked nervous symptoms, such as vomiting and convulsions. It is +characteristic of such cases that when the membrane is accidentally or +forcibly removed it is speedily reproduced; the lymphatic system, in +addition, takes an active part in the process. The neighboring glands +become swollen; the periglandular tissue does likewise, so that the +circumference of the neck becomes enormous, and the space between the +lower jaw and the clavicle appears one immense tumefaction. These are +the cases in which, as a rule, loss of strength and general debility +speedily ensue, and death occurs from exhaustion. The membrane in +cases of this description frequently undergoes changes in appearance; +under the influence of the atmosphere and of foreign substances, and +by admixture of blood, its color becomes yellowish or brownish. The +odor of the membrane and surrounding parts becomes sweetish and musty, +and occasionally so fetid that it contaminates the atmosphere of the +room, and the air in its transit through the nose and over the pharynx +becomes by inhalation dangerous to the patient. His throat becomes +more swollen, his respiration loud; he keeps his mouth open +constantly, has an indifferent expression; the saliva dribbles +continually, the color of the skin is sallow and livid, the {669} +appetite very poor, and pulse both frequent and small. When the +symptoms are of long duration, and a deep infiltration of the affected +parts occurs, hemorrhages not infrequently make their appearance. +These may be slight although frequent; occasionally, however, larger +blood-vessels are encroached upon in the process of destruction, and +dangerous, nay even fatal, hemorrhages may be the result. The septic +forms which I have here described are more dangerous than the mild +ones previously mentioned. Still, even in the latter bad results may +ensue from a direct absorption into the blood of putrid substances and +by the penetration of fetid gases to the lungs. + +Occasionally, where the infiltration has been extensive, we meet with +a condition that can only be considered as gangrene. In such cases we +see collections of a grayish pulpy mass, which on falling off leaves a +considerable loss of tissue, the further course of the disease being +either favorable, or dangerous through absorption of septic material, +or accompanied by local hemorrhages. When, after a time, health is +completely restored, marked cicatrices are left behind. Such loss of +tissue is generally seen in the tonsils only, but it may also be +encountered in the soft palate. Its cicatrices on the soft palate are +always a source of inconvenience, partly in swallowing, partly in +speaking. Actual local perforation of the soft palate I have seen but +five times in twenty-five years, sloughing without perforation very +often. + +The diphtheritic membrane not infrequently spreads from the pharynx to +the neighboring organs. From the posterior aspect of the soft palate +or pharynx the disease gradually ascends to the nasal cavities; this +is particularly apt to occur when the uvula is the seat of extensive +deposits, and by forced inspiration and deglutition its posterior +surface becomes affected. In such cases the membrane which extends +thence to the nasal cavities is very dense, and capable of narrowing +the capacity of the nasal cavities anteriorly, and occasionally even +to close them entirely; as a rule, however, several days elapse before +the membrane assumes such a condition. Usually, when this form of +nasal diphtheria is in its incipient stage, it is impossible to +diagnosticate it; the most important sign thereof, besides a more +nasal articulation and sometimes greater difficulty in deglutition, +and the result of close ocular examination while the uvula is turned +sideways or drawn forward, is a swelling of the deep facial glands at +the angle of the lower jaw; when these swell rapidly it can be +asserted positively that the nasal cavities have been invaded. There +is little or no discharge from the nostrils under these circumstances. + +The picture is a very different one, however, when the nose becomes +primarily affected. This usually occurs only where an acute catarrh +with but little secretion, not so often where a chronic catarrh, has +preceded infection. When the secretion is thin and serous, the +diphtheritic infection renders it no thicker, but makes it slightly +flocculent, and it may become very profuse. This form is frequently +attended with a disagreeable odor, equally unpleasant to the patient +and to those around him. During the prevalence of an epidemic one must +always be prepared to see an acute nasal catarrh or an influenza, or +even a chronic nasal catarrh, become complicated with diphtheria or +pass into it. Schuller reports the case of a five-weeks-old male child +who, having had a nasal catarrh since birth, became affected with +diphtheria of the nose. The glandular {670} swelling of which I spoke +above is a very important diagnostic, and likewise a decidedly +unpleasant symptom, which becomes very marked inside of twenty-four +hours; frequently a partial swelling remains long after the +disappearance of the diphtheritic membrane. Such glands rarely +suppurate or undergo a necrotic degeneration; sometimes they become +permanently indurated. This induration and a chronic pharyngeal and +nasal catarrh are very serious matters in many instances. Both of +these conditions are starting-points for a number of acute or subacute +attacks of diphtheria in the same person. It is they which constitute +the liability of persons once affected to be taken sick again. Not +only are they liable to be affected themselves, but they are a +constant danger to all around them. Diphtheria, in a large family of +children living in one of the best houses of the city, after having +returned half a dozen times in the course of a year, disappeared +instantaneously, not to return, when a seamstress living in an +infected neighborhood and suffering from occasional sore throats was +relieved of her daily work in the house. Oedematous swelling of the +mucous membrane and submucous tissue is often observed for a long +period to come; elongated uvulae, enlarged tonsils, often date back to +such an acute attack. Thus it is with the upper portion of the larynx +about the posterior insertion of the vocal cords (see below); its +large amount of loose submucous tissue is liable to swell considerably +in acute attacks. Frequent spells of croupy cough and a certain degree +of dyspnoea are often observed for years afterward. Though the cases +of genuine cicatrization between the arytenoid cartilages, as +described by Michael,[10] be rare, with their result of permanent +paresis of the thyroarytenoid interni muscles, when they do occur they +are either obstinate or altogether incurable. + +[Footnote 10: _Deutsch. Arch. f. klin. Med._, 1879, xxiv. p. 618.] + +Diphtheritic conjunctivitis occurs either primarily or as a +complication of pharyngeal or nasal diphtheria. Fortunately, it is not +of frequent occurrence; the cornea may become destroyed either by +pressure through the considerable swelling of the eyelid or by +diphtheritic keratitis. Usually the upper eyelid is the first to +suffer; it is red, rigid, swollen. In the beginning the conjunctiva +palpebrae is smooth, dry and pale, while that of the eye is chemosed; +afterward diphtheritic deposits take place either in floccules or in +solid masses. Knapp distinguishes between croup and diphtheria of the +eyelid according to the facility or impossibility of removing the +deposit. In favorable cases the membranes begin to macerate and the +eyelids to soften after a few days. In those less favorable +perforation of the cornea, prolapse of the iris, or total destruction +of the eye take place. + +The ear is but rarely the primary seat of diphtheria. A girl of three +years died of laryngeal diphtheria on Sept. 6, 1882, after an illness +of four days. A girl of seven years was removed from the house on +Sept. 6th and returned on Sept. 8th. On the afternoon of the 10th an +earring taken from the corpse was attached to the left ear of the +sister, after having been washed with soap and water only. About noon +on the 11th the lobe of the left ear reddened, on the 12th it +exhibited a membrane and became swollen, and some glands enlarged in +the neighborhood. On the right mastoid process the skin was not quite +healthy, a vesicatory having been applied three weeks previously. This +surface became {671} diphtheritic on the 12th, without consecutive +glandular swelling. On the 13th the membranes grew thicker; on the +14th the pharynx was also affected, and the physician called in. + +Most diphtheritic affections of the ear, however, are secondary. In +pharyngeal and nasal diphtheria the narrow orifice of the Eustachian +tube is easily obstructed by either catarrhal swelling or diphtheritic +deposit. The disease may invade the middle ear and the drum membrane +with perforation, caries, and deafness following. + +The descent of the diphtheritic process into the respiratory organs +may give rise to various conditions. The membrane is not always found +to pass uninterruptedly from the mucous membrane of the fauces into +the larynx; not infrequently isolated diphtheritic spots are found in +the pouches on either side of the attached extremity of the +epiglottis, or on the epiglottis, or in the larynx. At such times the +epiglottis is moderately swollen, its margins hard and reddened. +Occasionally the redness is interrupted by small diphtheritic +deposits, which may remain isolated for a considerable time, but +generally coalesce so as to coat the edges of the epiglottis with a +continuous membrane. As a rule, the upper surface of the epiglottis is +not completely covered by membrane, while only now and then +diphtheritic deposits are found on its under surface. + +The subjective symptoms accompanying the affection of the epiglottis +are not always in direct proportion to the extent of the membranes. +Dyspnoea and hoarseness occasionally occur where the only abnormal +condition is a marked oedema at the entrance of the larynx, +particularly of the posterior wall near the arytenoid cartilages and +the attachment of the vocal cords. The oedematous condition causes a +functional paralysis of the vocal cords, together with marked dyspnoea +on inspiration. The difficulty of breathing may become so excessive +that the clinical diagnosis of croup is unquestionable, and +tracheotomy resorted to, while expiration is comparatively free and +the voice not markedly affected. Furthermore, cases occur in which +there is no marked oedema, but merely a general catarrh of the +epiglottis and larynx; here, too, the subjective symptoms of +hoarseness and dyspnoea may become severe and necessitate the +performance of tracheotomy. Still, bearing this in mind, I have on +several occasions refrained from performing this operation where I +judged that, aside from the diphtheria of the pharynx, I had to deal +with a moderate oedema of the glottis or a laryngeal catarrh. + +Frequently, however, membranes form in the larynx in the same way as +in the pharynx or nose; then inspiration and expiration are equally +interfered with, and hoarseness is a more constant symptom than in the +above-mentioned cases. Fever and pain are not necessarily prominent +symptoms; in fact, they are frequently unimportant, but in proportion +as the degree of narrowing of the larynx increases the respiration +becomes more difficult, long-drawn, and loud. + +It may happen that the trachea and bronchi may become affected, +although diphtheria of the fauces does not exist. This does not occur +as rarely as Henoch and Oertel seem to believe. They think that +diphtheritic tracheo-bronchitis is mistaken for the primary condition, +because the throat is not examined early enough. + +Oertel is of the opinion that the membrane in the fauces is {672} +overlooked in such cases. Steiner,[11] too, asserts that "the tendency +of the times is to question, nay, rather to deny, the existence of +croup extending from below upward." Now, on the contrary, repeated +experience enables me to assert with positiveness that diphtheritic +tracheo-bronchitis may occur without an affection of the pharynx at +the same time. I do not deny that it may last for days without giving +rise to dangerous symptoms. I know it does. But when the process +reaches the larynx, the symptoms of suffocation become so urgent that +tracheotomy may be absolutely required at once, and, in spite of the +operation, death soon after occurs. + +[Footnote 11: _Ziemssen's Handb._, iv., 1, 126.] + +Of course these cases are exceptions; as a rule, laryngeal and +tracheal diphtheria result from a descent of the disease from the +fauces. More or less uncomplicated cases of primary laryngeal +diphtheria, or so-called sporadic membranous croup, were, however, +observed before the end of the sixth decade of this century. They were +then almost the only cases of diphtheria, and linked former epidemics +and the present one together. + +Inflammatory affections of the lungs may occur at various times and in +various forms during an attack of diphtheria. That which appears after +tracheotomy is usually a broncho-pneumonia, and results from +rarefaction of the air in the respiratory passages during the period +of impeded respiration, with consequent collapse of pulmonary tissue +and dilatation of the blood-vessels, and hence a disturbance of the +circulation. It may not fully develop until after tracheotomy, and is +a frequent cause of death on the second or third day after the +operation. Now and then a case of lobular pneumonia will result from +the aspiration of pieces of membranes into the smallest bronchi. It +can be easily recognized when the trachea is opened, but previous to +the operation the auscultatory signs are of little or no value, being +masked by the laryngeal rales. Percussion is equally useless, for a +dulness may just as well indicate collapse of the lung as +infiltration. The second form of pneumonia associated with diphtheria +is from the beginning fibrinous in character. Here, too, auscultation +and percussion are of little assistance in establishing a diagnosis +when there is a laryngeal diphtheria at the same time, for the above +reasons. Where, however, the dulness on percussion is accompanied by +high fever, and the long-drawn inspiration is replaced by rapid +respiratory movements, the diagnosis of pneumonic complication is +justified. + +Diphtheria of the mouth, as a primary affection, is not of very +frequent occurrence; not rarely, however, is it associated with +diphtheria of the fauces and nose, mainly when they have assumed a +septic or gangrenous character; it appears on cheeks, tongue, angles +of the mouth and gums, and, after the fetid discharges have excoriated +the skin, on the lips also. In all of these localities it appears less +in the form of an extensive, thick membrane than an infiltration of +the tissues. It is most apt to occur where, from the start, the mucous +membrane of the mouth was eroded or ulcerated. The ulcerated base of a +follicular stomatitis is very frequently the starting-point of a +general diphtheria of the mouth. It is always a disagreeable symptom, +points to a long duration of the whole process, and threatens septic +absorption. + +The oesophagus and the cardiac portion of the stomach are the seat +{673} sometimes of very massive and extensive, mostly fibrinous +exudations, in typhoid fever, dysentery, cholera, measles, and +scarlatina, or after injuries following contact with mineral acids, +alkalies, corrosive sublimate, or antimony. When the normal tissue was +not injured I never saw any that were not superjacent and could not +easily be peeled off (croupous). In cases of extensive pharyngeal and +laryngeal diphtheria the upper part of the oesophagus is often covered +to a distance of half an inch or an inch with membrane, the lower part +of which is thinning out into a mere film. A case of local +diphtheritic deposit near the cardiac portions of the oesophagus, upon +the seat of a stricture, I have described in my _Treatise_, p. 83. +Actual diphtheria of the stomach is rare. So is that of the intestine, +which is much more liable to be affected in animals than in man. In +the cow intestinal diphtheria is frequent (Bollinger). In the +gall-bladder, resulting from the irritation produced by calculus, it +was seen by Weisserfels. The diphtheritic form of inflammation of the +human colon and rectum--dysentery--is frequent enough, but will be the +subject of discussion in another place. But, besides this, in the +lower portion of the small intestines and in the colon long, tough, +coherent membranes are sometimes found in the male and female (not in +the hysterical female only). As a rule they are not diphtheritic, but +consist mostly of nothing but mucus hardened and flattened down by +protracted compression. The few cases of intestinal diphtheria I have +met with gave rise to the usual symptoms of enteritis, and were +diagnosticated as such. + +Wounds of all kinds are easily and rapidly infected by diphtheria; for +instance, vaginal abrasions and erosions of the external ear, tongue, +and corners of the mouth. Scarification or removal of part of the +tonsils is followed in half a day or a day by a deposit of +diphtheritic membrane on the wound. The wound caused by tracheotomy +becomes liable to be infected with diphtheria within twenty-four +hours. Leech-bites, skin denuded by vesicatories, removal of the +cuticle by scratching during cutaneous eruptions, all furnish a +resting-place for diphtheria in a short time. What Billroth has +described under the name of muco-salivary diphtheritis, as it occurs +after the extirpation of a large portion of the tongue and resection +of the lower jaw, belongs to this class. + +At times immediately at the beginning of an invasion of diphtheria, at +other times only on the second or third day, an erythematous eruption, +more or less general, appears on the skin. Now and then it appears on +the chest, shoulders, and back; at other times it covers the body, and +has not infrequently led to its being confounded with scarlatina. It +is not always accompanied by much fever, and cannot therefore be +mistaken for that form of erythema which frequently appears in +children with delicate skins during high fever from any source. I +cannot say that I have found this complication to give a more +malignant character to the disease, but true erysipelas does. I am not +prepared to prove that the two processes, erysipelas and diphtheria, +are identical under some circumstances, but the complication of the +two, and the ferocity with which they combine, renders a close +relationship probable. I have seen an infant dying from an erysipelas +added to a post-auricular diphtheria, this being due to a slight +abrasion of the surface. Erysipelas originating in the tracheotomy +wound, though ever so carefully disinfected and secured, is {674} +frequently observed after two or three days, and is a very ominous +symptom. Erysipelatous surfaces, denuded of their epidermis by +spontaneous vesication or injured by ever so slight a trauma, are very +liable to be covered with diphtheritic membranes. + +An eruption resembling urticaria in the beginning is as innocent as +erythema, but purpura in the latter stage is a symptom of mostly +ominous nature. + +On the vulva and vagina of little girls diphtheria is sometimes met +with; probably in every case it is due, under the epidemic influence, +to a local catarrh or erosion. In but few cases, comparatively, the +inguinal glands are swollen. There are not many cases of vaginal +diphtheria which are followed by the pharyngeal affection. Diphtheria +of the vagina in puerperal women is liable to become the cause of +general sepsis, and is a dangerous disease; it is seldom complicated, +but uterus, Fallopian tubes, and peritoneum may become the seat of +inflammatory and septic disturbances. In the bladder it may occur when +the urine is alkaline, in chronic cystitis, after lithotomy, +urethotomy, the operation for vesico-vaginal fistula, and in ectopia +vesicae. This form has a marked tendency toward localization, but by +extension of the phlegmon, when of putrid character, to the +retro-peritoneal cellular tissue, peritonitis may ensue and terminate +fatally. Sepsis from absorption is also frequent. Vesical diphtheria +is sometimes quite unsuspected. A man of sixty had urinary trouble a +long time; his urine was frequently very offensive, containing blood +and pus. About five days before his death he suddenly collapsed. I +found the bladder well filled, and introduced a catheter, but +succeeded in removing but a few drops of fetid liquid. Assuming the +presence of a malignant tumor at the neck of the bladder, I attempted +to draw off the urine by puncturing above the symphisis pubis; again +without success. At the post-mortem examination a thick membranous +lining of the bladder was found detached in the form of a sac +containing about a quart of urine. During life the beak of the +catheter evidently passed into the space between the bladder and the +membranous sac, which accounts for the unsuccessful attempts at +catheterization. + +Diphtheria of the placenta was observed by Schuller. The membrane was +between uterus and placenta, and attached to the latter. It resulted +from puerperal sepsis. Balano-posthitis is liable to result in local +and general diphtheria; so are circumcision wounds. They are apt to +become affected either primarily, without apparent cause, or when +other members of the family are suffering from the disease. + +The kidneys may become affected in various ways. Albuminuria is not +always of significance, as it occurs in severe and mild cases alike, +both before and after tracheotomy, and therefore is not connected +always either with the height of the fever or the degree of dyspnoea; +at times it disappears in a few days, in other cases it is of longer +duration. It is not invariably complicated with changes in the kidney, +neither do we always discover casts or degenerated epithelial cells in +the urine. In other respects also it does not behave like albuminuria +in scarlatina. In the latter it appears seldom before the second week +of the process, and frequently later, while in diphtheria it is often +seen early. It sometimes lasts but a few days, particularly in many +cases which set in with a high fever, which rapidly diminishes, and +terminates in speedy recovery. In {675} these occurrences the presence +of albumen appears to attend the rapid elimination of the poison. + +Albuminuria seldom lasts longer than a week, and is not often +complicated with oedema, but sometimes it is but a symptom of a local +or general nephritis, and then hyaline, epithelial, and fibrin casts +and granular cells are found in the urine. Nephritis then assumes as +serious a character as it possesses in scarlatina. Cases of nephritis, +fortunately rare in a very early period of diphtheria, are liable to +run a rapid and often fatal course. + +The heart and blood are affected in various ways by the diphtheritic +process. Where the disease runs a slow course, accompanied by high +fever, a granular degeneration occurs, similar to that appearing in +other acute infectious disorders--typhoid, for example. In diphtheria, +however, it would seem that this condition may arise even without +marked elevation of temperature. The pathological changes in the heart +produced by diphtheria are not always the same. Ecchymoses, cellular +hypertrophy, and granular degeneration have frequently been noticed +after death where the symptoms had been severe. The result, of course, +is considerable weakness of its muscular tissue, evidenced by the +formation of local (Beverly Robinson) thrombi, general sluggishness of +the circulation, dyspnoea, muffled heart-sounds, a cool and pale skin, +and sudden death, preceded by a very feeble and frequent, sometimes, +however, by a very slow, pulse. Aside from this, there is actual +endocarditis during the course of diphtheria or convalescence +therefrom. It affects especially the valves, and among them +particularly the mitral. It is characterized by high fever, precordial +pain, attacks of syncope, and a systolic murmur. + +The rapid decrease of red blood-cells and a moderate increase of +leucocytes were demonstrated by Bouchut and Dubrisay, but the +disproportion was not such as to necessitate the diagnosis of +leucocythaemia. Wunderlich reports two cases of Hodgkin's disease, the +pseudo-leukaemia developing during diphtheria. And the slowness of +final recovery in many cases, even of but short duration and not +complicated with nervous disorders, appears to point to a serious +disintegration of the elements of the blood. The dark color and +defective coagulation of the blood in autopsies of diphtheria cases +have often been remarked. + +The direct and rapid introduction into the blood of a foreign +substance has amongst its earliest symptoms fever. This reaction of a +nervous system depends both on the quantity and quality of the +substance or poison introduced, and on the susceptibility of the +patient. High temperatures are, however, not the only, nor are they +the most dangerous, nervous symptoms. To the latter belong the +different shades of paralysis met with during or subsequent to +diphtheria. + +Sudden and unexpected collapse is sometimes observed, not infrequently +in the earlier part of the disease. The changes found in autopsies, +such as a dark color of the blood, deficient coagulability, +extravasations into and friability and granular degenerations of the +tissues, accumulations of degenerated cells, and granules between the +fibres, degeneration mainly of the heart-muscle, the presence of +heart-clots, thrombi in remote veins,--they all show to what extent +the disease can destroy life in the shortest time possible. In the +heart either the pneumogastric or the ganglionic {676} nerves may be +affected, and the symptoms will vary accordingly. Paralysis of the +former will accelerate the pulse, degeneration of the sympathetic will +diminish its frequency, yet death may ensue in either. + +The usual form of diphtheritic paralysis makes its appearance during +the period of convalescence, at a time when all danger seems to have +passed by. As a rule, the soft palate and the muscles of deglutition +are the first to be attacked, while the condition of these organs is +apparently normal (and no longer oedematous, and thereby inactive, as +in the first period of the disease). While they are recovering, or +before, the accommodation muscles of the eyes become paralyzed. +Sometimes, however, these are the first to be affected. This paralysis +does not, as a rule, follow severe cases; on the contrary, it is not +uncommon to observe it after apparently mild attacks of the disease. +In consequence of the former paralysis, deglutition becomes difficult; +fluids are expelled through the nose or enter the larynx and bronchi, +thereby giving rise to pneumonia; in the latter there is strabismus. +The upper and lower extremities become paralyzed afterward. As a rule, +a number of muscles are affected at the same time, and improvement +will take place in about the same order in which the individual +muscles became affected. After paralysis has become affected, +circulation begins to suffer. The extremities now and then become +bluish, cool, emaciated; rarely atrophy and fatty degeneration have +been observed. The muscles of the neck also become paralyzed; the head +cannot be carried, or with difficulty only. The fingers are but seldom +affected. The same holds good of the bladder and intestines. The +respiratory muscles are not frequently attacked. Their paralysis is +very ominous, and may prove fatal in a short time from apnoea. + +Not only motory but sensory paralyses may occur. Anaesthesia, +amaurosis, deafness have been observed; a number of cases of locomotor +ataxia are on record, and but lately Hadthagen[12] publishes a case +which he claims as disseminated sclerosis. + +[Footnote 12: _Arch. f. Kinderheilk._, vol. v., 1883.] + +Sometimes the nervous affection in diphtheria is localized in a +peculiar manner; it seems as if there is a predisposition on the part +of a certain nerve to become diseased. The case of a boy, active and +healthy, in the practice of H. Guleke, is very interesting. In the +course of three years he had three attacks of diphtheria. In the very +beginning of the disease he always became soporous with an almost +normal temperature and a slow but regular pulse. Probably the heart's +ganglia are the first to submit to the influence of the poison and +exhibit symptoms of flagging function. In most of the cases of +diphtheritic paralysis the prognosis is good; the large majority will +run a favorable course in from six to ten weeks. + +INVASION.--Is diphtheria, primarily, a local or a constitutional +disease? Mercado's well-known case of diphtheria, engendered by the +biting of a finger, has been alluded to. I know of one case in which +the vagina became first affected, and later the pharynx. Bayles saw +denuded portions of skin assume a membranous character, and general +diphtheria develop afterward. Fresh wounds become diphtheritic, and +the general disease arises from this source. Even paralysis will +follow. I had a death from diphtheria when a long incision into a +phlegmon of the thigh had become diphtheritic. A little girl, who had +a considerable amount {677} of discharge from a catarrhal vagina, and +sore thighs in consequence, exhibited first, during the epidemic of +1877, membranes on the denuded cutis, and afterward general +diphtheria. Brehm reports the case of a woman on whom he performed +colotomy. The wound became thoroughly diphtheritic and gangrenous, but +the pharynx and respiratory organs remained intact. A few days after, +her daughter, who attended her in her sickness, was infected. In her +the pharynx was the seat of disorder. Besides, the tonsils are very +frequently coated with a membrane without any general symptoms in the +beginning, fever and general illness occurring only later on. Now, all +of these facts tend to show that there are cases in which the origin +of the disease is purely local. + +It must, however, not be forgotten that during the prevalence of an +epidemic every one is more or less under its influence, and but little +is wanting to call forth the disease. Some years ago a well-known +physician, with whom I was intimately acquainted, died from facial +erysipelas and meningitis which had originated in a slight abrasion of +the upper lip. During an epidemic of typhoid we daily see persons with +fever, headache, and lassitude. Diarrhoeas are frequent during an +epidemic of cholera. An epidemic of diphtheria is accompanied by a +great number of cases of pharyngitis. When, in the year 1860,[13] I +reported two hundred cases of bona fide diphtheria, I at the same time +observed one hundred and eighty-five cases of non-membranous +inflammations of the throat. Such occurrences may be considered as +possible or incipient cases of pharyngeal diphtheria. Therefore, +contrary to the view of a local origin of diphtheria, it may be +claimed that the individual taking the disease was already saturated +with the poison, and the local membrane represented perhaps nothing +but a symptom, or at the utmost the causa proxima. Accordingly, then, +there are undoubtedly cases in which the pharyngeal membrane is the +first cause and symptom of the final affection, and others in which +the poisoning of the blood through inhalation is the first step in the +development of the disease, amongst the symptoms of which the +pharyngeal or nasal membrane counts as one. + +[Footnote 13: _Amer. Med. Times._, Aug.] + +In these cases the first complaints of the patients relate to their +general condition. Sometimes they are ignorant of any local trouble +when they consult a physician. When it is perceptible, however, it is +usually found on the visible pharyngeal and respiratory mucous +membranes. This would seem to indicate that the infectious elements +while being inhaled are there deposited. Thus there is a possibility +of simultaneous affections of both the throat and the blood in the +lungs, in either equal or variable proportions. We are easily led to +defend at least a partial admission of the poison by the respiratory +act, when we reflect that the membranes which are swallowed are +rendered innocuous by the action of the gastric fluids, and, +therefore, the alimentary canal, from the oesophagus downward, cannot +be made responsible for the admission of the poison into the system. +Thus it is that the general symptoms--as fever, lassitude, +etc.--precede the local phenomena in very many cases, while there are +exceptional cases in which the membrane appears first and the fever +later. This is especially the case when the tonsils are very large and +occupy a prominent position in the throat. + +Those cases which begin with high fever and moderate or no local {678} +symptoms must be looked upon as constitutional diseases. If a person, +in the course of several hours or a day, be taken with high fever and +a moderate membrane-formation, these symptoms subsiding in one or two +days, leaving the patient weak and exhausted, but fully restored to +health at the end of a week, we would be justified in assuming +(caeteris paribus) that there was a rapid absorption of a large amount +of poison, and an equally rapid elimination thereof. They are, +moreover, the same cases in which the second or third day of the +disease furnishes albuminuria, with rapid elimination and speedy +recovery. When, however, the process is slow in developing, +accompanied by moderate fever, and the course is indolent, we have +reason to infer that moderate amounts of the poison are being +continually taken into the system and making their influence felt to a +moderate degree, but for a longer period. Such are the cases which, +without any violent symptoms, are accompanied by frequent local +relapses, or run, when the absorption is constant as well as copious, +a septic course, or terminate in paralysis. + +Thus there are cases in which a local infection of the skin or of a +wound may be one of the causes, or the only cause, of the disease, and +there are cases in which the poison, in passing through and caught in +the pharynx, gives rise to local phenomena before the system at large +gives evidence of infection. But, as a general thing, diphtheria must +be looked upon as a constitutional disease, giving rise to local +phenomena, in the same way as scarlatina does on the skin, on the +mucous membrane of the alimentary canal, and in the uriniferous +tubules; measles on the skin and respiratory mucous membrane; or +typhoid in the lymph-follicles and on the mucous membrane of the +intestine; or, in other words, the diphtheritic poison may enter the +system locally through a defective, or sore, or wounded integument or +through the lungs. + +Is diphtheria contagious? Undoubtedly it is. The contagious element is +liable to be directly communicated by the patient; it also clings to +solid and semi-solid bodies, and in this way is transmitted even after +a long time. There is hardly any disease which can cling so +tenaciously to dwellings and furniture; it can be transported by the +air, though probably not to a great distance, and hence in houses +artificially heated, while the windows and doors are mostly closed, +rises from the lower to the upper stories; and it is for this reason +advisable to keep the sick on the top floor. It is certainly +transmitted by spoons, glasses, handkerchiefs, and towels used by the +patient. The contagious character increases directly in proportion to +the neglect of proper ventilation. That it is spread by the feces is +not clearly established in my mind. I can give personally no examples +of its being carried by visitors or by the attending physician; this +is said to have occurred, however. The character of the disease +communicated, and the local manifestation, do not depend on that of +the original sufferer; thus mild cases may produce severe ones, and +vice versa, and convalescents can convey the disease in its full +force. Naturally, the softer character of the tissues in children +renders them more susceptible to infection, and the activity of their +lymphatic system more liable to severe forms of the disease. + +Many tragic cases are recorded in literature of infection by direct +contact from pharynx to pharynx, or from the opening in the trachea to +the mouth of the surgeon; and one of the saddest cases, perhaps, is +that of {679} the much-lamented Carl Otto Weber. Myself and others +have contracted diphtheria from sucking tracheotomy wounds. + +In regard to the length of the incubation periods, there can be no +better authenticated facts than those contained in a report of Elisha +Harris to the National Board of Health, an abstract of which is found +in No. 1, _National Board of Health Bulletin_, June 28, 1879. The +report says that in the fourth school district of the township of +Newark (Northern Vermont), amidst the steep hills where reside a quiet +people in comfortable dwellings, the summer term of school opened on +the 12th of May. Among the twenty-two little children who assembled in +the school-room in the glen were two who had suffered from a mild +attack of diphtheria in April, and one of them was, at the time school +opened, suffering badly from what appeared to have been a relapse in +the form of diphtheritic ophthalmia. Besides, it is proved that these +recently sick pupils had not been well cleansed, one of them having on +an unwashed garment that she had worn in all her sickness three weeks +previously. At the end of the third day of school several of the +children were complaining of sore throat, headache, and dizziness, and +on the fourth day and evening so many were sick in the same way that +the teacher and officers announced the school temporarily closed. By +the end of the sixth day from school opening, sixteen of the +twenty-two previously healthy children became seriously sick with +symptoms of malignant diphtheria, and some were already dying. The +teacher and six of the pupils were not attacked, nor have they since +suffered from the disease. + +A case[14] is reported of a surgeon who, while attending a +diphtheritic child, had some secretion thrown into his face. Twelve +hours after his right eye was inflamed and painful. The affection +proved diphtheritic, and recovery was completed after several weeks +only. In a case seen by me, with Dr. L. Bopp, a child removed from a +house infected with diphtheria was attacked after fourteen days and +eight hours. + +[Footnote 14: _Wurt. Med. Corresp. Bl._, 1878, No. 2.] + +It would then appear that, in the direct communication of the disease +to healthy or nearly healthy mucous membranes--as healthy as the +prevailing epidemic will allow--the period of incubation is from one +or two to fourteen days. In only a small number of cases the disease +has an even shorter period of incubation than this, as when +tonsillotomy or a similar operation is undertaken during the +prevalence of an epidemic. One may rest assured that any operation on +the tonsils while an epidemic of diphtheria is at its height will be +followed within twenty-four hours by diphtheritic deposits on the +wounded part. To what extent we are justified in considering this a +bona-fide incubation of the disease in a previously healthy body is, +of course, another question. It seems to me that these cases +positively prove that the operation is only the causa proxima of a +diphtheritic affection, and that we may take it for granted that +during an epidemic every individual is more or less under its +influence and affected by it, so that it needs but a wound or an +accidental abrasion of the surface of the mucous membrane to call the +disease into action. In a similar way, fresh wounds or morbid +conditions of the mouth may call forth the disease. The ruptured +vesicles of a follicular stomatitis are liable to serve as +resting-places for diphtheritic membranes, and thus I have seen the +complication of a follicular stomatitis with oral diphtheria; and any +{680} lacerations of the vagina during labor may become diphtheritic +within twenty-four hours. If now, on the one hand, incubation depends +on the condition of the affected surface, it is probable, on the other +hand, that the intensity of the poison at the time plays an important +part in determining the period that is to elapse between infection and +the invasion of the disease. + +ETIOLOGY.--Diphtheria is pre-eminently a disease of early life; in +this respect it is said to differ from the genuine fibrinous +bronchitis, which by some is held an absolutely different disease, and +stated to occur but rarely in children. But even this statement is +probably incorrect. In the spring of 1879 I met with four cases of +fibrinous bronchitis in children under three years of age. The number +of cases of diphtheria in adult life is not very large, while in old +age it is very small. Of 501 deaths in Vienna in 1868, only 1 had +reached the age of sixty-two; of more than 300 cases in which I +performed tracheotomy but 2 were over thirteen years old. + +I do not know that sex exerts any predisposing influence over +diphtheria, yet of the six hundred cases or thereabouts of laryngeal +diphtheria in which I either personally performed tracheotomy or +observed the progress of the disease in the practice of others, I +found the majority in males, and the recoveries in inverse proportion +to the number thereof, the mortality being greater among boys. As far +as age is concerned, nearly all the zymotic diseases are seen most +frequently in children. They exhibit a greater disposition to submit +to diphtheria than adults, if we except those under ten months. Where, +however, the disease has occurred previous to the seventh or eighth +month, the greater number of cases has been found under three months. +Tigri reports the disease in a child of fourteen days. A child of +fifteen days was seen with diphtheritic laryngitis and oesophagitis by +Bretonneau, one of seventeen days by Bednar, one of eight by Bouchut, +one of seven days by Weikert; Parrot mentions several cases, and +Siredey[15] reports eighteen cases of diphtheria in the newly-born. +They occurred in the Hospital Lariboisiere in the spring of 1877, and +were probably infected by the nurses of a neighboring children's +asylum. Membranes were found on the soft palate, tonsils, or larynx, +and also on both pharynx and larynx. One case occurred where the +posterior nares alone were affected. I have met with four cases of +diphtheria of the pharynx and larynx in the newly-born myself. One of +these became sick on the ninth day after birth, and died on the +thirteenth day; the other died on the sixteenth day after birth; the +third was taken when seven days old, and died on the ninth day. The +predisposition to diphtheria during childhood[16] seems to be +explainable by several circumstances. The mucous membrane of the mouth +and pharynx in the child is more succulent and softer, and frequently +the seat of a congestive and inflammatory process. The nasal cavities +are small and frequently affected by catarrhs, the buccal cavity often +the seat of catarrh and of stomatitis, and insufficient cleanliness +leads here to irritation of the mucous membrane. Any abnormal state of +the mucous membrane, with {681} the exception of an atrophic condition +and cicatricial changes, affords an excellent abode for diphtheria. +The tonsils are proportionally large; in fact, we rarely see the +tonsils in children completely sheltered by the arches of the palate. +On the other hand, the pharynx is anything but spacious, and while the +protuberant condition of the tonsils affords a resting-place for the +invading disease, the remaining space is so small that it becomes a +source of uneasiness to the well in many instances, and very much more +than that to the child during diphtheritic tumefaction. Furthermore, +we must take into consideration the large number and size of the +lymphatics, which can be more easily injected in the child than in the +adult, according to Sappey, and the fact of greater intercommunication +amongst the lymphatics and between them and the system; for S. L. +Schenck has found that the network of lymphatics in the skin of the +newly-born, at least, are endowed with stomata, loopholes through +which the lymph-ducts can communicate with the neighborhood, and vice +versa.[17] These circumstances, although they may have no influence in +calling the disease into existence, yet assist in its development and +in adding to the severity of the symptoms. + +[Footnote 15: These, Paris, 1877.] + +[Footnote 16: W. N. Thursfield (_London Lancet_, Aug. 3d, 10th, 17th, +1878) collects 10,000 cases of diphtheria in England between the years +1855 and 1877. Of these 90 per 1000 were under a year, 450 per 1000 +from 1-5 years, 260 from 6-10, 90 from 11-15, 50 from 16-25, 35 from +26-45; 25 per 1000 were 45 years and over.] + +[Footnote 17: _Mittheil. aus d. Embryol. Instit._, i., 1877.] + +On the other hand, while the above reasons go to prove that diphtheria +attacks children by preference, there is again an anatomical and +physiological condition--to wit, the free slightly acid secretion of +the mouth, beginning with the third month--that acts as a hindrance to +the frequent occurrence of diphtheria after the third month. A poison +or poisonous product of whatever nature can less readily find a +hiding-place so long as it can be readily--we might always say must +surely be--washed away. During these months of eruptive secretion from +the mouth diphtheria, therefore, is not very frequent; thus teething, +in the case of diphtheria, cannot be held responsible by mothers fond +of diagnosticating dental diseases. In this connection the remark of +Krieger ought not to be overlooked, who explains the relative scarcity +of the disease in the first year of life by the fact that cumulative +influences will produce a great number of cases, and cumulation +requires time. Undoubtedly, however, an important etiological +consideration is the fact of having had the disease previously. We can +cite a host of zymotic diseases the occurrence of which once serves as +a protection against future attacks. Not only can no such security be +expected after one attack of diphtheria, but, caeteris paribus, the +disease shows a preference for those who have survived a previous +attack. The statement that only the mild cases, with but slight +elevation of temperature and freedom from severe constitutional +symptoms, are likely to suffer a relapse is founded on error. True, I +have more frequently seen relapses after mild cases--which, +fortunately, are in the majority--but the disease has also recurred +where originally high fever and an extensive lymphadenitis proved it +to be a severe case. Besides, second attacks of membranous croup are +also recorded (Guersant, N. F. Gill, Quincke). + +As there are individuals, so there are families, which have a +predisposition to diseases, as there are others in whom, +notwithstanding ample exposure, infection does not easily take place. +Yet in the families in which diphtheria is of frequent occurrence it +cannot always be attributed to enlarged tonsils and a tendency to +pharyngeal or nasal catarrh. + +{682} Still, catarrh and the vulnerability of mucous membranes must be +considered as a frequent source of diphtheria; children will get +numerous relapses often after a nasal or pharyngeal catarrh. Sudden +changes in the temperature of the atmosphere or of the surface of the +body are therefore dangerous in predisposed persons. And thus it is +that while severe epidemics have spared no climate or land known to +us, the majority of cases have occurred in winter and spring; in other +words, at a time when catarrhal disorders are of most frequent +occurrence. In my experience at New York, the first quarter of the +year yielded more cases than any other. Still, they are frequent +enough in warm seasons. Krieger insists upon the injurious influence +of hot summers and dry hot rooms. I do not doubt the correctness of +his views, which cannot but be strengthened by the damaging results of +our furnace-heating. But the influence of season on the invasion and +course of diphtheria is but indirect and conditional, and may be, +perhaps, after all, compared with that exerted by filth--a term which +is lately used to express all sorts and forms of nastiness, from +filthy bodies of men to their clothes, their habits, their food, and +the air they breathe, whether polluted by carbonic acid, by +excrementitious gases, or by exhalations of sewers. + +Cases of diphtheria which are traced to exhalations from sewers (or +even to filthy habits of life) are very frequent. Yet typhoid is +attributed to the same causes. So is dysentery. Can, then, foul +exhalations produce alike diphtheria, typhoid, and dysentery? Do these +diseases arise from a common poison? Or is the poison of a treble +character, so that a part may give origin to diphtheria, another part +to typhoid, a third to dysentery?[18] Have we to deal, in such +occurrences, with specific influences, or only with a lowering of the +standard of health, thereby affording other morbid influences an +opportunity to exercise their power? These questions are still +involved in darkness, and constitute problems the solution of which +still engages the minds of both individual writers and authorities. A +report of the Board of Health of Massachusetts, closely adhering to +the results of exact observations,[19] leaves them doubtful, and the +affirmative reports of some modern writers do not bear scrutiny.[20] + +[Footnote 18: In regard to the causal connection of the two latter +diseases with sewer exhalations we can be more positive than in regard +to the former.] + +[Footnote 19: Author's _Treatise on Diphth._, p. 35.] + +[Footnote 20: M. A. Avery, _Med. Jour. and Obst. Rev._, Feb., 1882.] + +Air polluted by bad drainage or leaky sewers has been considered +responsible for diphtheria as well as for typhoid fever and dysentery. +Not only the impairment of general health, but the direct and +unmistakable disease, has been attributed to it. Thus Bayley refers, +in the endemic of Bromley,[21] the first cases to unventilated sewers +and cesspools. School-children multiplied the disease. Thursfield +attributes the diphtheria at Ellesmere[22] to the accumulation of +excrements under the school-room, and to deficient supply of water, +which, moreover, was of bad quality. Tripe (like Railton, Bailey, +Russell, Bell) accuses sewer gas;[23] others polluted waters or bad +drainage.[24] I have not been convinced, however, that diphtheria can +be considered a sewer-gas disease, in the same way as typhoid fever. +The deterioration of the general health resulting from the inhalation +of foul air is sufficient to explain the outbreak of the individual +attack during a prevailing epidemic. + +[Footnote 21: _Sanit. Record_, Aug. 10, 1877.] + +[Footnote 22: _San. Rec._, 158, 1877.] + +[Footnote 23: _Ibid._, June 14, 1878.] + +[Footnote 24: _Ibid._, April 18, May 2, 1879.] + +{683} In regard to polluted water, I do not think that pathologists +who attribute infectious diseases to bacteria only are justified in +condemning it. It may not be so guilty, after all, for the admixtures, +inorganic and organic, minerals, admixtures of wood and plants, also +lower fungi and their products--algae, infusoria--would render water +rather disagreeable, but not exactly unhealthy. The latter effect can +be accomplished--always assuming the bacteria theory correct, for the +sake of argument--by bacteria only. But when they arrive in the +stomach, their doom is sealed; they are decomposed. The only places +where, possibly, they could take root would be diseased or ulcerated +places in either the oral cavity or the upper portion of the +oesophagus. + +Not only water, but the milk of animals also, has been accused of +being the direct cause of diphtheria. Powers concludes, though a +connection between diphtheria and the consumption of milk have not +been proven as yet, that it is very probable indeed. His careful +investigations into the causes of some local epidemics in North London +exclude any other source from which the people could have been +affected. Perhaps one of the forms of garget, cow mammitis, is of an +infectious character. His reasoning, however, is not accepted by A. +Dowrus,[25] who still believes that the milk which gave rise to +diphtheria at a distance may have been soiled and infected. For though +the connection between milk and scarlatina and typhoid fever had been +known for years and variously studied, no observation of the kind had +yet been made in regard to diphtheria. Besides, where the young, in +England, drink much milk--viz. in the cities--diphtheria was very much +less frequent than where little or no milk was taken--viz. in the +country. Even in the country the well-to-do classes, who drink milk, +had but little diphtheria, while the children of the poor, who +obtained none, suffered a great deal from it. + +[Footnote 25: "Diphtheria and Milk-Supply," _Brit. Med. Journ._, Feb. +1, 1879.] + +In regard to this transmission of diphtheria by means of milk O. +Bollinger[26] hesitates to express any opinion, except that the matter +is very doubtful indeed. Probably the possibility of contracting +diphtheria directly from animals is very much greater than the danger +from water or milk. On a Pomeranian farm, during the winter 1875-76, +every newly-born calf died of diphtheria. The superintendent of the +farm and the woman who attended to the calves were taken with +diphtheritic angina.[27] Similar occurrences have been recorded. +Bollinger reports a mycotic disease of the trachea and lungs in birds. + +[Footnote 26: _D. Z. f. Thiermed. u. vergleich. Pathol._, vi., 1879, +p. 7.] + +[Footnote 27: Damman, in _D. Zeitsch. f. Thiermed._, 1876, p. 1.] + +Friedberger's report,[28] presented to the Veterinary Society of +Munich, on croup and diphtheria of domestic fowls, leaves no doubt as +to its frequency, particularly amongst the nobler varieties. + +[Footnote 28: _D. Zeitsch. f. Thiermed._, v., 1879, p. 16.] + +Nicati[29] studied an epidemic diphtheria amongst hens which had +similar symptoms and a course very much like that in man; it could be +inoculated into other animals, and was contemporaneous with the +outbreak of the epidemic amongst the human population of Marseilles. +Trasbot[30] succeeded in inoculating a healthy hen from a diphtheritic +one, but the {684} attempts at transmission to dog, pig, and man were +unsuccessful. The _Med. and Surg. Journal_[31] contains the following: +In a house at Ogdensburg, N.Y., five children were ill with +diphtheria. Three kittens who had been playing with them from time to +time took the disease and died. Post-mortem examination showed +diphtheritic membranes in their throats.[32] + +[Footnote 29: _Revue d'Hygiene et de Police sanitaire_, 1879, p. 3.] + +[Footnote 30: "De la transmission de la Diphth. des Animaux a +l'Homme," _Gaz. hebdom._, 1879 Avril 25.] + +[Footnote 31: _Med. Rec._, Nov. 8, 1879.] + +[Footnote 32: An elaborate description of the croupo-diphtheritic +inflammations of mucous membranes in hens, turkeys, pheasants, and +pigeons may be found in _Zurn. Krankh. d. Hausgeflugels_, 1882, p. +104.] + +Gerhardt[33] reports the following: 2600 hens were imported from +Verona, Italy, into a village, Messelhausen, in Baden. Some of these +hens were affected with diphtheria when they arrived. Within six weeks +600 of their number died of diphtheria, and 800 more soon after. In +the following summer 1000 chickens were raised by artificial breeding, +all of which died of diphtheria within six weeks. Five cats kept in +the place also died of diphtheria; a parrot fell sick with it, but +recovered. An Italian cook, suffering from diphtheria, in the month of +November, 1881, while being subjected to local treatment with carbolic +acid, bit the head-nurse's left foot and hand. Both these wounds +became diphtheritic, the man falling sick with high fever, and +requiring three weeks for his gradual recovery. Besides, four of the +six workingmen employed in taking care of the hens of the +establishment were taken with diphtheria. Not a single case, however, +occurred in the neighboring village. Thus, it is safe to assume that +the diphtheritic disease of hens can be transmitted to man. + +[Footnote 33: _Verhandlungen des_ (ii.) _Congresses fur Innere +Medicin_, Wiesbaden, 1883, p. 129.] + +Diphtheria may be also produced by outside influences. In this regard +the attempts at generating pseudo-membranes by artificial means are +very interesting indeed. As early as 1826, Bretonneau, by the +introduction of tincture of cantharides and olive oil into the +trachea, succeeded in producing a "dense, elastic, reed-like +membranous concretion." Delafond called croup into existence by the +use of ammonia, oxygen, chlorine, corrosive sublimate, arsenic, and +sulphuric acid. On the other hand, H. Mayer asserts that it is +impossible, by means of ammonia, to produce a croup in the windpipes +of animals which in the slightest degree resembles that occurring in +human beings. Trendelenburg, however, after producing membranes in the +trachea by the use of a solution of corrosive sublimate (1:120), +succeeded in hardening the entire mass with bichromate of potassium, +which it was impossible to do with the most tenacious mucus. + +Rey observed croup in horses that inhaled smoke in a burning +stable.[34] In the collection of the veterinary school of Zurich there +is a croup membrane from a heifer which had been exposed to a fire; at +Munich, one from the trachea of a horse, produced by forcibly +injecting medicines into the nose. Hahn made an observation on cows, +W. Ammon on horses, of long croup membranes after the animals had been +exposed to smoke and fire; and Oertel constantly insists on there +being "no actual difference between croup as it ordinarily occurs and +that excited in the windpipe of a rabbit by means of ammonia. The +color and texture, the physical, chemical, and histological +characteristics, are identical." + +[Footnote 34: _Journ. de med. vet. de Lyon_, 1850, p. 249.] + +{685} MORBID ANATOMY.--Either the membrane or the granular +infiltration is characteristic of diphtheria. The statement that the +former occurs only when atmospheric air can gain access thereto, as A. +d'Espine and C. Picot still hold,[35] is plainly contradicted by its +appearance on the mucous membrane of the lower intestines. The +condition of the membrane is not unalterable, any more than the +clinical symptoms of the disease, for, according to different +circumstances, epithelium, mucus, blood, and vegetable parasites are +added thereto. The membrane can either be lifted from the mucous +membrane on which it lies or is imbedded into and underneath it. In +the first instance, it consists to a great extent of fibrin, the +result either of epithelial changes or derived directly from the +exuded blood-serum. E. Wagner, who makes no anatomical distinction +between croup and diphtheria, considers epithelial changes the +principal source. The pavement epithelium becomes altered in a +peculiar manner. It becomes turbid, larger, dentated, and dissolves +into a network; it is at first uninhabited, but serves later as the +vehicle of newly-formed cells; there also occurs a considerable +infiltration of the mucous membrane pus-cells and granules; besides, +the cellular tissue is studded with granules, the granular +degeneration resulting sometimes in necrotic destruction, which is +looked upon by Virchow as the most important element in severe forms +of diphtheria. The several conditions or degrees may occur independent +of each other, associated or in succession. Classen shares Wagner's +views, but, according to Boldygrew, the pseudo-membrane consists of +successive coagulations of a fibrinous fluid which exudes from the +diseased surface. Steudener also opposes the views of Wagner. He does +not believe in the probability of an exclusively endogenous origin of +the cellular elements of croup membrane; in fact, he doubts the +occurrence of an endogenous formation of pus-globules in epithelium. +Croupous membrane, according to him, is formed by the migration of +numerous white blood-globules through the walls of the vessels in the +mucous membrane, and by a direct formation of fibrin from the +transuded plasma. In addition to this, the mucous membrane is stripped +of its epithelium (except at the mouths of the acinous glands) and +infiltrated with migrating cells. Fresh croupous membrane consists of +a delicate network of homogeneous structure and shining appearance, in +which numerous cells and the epithelium of the various layers of the +trachea are imbedded. In old membranes the cells are destroyed by +granular degeneration and general maceration. Tenacious mucus with +pus-cells and detritus are then found. C. Weigert looks upon the +deposits as analogous to those on serous membranes. Every inflammation +yields an exudation which may coagulate when the coagulating ferment +is added. This latter is probably produced by the white blood-cells +when in disintegration. But he does not say why it is that there is no +such coagulation in suppurative processes, where the leucocytes are +more numerous. He believes himself justified in establishing +pathological differences of croup, pseudo-diphtheria, and diphtheria. +A croupous inflammation means destruction of epithelium, which gives +rise to a fibrinous exudation upon the surface, while the cellular +tissue remains intact. The only difference between it and the +pseudo-diphtheritic inflammation is looked for in the larger number of +emigrated white {686} blood-cells. The superficial deposit consists, +to a great part, of them and the fibrinous exudation. When there are +but few leucocytes the deposit is a network of fibrillae (croup). When +there are many, the masses are more solid and voluminous +(pseudo-diphtheritis). When, however, the tissue is changed into a +hard substance resembling coagulated fibrin, when the exudation does +not exist on the surface, but takes place into the mucous membrane, +the process is diphtheria. Zahn also establishes three varieties--viz. +1st, such as result from a peculiar degeneration of pavement +epithelium; 2d, such as originate in the solidification of a +muco-fibrinous, and, 3d, of a fibrino-purulent, exudation. Each of +these varieties may contain colonies of micrococci, but these +organisms are neither essential nor are they constantly found. + +[Footnote 35: _Man. prat. des mal. de l'enfance_, 1877, p. 81.] + +The diphtheritic process does not merely consist of the membranous +changes in the pharynx and air-passages. Its fatal cases have afforded +marked evidence of the implication of most of the organs. Reimer's 17 +cases give the following post-mortem results: the lungs were +hyperaemic in 8 cases, twice the seat of pneumonia, and three times of +embolic infarctions; in addition, emphysema in 12, oedema in 6, +atelectasis in 7, subpleural ecchymoses in 7, pericardial ones in 4. +The heart-muscle had undergone fatty degeneration in 6, and was the +seat of ecchymoses of the size of a pin's head in 3. In addition to +frequent hyperaemic conditions of the abdominal viscera, emboli of the +liver in 3 (with capillary hemorrhages of the peritoneal covering in +1), emboli of the spleen in 5, desquamative nephritis in 7 (in 6 of +which there were colonies of micrococci in the uriniferous tubules), +cellular hyperplasia of the cervical and mediastinal glands in 14 +(complicated in 6 with capillary hemorrhages in the glandular tissue). +The blood was frequently normal, very often watery and dark, at times +leucocythaemic. Thus the disease exerts its influence everywhere. + +Rindfleisch defines diphtheritic inflammation as that form of +inflammation which produces a coagulating necrosis in the tissues by +the immigration of schizomycetae. The coagulating necrosis differs +from the usual form of necrosis in this, that the change from life to +death is accompanied with the coagulation of fluid albuminoids. This +process takes place mainly in the interior of cells and other parts of +tissues, and therein differs from the coagulation of fibrin. In the +cells there is taking place a peculiar homogenization of protoplasm; +at the same time the nuclei disappear, and are changed into irregular +masses liable to cohere and form membranous conglomerates, which owe +their peculiar wax color to the invasion of a solid albuminoid endowed +with a strong tendency to refract the light. Coagulating necrosis is +found in circumscribed localities, and gives rise, in the +neighborhood, to a marked amount of inflammation and suppuration, +which leads to the expulsion of the necrotic part, with more or less +loss of substance--either mild or phagedenic ulceration. + +Leyden describes a gray degeneration of the muscular tissue which he +believes to be truly inflammatory, and Unruh has lately published an +account of some cases in which myocarditis occurred. In Leyden's +cases, the muscular nuclei were increased, became atrophied, and +underwent fatty degeneration, giving rise thereby to extravasations, +softening, dilatation and debility of the heart, with general +debility, collapse, {687} and--probably by reflex action on other +branches of the pneumogastric--vomiting. Micrococci he found neither +in the heart nor in the kidneys. + +In the heart, particularly on the right side, numerous thrombi are +frequently found in various stages of development; its muscular tissue +is often in a state of fatty degeneration or the seat of +parenchymatous inflammation and hemorrhages. Bridges first called +attention to the occurrence of endocarditis in diphtheria.[36] This +complication, which, however, occurs more frequently with rheumatism, +puerperal fever, diphtheria of wounds, pyaemia, and old valvular +affections than in the course of an acute diphtheria, does not, as +found in the latter affection, consist simply of a fatty degeneration +and subsequent ulceration, but is considered a genuine diphtheritic +process (Virchow), affecting the mitral valve more frequently than the +tricuspid or pulmonary valves. It begins with hyperaemia and the +exudation of plasma in the cellular elements, so that they appear +larger and darker. The granulations which form are frail and easily +destroyed, so that ulcers form on which fibrin is deposited, and +whence it is conveyed as emboli into the terminal arteries (Cohnheim) +of the spleen, nerves, brain, and eye. Infarctions may also occur in +the valveless veins of these organs, giving rise rather to small +multiple abscesses than to large purulent collections. Suppuration but +rarely takes place in the heart; the granular mass found there resists +the action of aether and alcohol, and spreads throughout the cardiac +parenchyma, so that perforation of the septum and of the right auricle +and aorta has been observed. + +[Footnote 36: _Med. Times and Gaz._, ii. p. 204.] + +Bouchut and Labadie-Lagrave, out of 15 cases of diphtheria, met in 14 +with a plastic endocarditis, which became the source of emboli. Thus, +there were infarctions of the lungs, at times in their centre +colorless, at other times in a state of purulent degeneration; +superficial thrombi of the small veins of the heart, subcutaneous +connective tissue, pia mater, brain, and liver; and in addition, +moderate leucocytosis. + +The lungs exhibit (post-mortem) all sorts of inflammatory and +congestive conditions, with their consequences, as oedema, catarrh, +broncho-pneumonia, atelectasis, emphysema, ecchymoses, and large +infarctions. + +The spleen (and occasionally the liver) is frequently large, +congested, and friable, and studded with infarctions to a greater or +less extent. + +The kidneys are either simply congested or the seat of nephritis or +infarctions. The same forms of inflammation which accompany +scarlatina--to wit, the desquamative and the diffuse--are here +observed. The diffuse form is not of so frequent occurrence as in +scarlatina, but is sometimes extensive and dangerous. + +The muscles occasionally exhibit ecchymoses, and are at times the seat +of parenchymatous inflammation, gray degeneration, and atrophy. + +The lymphatic glands are frequently inflamed and swollen, either hard +or doughy, oedematous or congested. Large abscesses are rare. It is +more especially the gland tissue, and less the connective tissue of +the glands, which takes part in the pathological process. The +periglandular tissue very soon becomes involved, however. Necrotic +foci have been described by Bizzozero. When the entire surface of the +mucous membrane of the mouth and of the air-passages, from the nose to +the trachea, is the seat of the disease, there is an impregnation of +the mucous membrane, from the epithelial surface to the submucous +tissue, of the entire {688} tongue, borders of the lips, and +frequently of the lips and cheeks, as well as of the tonsils, the +lower portion of the nasal cavities and the upper, and especially the +anterior, portion of the larynx. The fossae Morgagni and the posterior +aspect of the soft palate are more frequently affected in the same way +than the anterior aspect. Small isolated spots are found on the +tonsils and occasionally on the posterior wall of the pharynx. The +so-called croupous form--that is to say, the one in which the +membranes deposited may either be removed in large patches or lie +macerated in the profuse secretion of subjacent mucous glands--is +found partly in the nasal cavities, on the posterior surface of the +soft palate, and also in the trachea and its subdivisions. + +The character of the mucous membrane varies with the locality. Its +different elements, as the epithelium, the basement membrane, the +connective tissue mingled with elastic fibres, the blood-vessels, the +nerves from the cerebro-spinal and sympathetic systems, and the +papillae and ducts of numberless glands, all influence the +pathological process going on upon the surface. Their distribution in +the oral cavity and the respiratory organs is a very interesting +study, and in a table already published,[37] I have exhibited it in a +condensed tabular form. + +[Footnote 37: _Treatise on Diphtheria_, p. 126.] + +Where elastic tissue predominates, diphtheritic impregnation is slow +to take place, and recovery is also slow when the tissue has finally +submitted. Pavement epithelium yields the easiest foothold to +diphtheritic membrane. Thus it is that the tonsils, not from their +prominent situation alone, favor the reception and development of the +infection. But the elastic and connective fibres when once affected +are apt to harbor the disease a long time. Still, there is another +reason why the diphtheritic process should favor the tonsils. For Th. +Hohr has demonstrated that their epithelium exhibits interruptions in +its continuity. Through them round cells may emigrate. Wherever the +epithelial covering of the integuments (skin or mucous membrane) is +intact and unbroken, diphtheria takes hold with difficulty. But where +a defect is established, large or small, diphtheritic formations will +be apt to take place according to the size of the abrasion. This is +one of the modes of the formation of small diphtheritic deposits on +the tonsils, which it has been the tendency of many, both +practitioners and authors, to honor with special names. + +Ciliated epithelium is not so liable to be affected. It occupies a +higher rank in the scale of animal formations, has a more complex +function and a greater power of resistance. The presence of a large +number of mucous glands impedes, as a rule, by the presence of the +normal secretion, an extensive destructive action upon the tissues. +The secreted mucus assists in removing epithelial masses, and even +fibrinous exudations, from the surface. Thus it is that the deposits +in the respiratory portion of the nasal cavities are frequently cast +off through the nostrils, and in a similar manner the membranes that +have formed in the trachea are ejected in a semi-solid condition +through the opening made by tracheotomy. The large number of mucous +glands in the larynx and trachea is unquestionably the reason why the +lymphatic vessels of the mucous membrane are not influenced by the +overlying loosened masses, and will not absorb; hence laryngeal and +tracheal diphtheria, when not complicated, have decidedly a local +character, and are usually devoid of constitutional symptoms. For the +{689} same reason the usual form of tonsillar diphtheria is a mild +disease. On the other hand, the large number and size of the lymphatic +ducts of the Schneiderian mucous membrane, as well as their direct +communication with the lymphatic glands of the neck, accounts for the +dangerous character of nasal diphtheria. + +Diphtheria of the intestinal canal is characterized by fibrinous +deposits on the surface and in the tissues of the intestine, with +subsequent granular degeneration. It is mostly preceded by a catarrhal +process. The same condition is found in the urinary organs. + +There are but few autopsies of cases which have died of, or during, +diphtheritic paralysis. In some instances there was considerable +thickening of the spinal nerves at the junction of the posterior and +anterior roots, with hemorrhages. The superficial connective tissue in +these places exhibited a diphtheritic exudation (Buhl). There was in +the sheath of the nerves of the cerebral and spinal meninges and in +the gray substance of the cord voluminous nuclear infiltration; in one +case there were extensive hemorrhages in the spinal meninges, with +nuclear proliferation in the gray substance of the cord (Oertel). +Disseminated meningitis with perineuritis of the neighboring roots, +characterized by infiltration of nuclei between the nerve-fibrillae +was found by Pierret; and degeneration of the palatine nerves and +fatty degeneration of the palatine muscles by Charcot and Vulpian. +Dejerine, in five autopsies, records an atrophy of the anterior roots +secondary to a myelitic degeneration of the ganglia of the anterior +horns. E. Gaucher found the same in the case of a boy who died with +paralysis of the muscles of deglutition, of the extremities, and of +the trunk. In a child of two years with paralysis of the palate and +extremities the autopsy was negative. In two cases Dejerine reports +finding changes in the intramuscular nerves, such as liquefaction of +myelin and loss of axis cylinders. + +Thus, Buhl, Charcot, Vulpian, and Dejerine are unanimous about an +affection of the peripheric nerves and muscles. Oertel, Dejerine, and +Gaucher believe in a disease of the spinal cord. It is true that a +disease of the gray substance would fully explain the symptoms of the +bad cases, but what we know of poliomyelitis anterior, with which this +affection would be identical, precludes the idea of the rapid and +almost certain complete recovery. Therefore, in most cases, +diphtheritic paralysis consists of a trophic affection of the motor +system, almost always seated peripherally in the nerves and muscles, +seldom, if ever, in the centres. This affection must be compared, in +most of its relations, with the degenerative processes taking place in +the muscular tissue after typhoid fever, or in the renal epithelium +after infectious diseases, both of which give rise to serious results, +with usually a favorable termination. + +DIAGNOSIS.--The characteristic sign of diphtheria is either the +membrane or the gray infiltration, with more or less injection of the +surrounding parts. In regard to this greater or less injection, I will +say that pharyngeal congestion, when it is uniform, may or may not +point to imminent diphtheria. When it is local, confined to one side +mainly, it is either traumatic or diphtheritic. White spots which are +easily washed away, or which can be removed with a brush, or squeezed +out of the follicles of the tonsils, into which a probe can be +introduced sometimes to the depth of one-half inch, soon announce +their true character--viz. either a {690} simple catarrhal secretion +or suppuration. Even though the superficial deposit contain oidium or +leptothrix in considerable numbers, it can easily be removed; I have +only known the totally inexperienced to mistake muguet (thrush) for +diphtheria. In the larynx muguet is, moreover, very rare indeed, and +always circumscribed. It is sometimes seen on the true vocal cords. +The gray discoloration of superficial follicular ulcerations, as +observed in the ordinary form of stomatitis follicularis, can hardly +fail to be recognized. Such patches are very numerous in the fauces +and on the lips and cheeks--never on the gums, except in ulcerous +stomatitis (which is not follicular). They are accompanied, too, by +vesicles containing more or less serum which have not yet ruptured. It +must be remembered, however, that the mucous membrane, when deprived +of its superficial covering, is liable during an epidemic of +diphtheria to become infected, like every other wound. I have seen +cases in which stomatitis and diphtheria existed side by side, the +latter having invaded the surfaces exposed by the former. The +examination of the entire throat is not always easy. Very young +children vomit frequently and persistently before the whole surface is +exposed to view, and not infrequently repeated examination with the +spatula is absolutely necessary. In general, however, the slight +attempts at vomiting suffice to cause a great part of the swollen +posterior portion of the tonsils to become visible. I have heard that +the pale surface of old hyperplastic tonsils has been mistaken for +diphtheria; I merely mention the fact. When a discoloration happens to +be the result of a deposited flake of mucus, a drink of water will +remove it. + +Fever is not always a prominent symptom; as a rule, simple diphtheria +of the tonsils is accompanied by very little fever. Still, there are +plenty of exceptions. But the differences of temperature are not more +striking than in most other infectious diseases, whose either mild or +severe invasion may offer an obstacle to immediate diagnosis. As the +height of the fever does not absolutely determine, or even indicate, +the character of the subsequent course of the disease, but little +importance is to be attached to the temperature unless there be a very +marked elevation. A sudden rise frequently occurs with lymphadenitis. +High fever in the beginning may render the diagnosis difficult or may +postpone it. + +The absence of glandular swelling does not exclude the diagnosis of +diphtheria, for when the tonsils are affected by the disease there is +usually little or no swelling of the neighboring glands. Swelling of +the glands enables us to locate the affection in a mucous membrane +richly endowed with lymphatic vessels. It is very marked when the nose +is affected. A few hours' duration of nasal diphtheria suffices for +the development of a severe lymphadenitis, especially at the angles of +the jaw. When the latter condition is found to exist, the throat +should be examined with the idea of finding a membrane extending +upward; nasal diphtheria is very liable to complicate an affection of +the uvula and arches of the palate. The membrane cannot well be seen +by looking through the nostrils; highly serviceable for this purpose +is a very short, broad rhinoscope reaching upward to the bony +structure of the nose. However, nasal diphtheria may frequently be +diagnosticated some days before the membrane becomes visible, by the +rapid development of lymphadenitis; this may be done even where the +sweetish, musty odor of certain forms {691} of diphtheria is absent. +Still, nasal diphtheria may occur without much lymphadenitis; as, for +instance, when the blood-vessels are very numerous and superficial, +and thereby give rise to slight hemorrhages at the very beginning of +the sickness. In such cases the lymphatic vessels are little, if at +all, required to transmit the poison, the open blood-vessels replacing +them in the function of absorbing. Naturally, there are cases in which +an ocular examination cannot be satisfactorily made. In the journals +we read of brilliant results of rhinoscopic and laryngoscopic +examination; in practice we see but few. This holds good especially +for the cases of dyspnoea accompanying laryngeal diphtheria, where the +diagnosis may be doubtful when no membrane can be detected in the +fauces; even if membrane be observed there, symptoms of suffocation +may still arise from a laryngeal stenosis independent of membranous +deposits in the larynx. If aphonia and difficulty of both inspiration +and expiration be present at the same time, there is certainly +membranous occlusion. If aphonia appear late, or even toward the very +last, and only inspiration be impeded while expiration is +comparatively free, there is an oedematous saturation of the +ary-epiglottidean folds and of their copious submucous tissue, and +consequently of the posterior attachment of the vocal cords. Although +a general oedema glottidis in connection with diphtheria is of +exceedingly rare occurrence, the above condition is not at all +uncommon, and has forced me to tracheotomize many times; but, again, a +comprehension of the true condition, where it occurred in not very +severe cases, has on several occasions enabled me to avoid an +operation. This local oedema may sometimes be detected by palpation in +the region of the swollen posterior wall of the pharynx. + +One of the diagnostic symptoms of membranous laryngitis, believed in +and referred to by Kronlein, does not exist--viz. the swelling of the +lymphatic glands, which in his opinion is pathognomonic. Not only is +that not the case, but the absence or scarcity of lymphatics on the +vocal cords and in their neighborhood renders the absence of glandular +swellings a necessity, provided the latter do not depend on +complicating diphtheria in other localities. In uncomplicated +diphtheritic laryngitis I expect no lymphadenitis. The character of +the laryngeal pseudo-membrane does not depend at all on the condition +of the pharynx. The latter may have membranes of any description or +consistency without permitting the diagnosis of the condition of the +larynx. I lay stress on this fact because no less a writer than +Kronlein believes that where there is but little or no membrane in the +pharynx, that in the larynx is rather loose and movable. + +One of the diagnostic symptoms of diphtheritic laryngitis, or +membranous croup, is the relative absence of fever. Catarrhal +laryngitis, or pseudo-croup, is a feverish disease. A sudden attack of +croup with high temperature, provided there is no pharyngeal or other +diphtheria present, yields a good prognosis; without much fever, a +very doubtful one. + +The diagnosis of diphtheritic paralysis offers very little difficulty +in most cases. Its occurrence after an attack of diphtheria, its +beginning in the fauces or in the muscles controlled by the ciliary +nerves, the immunity of the sphincters, the gradual development, the +irregularity of its progress, are good diagnostic points. Examination +by the interrupted or continuous current is not conclusive. Very +frequently in the {692} beginning the response to the interrupted +current is normal, sometimes deficient; to the continuous current, +exaggerated. After some time the power of both to excite contraction +is diminished. When we reflect on the numerous causes which may +underlie diphtheritic paralysis, and that we have not to deal with one +and the same anatomical change in all cases, it becomes apparent that +no reliable conclusions can be based upon electrical examination. + +PROGNOSIS.--In general, the prognosis in diphtheria is favorable when +the affected surface is of small extent and where such parts are the +seat of disease as have little communication with the lymphatic +system. To the latter class belongs simple diphtheria of the tonsils. +Marked glandular swelling, particularly if arising suddenly, is always +an unfavorable sign, and calls for the utmost caution in prognosis, +especially if the region of the angles of the jaw be speedily and +markedly infiltrated. This, as we have seen, is particularly apt to +occur with nasal diphtheria, whether developed primarily, (and then +accompanied by a thin fetid discharge), or, as is more commonly the +case, secondarily from an affection of the pharynx and palate which +ascends into the posterior nares. With the appropriate local +disinfection this form of the disease is neither so alarmingly +dangerous as Oertel depicts it, nor so assuredly fatal as Roger but a +few years ago taught in his clinique, or as Kohts appears to +believe,[38] yet it is ever grave. With energetic treatment many cases +will, however, get well. Diphtheria of wounds, complicating diphtheria +of the pharynx, is always an unfavorable sign; that of the mouth and +angles of the mouth, associating itself with a previously existing +diphtheria, having an indolent course, and producing more frequently a +deep impregnation of the tissues than a thick deposit, causes a +painful and serious condition. Diphtheria of the larynx, whether it be +of primary origin or the result of extension from the fauces, is +nearly always fatal. In severe epidemics the mortality is 95 per cent. +Tracheotomy, too, saves but few of those who take the disease at such +a time. In fifty consecutive tracheotomies from 1872 to 1874 I did not +see one recovery. In the last few years I have seen few good results. +In average epidemics tracheotomy will save 20 per cent. A pulse of 140 +to 160, and high fever immediately after the operation, render the +prognosis bad; so does absence of complete relief after the operation. +An almost normal temperature the day after the operation is an +agreeable symptom, but does not exclude a downward extension of the +diphtheritic process, and hence cannot be looked upon as assuring a +favorable prognosis. A marked elevation of temperature is apt to +indicate a renewed attack of diphtheria or a rapidly-appearing +pneumonia, and is an unfavorable symptom. A dry character of the +respiratory murmur some time after tracheotomy indicates the approach +of death within from twelve to twenty-four hours from descent of the +membrane; so does cyanosis, whatever be its degree of intensity. +Diphtheria of the trachea, which ascends to the larynx, is positively +fatal. It has a rapid course, and tracheotomy only postpones the end +for a little while, if at all. The general health and strength of the +little sufferer have no influence whatever. + +[Footnote 38: Gerhardt, _Handb. d. Kinderkr._, iii., 2, p. 20, 1878.] + +Thick, solid deposits need not of themselves render the prognosis so +unfavorable as do septic and gangrenous forms. Even in the nose they +{693} are not of as serious import as the thin, putrid discharge. I +have seen recovery ensue in cases where I was obliged to bore through +the occluded nasal cavities with probes and scoops. Fetid, putrid +discharges are unfavorable, but in no wise fatal; conscientious +disinfection accomplishes a great deal. Slight epistaxis indicates the +possibility of rapid absorption through the blood-vessels; but here, +too, the final result depends on whether the disinfection be equally +rapid and thorough. The same holds true for the sweetish, fetid odor +of the breath, whether of the nose or mouth, which, on the one hand, +demonstrates the significance of the disease, while, on the other +hand, it indicates the possibility of infection by inhalation. + +The height of the fever is not in proportion to the danger in any +individual case; some have a favorable, some an unfavorable +termination, without fever of any account. Simple catarrh of the +pharynx and larynx frequently begins with a sudden and marked rise of +temperature; diphtheria in the same parts but rarely. There are cases, +however, in which the height of the fever and the deposited membranes +are in inverse proportion to each other. In these cases the fever may +subside rapidly, owing to a speedy elimination of the poison. Young +children only are in danger of death from convulsions or a rapid +tissue-degeneration due to hyperpyrexia. If the temperature rise +suddenly after some days of sickness, either a complication or a fatal +termination is to be apprehended. Yet, there are as many deaths in +cases with comparatively low as with very high temperatures. Whether +collapse has resulted rapidly or slowly, the patient dies often with +low temperature. Thus, a rapid elevation is hardly a more unfavorable +sign than a rapid fall. The pulse, too, may be very variable. True, a +small, rapid, and irregular pulse is always unfavorable, because it +indicates a weakening of the cardiac function; yet as long as it +retains an approximately normal relation to the frequency of +respiration a rapid pulse gives no cause for alarm. Moreover, the +pulse is not always rapid when the strength gives way. It occasionally +becomes slower, and sometimes very slow, and may then become a +dangerous symptom. + +Every complication adds to the danger. Bronchitis and pneumonia are +not infrequent, yet I have seen cases of laryngeal diphtheria recover +in which I had suspected pneumonia before performing tracheotomy, and +was enabled to diagnosticate it after operating. Albuminuria in the +early part of a diphtheritic attack with high fever is of little +significance; nephritis, later in the course of the disease, partakes +of the character of scarlatinous nephritis; cases of acute diffuse +renal disease are fortunately infrequent, and the remainder are very +submissive to treatment. The cases of diphtheria complicated with +endocarditis in my practice have ended fatally. An early affection of +the sensorium, not dependent on pressure upon the jugulars by greatly +swollen glands, is an unfavorable symptom. Purpura, with profuse +hemorrhages and a livid hue of the skin, is ominous; icteric +discoloration, together with marked glandular and periglandular +tumefaction, is absolutely fatal. + +Most cases of diphtheria of the pharynx and of the tonsils have a +favorable termination, yet a positive prognosis can in no case be +given with certainty. Still, even in malignant epidemics the mortality +is not very great, for even though there be a large number of severe +cases in {694} any one epidemic, yet it is greatly overbalanced by the +number of moderately severe and mild ones. True, not a few cases end +fatally in several days, owing to the high fever, or to septic +absorption, or nephritis, or croup, but the majority of cases end in +recovery in one or two weeks. Yet diphtheria does not always take so +regular a course; not infrequently, after the pulse has become +stronger, the appetite improved, and the pharynx cleared, and the +patient is apparently on the high road to recovery, another attack +occurs accompanied by fever, as before, and a rapid formation of +membrane. Occasionally two or three such relapses may occur in the +course of three, four, or five weeks; not to speak of the fact that +those who have once suffered from diphtheria are more susceptible to +the action of the poison than those who never suffered before. + +TREATMENT.--Every case should be treated on general principles; thus, +it is not possible to lay down a routine treatment for every +individual case. High fever should be reduced by sponging and bathing, +quinia, and sodium salicylate; collapse speedily treated, and severe +reflex symptoms, as vomiting, etc., checked at once. Whether to employ +for this purpose ether, wine, cognac, champagne, or coffee must be +decided by the physician in individual cases. The administration of +the remedy, whether by mouth, by injection into the bowels, or +subcutaneously, as I have employed cognac, ether, alcohol, and camphor +dissolved in ether or alcohol, in some cases with decided and rapid +success, must depend on the condition of the organs and on the urgency +of the case. However, all the above remedies are frequently of no +service, because administered too late and in too small doses. If I +have ever had cause to feel contented with the results of treatment in +diphtheria, it is owing to the fact that I lost no time. No medicines, +however, must be resorted to which are apt to derange the digestion of +the patient; alcoholic stimulants must be given in fair dilution only, +for that reason. The nourishment of the patient is a matter of very +great importance. On general principles it is true that care must be +taken in regard to food administered to febrile patients, but we must +bear in mind that, when the lymphatic vessels are kept empty and no +new and proper material is introduced into them, the absorption of +locally-existing poisonous substances is proportionately increased. +Hungry lymph-vessels are the organism's fiercest enemies. + +I dwell particularly on the foregoing remarks for the reason that in +diphtheria, unlike certain diseases having a typical course and those +of a simple inflammatory character, expectant treatment should not be +indulged in. Oertel's advice, that when neither high fever nor +complications are present we should quietly wait, and "act only when +new and most alarming symptoms present themselves," is decidedly +perilous. A mild invasion does not assure a mild course. Never has a +"possibly superfluous" tonic or stimulant done harm in diphtheria, but +many a case has a sad termination because of a sudden change in the +character of the disease, putting the bright hopes of the physician to +shame. Only the philosopher may be a passive spectator; the physician +must be a guardian. When I again read, in the work of the same +meritorious author, "that when in exceptional cases, in children and +young people, death is imminent, not from suffocating symptoms in the +larynx and trachea, but from septic disease and blood-poisoning, it is +necessary to resort to {695} powerful stimulants," it strikes me that +he is frequently too dilatory with his remedies, and, furthermore, +that his experience concerning the terrible septic form of diphtheria +which is so frequently met with in some epidemics must have been very +limited at the time he was writing. In New York, during the past +twenty-five years, for every death from diphtheritic laryngeal +stenosis (membranous croup) there have been three from diphtheritic +sepsis or from exhaustion.[39] + +[Footnote 39: We have to improve somewhat on the plan of Thomas +Wilson, though his general instructions be good (as laid down in his +_Tentamen medicum inaugurale de cynanche maliqna_, Edinb., 1790, p. +24): "Cum hactenus nullum inventum est remedium quod contagionem in +corpus receptam suffocare possit; cum medicamenta pleraque quae +putredinem corrigere dicuntur, corpus ejusque functiones manifesto +roborant; et denique cum hunc morbum comitantur virium prostratio, et, +etiam ab initio, summa functionum debilitas, qualis evacuantia +omnigena prohibet, indicationem curandi unicam, scil. debilitatis +effectibus obviam ire, proponam. Hinc corporis conditioni obviam itur +praecipue tonica et stimulantia administrando." (As no remedy has yet +been found which can extinguish the contagion after it has been +received into the body; as most medicines which have the reputation of +correcting putrefaction are roborants for the body and its functions; +and, lastly, as this disease is attended with great prostration and +such debility of functions as to preclude the use of all sorts of +evacuants,--I propose but this one indication for treatment--viz. to +meet the effects of debility. This is fulfilled by the administration +mainly of tonics and stimulants.)] + +In regard to the dose of stimulants, it is a fact that there is more +danger in diphtheria from giving too little than too much. When the +pulse barely begins to be small and frequent they must be administered +at once. A three-year-old child can comfortably take thirty to one +hundred and fifty grammes (fl. oz. j-v) of cognac, or one to five +grammes of carbonate of ammonium, or a gramme of musk or camphor (gr. +xv) and more, in twenty-four hours. In the septic form especially the +intoxicating action of alcohol is out of the question; the pulse +becomes stronger and slower, and the patient enjoys rest. In those +cases in which the pulse is slow, together with a weak heart's action, +the dose can hardly be too large. The fear of a bold administration of +stimulants will vanish, as does that of the use of large doses of +opium in peritonitis, of quinia in pneumonia, or of iodide of +potassium in meningitis or syphilis. I know that cases of young +children with general sepsis commenced immediately to improve when +their one hundred grammes (fl. oz. iij) of brandy were increased to +four times that amount in a day. + +The remarks I have made in reference to the general treatment of +diphtheria naturally render superfluous a discussion of the value of +abstraction of blood. To be sure, it could only be a question of local +bleeding. For nobody would dare to resort to jugular venesection, as +our predecessors did in the last century. It may be safely asserted of +the latter that it has no influence on the process, but frequently +increases the local swelling and makes the patient more anaemic. There +is no case in which a resort to it would not be criminal. I can +distinctly recall the time when bleeding and calomel formed the +groundwork of the treatment. Until the year 1862 the death-rate in +Rupert, Vermont, from diphtheria was 90 per cent., according to the +reports of the local physicians, and particularly of my pupil, Dr. +Guild, who at that time finished his studies in New York and commenced +practising. When, in the same epidemic, bleeding and calomel were +replaced by stimulants and iron, with the chlorate of potassium, 90 +per cent. recovered. + +That attention must be paid to the general condition mainly during a +{696} retarded convalescence from previous sickness is self-evident. +Any complications, too, must be subjected to early treatment. +Diarrhoea must be mentioned among these; it reduces the patient's +strength very quickly; likewise, the early appearing nephritis, which +may suddenly end life. + +In this connection I must allude to the great danger of +self-infection, which may occur in every variety of cases, severe or +mild. The poison is diffused by expiration and expectoration. Though +care may have been taken to disinfect the linen, towels, +handkerchiefs, the bedstead and bedding, chairs and wall-papers, and +carpets and curtains, even the clothing of the attendants will be +infected. While the patient is getting well he will be infected again, +and have a more serious relapse; and a third one, and succumb. I have +met with such cases often, and with some which went from one attack +into another, and would certainly have perished but for their removal +to a distant part of the town. Where there are vacant rooms the +indication is to change rooms every few days and to thoroughly +disinfect (with sulphurous acid) that which has been used and +infected. + +One important axiom must be borne in mind--namely, that prevention is +easier than cure. I do not refer simply to the removal of the healthy +members of the family beyond the danger of infection or to the +isolation of the patient. If the latter becomes necessary, the first +indication is his removal to the top floor of the house. There are, in +addition, however, certain prophylactic measures which will prove +valuable in the hands of every good physician. It is necessary under +all circumstances that the mouth and pharynx of every child be +constantly kept in a healthy condition. Eruptions of the scalp must be +treated at once, and glandular swellings of the neck caused to +disappear. Some cases of laryngeal diphtheria have been traced +directly to the presence of suppurating bronchial glands, with or +without perforation.[40] The same rule applies to nasal and pharyngeal +catarrhs, the treatment of which should be commenced in warm seasons, +when general or local remedies yield better results. Enlarged tonsils +should be resected, or, where that can not be done, scraped out with +Simon's spoon, at a time when no diphtheritic epidemic is raging. It +is important that this take place at a time when, even though sporadic +cases of diphtheria occur, the danger of infection is not great; for +during the height of an epidemic every wound will give rise to general +or local infection. This holds good for any part of the body as well +as of the mouth. I avoid, therefore, an operation at such a time, +provided it can be postponed. + +[Footnote 40: Weigert, in _Virch. Arch._, vol. lxxvii., p. 294, 1879.] + +Prevention, after all, is not the business of the physician only, but +just as much that of the individual or the complex of +individuals--viz. the town, the state, and the nation. Those sick with +diphtheria must be isolated, though the case appear ever so mild, and, +if possible, the other children must be sent out of the house +altogether. If that be impossible, let them remain outside the house, +in the open air, as long as feasible, with open bedroom windows during +the night, in the most distant part of the house, and let their +throats, and those of their nurses, be examined every day. The +watching eye of a father or mother will discover deviations from the +norm, so that the physician can be notified. Let the temperatures +{697} of the well children be taken once a day, toward evening. Ten +minutes of a mother's time are well paid by the discovery of a slight +anomaly which may require the attention of the physician. Happily, +there are now many mothers who keep and value a self-registering +thermometer as an important addition to their household articles. The +attendant upon a case of diphtheria must not get in contact with the +rest of the family, particularly the children, after his visiting and +handling the patient, for the poison may be carried, though the +carrier remain well or apparently well. Unnecessary petting of the +patient on the part of the well ought to be avoided, and kissing must +be forbidden; the bed-clothing and linen should be changed often and +disinfected, the air of the sick-chamber should be cool and often +changed, and if possible the chamber itself should be changed every +few days. + +The well or apparently well children of a family that has diphtheria +at home must not go to school nor to church. The former necessity is +beginning to be recognized by the authorities and teachers, and also, +in consequence of partially enforced habit, by parents; the latter +will be resisted longer. Schools ought to be closed entirely when a +number of cases have occurred. Even when the school-children have not +been affected to a great extent, but an epidemic of diphtheria has +commenced in earnest, it will be better to close the schools for a +time. If that be not advisable, the teacher ought to be taught to +examine throats, and directed to examine every child's throat each +morning, and to send home every one with even suspicious appearances. + +In times of an epidemic every public place, theatre, ball-room, +dining-hall, or tavern ought to be subjected to supervision. Where +there is a large conflux of people there are certainly many who carry +the disease with them. Disinfection must be enforced by the +authorities at regular intervals. Public vehicles must be treated in +the same manner. That it should be so when a case of small-pox has +happened to be carried in them appears quite natural. Hardly a +livery-stable keeper would be found who would not be anxious to +destroy the possibility of infection in any of his coaches. He must +learn that diphtheria is, or may be, as dangerous a passenger as +variola. And what is valid in the case of a poor hack is more so in +that of railroad-cars, whether emigrant or Pullman. They ought to be +thoroughly disinfected in times of an epidemic, at regular intervals, +for the highroads of travel have always been those of epidemic +diseases, and railroad officers and their families have often been the +first victims of the imported scourge. Can that be accomplished? Will +not railroad companies resist a plan of regular disinfection because +of its expensiveness? Will there not be an outcry against this as +despotic and as a violation of the rights of the citizen? Certainly +there will be. But so there was also when municipal authorities began +to compel parents to keep their children at home when they had +contagious diseases in the family, and when a small-pox patient was +arrested because of endangering the passengers in a public vehicle. In +such cases it is not society that tyrannizes the individual; it is the +individual that endangers society. And society begins at last, even in +America, to believe in the rights of the commonwealth, and not in the +rights of the democratic person only. The establishment of State and +National Boards of Health proves that the narrow-hearted theories of +the strict constructionists {698} have not only disappeared from our +politics, but also from the conscience and intellect of society. + +The sick room must be kept cool, the windows kept open--more or +less--by night as well as by day, the floor frequently washed, the +linen soaked at once, the excrements removed. Dead bodies ought to be +kept moist, for infectious material, chemical or otherwise, will +spread more easily when dry. Attendants must not talk unnecessarily +over the mouth or diphtheritic wounds of the patient, and will do well +to carry a little dry loose cotton--to be changed often--in each of +the nostrils, for it aids in protecting those who are necessarily +exposed to infection.[41] + +[Footnote 41: Wernich, in _F. Cohn's Beitr._, iii., 1859, p. 115.] + +A very important mode of prevention consists in disinfection. The +experiments of Schotte and Gaertner, and of Sternberg, prove the +inefficiency of small doses of most of the disinfectants in common +use. The popular idea, sometimes even shared by physicians, that the +faint odor of chloride of lime or of carbolic acid in a sick room or +in a foul privy is evidence that the place is disinfected, is entirely +erroneous. Particularly in regard to the latter agent, it may be +stated at once that its employment for disinfecting purposes on a +large scale is impracticable, both on account of the expensiveness of +the pure acid and the enormous quantities required to produce the +desired effect. For in regard to its efficiency it does not rank very +high in comparison with a great many other articles, as may be seen +from a table of the disinfectant properties of different chemicals +published by Miquel in the _Semaine Medicale_. + +For practical purposes I know of no better or simpler rules for +disinfection than those published by the National Board of Health. In +its _Bulletin_ No. 10, of September 6, 1879, the following +instructions for disinfection were published: Deodorizers, or +substances which destroy smells, are not necessarily disinfectants, +and disinfectants do not necessarily have an odor. + +"Disinfection cannot compensate for want of cleanliness nor of +ventilation. + +"I. Disinfectants to be employed: + +"1. Roll-sulphur (brimstone) for fumigation. + +"2. Sulphate of iron (copperas) dissolved in water in the proportion +of one and a half pounds to the gallon; for soil, sewers, etc. + +"3. Sulphate of zinc and common salt, dissolved together in water in +the proportion of four ounces sulphate and two ounces salt to the +gallon; for clothing, bed-linen, etc." + +Carbolic acid is not included in the above list, for the following +reasons: It is very difficult to determine the quality of the +commercial article, and the purchaser can never be certain of securing +it of proper strength; it is expensive when of good quality, and +experience has shown that it must be employed in comparatively large +quantities to be of any use; it is liable by its strong odor to give a +false sense of security. + +"II. How to use disinfectants: + +"1. In the sick-room.--The most available agents are fresh air and +cleanliness. The clothing, towels, bed-linen, etc. should, on removal +from the patient and before they are taken from the room, be placed in +a pail or tub of the zinc solution, boiling hot if possible. + +"All discharges should either be received in vessels containing +copperas {699} solution, or, when this is impracticable, should be +immediately covered with copperas solution. All vessels used about the +patient should be cleansed with the same solution. + +"Unnecessary furniture--especially that which is stuffed--carpets and +hangings, should, when possible, be removed from the room at the +outset; otherwise they should remain for subsequent fumigation and +treatment. + +"2. Fumigation with sulphur is the only practical method for +disinfecting the house. For this purpose the rooms to be disinfected +must be vacated. Heavy clothing, blankets, bedding, and other articles +which cannot be treated with zinc solution should be opened and +exposed during fumigation, as directed below. Close the rooms as +tightly as possible, place the sulphur in iron pans supported upon +bricks placed in wash-tubs containing a little water, set it on fire +by hot coals or with the aid of a spoonful of alcohol, and allow the +room to remain closed for twenty-four hours. For a room about ten feet +square at least two pounds of sulphur should be used; for larger rooms +proportionately increased quantities. + +"3. Premises.--Cellars, yards, stables, gutters, privies, cesspools, +water-closets, drains, sewers, etc. should be frequently and liberally +treated with copperas solution. The copperas solution is easily +prepared by hanging a basket containing about sixty pounds of copperas +in a barrel of water. + +"4. Body- and bed-clothing, etc.--It is best to burn all articles +which have been in contact with persons sick with contagious or +infectious diseases. Articles too valuable to be destroyed should be +treated as follows: + +"A. Cotton, linen, flannel, blankets, etc. should be treated with the +boiling-hot zinc solution; introduce piece by piece; secure thorough +wetting, and boil for at least half an hour. + +"B. Heavy woollen clothing, silks, furs, stuffed bed-covers, beds, and +other articles which cannot be treated with the zinc solution, should +be hung in the room during fumigation, their surfaces thoroughly +exposed and pockets turned inside out. Afterward, they should be hung +in the open air, beaten, and shaken. Pillows, beds, stuffed +mattresses, upholstered furniture, etc. should be cut open, the +contents spread out, and thoroughly fumigated. Carpets are best +fumigated on the floor, but should afterward be removed to the open +air and thoroughly beaten. + +"5. Corpses should be thoroughly washed with a zinc solution of double +strength; should then be wrapped in a sheet wet with the zinc +solution, and buried at once. Metallic, metal-lined, or air-tight +coffins should be used when possible; certainly when the body is to be +transported for any considerable distance. + +"It might have been added here that no public funeral must be +permitted." + +In this connection I have to speak of a remedy which I class among the +prophylactic agents--namely, the chlorate of potassium or the chlorate +of sodium. I cannot say that I rely on either of these remedies as +curative agents in diphtheria, and yet I employ them in almost every +case. The reason lies in the fact that the chlorate is useful in most +cases of stomatitis, and thereby acts as a preventive. + +There are very few cases of diphtheria which do not exhibit larger +surfaces of either pharyngitis or stomatitis than of diphtheritic +membrane. There are also a number of cases of stomatitis and +pharyngitis, {700} during every epidemic of diphtheria, which must be +referred to the epidemic, sometimes as kindred diseases, and sometimes +as introductory stages only, which, however, do not, or do not in the +beginning, show the characteristic symptoms of the disease. + +When, in 1860,[42] I wrote my first paper on diphtheria, I based it +upon two hundred genuine cases, and at the same time enumerated one +hundred and eighty-five cases of pharyngitis, which I considered to be +brought on by epidemic influences, but which, the membrane being +absent, could not be classified as bona fide cases of diphtheria. + +[Footnote 42: _Amer. Med. Times_, Aug. 11th and 18th.] + +Such cases of pharyngitis and stomatitis, no matter whether influenced +by an epidemic or not, furnish the indication for the use of chlorate +of potassium. They will usually get well with this treatment alone. +The cases of genuine diphtheria, complicated with a great deal of +stomatitis and pharyngitis, also indicate the use of chlorate of +potassium; not, however, as a remedy for the diphtheria, but as a +remedy for the accompanying catarrhal condition in the neighborhood of +the diphtheritic exudation. For it is a fact that, as long as the +parts in the neighborhood of the diphtheritic exudation are in a +healthy condition, there is but little danger of the disease spreading +over the surface. Whenever the neighboring surface is affected with +catarrh or inflammation, or injured so that the epithelium gets loose +or thrown off, the diphtheritic exudation will spread within a very +short time. Thus chlorate of potassium or sodium, the latter of which +is more soluble and more easily digested than the former, will act as +a preventive rather than as a curative remedy. Therefore it is that +common cases of pharyngeal diphtheria will recover under this +treatment alone; and these are the cases which have given its +reputation to chlorate of potassium as a remedy for diphtheria. + +The dose of chlorate of potassium for a child two or three years old +should not be larger than half a drachm (2 grammes) in twenty-four +hours. A baby of one year or less should not take more than one +scruple (1.25 grammes) a day. The dose for an adult should not be more +than a drachm and a half, or at most two drachms (6 or 8 grammes), in +the course of twenty-four hours. + +The effect of the chlorate of potassium is partly a general and partly +a local one. The general effect may be obtained by the use of +occasional larger doses, but it is better not to strain the +eliminating powers of the system. The local effect, however, cannot be +obtained with occasional doses, but only by doses so frequently +repeated that the remedy is in almost constant contact with the +diseased surface. Thus, the doses, to produce the local effect, should +be very small, but frequently administered. It is better that the +daily quantity of twenty grains should be given in fifty or sixty +doses than in eight or ten; that is, the solution should be weak, and +a drachm or half a drachm of such solution can be given every hour or +every half hour or every fifteen or twenty minutes, care being taken +that no water or other drink is given soon after the remedy has been +administered, for obvious reasons. + +I have referred to these facts with so much emphasis because of late +an attempt has been made to introduce chlorate of potassium as the +main remedy in bad cases of diphtheria, and, what is worse, in large +doses (Seeligmuller, Sachse, L. Weigert, C. Kuster, Edlefsen.) + +{701} Large doses of chlorate of potassium (2 drachms daily to an +adult I claim to be a large dose, particularly when its use is +persisted in for many days in succession) are dangerous. In several of +my writings I have given instances of its fatal effects.[43] I have +seen fatal cases since, and scores have been published in different +journals. The first effects of a moderately large dose are gastric +and, more especially, renal irritation; the latter it was which I +experienced when I took half an ounce twenty-five years ago. Fountain +of Davenport, Iowa, experienced the same before more serious symptoms +developed, of which he died.[44] The symptoms are those of acute +diffuse nephritis, with suppression of urine, or scanty secretion of a +little black blood, and uraemia deepening toward death in fatal cases. +My earlier cases I considered as primary diffuse nephritis, and I have +even been inclined to attribute the frequent appearance of chronic +nephritis, amongst all classes and ages, in part to the influence of +the chlorates, which have become a popular domestic remedy and are +found in every household. But the experimental researches of +Marchand[45] and others prove that, at least in many instances, the +extensive destruction of blood-cells is the first and immediate result +of the introduction into the circulation of the chlorate, and that the +visceral changes are due to embolic processes. + +[Footnote 43: _C. Gerhardt's Handbuch der Kinderkrankheiten_, vol. +ii., 1876; _Med. Record_, March, 1879; _Treatise on Diphtheria_, +1880.] + +[Footnote 44: Stille, _Therap. and Mat. Med._, 2d ed., 1874, p. 922.] + +[Footnote 45: _Sitzungsber. d. Naturforsch. Ges. h. u. Halle_, Feb. 8, +1879, and _Virch. Arch._, vol. lxxvii.] + +Special Treatment.--The first axiom in the treatment of diphtheria is +that there is no specific; the second, that in no other disease the +individualizing powers of the physician are tested more severely. + +The treatment is both internal and external. The local remedies are +either such as dissolve the mucous membrane, or such as thoroughly +modify the mucous membrane from which the pseudo-membrane has been +removed, or real antiseptics, with the power of destroying either +chemical or parasitic poisons. + +The number of remedies recommended in diphtheria is immense. No other +proof of its dangerous nature is needed. In the following I shall +review those which I consider it worth while either to reject or to +recommend. + +Steam is used partly to soften the membranes, but principally to +increase the secretion from the mucous membrane, and thereby throw off +the superjacent membrane. This can be done to advantage only where +there is a natural tendency to it; that is, where there are a great +many muciparous follicles under a cylindrical or fimbriated +epithelium. This is the condition on part of the pharynx, but not on +the tonsils; and in a small portion of the larynx, in the trachea and +bronchi, but not on the vocal cords. Wherever there is pavement +epithelium on the normal surface, and where the membrane is imbedded +into the tissue, steam can hardly be expected to do good. In the other +cases it will. Thus, the locality of the diphtheritic process +determines to a great extent whether steam is indicated or not. If it +be used, the necessity of a full supply of atmospheric air must not be +disregarded. Steam, with an overheated room and without pure air, is +liable to be as injurious as steam in pure air is beneficial in a +number of cases. + +{702} There can be no better proof for the necessity of +individualizing, and the impossibility of treating all cases alike, +than the fact that many will do well under steam treatment, and others +are certainly injured by it. I have repeatedly had the joy of seeing +children with croup become less cyanotic after their removal from an +atmosphere of vapor, and I can readily see that pure atmospheric air +would be more agreeable and wholesome to a child with stenosis of the +larynx than an atmosphere laden with steam. Of course this remark does +not apply to cases of pseudo-croup and bronchitis, which are generally +benefited by a warm, moist atmosphere. Those, however, who deem it +judicious to employ steam as a vehicle for carbolic acid, salicylic +acid, chloride of sodium, chlorate of potassium, or lime, had best +resort to the atomizer for applying these remedies. It can be used +without trouble; most children are sufficiently intelligent to allow +the spray to be directed upon the fauces and larynx every ten or +fifteen minutes in case of necessity. When it is deemed advisable to +administer steam, I warn against the use of gas stoves. They require a +great deal more oxygen than an alcohol lamp, which ought to be +preferred when a stove or slaking lime or hot iron or bricks immersed +in water are not available. + +Water may be made serviceable in different ways. Its effect on the +skin, when taken in large quantities, under normal or abnormal +circumstances, is a matter of daily experience. Copious perspiration +is its immediate result. The very same effect is produced on the +mucous membranes. In diphtheria, besides professional hydropathists, I +know of but one[46] who favors the plentiful use of water, 100-200 +grammes (3-6 ounces) every hour or oftener, either by itself or mixed +with an alcoholic beverage. + +[Footnote 46: C. Rauchfuss, in _C. Gerhardt's Handb. d. Kinderkr._, +iii. 2, 1878.] + +Severe inflammatory symptoms, such as redness of the throat, great +pain, swelling of the glands, require cold applications, either an +ice-bag or ice-cold cloths well pressed out and frequently changed. +They must, however, be placed where they can do most good--in +laryngeal diphtheria around the neck, in pharyngeal diphtheria with +glandular swelling over the affected part. In the latter, therefore, +the flannel cloth which covers the whole of the application must be +tied over the head, and not behind. When ice-bags are used, care is to +be taken lest they should be too large; if so, they will not affect +the desired spot at all. Small pieces of ice frequently swallowed are +greatly relished by the patient; water-ices in small quantities will +render the same service; ice-cream, in half-teaspoon or teaspoon doses +every five or ten minutes, adds to the necessary nutriment. When the +fever is high and the surface hot, sponging with tepid or cold water, +or water and alcohol, will mitigate both. For the cold bath or the +cold partial pack (trunk and upper part of the thighs) the general +indications hold good. As a rule, I favor the latter, for many cases +have such a tendency to debility and collapse that sometimes the +circulation of the surface of the body is badly interfered with by +cold bathing. Therefore, a contraindication to cold bathing must be +found at once in cold feet, either before or after a bath. When, +unfortunately, the feet do not recover their normal temperature in a +very short time, they ought to be warmed artificially, and the cold +bath not repeated. In such cases the cold pack, however, is still +indicated. A linen or cotton cloth, {703} large enough to cover the +trunk and half of the thighs, is dipped in cold water, well pressed +out, and the body of the patient wrapped tightly in it. The arms +remain outside; the whole body is then wrapped up in a blanket; the +feet may be warmed meanwhile when necessary, and the cold pack +repeated as often as required to reduce the temperature--viz. once +every five minutes, every half hour, every hour. + +The contraindications to the use of cold have in part been alluded to. +Very young infants bear it but to a limited extent. The beginning of +recovery contraindicates it, unless for some local cause; for +instance, an inflamed gland. The extensive use of cold water or ice is +also forbidden when there is no fever, where there is perhaps an +abnormally low temperature, where we have to deal with the septic or +gangrenous form of diphtheria, where the vitality is low and the +mucous membranes pale or even cyanotic. In such cases, on the +contrary, while unlimited internal stimulation is required, the hot +bath, or hot pack and hot injections into the bowel, will be found +beneficial. + +Lime-water, glycerine, lactic acid, pepsin, neurin, papayotin, +chinolin, and pilocarpine are all solvents of pseudo-membrane, but +whether there is sufficient time and opportunity to produce a curative +effect by every one of them is a question open for discussion. Of +lime-water and glycerine I have employed a mixture of equal parts in +considerably more than a hundred cases after the completion of +tracheotomy, directing the remedy through an atomizer into and below +the canula, but cannot say that the descent of the membrane into the +trachea or bronchi was prevented by it. Lime-water may be used in the +nose and throat as an injection, spray, or gargle, but its solvent +effect is greatly diminished by the action of the carbonic acid of the +breath on the lime. I have no doubt that if water alone was used with +the same persistence as lime-water, its effects would be nearly the +same. Still, what little effect the minute dose of lime (1:800) in the +lime-water may have may just as well be utilized. What I object to is +the omission of more powerful agents. If lime is to be used, slaking +lime frequently in the presence of the patient is attended with vastly +more benefit, inasmuch as by that proceeding a large amount of +powdered lime is projected into the air of the room and the mouth and +respiratory organs. + +Lactic acid also, in from ten to twenty-five parts of water, has +yielded no better results in my hands. Those cases of tracheotomy +which I afterward treated with lactic acid spray terminated no better +than such as were treated with lime-water and glycerine. Of the +solvent effect of pepsin I have not been able to convince myself so as +to recommend it. The accounts of neurin have not encouraged me to try +it at all. Chinolin (tartrate) has been used locally by O. +Seifert,[47] Muller, and others. It is said to remove the membranes +and relieve the fever. For a gargle it is dissolved in five hundred +parts of water, or it is mixed with ten parts of water and alcohol +each, and applied by means of a sponge. To relieve the burning +sensation ice is swallowed afterward. The local applications of +alcohol have the same drawback. There are but few patients who do not +suffer intensely from its local contact. + +[Footnote 47: _Berl. klin. Woch._, Nos. 36, 37, 1883.] + +Papayotin has been recommended by Rossbach for the purpose of +dissolving membranes in a one-half per cent. solution. It peptonizes +{704} albuminoids, and macerates meat, intestinal worms, and croup +membranes in both neutral and feebly alkaline solution. In +concentrated solutions it has a caustic effect. It is recommended, not +as an anti-diphtheritic, but merely as a solvent remedy.[48] Whatever +reliance may have been placed upon it has, however, been jeopardized +by Rossbach's remarks[49] on the variability of the preparations in +the market. Not only are the specimens very unequal, but each of them +is variable, easily spoiled, and particularly affected by moisture. + +[Footnote 48: _Berl. klin. Woch._, March 10, 1881.] + +[Footnote 49: _Transactions of the Congress for Int. Medicine_, 1883, +p. 162.] + +Muriate of pilocarpine was recommended for this purpose three years +ago. It was praised by Juttmann as a specific, and has failed. The +quackish recommendations of the drug have, indeed, earned for it a +certain amount of distrust which it does not deserve in all cases. It +is expected to increase the secretion of the mucous membranes to such +an extent as to float the pseudo-membranes. It sometimes succeeds in +so doing, but only in those cases in which the membrane is deposited +upon the mucous membranes. When the tissue is impregnated the drug +fails. It also fails in septic cases, and mostly for the reason that +it diminishes and paralyzes the heart's action. It ought, therefore, +never to be given unaccompanied with large amounts of stimulants. +Where the patient is strong, and the heart healthy, it may be tried; I +know that a few cases of moderate laryngeal diphtheria improved with +pilocarpine, steam, and turpentine inhalations. The dose is 1/30 +grain, dissolved in water, every hour. + +Turpentine inhalations were recommended by C. Edel.[50] Fifteen drops +of oil of turpentine are inhaled from a common inhalation apparatus, +which is placed at a distance of three inches from the mouth of the +patient, for a period of ten minutes every hour. He claims recoveries +in from twelve to forty-eight hours. I allow the patient to remain in +his bed, and keep water boiling constantly on an alcohol lamp, on the +stove, or over the gas. A tablespoonful of turpentine, more or less, +is poured on the water, care being taken that nothing is spilled in +the fire. Thus the room is constantly filled with a penetrating odor +of turpentine, which is not at all disagreeable, even when in great +concentration. The effects are very satisfactory indeed. Where +circumstances allowed or required it I have raised a tent over the +bed, large enough not to give inconvenience to the patient and to +admit either the whole apparatus or the tube containing the mixed +vapor of water and turpentine. + +[Footnote 50: _Med. Rev._, Jan. 19, 1878.] + +Ammonium chloride may sometimes be used to advantage for its softening +and liquefying effects. Its internal administration in bronchial and +tracheo-laryngeal catarrh is so old that it has several times been +obsolete. Of late, more stimulant effects have been attributed to it +than it actually possesses. But its liquefying action, in cases where +the secretion of mucus is defective and expectoration scanty and +viscid, is undoubted. Thus it proves valuable in many cases of simple +catarrh, both when administered internally and inhaled. The latter +mode I have often resorted to, and believe that its macerating +influence has been of service to me in cases of laryngeal diphtheria. +Half a teaspoonful of the pure salt is spread on the stove or burned +over alcohol {705} or gas. It evaporates immediately, and fills the +room or the tent with a white cloud, which, when dense, excites +coughing. But it does not irritate to any uncomfortable degree, and +the process may be repeated in an interval of an hour or more. + +Not all cases of diphtheria are septic or gangrenous, nor are all the +cases occurring during an epidemic of the same type. Some have the +well-pronounced character of a local disease, either on the tonsils or +in the larynx. The cases of sporadic croup met with in the intervals +between epidemics present few constitutional symptoms, and assume more +the nature of an active inflammatory disease--very much like the +sporadic cases of fibrinous tracheo-bronchitis. These are the cases in +which mercury deserves to have friends, apologists, and even +eulogists. Calomel, 0.5-0.75 gramme (gr. viij-xij), divided into +thirty or forty doses, of which one is taken every half hour, is apt +to produce a constitutional effect very soon. Such doses, with minute +doses, a milligramme or more (gr. 1/60), of tartar emetic, or ten or +twenty times that amount of oxysulphuret of antimony, have served me +well in fibrinous tracheo-bronchitis. But the mucous membrane of the +trachea and bronchi is more apt to submit to such liquefying and +macerating treatment than the vocal cords. The latter have no +muciparous glands like the former, in which they are very copious. And +while the tracheal membrane, even though recent, is apt to be thrown +out of a tracheal incision at once, the pseudo-membrane of the vocal +cords takes from six days to sixteen or more for complete removal. +Still, a certain effect may even here be accomplished, for maceration +does not depend only on the local secretion of the muciparous glands, +but on the total secretion of the surface, which will be in constant +contact with the whole respiratory tract. Thus, either on theoretical +principles or on the ground of actual experience, men of learning and +judgment have used mercury in such cases as I detailed above, with a +certain confidence. + +If ever mercury is expected to do any good in cases of suffocation by +membrane, it must be made to act promptly. That is what the blue +ointment does not. In its place I recommend the oleate, of which ten +or twelve drops may be rubbed into the skin along the inside of the +forearms or thighs (or anywhere when their surface becomes irritated) +every hour or two hours. Or broken doses will be useful, such as given +above, or hypodermic injections of corrosive sublimate in 1/2 or 1 per +cent. solution in distilled water, four or five drops from four to six +times a day, or more, either by itself or in combination with the +extensive use of the oleate, or with calomel internally. Lately, the +cyanide of mercury has been recommended very strongly. I hardly +believe that it will work more wonders than any other equally soluble +preparation. Within the past few years the internal administration of +bichloride of mercury has been resorted to more frequently and with +greater success than ever before. My own recent experience with it has +been encouraging, and so has that of some of my friends. Wm. +Pepper[51] gave 1/32 grain of corrosive sublimate every two hours in a +bad form of diphtheritic croup, with favorable result. But in this +very bad case, desperate though it was--child of five years, resp. 70, +pulse 160--large membranes, "evidently from the larynx," had been +expelled before the treatment was commenced on the {706} seventh day +of the disease. The remedy ought to be given in solution of 1:5000, +and in good doses. A baby a year old may take one-half grain every day +for many days in succession, with very little if any intestinal +disorder and with no stomatitis.[52] A solution of the corrosive +chloride of mercury in water is frequently employed of late as a +disinfectant. It acts as such in a dilution of 1:20,000. As healthy +mucous membranes bear quite well a proportion of 1:2000-3000, any +strength between these extremes maybe utilized. A grain of the +sublimate in a pint or more of water, with a drachm of table-salt, +will be found both mild and efficient. As a gargle or nasal injection +it will be found equally good. But it has appeared to me that frequent +applications give rise to a copious mucous discharge; hourly +injections into a diphtheritic vagina became quite obnoxious by such +over-secretion, which ceased at once when the injections were +discontinued. Thus, when it is desirable not only to disinfect but +also to cleanse the diseased surface, the injections with corrosive +sublimate appear to yield a result inferior to less irritating +applications. + +[Footnote 51: _Trans. Am. Med. Ass._, 1881.] + +[Footnote 52: _Med. Record_, May 24, 1884.] + +Chloride of iron is undoubtedly a valuable remedy in diphtheria, but +in its administration it must by no means be forgotten that small +doses at long intervals are out of the question. I have not the least +doubt but that the failure of the remedy may be attributed in most +cases to the fact that the doses were too small and administered too +seldom. A dose of from five to fifteen drops, properly diluted, every +fifteen minutes, half hour, or hour is indispensable for a proper +estimation of its effects. Gargles are not of much service, for the +simple reason that they do not come into sufficient contact with the +affected parts, and reach at the utmost to the anterior pillars of the +soft palate. A direct application of the remedy to the mucous membrane +of the pharynx may also be desisted from, thereby avoiding any +irritation, the internal administration at short intervals causing the +pharynx to be sufficiently influenced by local contact with the +remedy. It must, of course, not be expected that the chloride will +remove the membrane, but it can frequently be seen to reduce the +hyperaemia and swelling and prevent the reproduction of exuded +material. The chloride of iron exerts a decided influence on the vital +contractility of the blood-vessels. This increased contractility +certainly assists in diminishing the rapidity of absorption of putrid +fluids through the blood-vessels, which constitutes the principal +source of danger from the disease. + +It cannot yet be positively asserted that the chloride of iron exerts +a direct effect on the lymphatic vessels. Naturally, this was claimed +when the remedy was recommended, in the treatment of diphtheria, on +account of its therapeutic effects in erysipelas, with the +accompanying inflammation of the lymphatic vessels of the skin. +Although we know of no direct compression of the lymphatic vessels due +to the action of the chloride, yet it may be assumed that perhaps the +compression of the blood-vessels exerts a similar influence upon the +neighboring lymphatics. In consequence of this there would be an +impediment to the absorption and further development of poisonous +substances in the lymph. The chloride, like the sulphate of iron, is a +tolerably powerful disinfecting agent. If this observation be correct, +it may go very far toward explaining the action {707} of the chloride +of iron in septic diseases, which are accompanied by an exalted +activity of the lymphatic vessels and an increase of the white +blood-corpuscles. Furthermore, Saase has endeavored to show that the +ferrous salts possess the power of converting oxygen into ozone. They +share this power with the blood-globules exclusively, and could hence, +to a certain degree, supply a deficiency of the latter. Pokrowsky, +too, has shown that iron increases the process of oxidation in the +body by demonstrating that in health there is an elevation of +temperature and an increase of the percentage of urea in the urine +during its administration. In anaemic persons, to whom iron has been +given for the purpose of increasing the amount of blood, the above +phenomena may be observed before this object is accomplished. Thus +iron appears to replace the blood-corpuscles to a certain extent. Now, +in infectious disorders of the blood, where the red globules are +perpetually menaced with destruction, it seems plausible that the +preparations of iron should exert an antiseptic action. + +Finally, it has been found that of all the preparations of iron the +chloride possesses the greatest power of stimulating the nervous +system. Possibly this effect may be traced to an increase of the +arterial pressure in the nerve-centres. It has been said that this +effect has been vividly illustrated in certain forms of chlorosis. If +this be true, iron would be all the more indicated in diphtheria, +since it would act as a prophylactic against a series of nervous +phenomena that so frequently present themselves, both during and +subsequently to the diphtheritic process. Thus it is that for many +years the muriate of iron has constituted the main element, with me, +of internal medication in most cases of diphtheria, both of the mild +and the most dangerous septic type. A common formula is, for a child +of two years, + + Rx. Tinct. Ferri Chloridi fl. drachm ij; + Potass. Chlorat. gr. xx; + Aquae fl. oz. v; + Glycerin. Pur. fl. oz. j. M. + +S. A teaspoonful every fifteen, twenty, or thirty minutes. + +Carbolic acid exerts a powerful influence on the vitality of all +living elements, and hence also on rapidly proliferating epithelium, +which constitutes a part of the diphtheritic membrane. It is of great +advantage for local use. Its local effect, undiluted or diluted with +equal or larger parts of glycerine or alcohol, in shrinking and +removing membranes, is sometimes very useful; in mild solutions in +water (1/2, 1, or 2 per cent.) it is very efficient in nasal +injections or for external applications or mouth-washes. Rothe's +prescription for external use is carbolic acid and alcohol each 2 +parts, water 10, tincture of iodine 1. Its internal administration to +the extent of five to twenty grains daily, given largely diluted, in +small and frequent doses, is of less positive value. + +Salicylic acid, in a solution of 1:30-50, is caustic. A milder +solution, 1:200-300 relieves or removes foul odor from the nose or +throat, but it does not detach membranes or shorten the duration of +the disease, apparently. Internally, it acts no longer as a +disinfectant, but is changed into a salicylate and is an antipyretic. +It is then better to replace it by the sodium salicylate. With its +administration (for a child of 2 years 3 grains every hour until 20 or +25 grains are taken) it ought not to be {708} forgotten that serious +brain troubles, collapse, and irregular and paralytic breathing, as +well as gastric and intestinal disturbances, may follow its use. It +ought not to be given without careful watching and the simultaneous +free use of alcoholic stimulants. + +Binz found, as the result of experiments with solutions of pure quinia +varying from one part in a hundred to one in a thousand, that the +latter sufficed to prevent the development of bacteria in fluids +capable of undergoing putrefaction; but even estimated thus, a patient +with eighteen pounds of blood would require one hundred and +thirty-eight grains of quinia circulating therein in order to satisfy +the conditions of Binz's experiment. If Binz considers two grammes +(half a drachm) of quinia per day sufficient for an individual +weighing one hundred and twenty pounds, his calculation is founded on +experiments with dogs, in which septicaemia was avoided by the +injection of quinia. It is also necessary to bear in mind that Binz +makes a distinction with regard to the preparations of quinia +employed. He warns against the use of the bisulphate as being the most +inactive. No matter which preparations are used--I prefer the +muriate--I have come to look upon quinia as of no great service in +reducing the temperature in infectious fevers. The main indication for +its use can only be found in inflammatory fevers. When it is given, +however, salicylate of sodium may be added for a short time to obtain +a speedier effect. + +On the part of bromine Wm. H. Thompson claims the following +advantages: 1. When applied locally, it promptly arrests fetor by +arresting directly the gangrenous process, and thus lessens risk from +absorption. 2. It acts as an anti-putrefactive likewise in the fluids +of the body generally--_i.e._ blood, interstitial circulation, and +secretions--owing to its high rate of diffusibility, equal to that of +sodium chloride itself. 3. It locally destroys the communicable +property of the discharges, shown by the immunity of attendants from +any sore throat when it is used, and from its checking the spread of +the disease in the locality. He orders two solutions to be used: the +first of equal parts of Lawrence Smith's solutio bromini and of +glycerine, applied with a hair pencil to the membrane, as gently as +possible. Sometimes he uses the solution full strength. The brush +should be washed at once in water, and does not last more than one +day, owing to the action of the bromine on the hair. If, however, the +membrane be very extensive and the parts much swollen or difficult to +reach, he resorts instead to douching with a Davidson syringe, using +half a drachm to one drachm of the solution to a pint of warm water. +By beginning gently with the stream directed against the buccal mucous +membrane, the child soon becomes accustomed to the current and allows +it then to play against the deeper parts. + +Internally he orders from six to twelve drops of the solution in a +half ounce of sweetened water, every hour, two, or three hours, +according to the urgency of the case, and continuously. + +The most convenient way of making Smith's solution is: Take two ounces +of a saturated solution of potassium bromide in water; add to this, +very slowly, in a bottle and with constant shaking, one ounce of +bromine. It is better to add a part, and then let it stand a while +before adding the rest; then fill up gradually, and with constant +shaking with water, until it measures four ounces. + +{709} Ozone has been used as an anti-fermentative in inhalation during +three or five minutes every hour or two, by Jochheim. + +Boric (boracic) acid, in saturated (1:25) or milder solutions, has +some antiseptic effect. It is mild, and not very injurious when +swallowed by necessity or mistake. In diphtheritic conjunctivitis it +is valued highly, and in nasal injections I have found it very useful. +It is less repugnant than most other substances administered in that +way. + +Sodium benzoate cannot be relied on either as an anti-diphtheritic nor +as an anti-febrile. The doses which were recommended were two scruples +or a drachm daily for a child a year old. + +Sulphur has been used locally. It gives rise to coughing and vomiting. + +Cubebs have been given in incredible doses, two drachms of the powder +to a child a year old. The drug disorders the stomach and kidneys. + +Local Treatment.--The mechanical removal of the membranes is not +permissible unless they are almost detached. It is best to avoid their +being cast off, unless partly loosened membranes in the larynx or +trachea afford an indication for an emetic. Scratching and eroding the +mucous membrane of the neighborhood give rise to new deposits. Even +after spontaneous elimination of a membrane a new one may be formed +within a few hours. + +To cauterize a diphtheritic membrane or infiltration I consider wrong, +unless I shall be able to do so thoroughly and to limit the action of +the caustic to the diseased surface. Therefore potassa or chromic acid +cannot be utilized, because of the impossibility of limiting their +effect. Nitrate of silver and mineral acids can be restricted in their +effects, but these are not sufficiently thorough, particularly as but +few patients will consent to have the remedy applied properly. When I +do cauterize, I prefer a mixture of equal parts of carbolic acid and +glycerine or the undiluted acid. The membrane crumbles and falls off +in pieces. Force must never be used. Where it would be required in the +case of obstinate children mild washes must be employed instead of the +caustic. Besides, the internal medication detailed above meets every +indication. When there is a slight swelling of the lymphatic glands, +cold water or ice applications are usually all that is needed. The +latter should be made according to general indications. The glandular +and peri-glandular swellings are less the result of an actual filling +up with foreign matter than of secondary irritation. Ice has a happy +effect in such cases, both on internal administration, in the form of +frequent small quantities of ice-water, ice-pills, ice cream, and iced +medicaments, and also externally by ice-cold cloths or india-rubber +bags filled with ice. + +In general, the treatment of the swelled glands must be both based on +its causes and adapted to the present condition. The adenitis and +peri-adenitis is of secondary nature, the irritation being in the +mouth, pharynx, and nares. In these localities is where the main +treatment is required. The sooner the primary affection is removed or +relieved or rendered innocuous, the better it is for the secondary +complaint. Frequent doses of chlorate of potassium or sodium, or +biborate of sodium in mild doses frequently repeated, according to the +principles laid down in another part of this article, mouth-washes, +gargles, nasal injections with water, salt water, or solutions of +disinfecting substances, are not only {710} indicated, but highly +successful. When the case is recent, cold applications are required, +but no washes. When it is of older date, stimulant embrocations are in +order. Iodine ointments are absorbed but slowly; mercurial plasters do +good in some cases; iodide of potassium dissolved in glycerine +(1:3-4), frequently applied, iodine in oleic acid (1:8-12), iodoform +in collodion or flexible collodion (1:12-15) applied twice daily, the +latter frequently with very good result, are beneficial. Copious +suppuration is very rare. Cases in which a free incision meets with an +abscess ready to heal are very uncommon. But numerous small abscesses +with gangrenous walls and pus mixed with a sero-sanguinolent or +sero-purulent liquid, are more frequently found. In such cases a probe +introduced into the lancet wound enters easily into the broken-down +tissue in every direction, to a distance even of three to six +centimetres, (several inches), according to the size of the +tumefaction. I have seen fatal hemorrhages from such gangrenous +destructions; therefore the treatment must be both timely and +energetic. The incision must not be delayed too long. When the skin +assumes a purplish hue or is simply discolored, it is time to incise +and to apply concentrated or nearly concentrated carbolic acid to the +interior, unless the neighborhood of very important blood-vessels or +nerves yields a contraindication to concentrated applications. In that +case a milder preparation is advisable, but the application should be +repeated often, until the suppuration becomes more normal. Then mild +disinfectant injections into what has now become a cavity will be +found satisfactory, particularly when meanwhile the general condition +of the patient has been improved. + +Treatment of Nasal Diphtheria.--Especially during the prevalence of an +epidemic of diphtheria must we be careful not to allow a nasal catarrh +to have its own way; we must likewise guard against considering the +thin and flocculent discharge in infected cases as a mucous secretion. +Whatever be the origin of nasal diphtheria, whether primary or the +result of a similar affection in the throat, local treatment should at +once be instituted, and if this be done the great majority of cases +will terminate favorably. The danger in this form of disease consists +in an excessive absorption of putrid substances and in the breathing +of contaminated air. The interior of the nasal cavities must be +thoroughly cleaned and disinfected. If this be commenced early, the +original seat of the affection may be reached, and the disinfectant +process will, as a rule, have good results. It is not necessary to +select very energetic disinfectants; a solution of twelve to +twenty-five centigrammes (two to four grains) of carbolic acid in +thirty grammes (an ounce) of water is at once mild and effective, and +hardly gives rise to more discomfort than lukewarm water. Nasal +injections must be made very frequently, until each time the stream of +fluid has a free exit through the other nostril or through the mouth. +They must be made at least every hour, and even oftener if necessary; +at the same time it is advisable to be careful that the fluid does not +enter the Eustachian tube. This can be prevented, to a certain extent, +by compelling the patient to keep the mouth open during the procedure. +I have seldom seen evil or even disagreeable results from the +administration of nasal injections in diphtheria. It is likely that +the mucous membrane of the pharynx is swollen as far as the openings +of the Eustachian tubes to such a degree as to render the entrance of +fluids into the latter improbable. {711} The hardness of hearing, +which is of so frequent occurrence in the course of a severe catarrh +or of a diphtheritic attack, seems to indicate that the mucous +membrane of that part is in a state of swelling. An ordinary syringe +will suffice. However, when administered by parents or nurses the +blunt nozzle of an ear syringe is preferable. Occasionally here, as in +local applications to the mouth and pharynx, the atomizer may be used +to advantage, but the tube must be properly introduced into the +nostrils. There are cases of nasal diphtheria, however, which are far +more troublesome to manage than the foregoing would seem to indicate. +I have seen cases in which the nasal cavities, from the anterior to +the posterior nares, were filled and completely occluded by a dense, +solid membranous mass. I was then compelled to bore a passage with a +silver probe, to gradually introduce a larger-sized one, and then to +apply the pure carbolic acid, in order to remove the densest and +thickest masses, and finally was able to make injections; even in such +cases I have had the gratification of being able to give a favorable +prognosis. The dangerous secondary swelling of the glands will often +subside after a steady employment of disinfectant injections for from +twelve to twenty-four hours. It will be found that children frequently +do not object to this method of treatment; I have even met with some +who, after convincing themselves of the relief afforded thereby, asked +for an injection. When we are about to bring each injection to a close +it is well to press together the nasal cavities for an instant with +the fingers. By this procedure the fluid is forced backward to the +pharynx, and is swallowed or ejected through the mouth, and thus +washes the pharynx and mouth at the same time. Frequently, however, +this latter object is obtained with every injection; for, the palate +being swelled, oedematous, and paretic, the fluid is not prevented +from reaching the pharynx, even in the average case. In regard to the +choice of a disinfecting agent, I have but a few words to say. I +believe that no one of them has important qualifications above the +others. I avoid those which stain or which produce firm coagula. For +the latter reason I do not use the subsulphate and perchloride of +iron; for the former, the permanganate of potassium. I employ, as a +rule, carbolic acid in solution, of the strength above mentioned. +Where there is but a slightly fetid odor I have frequently employed +lime-water or water with glycerine, or a solution (1:100, 1:50) of +chloride of sodium, or of bicarbonate of soda or of borax, or a +saturated solution of boric acid. Disinfecting agents and antiseptics, +whether carbolic acid, salicylic acid, or iron, are of no service when +administered internally only, unless the seat and cause of the septic +infection be attended to previously. Under the local employment of +antiseptics, as described, or by simply washing out with water or salt +water, most cases recover; without them, death will result. Of late, +in many cases, the local applications, injections, etc. of the +corrosive chloride of mercury in water (1:5000-10,000) has proved very +effective. It has this advantage over carbolic acid, that the +swallowing of the former is not so dangerous. This much, after all, my +experience has assured me of, that there is a certain number of cases +which terminate fatally; but it is likewise true that the mortality +need not be excessively great. I cannot grant that it is hard to carry +out the exact and apparently barbarous treatment necessary for a +favorable result, for it is certainly more barbarous to sacrifice than +to save life. + +{712} It is a positive fact that when children suffering from nasal +diphtheria, with its peculiarly septic character, are permitted to +sleep much--and they are apt to be drowsy under the influence of the +poison--they will certainly die. To allow them to sleep is to allow +them to die. + +The first symptom of improvement is often a rapid diminution of the +glandular swelling wherever it exists. It is not present in all cases, +but chiefly in those in which a bloody serum was discharged in an +early period of the disease. In these the blood-vessels appear to be +very vulnerable, superficial, and apt to absorb; these are also the +most dangerous cases, and require the greatest attention and care, and +also prompt disinfection. + +Treatment of Laryngeal Diphtheria.--The severest form of diphtheria is +that located in the larynx, constituting membranous croup. Its general +treatment, whether the disease has originated primarily in the larynx +or trachea or has been communicated from the pharynx, does not differ +from that laid down for diphtheria in general. Naturally the larynx +calls for special treatment on account of the symptoms of suffocation +which result from its stenosis. The main indication of removing viscid +mucus or partly-detached membranes is best met by the administration +of an emetic. Such is their only indication in my experience. The +selection of the emetic, when indicated, is of great importance. +Antimonials ought to be avoided because of their depressing and +purgative effect. Ipecacuanha is but rarely effective. The sulphates +of zinc and copper, and particularly the latter, deserve preference. +Turpeth mineral acts promptly and satisfactorily. When no emesis can +be obtained the prognosis is decidedly bad. Recourse must then be had +to tracheotomy, the good results of which are however only too often +delusive and transient. + +When, after the operation, there is scarcely any relief, and +particularly when the case takes a very rapid course, it is probably +one of ascending croup which commenced in the trachea. Mechanical +relief by pushing down a hen's feather or a bundle of them, and +turning it about and twisting, must be tried. It is a much better +instrument than pincers of all sorts and shapes. But what relief will +be accomplished is but of very short duration. When fever sets in +within a few hours it means very much more frequently pneumonia than +diphtheritic fever. It is apt to be soon complicated by that +disproportion between pulse and respiration so characteristic of +inflammatory diseases. Then quinia in larger doses, 0.25 or 0.5 (grs. +iv-viij) every two, four, eight hours, at the same time doses of +sodium salicylate 0.25-0.40 (grs. iv-vj) every hour or two hours until +the temperature goes down, and small doses of digitalis where the +heart requires it, must be given at once. Procrastination is +dangerous; the patients want careful watching; many of them die within +two days after the operation. + +Diphtheritic conjunctivitis requires great attention and permits of no +loss of time. Cold applications to the affected eye must be made +constantly. Pieces of linen or lint kept on ice (better than in +ice-water) of little more than the size of the eye, must be changed +every minute or two day and night. The danger to the cornea is so +imminent that constant watchfulness is required. Boric acid in +concentrated solution should be dropped into the eye once every hour. +Care must be taken that the well eye shall not get infected; for that +purpose it is best to cover it {713} with lint and collodion, or with +lint or cotton held in place by adhesive plaster. + +Cutaneous diphtheria requires the destruction of the membrane or of +the infected surface by carbolic acid, either concentrated or somewhat +diluted with glycerine, or the application of the actual cautery. +After that the use of ice or iced cloths, or diluted carbolic acid, is +indicated. As soon as the surface is no longer diphtheritic the local +and general treatment is to be continued on general principles. + +Diphtheritic paralysis is invariably complicated by anaemia and +debility, and the diet and medical treatment must be regulated +accordingly. However, neither overfeeding nor a sameness of diet are +to be permitted, for not rarely the muscular coat of the stomach +suffers with the rest of the muscular tissue, and the secretion of +gastric juice is very deficient in anaemic individuals. While, +therefore, iron is indicated, we must not neglect to pay particular +attention to nutrition and digestion, and to aid the latter with +pepsin and moderate amounts of muriatic acid, well diluted. Quinia in +small doses and stimulants are appropriate whenever there is no +contraindication to their employment. The treatment of the paralysis +itself will naturally depend on the diagnosis of the condition present +in each individual case, which we have seen to differ considerably. +This alone can explain why various modes of treatment, the electric +current among others, after being recommended by some authors, are +branded by others. Where we have to deal with those rare changes in +the brain and spinal cord, the utmost care is necessary in order not +to make the condition still worse; and in such cases there would be a +contraindication to the use of the faradic current, though this would +not hold true with regard to the use of the galvanic current in short +sittings. Besides, central paralyses are by no means so frequent as +peripheral ones. In most cases there is not the slightest elevation of +temperature during the course of the paralytic phenomena. I lay great +stress upon this point, for I am aware that many cases of central +congestion and even of inflammation exhibit but very insignificant +elevations of temperature. But, as the diagnosis will depend on a +positive knowledge of whether there have been changes of temperature, +I rely on the rectal temperature only, for many a myelitis runs its +course with no greater elevation above the normal than one-half or one +degree. In all cases in which the temperature is normal or subnormal, +I do not hesitate for a moment to employ the faradic or the galvanic +current. In addition to the internal administration of iron I advise +by all means the employment of strychnia. When there is no necessity +for haste, we may give moderate doses, gradually increasing them, and +using iron in combination. When there is danger in delay, recourse +ought to be had to subcutaneous injections of the sulphate of +strychnia, once or twice daily. They are mainly indicated in paralysis +of the muscles of deglutition and of respiration. Of course, where the +former are affected it is necessary to nourish the patient +artificially, partly perhaps by nutrient enemata, but principally by +means of the stomach-tube. In using the latter it is unnecessary to +introduce it into the stomach, as it only requires to be passed a few +inches below the affected parts, when the oesophagus will usually be +found able to undertake the further disposal of the food. In these +cases strychnia should be injected subcutaneously in the neck, {714} +once or twice daily. In a similar manner it should be injected in the +region of the chest, diaphragm, or neck in paralysis of the +respiratory muscles or of the glottis. In paralysis of the muscles of +accommodation (in which Scheby-Buch claims to have seen the process +cut short by the use of the Calabar bean, considered as inert by +Hassner) they may be given in the forehead or temples. + +Frictions dry and alcoholic, hot bathing, friction with hot water, +kneading of the affected parts, will be found beneficial and pleasant. + + + + +{715} + +CHOLERA. + +BY ALFRED STILLE, M.D., LL.D. + + +DEFINITION.--Cholera is an epidemic disease, characterized by the +transudation of serum into the stomach and bowels, and usually by the +profuse discharge by vomiting and purging of a liquid resembling +rice-water, followed by a tendency to collapse. It is endemic in +India, but has been conveyed thence to almost every part of the world. + +SYNONYMS.--Cholera algida, C. asiatica, C. asphyxia, C. maligna, C. +spasmodica. In English it is generally spoken of as Asiatic cholera. + +HISTORY.--It is sometimes stated that Hippocrates, Galen, Celsus, and +the Greek, Roman, and Arabian medical writers generally record "the +fact of the presence of cholera in the various countries in which they +lived" (Macnamara). Nothing could be more contrary to the truth. All +of these writers describe "cholera morbus" in nearly identical terms; +they all include bilious discharges among its symptoms, and no one of +them speaks of it as a mortal or even as an epidemic disease. +(Compare, especially, Celsus, Aretaeus, Caelius Aurelianus, and Paulus +Aegineta.) Their description of sporadic cholera morbus is very +precise. For example, Caelius Aurelianus says: "Cholericam passionem +aiunt aliqui nominatam a fluore fellis, per os et ventrem effecto."[1] + +[Footnote 1: _Acut. Morb._, lib. iii. cap. xix.] + +Asiatic epidemic cholera is a very different disease. It seems to have +been known in India from a very remote period, but no detailed account +of it was published until the beginning of the sixteenth century. +During that century many successive descriptions of the disease +exhibited its extreme violence and mortality. It is believed to have +occurred repeatedly, if not annually, in the same localities down to +the present time. The invasion of India by the Portuguese, and +afterward by the English, contributed to spread the disease throughout +the Peninsula, partly by military occupation and partly through +commercial channels, by which it was also carried to the islands in +the Indian Ocean. It prevailed in Batavia in 1629. Between 1768 and +1790 numerous epidemics of cholera occurred. About the former date no +less than 60,000 persons are said to have perished near Pondicherry, +and in 1783 it is reckoned that 20,000 victims to the disease fell in +a single week during the religious gathering at the sacred city of +Hurdwar, where, as will be seen hereafter, it became in later years +more fatal still. The English armies extended their conquests in +Hindostan, and established commerce between that country and Western +Asia and Europe, and by the year 1817 opened new channels of {716} +communication in every direction, both within and beyond the +Peninsula. Along them the disease was carried; it invaded Ceylon and +the Burmese empire, and extended to Batavia, Java, and China on the +east, and advanced westward to Persia in 1821. In that year also it +was carried from Arabia into Africa, and at various later periods +penetrated more and more deeply into the Dark Continent, always +following the track of pilgrims returning from Mecca, the routes of +armies engaged in war, or those of trading caravans.[2] + +[Footnote 2: Christie, _Cholera Epidemics in Africa_, 1876.] + +In these cases, as in others elsewhere, the spontaneous origin of the +disease has been assumed by certain writers, but at every stage of its +progress careful investigation led uniformly to the conclusion that it +was propagated directly or indirectly from pre-existent cases of +cholera. From Persia it moved northward as far as the shores of the +Caspian Sea, and westward to the Levant in 1823, and there for a time +its ravages were stayed. Meanwhile, it prevailed at various places +throughout Hindostan, and, assuming a greater degree of violence in +1826, it advanced steadily in a north-western direction across +Afghanistan and Persia in the following year. In 1829 it reached +Orenburg, to the north of the Caspian Sea, and was speedily conveyed +into the interior of the Russian empire, where it raged with great +violence in 1830. In 1831 it prevailed at Mecca among the pilgrims, +who had brought it from India, and so virulently that one-half of them +are computed to have perished. Hence it speedily passed with returning +pilgrims to Alexandria and Constantinople, and was carried to St. +Petersburg, to Sweden, to Hamburg, and other places in Northern +continental Europe. From Hamburg and other seaports it was conveyed to +commercial towns on the eastern coast of England, whence it extended +to Edinburgh in the north and London in the south. + +In 1832 cholera prevailed in France, and within the year caused +120,000 deaths, 7000 of which occurred in Paris in the space of +eighteen days. In the spring and summer of that year it was reproduced +in England, and extended to Ireland. From Liverpool, Cork, Limerick, +and Dublin five vessels filled with emigrants sailed for Quebec, +Canada, and they, together, lost 179 passengers by cholera during the +voyage. + +The immediate results of this importation and first appearance of +cholera on the American continent are described by Dr. Peters as +follows: "All these ships and their passengers were quarantined at +Grosse Isle, a few miles below Quebec. On June 7th the St. Lawrence +steamer Voyageur conveyed a load of these emigrants and their baggage, +some to Quebec, but the majority to Montreal on the 10th. The first +cases of cholera occurred in emigrant boarding-houses in Quebec on the +8th, and the same pest-steamboat, the Voyageur, landed persons dead +and dying of cholera at Montreal, a distance of two hundred miles, in +less than thirty hours. Over this long distance, thickly inhabited on +both shores of the St. Lawrence, cholera made a single leap, without +infecting a single village or a single house between the two cities, +with the following exceptions. A man picked up a mattress thrown from +the Voyageur, and he and his wife died of cholera; another man, +fishing on the St. Lawrence, was requested to bury a dead man from the +Voyageur, and he and his wife and nephew died. The captain of a +passing boat requested an Indian to bury a man from on board; this man +and five other Indians were attacked {717} and died. The town of Three +Rivers, halfway between Quebec and Montreal, forbade steamers to land, +and escaped for a long time. From Montreal the great influx of +emigrants were forwarded away, by the Emigrant Society, as fast as +they arrived, and by them the pestilence was sown at each +stopping-place. Kingston, Toronto, and Niagara soon became affected. +In the end, over 4000 persons died of cholera in Montreal, and more +than an equal number in Quebec. The epidemic reached Detroit in the +same way, ... and continued west along the Great Lakes, until in +September it reached our military posts on the Upper Mississippi.... +Fort Dearborn, near Chicago, was temporarily reoccupied in 1832, and +it was here that epidemic cholera displayed its most fatal effects +among our troops. Out of 1000 men, over 200 cases were admitted into +hospitals in the course of seven or eight days.... When these troops +again marched for the Mississippi, they appeared in perfect health, +yet the cholera broke out again on the way, and when the command +reached the Mississippi it had been as fatal as it had been at Fort +Dearborn." + +Meanwhile, an emigrant ship with cholera on board reached New York, +whence the disease spread up the Hudson River, and was also carried +southwardly to Philadelphia and the West. The mortality in New York +City from this epidemic is stated at 3500. In 1833 the disease broke +out in the cities of Havana and Matanzas in Cuba, and is said to have +destroyed one-tenth of the entire population. Hence it was carried to +Mexican and American towns on the Gulf of Mexico, and up the +Mississippi and Ohio as far as the western border of Pennsylvania. In +the following year it was again introduced at the port of Quebec by a +vessel filled with emigrants, of whom many had died during the +passage. It prevailed in Canada and the State of New York and spread +over the whole country in 1835 and 1836. In the former of these two +years it was confined to several Southern cities, whither it was +brought, as on a former occasion, directly from Cuba. It then +gradually subsided, and at last disappeared for the space of nearly +ten years. + +But in 1845 it was known to be advancing on its former path, which it +steadily pursued, and entered England in October, 1848, at Sunderland, +the very town at which it first appeared in 1831. "During the second +epidemic in Europe, in 1848, two vessels sailed from Havre, where +cholera prevailed--one, the New York, for New York, and the other, the +Swanton, for New Orleans. Both contained large numbers of German +emigrants. On one vessel the cholera appeared when it was sixteen days +out, with fourteen deaths; on the other, in twenty-six days, with +thirteen deaths. The New York arrived at Staten Island Dec. 2, 1848, +and a severe epidemic broke out, but was confined to the quarantine +grounds. The Swanton arrived at New Orleans Dec. 11th; no quarantine +was instituted, and in two days its sick were taken into the Charity +Hospital. This was the beginning of a severe epidemic, which increased +in power all winter, till, in June, 1849, 2500 died of it in New +Orleans. December 20, 1848, it reached Memphis by steamboat from New +Orleans, and for twenty-five days was confined to the landing-place of +the former city, whence it afterward spread. In the spring it was +carried to St. Louis and Cincinnati and the whole Mississippi Valley. +In October it reached Sacramento, Cal., by means of overland +emigrants, and, almost at the same time, San Francisco, by the U.S. +steamer Northerner from {718} Panama. The Chinese of California +suffered most severely" (Peters). In April, 1849, cholera reappeared +in the public stores at the quarantine station, Staten Island, N.Y., +and in the city of New York, where it was fatal to 5000 persons. + +A pause now took place in the ravages of the disease which lasted +until 1853. In that year it destroyed no less than 11,000 persons in +the Persian city of Teheran. At Messina its victims numbered 12,000, +in France 114,000, and in England about 16,000. In 1854 it was +introduced by emigrant ships into New York, causing a mortality of +2000 persons, and was carried to Philadelphia, where its victims +numbered 500. It extended to many towns in New England and westward +along the great channels of emigration. In Montreal the deaths were +1300, and in the then small town of Detroit, 1000. + +After an interval of quiescence longer than any previous one the +cholera again broke out among the pilgrims to Mecca in December, 1864. +It appeared in Alexandria during May, 1865, and thence was carried to +many parts of Europe, and from them to North America and the West +Indies. This period of exemption included that of the Civil War in the +United States, when, if ever, the local causes which have been +erroneously assigned to the disease existed in all their forms and in +the most intense degree. It was only when its specific germs were once +more imported that cholera began to prevail again. Official records +show that in 1866 it was introduced from Europe into Halifax, N.S., +the city of New York, and the military posts of New York harbor. +Thence it was carried in troop-ships to various Southern ports, from +which its progress could be traced to Texas and other Gulf States, and +to the towns on the Mississippi and Missouri Rivers. From New York, +also, the disease travelled westward to Cincinnati and the U.S. +barracks at Newport, on the opposite side of the Ohio River, whence it +advanced in a south-westerly direction to meet the trail that, coming +from the South, followed the great rivers of the Mississippi Valley. +During the summer of 1867 cholera again prevailed, although less +fatally, at most of the points, especially of the Mississippi Valley, +which had been invaded the previous year, and some cases occurred at +the military posts around New York in recruits who had shortly before +arrived from places in the West where cholera prevailed. Thus did the +disease complete the circuit of the United States. + +Meanwhile, cholera prevailed to a greater or less extent in the east +of Europe between 1865 and 1874. After the latter date it seems to +have been confined to Syria, Arabia, and the African shore of the +Mediterranean. In 1877-78 it existed to a limited extent among the +pilgrims at Mecca, and since then it has not been known in Europe. The +latest appearance of cholera in the United States was in 1873, when it +occurred at three points far distant from one another. It was +introduced in the effects of immigrants. The vessels that brought them +were in a perfect sanitary condition. The passengers themselves were +healthy, and remained so after landing and until they reached the +distant points of Carthage, Ohio, Crow River, Minn., and Yankton, +Dak., where their goods were unpacked. At each place, "within +twenty-four hours after the poison particles were liberated, the first +cases of the disease appeared, and the unfortunates were almost +literally swept from the face of the earth" (E. McClellan). + +{719} In 1881 cholera was brought from Hindostan to Arabia by pilgrims +on their way to Mecca, where it soon afterward broke out and caused +the death of about 8000 persons. In the following year several vessels +from Bombay evaded the quarantine and reached Djeddah, the port of +Mecca, and the pilgrims on reaching the latter city disseminated the +disease. The unusually small number of persons who were there at the +time, and their prompt dispersion before the danger, limited the +mortality, and gradually cases of cholera ceased to appear. In 1882, +the English at that time carrying on war in Egypt, very rigid sanitary +precautions against the importation of cholera were enacted and +successfully enforced, but in the following year, the same urgent +necessity no longer commanding, they were considerably relaxed. At the +end of June, 1883, the cholera made its appearance at Damietta (at one +of the mouths of the Nile), and soon afterward at Rosetta, Port Said, +and Mansourah. During July it spread to various places in direct +communication with those named. At Cairo it was peculiarly fatal, and +on July 20th it was reported to have caused 600 deaths. For several +days the daily mortality varied between 500 and 600. The disease +prevailed somewhat in Alexandria during the height of the epidemic, +and near the end of October it was fatal to numerous European +residents of that city, and some deaths occurred in the British army +of occupation. In all Egypt, during the week ending Aug. 13th, the +total mortality is said to have been 5000, but in the following week +it fell to 2000. It is estimated that the epidemic destroyed at least +20,000 lives. The germ of this epidemic has not been accurately +determined. Some regard it as a survival of the cholera of the +previous year--a supposition which is at least plausible and +sufficient; but certain "sanitarians" have attributed the outbreak to +the ordinary causes of disease intensified by the civil war which had +recently devastated Egypt. It is sufficient here to say that while +such causes have in all ages generated typhus and typhoid fevers and +dysentery, they never produced cholera. Some, more unwise than +judicious, declared that the Egyptian disease of 1883 was not cholera. +It is alleged, on the one hand, that several East Indian merchants +from Bombay arrived at Damietta on June 18th, or three days before the +disease was recognized in that city. It is also said that a stoker +from on board an English steamer from Bombay introduced the cholera +into Damietta. But the judgment of Surgeon-General Murray carries with +it greater weight.[3] He is of the opinion that the Egyptian epidemic +of 1883 was simply a revival of the Arabian epidemic of 1882. He shows +that cholera existed in several villages on the Damietta branch of the +Nile in the latter part of May and during June, and that it broke out +in the capital itself, during a fair which had lasted for eight days, +on the 22d of June, and was spread by the people on their return from +Damietta to their villages. This, adds Mr. Murray, "is a literal +transcript of the accounts of many of the severe epidemics that have +raged over India." It also appears from M. Proust's narrative[4] that +the Ottoman government had already, as early as April, notified the +government of Egypt that certain Indo-Javanese pilgrims were on their +way to Mecca, and that ought not to be allowed to land without +quarantine. The French delegate to the sanitary council also begged +that those of the pilgrims who reached Suez without previous +quarantine should be isolated and kept under {720} surveillance for +three days. But owing to the opposition of the English delegates these +measures were not duly enforced, the council did not meet again, and +no protective system was adopted. + +[Footnote 3: _Times and Gazette_, Feb., 1884, p. 209.] + +[Footnote 4: _Le Cholera_, 1883.] + +ETIOLOGY.--The essential cause of cholera is unknown, unless the +investigations of Koch, described below, may have revealed it. Its +secondary causes, or the conditions of its dissemination, are better +understood. Some general propositions concerning them will here be +laid down, and illustrated so far as the argument requires and the +available space will allow. + +Cholera is endemic in no other country than India, and more +particularly in Bengal. When it has occurred elsewhere it has +invariably been carried from India. The cholera poison has been +imagined to be of an aerial nature, but its diffusion has no relation +whatever to the velocity or the direction of the wind. In no instance +whatever has its rate of progress exceeded that of man on land or +water, nor has it ever taken a direction different from that of +commercial or military movements. On land it has usually crept from +place to place, and if sometimes it has seemed to leap across wide +spaces, and even seas and oceans, it has never invaded any inland town +or seaport without having been brought thither from a point already +affected with the disease. Nor, having once entered an inland or +seaboard town, does it spread equally therein in all directions, but +prevails chiefly in the quarter immediately surrounding the place of +its entrance. If appropriate sanitary measures are enforced, it is +sometimes confined to that quarter, and, in the case of quarantine +stations, it has repeatedly been prevented from extending beyond them. +This statement may be illustrated by the fact that of fourteen +epidemics of cholera at Staten Island, the quarantine station of New +York, all but four were prevented from reaching that city.[5] When the +disease does overleap the barrier opposed to it, its origin and +subsequent course can usually be traced. + +[Footnote 5: Peters's _Notes, etc._, 2d ed., p. 94.] + +A high atmospheric temperature is everywhere associated with the +prevalence of cholera. Its origin in the hot climate of Hindostan and +its general progress prove this conclusively. In nearly all of the +places where a great difference exists between the summer and the +winter temperature the disease has disappeared during the cold season, +and attained its greatest intensity during the hot months of the year. +The only apparent exception to this rule is, that cholera has +prevailed in several Russian, Swedish, and Norwegian cities during the +winter. But these very exceptions confirm the rule; for in the +countries mentioned the intense cold of the winter compels the +inhabitants to seal their houses by every possible means, while the +atmosphere within them is kept at a high temperature by huge stoves, +which hinder ventilation, and indeed render it almost impossible. +Difference of temperature likewise explains the fact that of two +cholera-ships arriving from Havre, the one at New York and the other +at New Orleans, in December, 1848, the former did not disseminate the +disease, but the latter formed the starting-point of an epidemic which +lasted all the winter. + +A good deal has been written of the predisposing causes of cholera, +and poverty, crowding, filth, intemperance, and depression of spirits +have been given prominent places in the catalogue. But to any one +familiar {721} with the history of epidemic diseases it will at once +be apparent that every one of these conditions favors the spread of +all communicable infectious diseases. There is not the slightest +evidence that these agencies, singly or combined, can generate cholera +or favor its spread apart from the presence of the specific poison of +the disease and the facility with which it is transmitted from the +sick to the well whenever the population is crowded, poor, of filthy +habits, and weakened by dissipation. Because among such people +intemperance prevails, this vice has been regarded as predisposing to +cholera. Apart from the brutish mode of living of drunkards, there is +nothing to show that they are more liable to cholera than the most +abstemious of water-drinkers. On the contrary, it is notorious that +during cholera epidemics drunkards in the better classes of society +enjoy a certain degree of immunity from the disease; which it is easy +to explain on the ground that they imbibe but little water, which is +the main channel through which the infectious principle of the disease +is spread. + +The specific cause of cholera is taken into the alimentary canal, and +acts through it to produce the characteristic symptoms of the disease. +It is conveyed from the sick to the well by means of the +gastro-intestinal discharges, either moist or dry; in the former +state, by means of drinking-water, and in the latter through the air, +whose suspended noxious particles are received into the fauces and +swallowed. There is reason to believe that the poison does not enter +the system through the lungs, or through any other channel than the +gastro-intestinal canal. W. B. Carpenter[6] appears to hold, however, +that the poison may be absorbed through the lungs. To this view there +are two objections: 1, That whatever is taken into the mouth or throat +by inspiration may very well be swallowed; and, 2, that all the +primary lesions of cholera affect the digestive and not the +respiratory apparatus. It is not at all necessary to the propagation +of cholera that its excreta should be furnished by persons laboring +under the fully-formed disease. A specific choleraic diarrhoea is as +infectious as the evacuations which occur in completely developed +cholera. But neither will propagate the disease through the air to a +distance. The tendency to its propagation in this manner depends +chiefly upon the concentration of the poison; thus, it much more +frequently occurs in close than in well-ventilated rooms or than in +the open air. It has been argued that cholera is not contagious, +because so few, comparatively, of the attendants upon cholera patients +contract the disease. On the other hand, as some of them are attacked, +this positive fact outweighs an indefinite number of negative +instances. It should also be noted that different diseases enter the +system and infect it through different channels--some through the +lungs, others through the alimentary canal, etc. Small-pox, the most +contagious of all diseases, is introduced through the air-passages, +and is probably harmless when its virus is taken into the stomach. +That the converse of this proposition applies to cholera is sustained +by the whole history of the disease. Cholera poison may be taken to +considerable distances in either a moist or a dry condition. In the +former state it is mainly conveyed by water, as in rivers, +water-pipes, etc.; in the latter, by fomites and especially by +clothing saturated or merely soiled with cholera discharges, and which +may retain their infectious quality for an indefinite time. + +[Footnote 6: _The Nineteenth Century_, Feb., 1884.] + +{722} Great stress has been laid upon the humidity and foulness of the +soil, a damp atmosphere, filth, crowding, etc., as elements in the +production of cholera, but in reality they have no more essential +relation to it than to any other disease that occurs epidemically. +Cholera may prevail whether they are present or absent. It is evident +that from the earliest historical periods all of these causes of +disease have existed, and in Europe much more generally and +excessively than during the present century, and that they have never +been removed in Asia Minor, Egypt, Arabia, and Africa. Yet cholera +never was known in any of these countries until it was brought into +them about the end of the first third of the present century. + +According to Pettenkoffer, cholera is most prevalent when the subsoil +water is lowest, and least so when the subsoil water is highest. It +would be more descriptive of the fact to say that, so far as cholera +has anything to do with the condition of the soil, it is most apt to +be severe and prevalent when very dry weather follows a very wet +period. Such circumstances are the most favorable to putrefactive +fermentation and the dissemination of its products, which thus reach +wells of drinking-water, and even rivers, especially when sewers empty +into the latter. The identity of this explanation with that which is +generally accepted for the dissemination of typhoid fever is too +evident to be insisted upon. We might go farther, and say that, in +typhoid fever as in cholera, the disease is communicated, although +exceptionally, by the air of the sick room and by the exhalations of +the soiled fomites of the patient. Now, if typhoid fever resembled +cholera not only in being transmitted by means of the dejections, but +also in its poison being derived from one primary source only, the +analogy between the causes of the two diseases would be very striking +indeed. But, in point of fact, the typhoid-fever poison may probably +be generated de novo by fecal fermentation and other forms of +putrefaction, and the disease is only exceptionally communicable; +whereas, the poison of cholera, once received, is conveyed from man to +man and far and wide through various channels; but, so far as is +known, it has but one primary source, and that is in India. Lebert +states that he did not find the localities that are the ordinary seats +of typhoid fever peculiarly liable to invasions of cholera. But it +must be noted that typhoid fever is very far from being exclusively a +disease of the poor, squalid, and vicious. Like death itself, "regum +turres pauperumque tabernas aequo pede pulsat;" while cholera much +more commonly plants itself and disseminates its seeds in the rank +soil of moral and physical degradation. + +All morbid causes whatever, derived from race, climate, religion, +dwellings, food, clothing, habits of living, etc., have no more to do +with the development of cholera than with that of the eruptive fevers, +and even less than with the causation of typhus and typhoid fevers and +dysentery. The eruptive fevers are caused, as cholera probably is, by +specific germs which no known combination of natural causes has ever +developed, while the poisons of the other diseases named appear to be +generated anew whenever certain more or less definite physicial +conditions coexist. It would seem that cholera differs radically from +all of these affections by the fact that its cause does not enter the +circulation, but confines its direct operation to the +gastro-intestinal mucous membrane. In this way it becomes intelligible +that while, on the one hand, physicians and nurses of {723} cholera +patients, although often, in fact, yet in relation to their numbers, +are comparatively seldom infected, provided they duly observe proper +sanitary rules, the disease, on the other hand, spreads like wildfire +among those who drink water polluted by cholera excretions, and only a +little less rapidly among people crowded into ill-ventilated +apartments along with cholera patients. + +The special fomites of the cholera poison are articles of clothing and +furniture soiled with the discharges of the sick, and the emanations +from privies, sewers, etc. into which these discharges have been cast. +Many considerations render it probable that a very small quantity of +cholera matter may suffice to render infectious a very large quantity +of liquid, and especially of matters in process of putrefactive +fermentation, and that the gaseous or vaporous emanations from them +become diffused in the atmosphere and infect all who imbibe them. But +water contaminated by cholera discharges is the most rapid and +efficient agent in disseminating the disease. Innumerable instances of +this mode of action are furnished by its history in Asia and Africa, +where water is often scarce, and naturally so impure that its +additional defilement by cholera dejections is apt to pass unnoticed. +From the illustrations of this proposition which might be adduced only +a few of the more striking will here be selected. + +Hurdwar is a town in Northern India at the base of the Himalayas, +where the Ganges begins its course in the plains. It is the seat of a +great Hindoo pilgrimage, which takes place annually in April, when +sometimes from 2,000,000 to 3,000,000 of people occupy an encampment +of about twenty-two square miles, comprising a low flat island in the +Ganges and the opposite banks of the river. Bathing in the sacred +stream on a certain day is the main object of the devotees; which day, +in the year 1867, fell on the 12th of April. The bath was taken early +in the morning. From noon on that day the pilgrims began to disperse +so rapidly that on the morning of the 15th the encampment was quite +deserted. It appears that up to the former date the health of the +encampment was excellent, and it was the opinion of the reporter (Dr. +Cunningham) that cholera was introduced into the camp by pilgrims from +the neighboring districts going late to the fair. He believed that the +cholera excreta may have been buried in the trenches and carried by a +heavy rain into the river, and there swallowed by the pilgrims; for to +drink of the water of the Ganges as well as to bathe in it is a +religious obligation. + +Immediately after the breaking up of the camp cases occurred in the +surrounding districts, the epidemic widening in all directions. The +pilgrims were almost always the first persons attacked in any +locality, and the cholera attended them on their route wherever they +went. In all the districts where the disease prevailed no cases +occurred until ample time had been given for the pilgrims to reach +them. In a word, "the cholera first showed itself among them; it +followed their lines of route only, and did not outrun them; their +progress was its progress, and their limits its limits." The mortality +caused by this epidemic among the whole civil population of the +North-western Provinces of the Punjab has been estimated at about +117,181.[7] The history of the religious festival of 1879 {724} was +identical with that just sketched, except that the number of the +pilgrims was smaller and the deaths proportionally less.[8] + +[Footnote 7: _Brit. and For. Med. Chir. Rev._, Jan., 1870, p. 137.] + +[Footnote 8: Murray, _Practitioner_, xxvi. 309.] + +Out of the numberless illustrations of the manner in which cholera is +disseminated by water the following may be cited: In 1865 about +100,000 pilgrims were assembled at Mecca, of whom from 10,000 to +15,000 fell victims to the disease, two-thirds of them within a period +of six days. Some cause acting simultaneously upon the whole number of +persons must be admitted to account for so extraordinary a fact, and +such a cause is not far to seek. At a certain sacred well "one hundred +thousand people had skinfuls of water poured over them at the side of +the well, and every one of them then drank largely of water drawn from +the well. Much of the water poured over the pilgrims must have found +its way by soakage back into the well, and if any of the pilgrims were +at the time suffering from cholera, or had cholera-tainted garments +about them, the well would be exposed to pollution."[9] + +[Footnote 9: Christie, _Cholera Epidemics in East Africa_, p. 488.] + +In the cholera epidemics of Zanzibar the disease produced the greatest +havoc among the negroes, the Persians, and the East Indians; very few +Europeans were attacked, and quite as few of the sect of the Banyans, +who drank only water drawn from their own wells. The persons among +whom the disease prevailed so fatally used chiefly the water of a +certain well which was highly prized, but which on this occasion had +become polluted by soakage from an adjacent cesspool into which the +dejections of cholera patients had been thrown. It appears, also, that +in Zanzibar the streams are very rarely bridged, and hundreds of +negroes, in passing backward and forward, wade through them and +pollute them. In these streams, also, the negroes wash their clothes +and all the foul clothing of the contiguous town. While this business +is going on "a gang of negroes may be at work at not many hundred +yards' distance filling water-casks for the shipping." Subsequently to +the watering of the ships in this manner sailors were attacked with +cholera, and others who used water drawn from the stream below the +place where it became polluted were attacked, and many of them died; +while Europeans living on shore, and who drank the water of the same +stream, but drawn from a much higher point in its course and after +having been filtered, escaped the disease.[10] + +[Footnote 10: _Ibid._, pp. 320, 492.] + +The history of the disease in Europe furnishes a multiplicity of +similar cases, and even more distinctly exhibits the dissemination of +cholera by contaminated water.[11] In Holland not less than five +epidemics of the disease occurred between 1832 and 1869, all of them +causing a great mortality, to which the epidemic of 1866 alone +contributed not less than 20,000 deaths. This was about 55 deaths for +every 10,000 inhabitants. Such exceptional mortality over so wide a +territory has been ascribed to the extreme porosity and humidity of +the soil, which is nearly all below the level of the sea. Such a soil +must necessarily retain longer than other soils whatever it absorbs, +and thus tend to render the well-water habitually impure. If, then, to +the ordinary impurities a specific {725} poison is added, its +characteristic effects may assuredly be looked for. The conditions now +stated explain the conclusions of Ballot of Rotterdam, drawn from a +study of the several epidemics referred to. They are as follows: "1. +Holland is highly affected by the cholera at every epidemic, chiefly +in those parts where they drink water directly from the rivers and +canals or from ground saturated with sewage. 2. In places where +rain-water is generally drunk the disease is far less violent. 3. +Places where there is no other drinkable water but rain-water are not +affected by the epidemic; the single cases occurring there are +imported. 4. When places affected by the cholera were supplied with +pure water instead of the vitiated water the disease disappeared."[12] +In like manner, we find that the cholera epidemic of 1873 in Germany +seemed specially to select those situations where the subsoil was +impregnated with decomposing organic matter; and it is evident that, +in cities especially, such situations would include the most +poverty-stricken districts, while the higher, drier, and at all times +more salubrious localities are inhabited by the classes enjoying the +greatest material prosperity.[13] + +[Footnote 11: It is of interest to note that on the first appearance +of cholera in England, at Sunderland, in 1831, a surgeon of that +place, Mr. Ainsworth, collected and published conclusive proofs of the +importation of the disease, of its communication from the sick to the +well, "and of its propagation by clothes, and even by emanations, from +the dead" (_Observations on the Pestilential Cholera_, London, 1832).] + +[Footnote 12: _Med. Times and Gaz._, May, 1869, p. 459; June, 1869, p. +626.] + +[Footnote 13: "Report of the German Imperial Commission," +_Practitioner_, xxvi. 153.] + +This mode of infection has been traced in numberless individual cases +of cholera. In London there was a certain well into which the liquid +contents of a sewer had been percolating for months. Of the water of +this well hundreds of persons had been drinking without obvious +injury. At last a case of cholera occurred hard by; the discharges +were thrown into a privy which communicated with the sewer and +indirectly with the well, whereupon more than 500 persons who drank +water drawn from that particular well were attacked with cholera +within three days. So in 1856 cholera prevailed in the county jail of +Oxford, Eng., the drain from which emptied into a pool from which the +water was drawn to supply the city prison. In the latter institution +cholera began to prevail, but declined as soon as the pipes conveying +the water were cut off, and soon afterward ceased entirely.[14] Again, +in Constantinople in 1865 the clothes, mattrasses, etc. of cholera +patients were washed at a fountain the basin of which was divided into +two parts by a wall; one part was used for washing clothes and the +other for drinking purposes. Unfortunately, the waste-pipe of the +former being obstructed, the foul water of one side communicated with +the clean water of the other, and in one day 60 people died of cholera +in the small portion of the city which was supplied from the infected +source. The striking case has often been cited which occurred at +Epping, Eng., where a woman brought the disease from a distance into a +perfectly healthy house and neighborhood, and of ten persons affected +with it seven died, including a physician in attendance upon one of +them. An examination of the premises "discovered, below the pipes +leading from the water-closet and from the eye-hole of the sink +through which the choleraic dejections had been passed, a leakage +which extended under the foundations of the building and entered the +well. The sewage was distinctly traceable on the side of the well +corresponding with the leakage in the drain." After this discovery and +the disuse of the foul water not another case occurred.[15] In 1868, +Dr. {726} Farr, in his _History of the London Cholera Epidemic of +1866_, showed that water into which cholera dejections find their way +produces cases of cholera all over the district in which it is +distributed for a certain period of time, and that if the distribution +is in any way cut short the deaths from cholera begin to decline +within about three days of the date at which the distribution is +stopped.[16] + +[Footnote 14: _Edinb. Med. Jour._, i. 1122.] + +[Footnote 15: _Trans. of the Epidemiological Soc._, ii. 428.] + +[Footnote 16: _Lancet_, April, 1868, p. 217.] + +Analogous instances are furnished by every cholera epidemic of which +the history has been accurately observed, including that which +extended so widely over the United States in 1873. Most of the +following are cited from the official reports prepared, under the +direction of the Surgeon-General of the army, by Surgeon Ely McClellan +and Dr. John C. Peters. Several of the first cases, however, are +foreign. + +In 1861, at a station in India, some fresh cholera dejecta found their +way into a vessel of drinking-water. Early on the following morning a +small quantity of this water was swallowed by nineteen persons, five +of whom were attacked with cholera between the first and the third day +afterward.[17] In 1876 an outbreak of cholera took place in a village +in Hindostan, which followed the arrival of wedding-guests, one of +whom was attacked, and from whom it rapidly spread. The soiled clothes +of one or more of the patients were washed in a pool from which all +the villagers obtained their drinking-water, and on the discontinuance +of this source of water-supply cholera speedily diminished in +frequency and fatality.[18] In the German epidemic of 1873 many cases +occurred where persons deriving their drinking-water from special +sources were attacked with cholera, while their neighbors, supplied +from a different source, remained free. Again, it has frequently +happened that outbreaks of cholera have been checked by the +prohibition of the suspected water and the substitution of a pure +supply.[19] It seems probable that a very small portion of cholera +discharges suffices to infect a very large body of water and maintain +its infectiousness for a considerable time. + +[Footnote 17: Macnamara, _op. cit._, p. 196.] + +[Footnote 18: Surg.-Major Cornish, _Practitioner_, xxiv. 215.] + +[Footnote 19: _Practitioner_, xxvi. 159.] + +In December, 1871, an outburst of cholera occurred which was confined +to the inmates of three excellent houses in a fine block of buildings +in Calcutta. There had been no cholera in that neighborhood for four +years. Within forty-eight hours a majority of the lodgers were sick, +and on investigation it was found that the disease was carried in the +drinking-water and in the milk diluted with it.[20] The particular +locality in which Dr. Koch made the discovery of the microscopic +representative of cholera furnishes an example of the same nature: "At +Saheb Ragau, a locality which has repeatedly been visited by cholera +during the last hundred years, numerous cases of the disease were +reported, and these, on inquiry, were found exclusively in the huts +situated round a certain tank. Of the few hundred people who dwelt in +these huts, as many as seventeen died of cholera, though the disease +was not at that time prevalent in the neighborhood, or indeed in the +whole police district of Calcutta. It was proved that, as usual in +such cases, the dwellers around the tank used it for bathing, and drew +thence their drinking-water; it was also elicited that the linen of +the first fatal case, befouled with cholera dejections, had been +washed in the tank."[21] In June, 1873, a new {727} hotel was opened +at Vienna, and many of the guests became affected with diarrhoea that +was attributed to the drinking-water, which was offensive to the taste +and smell. After a fortnight a gentleman died of cholera in the hotel, +and two days later several of the guests were attacked with the +disease, of whom fourteen died. The gentleman who first died was +believed to have brought the poison with him into the hotel, so that +the drinking-water, which previously had been polluted with ordinary +fecal discharges, became specifically affected through him.[22] The +discharges of one ill of cholera were thrown into, and the vessels +used by him were washed near, a well from which all the residents of a +farm-house drank. The wooden curbing of the well had rotted, and the +ground immediately around had sunken; a heavy rain burst the curb, +overflowed the well, and washed into it the entire surface-drainage of +the surrounding ground. No attention was paid to this, and the water +was used as before. It became so offensive that its use was forbidden, +but too late to save the family, nine of whom died of cholera.[23] + +[Footnote 20: _U.S. Report_, p. 85.] + +[Footnote 21: _Times and Gaz._, April, 1884, p. 527.] + +[Footnote 22: _Times and Gaz._, p. 86.] + +[Footnote 23: _Ibid._, p. 140.] + +At Farmington, Tenn., a man arrived who had contracted the cholera at +Nashville; his illness ran its course at a point just forty paces from +a well. Families that obtained their water from this well suffered in +nearly all their members; where only certain members drank of it, they +alone were affected.[24] At Huntsville, Ala., during an epidemic of +cholera, the city authorities forbade the use of well-water, and +supplied pure water from another source, but only for one week. During +this time no new cases of the disease occurred, and the negroes, +thinking themselves secure, resumed the use of the well-water, and +within four days six fatal cases of cholera occurred in the vicinity. +The use of the well-water was again prohibited, and again the progress +of the disease was arrested.[25] + +[Footnote 24: _Ibid._, p. 172.] + +[Footnote 25: _Ibid._, p. 408. For other examples of the spread of +cholera by means of drinking-water see Macnamara, p. 149 and seq.] + +It has already been intimated that the cholera poison may be diffused +through the air from either moist or dry sources, and especially from +contaminated clothing, and then be taken into the throat and +swallowed. Dr. Richardson refers to a local epidemic in England in +which "the persons most constantly and fatally attacked were the women +who washed the clothes of the sick;" and this circumstance has been +largely confirmed by other observers.[26] In a village not far from +Marseilles, and in an isolated place, a peasant and his wife who had +not left the country sickened and died of the disease. The woman, who +was a laundress, had received a bundle of linen belonging to a person +recently arrived from Egypt, and the husband opened the bundle and +unfolded the pieces. During the Crimean War many of the washermen +attending to the washing of the French hospitals were attacked by +cholera. In the post-office at Marseilles none of the clerks who +handled the outgoing mails were attacked, but of those who sorted the +mails coming from the East, where the disease prevailed, one after +another suffered from cholera.[27] + +[Footnote 26: _Trans. Epidem. Soc._, ii. 429.] + +[Footnote 27: Read, Boston, 1866.] + +The cholera was introduced into Guadaloupe by clothing contained in a +trunk belonging to a person who died on the voyage thither from +Marseilles, where the cholera then prevailed. The woman who washed the +clothing died, with all her family. Attracted by the circumstances of +{728} the case, many came to her house, and of these several died. +From this point the disease spread over the island.[28] A sailor died +at some port in Europe of Asiatic cholera in 1832. A chest containing +his personal effects, clothing, etc. was sent home to his family, who +lived in a small straggling village on the Atlantic coast of the State +of Maine. It reached them about Christmas, and was opened on its +arrival. The inmates of the house were all immediately and suddenly +seized with a disease resembling Asiatic cholera in all its malignity, +and died. There had been no cholera in the State. The last case of +cholera that occurred in the garrison at Malta in the epidemic of 1865 +was that of a woman who had stolen a chemise the property of one who +had died of the disease. She put on this fatal garment, probably +soiled with cholera discharges, and certainly unwashed, many days +after the death of its former possessor; she took the disease and +died.[29] + +[Footnote 28: _Med. Times and Gaz._, April, 1874, p. 387.] + +[Footnote 29: _Lancet_, Feb. 17, 1866.] + +It is sometimes said, and oftentimes repeated, that cholera is not +directly contagious--is not communicated by the sick to the well. No +statement could be more unfounded. The whole history of cholera proves +that the physicians and nurses of cholera patients are often affected +by the disease. "In Constantinople no less than twenty-seven +physicians and medical assistants were attacked and died during their +attendance on cholera patients; and in Paris and Toulon similar +results followed. At Halifax, N.S., two of the physicians who +volunteered in aid of the steamer England, which put in there disabled +by the ravages of cholera among the officers and crew, as well as +among the steerage passengers, took the disease, and one died" (Read). +In 1832 the cases of cholera in Edinburgh were in the proportion of 1 +to every 1200 of the population of the city, while among those in +attendance upon the sick the proportion was 1 to 5. In 1848-49 +one-fourth of the nurses employed in the cholera hospital took the +disease, while in the general hospital, only a few paces distant, +where no cholera patients were received, not a single attendant was +attacked. In the London Hospital, in 1866, none of the medical +officers, volunteer nurses, or sisters were attacked. Of the (regular) +nurses five contracted the disease, and of these four died.[30] In +1849 a severe and fatal epidemic broke out in the Philadelphia +Almshouse. The resident physicians of the hospital were abundantly +occupied with the care of the sick of other diseases, and it was +thought prudent not to allow any, even an indirect, communication +between them and the cholera patients. The latter were therefore +removed to an isolated building in the middle of the quadrangle, and +attended by physicians from the city who had volunteered their aid. +Three or four of these physicians had attacks of cholera, and two of +them died.[31] At this time there was no cholera at all in the city, +and the young physicians could not have become infected outside of the +almshouse. They were attacked while attending the sick of cholera, but +the regular house-physicians, who seldom visited the cholera patients, +escaped altogether. + +[Footnote 30: _London Hosp. Rep._, iii. 439.] + +[Footnote 31: _Philada. Med. Examiner_, Nov., 1849.] + +The importance of recognizing the communicability of cholera is so +great that no apology need be made for introducing the following +additional illustrations of it furnished by Griesinger in his article +on the dangers of cholera to medical men. They are the more important +because {729} in many other instances cholera physicians have suffered +little for their devotion to duty: "At Moscow, in 1840, hospital +attendants contracted the disease to the extent of 30 or 40 per cent., +while in the general population only 3 per cent. were attacked; at +Berlin, in 1831, in Romberg's hospital, 54 out of 115 persons were +attacked: in 1837 one-fifth of the attendants took the disease, and on +one occasion no less than seven of them fell ill on a single day. In +La Charite Hospital in Paris, in 1849, one-sixth of the attendants had +the disease, while only one-twenty-fifth of the general population of +the city suffered from it; at Mittau, in 1848, one-half of the +physicians took the disease; in 1842, at Toulon, ten health officers +out of thirty-five were ill with cholera, and five of them died, while +of thirty workmen who were employed to carry the dead bodies one-third +succumbed; at Stockholm, in 1853, of 536 attendants one-eighth took +the disease, and half of that number died; at Vienna, in 1854, out of +thirty-six nurses, seven caught the disease, and seven men employed in +removing the dead became affected with a prolonged and exhausting +diarrhoea; in 1849, at Strasburg, five nurses out of ten were +attacked, etc." ... "Physicians, nurses, students, etc. are less +frequently affected, however, than patients ill with other diseases +who are lying in the wards where cholera patients are treated, and are +therefore more constantly exposed to the emanations from the +discharges; and physicians usually suffer less than the attendants who +are constantly waiting on the cholera patients."[32] + +[Footnote 32: _Traite des Maladies infectieuses_, 1868, p. 409.] + +It may be added that Surgeon-General John Murray, who served +continuously for thirty-eight years in British India, caused upward of +five hundred circulars to be addressed to the local governments and +filled up by the local medical officers. From these returns it +appeared that the belief in the communicability of cholera, in one way +or another, was practically unanimous; for of the whole number, those +who believed that it is conveyed from person to person were 75 per +cent.; from place to place, 85 per cent.; through the atmosphere, 80 +per cent.; with the drinking-water, 85 per cent.; by the evacuations, +92 per cent.; and by clothing, 98 per cent.[33] This gentleman has +more recently furnished additional facts supporting the same +conclusion. For example: Out of fourteen cases that occurred at Ramleh +during the Egyptian epidemic, eleven occurred in patients already in +the hospital for other diseases. In 1856, after visiting the +dead-house where the bodies of fourteen cholera patients lay, as he +entered the cholera ward he felt a sudden shock in the epigastrium, +followed by a deadening sensation that rapidly spread over the whole +body. On another occasion he saw a clergyman who was talking to a +cholera patient suddenly seized with vomiting of a watery liquid. +Several analogous instances are related by him.[34] + +[Footnote 33: _Practitioner_, xix. 470.] + +[Footnote 34: _Med. Times and Gaz._, March, 1884, p. 281.] + +It has been objected to the communicability of cholera that its +dissemination does not always follow the deposit of cholera discharges +in privies, wells, etc., and also that when infection does take place, +it may occur between remote extremes as to time, and therefore cannot +be attributed to infectious germs. Such objections are frivolous, +because we know nothing of the nature or vitality of cholera-germs, +and they are, moreover, drawn from exceptional cases. The power of +infected fomites to develop {730} the disease has been preserved, in a +journey from Arabia into Africa, for at least twelve days, and for +even a longer period in passing from Germany to Chicago, as already +related. It is true of every infectious and contagious disease that it +may possess one or both of these qualities in various degrees--that at +one time it is only exceptionally communicated, and that at another +time it appears to propagate itself virulently. So the phenomena of +cholera may consist of little more than a watery diarrhoea, which may +be so mild as hardly to disable the patient from working, while at +other times the attack may include all those terrible and fatal +symptoms which have won for the disease the name of malignant. That a +certain quantity, or "dose," of the cholera poison is required to +develop the disease, but one that varies considerably in different +cases, may be inferred from these facts: 1. Out of a certain number of +persons equally exposed to receive the disease, only a portion may be +attacked at all, and these in very unequal degrees. 2. Persons so +slightly affected as to be ignorant of the nature of their sickness, +and believing it to be an ordinary diarrhoea, may nevertheless become +the innocent, because ignorant, disseminators of cholera. The +explanation of such facts may be manifold: they may depend upon the +dose or upon the energy of the morbid poison, on various possible +conditions of its recipient, and so on; but, however explained, their +reality is none the less certain. The receptivity of persons exposed +to the contagion of cholera is very different. It is well known that +some persons appear to be proof against other contagious diseases, +while others seem never to acquire an immunity from them. On this very +important point the conclusions of Fauvel directly bear.[35] They +include the following propositions: The East Indian ports where +cholera exists as an endemic disease are never the seat of an +extensive epidemic among the native population. But strangers to these +localities are liable to the disease, and such are the Mussulman +pilgrims who come to Bombay to take ship for Mecca. A severe epidemic +of cholera confers upon the locality in which it has taken place an +immunity which in India appears to be of several years' duration. Such +an epidemic in any country is a proof that the cholera is not endemic +there. + +[Footnote 35: _Memoire lu a l'Academie des Sciences_, 1883.] + +If a contagious disease preserved its virulence undiminished, it might +continue to prevail indefinitely. But we know that all other +contagious epidemics do come to an end sooner or later, and hence we +must conclude that their specific cause progressively loses its +virulent qualities. There is every reason, therefore, to believe that +the same is true of cholera. Its communicability, and therefore its +diffusion, may vary with climatic, seasonal, local, personal, and +other conditions; but of what nature those conditions are, and +especially of the last and most important, the personal, hardly +anything is known. Nor need we too curiously investigate them, so long +as the fact remains that outside of, and independent of them all, +there is but one essential cause of cholera--a morbid poison as +specific in its nature as that of any of the eruptive fevers--a poison +which no determinable conjunction of circumstances has ever +engendered, and which was unknown in Europe and America before it was +carried to them from India. In just such a way did small-pox first +arise in the Western World. It had never appeared in Europe until the +latter part of the {731} sixth century, when for a short time it +prevailed in Marseilles and the neighboring country. Afterward it was +not heard of until it was reintroduced by the Crusaders on their +return from Palestine in the twelfth century, since which period it +has hardly ever ceased. The history of the diffusion of cholera is +closely analogous to this in several particulars, and we may +reasonably expect that what was in the last generation a new disease +will henceforth be liable to prevail again and again as the +intercourse increases between the nations of the West and the +immemorial source of cholera in Hindostan.[36] + +[Footnote 36: Additional illustrations of the communicability of +cholera are contained in the _Brit. and For. Med. Chir. Rev._, July, +1872, p. 56.] + +In the preceding discussion of the origin and dissemination of cholera +the broad facts of its specific nature and its contagion by means of +excreta have been chiefly insisted upon. Little has been said either +of the nature of the contagium or of the conditions that modify its +activity. These points will be considered hereafter. But it is proper +in this place to state that, in the opinion of most investigators, the +contagious element has the power of multiplying itself, not only +within the body, but wherever it is in contact with decomposing +organic matter, provided that the degree of heat and amount of +moisture present are adapted to promote such a change, which is +certainly analogous to fermentation, if not identical with it. And the +facts already mentioned may be recalled, which show that the contagium +cannot be a light and subtle substance, since, as has been stated, the +immediate attendants upon cholera patients are not as apt as might be +expected, on that hypothesis, to contract the disease, while +washerwomen inhaling, and probably swallowing, the moist fumes from +cholera fomites much more frequently do so; that fomites saturated +with the dried discharges are very infectious; and that water is the +principal vehicle by which cholera-germs are carried into the stomach. + +SYMPTOMATOLOGY.--Like other diseases, cholera occurs under very +dissimilar aspects and with various degrees of gravity. Like those +especially which are caused by specific morbid poisons, it may be so +insignificant as to escape recognition, or, on the other hand, it may +give rise to violent and distressing symptoms which come on without +warning and hurry the patient to inevitable death. Whenever epidemic +diseases present such opposite extremes of severity in their symptoms, +it may reasonably be inferred that the differences depend mainly upon +the quantity of the poison that has been received into the system, +precisely as the dose which has been taken of a narcotic or acrid +poison may be estimated by the gravity of its effects. Individual +peculiarities, constitutional or acquired, may modify the +characteristic phenomena, and sometimes a careful inquiry may be +necessary even to detect their existence; but a study of cholera in +all its grades shows that its symptoms are all the effects of one and +the same cause, and that the cholera poison acts primarily upon the +gastro-intestinal mucous membrane. It follows, as a matter of course, +that, being thus applied, it will occasion symptoms differing in +degree and in kind according to the energy of its action, and that +this, again, will depend partly upon the inherent virulence of the +agent and partly upon its quantity. In fact, this feature in the +clinical history of the disease can be explained only by the operation +of a special irritant acting with different degrees of power upon the +gastro-intestinal {732} mucous membrane. In other words, the different +forms under which it is convenient clinically to recognize and +describe cholera are nothing more than different degrees of the +operation of one and the same poison, modified more or less by the +peculiarities of individual patients. In the most typical of the +fully-formed cases of cholera there is a stage of diarrhoea, a stage +of cholera morbus--_i.e._ of vomiting and purging--with more or less +evidence of stagnation of the blood, which is followed either by +reaction and recovery or collapse and death. The phenomena of those +several stages will now be described, after which certain symptoms +will be more particularly considered. + +It has more than once been pointed out that, however mild an attack of +cholera may be, the dejections accompanying it are infectious, and may +produce in other persons the gravest types of the disease. Hence the +importance, not only to the patients, but also to others, of +recognizing it in the earliest stage; for while this knowledge may +suggest measures for preventing an extension of the disease, it leads +to the prompt use of remedies at the only period in which their +success can at all be counted upon. The characteristic of this stage, +which has generally been called either choleraic diarrhoea or +cholerine, is a diarrhoea remarkable for its profuseness and the +frequency and serous quality of the stools, which are, however, of a +more or less yellow color. They are preceded by rumbling and gurgling +noises in the abdomen, are voided without colic or tenesmus, and are +followed by a remarkable sense of exhaustion or faintness, which is +sometimes also accompanied with nausea, and, if they are very frequent +and copious, cramps are apt to be felt in the calves of the legs. In +this variety or stage of the attack, as a rule, there is not any +vomiting; there is complete anorexia, but urgent thirst, a white and +clammy tongue, and a peculiar alteration of tone, a huskiness, +faintness, or hoarseness of the voice. The stools vary from six to +twelve a day, and, as above stated, are slightly yellow; they are also +alkaline, and on standing deposit a granular sediment which consists +largely of the debris of intestinal epithelium. Unless the attack is +very severe the temperature is not lowered by much more than 1 degree +F. The symptoms now described, especially in their milder grades, may +last for a week or even longer, and then, according to circumstances, +end either in cure or in fully-developed cholera; but under +appropriate treatment they usually subside in a day or two, and more +or less rapidly according to the degree of damage done to the +digestive mucous membrane. + +Between the above, which is the mildest type of epidemic cholera, and +the fully-developed disease must be placed that grade of the disease +which is more appropriately called cholerine, comprising cases in +which vomiting occurs as well as purging, with increased debility and +a tendency, more or less decided, to collapse. The matters vomited, +after the rejection of undigested food, are at first bilious, but they +gradually become less and less so the longer the attack lasts, and, +together with the stools, assume the appearance of rice-water--_i.e._ +they consist of a pale grayish, semi-transparent liquid in which white +flocculi are suspended. Its reaction is alkaline, and it has a faint +albuminous or spermatic smell. Along with these symptoms the other +effects of serous depletion arise--debility with pallor, duskiness, +coldness, profuse perspiration, and a sodden condition of the skin, +while the secretion of urine is diminished, {733} and all the symptoms +that belong to the first stage of cholera are present in an aggravated +degree. + +A curious feature of this disease is that sometimes the onset even of +its graver forms is not attended by any evacuations, although the +stomach and intestine may be filled with liquid. It is perhaps chiefly +in such cases that the patient experiences a rapid depression of all +the mental and physical faculties. The senses are irritable, the head +aches and is confused, there is a disinclination to sleep, the limbs +totter under the weight of the body, the pulse is frequent and feeble, +occasionally fainting takes place; the skin is cool and bedewed with +perspiration. In other cases, again, the attack is sudden; the patient +is smitten with an unaccountable feebleness, speedily followed by +profuse vomiting and purging and general spasms, and dies without any +suspension of the symptoms or any tendency to reaction. + +But more usually the attack begins with the diarrhoea and vomiting +described above, which then assume, more or less rapidly, a high +degree of violence, expressed by their frequency and excess. The +stools with proportionate rapidity lose all their fecal qualities and +acquire the rice-water appearance before mentioned, and the liquid +rejected by vomiting in all respects resembles them. It is poured +forth less by an ordinary act of vomiting than by gushes, as if it +overflowed from the throat and mouth; and it often escapes from the +stomach and the bowels at the same instant. Such profuse evacuations +necessarily occasion an urgent thirst which cannot be satisfied, for +liquids are thrown up immediately on being swallowed. Sometimes a +distressing hiccough accompanies these symptoms. It is indeed only one +of the many spasms which may affect the muscular system. They +generally begin in the fingers and toes, which become bent and stiff; +they seize upon the muscles of the calves of the legs, and render the +muscular wall of the abdomen as hard as a board. The pain they produce +is extremely severe, and unless the patient is exceedingly prostrated +he endeavors to assuage it by a constant change of position. + +At this period the debility is very great, and progressively +increases, and the patient is unable to rise, or even to move at all +except under the stimulus of the painful spasms. The features are +shrunken; the nose is sharp and pallid, and bent to one side; the +dusky, lack-lustre, and sunken eyes, the thin lips, the hollow cheeks, +and the contracted muscles that stand out like cords under the tense +and clammy skin, present a physiognomy that belongs to no other +disease in the same degree. The hands and feet grow cold, and steadily +the coldness creeps upward toward the trunk; the temperature falls to +94 degrees or 95 degrees F.; the feeble and even flickering pulse +ranges from 100 to 120. The integuments of the limbs are shrivelled +and damp, and look as if they had been macerated in water; and if a +fold of the skin is pinched up it subsides very slowly indeed. The +eyes grow dull and dry, the tongue has a pasty or sticky feel, and the +urine is almost suppressed. If any of this excretion can be obtained +for examination, it is found to contain both albumen and sugar. As the +attack advances the patient falls into a dull, listless, and +motionless state, which may be mistaken for insensibility or even +unconsciousness but is really due to exhaustion of all the faculties +of mind and body. He may express no interest in anything, and hardly +notice the {734} attention or the distress of his friends, yet he will +generally give clear, although languid, answers to questions, and fall +again into an inert and unobservant state. + +As these symptoms continue and the fluids of the body decrease, the +blood accumulates and stagnates in the veins, giving to the hands and +feet, the nose and lips and other features, to the neck, and even to +the entire surface of the body, a bluish, leaden, or violet tint, +precisely like that of cyanotic children. The pulse, that was already +weak and thready, is no longer perceptible; the carotids even and the +impulse of the heart cease to be felt, and the second sound of the +latter becomes inaudible. The skin is everywhere cold; the hands, +feet, and face are sometimes of an icy coldness, and yet the patients +seldom perceive that they are so; indeed, complaint is more apt to be +made of suffering from internal heat. Even the breath as it issues +from the nostrils feels cold. The blood no longer circulates, and the +heart seems still. If a vein is opened a few drops of black and viscid +blood will trickle from the wound, which if it coagulates, yields but +little serum, and in place of a firm clot only a diffluent jelly. The +voice has sunk to a mere whisper or is quite extinct. The features +assume a distorted and frightful expression; the temples and cheeks +are hollowed; the nose is twisted and pointed, and the nostrils are +obstructed with dry and powdery crusts; the eyes are also dry, dull, +and sunken behind the half-closed and purple lids; the conjunctiva is +no longer moistened by its secretion and becomes bloodshot; the +temperature in the mouth may fall to 79 degrees or 80 degrees F.; a +viscid exhalation bedews the icy and marbled skin; and the whole body +is so shrunken from its natural proportions as to lose all the marks +by which its identity has been recognized. From this pulseless, +exhausted, cold, and cyanotic condition there can be but one step to +death. It generally comes on gradually, the patient sinking into the +state of apparent insensibility before mentioned; on the other hand, +he may expire suddenly on attempting to make some unusual effort. + +At any period in the progress of cholera, except that of complete +asphyxia, the contest between the system and the disease may be +decided in favor of the former. If this occurs before profuse +evacuations have taken place or blueness of the skin appeared, the +recovery may be gradual and present no special phenomena. The pulse +regains by degrees its natural force; the skin grows warm again, first +upon the trunk and afterward upon the extremities; the breathing +becomes easy, and, the diarrhoea having already ceased, convalescence +is established. But in proportion to the severity of the symptoms, the +intensity and duration of the cold stage, the cramps, and the +evacuations, will there be a tendency to febrile reaction, with more +or less passive congestion of the internal organs, and therefore a +slower return to health. If the attack has been very severe, and +particularly if the algid stage has been prolonged, fever of a low +type is apt to occur, and indeed may terminate fatally. This fever +presents all the characters of the typhoid state, and is marked by +dryness of the tongue, a brown crust upon the teeth and gums, jerking +of the tendons, delirium, and coma. These symptoms are partly +evidences of exhaustion, of inability of the system to resume its +normal action, and perhaps also they denote the retention of the +effete products of nutrition in the blood; but sometimes they appear +to be associated {735} with, and caused by, a local and latent +inflammation of low grade, established usually in the lungs. Again, +the nervous system seems to bear the brunt of the reactionary effort, +and the patient is attacked by convulsions or perishes in an +apoplectic fit. These phenomena appear to be due in most instances, if +not in all, to renal obstruction, and, as it is supposed that their +immediate cause is the retention of urea in the blood, they have +received the title of uraemic. In other cases a wasting diarrhoea, due +probably to the damaged state of the intestinal mucous membrane, is +superadded to the already existing typhoid state. Occasionally the +parotid glands become enlarged and painful, and sometimes a measly or +roseolous eruption appears upon the skin. + +It frequently happens that the convalescence from cholera is slow and +irregular. The system seems to be shattered by the trial it has passed +through; the nervous susceptibility is for a long time morbidly +increased, or, what is still more usual, the digestive function is +greatly impaired. The appetite is capricious and the digestion feeble. +The mouth is pasty, the abdomen tympanitic, the bowels are irregular +and alternately confined and relaxed. Finally, patients who leave the +bed too soon or indulge prematurely in their ordinary diet are liable +to a relapse, perhaps fatally, into the original disease. It has +sometimes happened that such a relapse has taken place several days +after an apparent restoration to perfect health. + +COMPLICATIONS AND SEQUELAE.--In a small proportion of cases, as above +stated, cutaneous eruptions have been observed during the attack of +cholera, or rather during its decline, for they coincide with the +reaction or follow it, and may be regarded as indications of +increasing vitality. They belong to the exanthematous class, and +comprise roseola, erythema, urticaria, and rarely vesicular +eruptions.[37] But, instead of them, there may occur destructive +tissue-lesions in the form of abscesses or ulcers. These affections +are more usual on the limbs than on the trunk or face, but some of +them may appear even in the mouth or fauces. Profuse sweats have been +noticed elsewhere, and the important fact that they carry off large +quantities of urea, which they deposit upon the skin. Diphtherial +exudation has also been met with upon tender parts of the skin and in +the fauces, as well as in the stomach and intestine. In some epidemics +of cholera suppuration of the parotid gland is occasionally observed, +while in others it may be entirely absent. Instances have been +reported of double parotitis, and in several of them the termination +of the attack was fatal. Still more rarely suppuration of the +submaxillary or the cervical glands has been met with. Another sequela +of cholera is a tetanic contraction of the flexor muscles of the +limbs. Between the tenth and fifteenth days of convalescence the +patient is attacked with a tearing, rending pain in the hands and +forearms, the legs and feet, followed by tonic contraction of the +flexor muscles of these parts. The sensibility is not impaired. The +attack lasts for one or several days, and seems always to end in +recovery (Guterbock). + +[Footnote 37: Compare _London Hosp. Reports_, iii. 457.] + + * * * * * + +Some of the individual symptoms of cholera call for a more detailed +notice than they have received in the foregoing epitome, in which the +continuity of the narrative could not be interrupted by a description +of variations depending upon the stage and grade of the disease. + +{736} The first to be considered is the temperature. The animal +temperature in cholera varies according to the part of the body at +which it is taken more than in any other disease. In cases of average +severity it rarely falls below 95 degrees F. in the axilla. The +temperature under the tongue does not furnish trustworthy indications. +In the stage of asphyxia it seldom exceeds 87.8 degrees F., and even +in cases that recover it may fall to about 78.8 degrees F. +(Wunderlich). In the cold stage it is not uncommon for a difference of +temperature to be noted of nearly ten degrees between the axilla and +the rectum. In a female aged thirty-two the temperature in the axilla +was 93 degrees F., and that in the vagina 102.8 degrees F. +(Mackenzie). In other cases a vaginal temperature of 104 degrees F., +and even of 108.32 degrees F., has been reached (Guterbock). Such high +temperatures furnish an unfavorable prognosis. As Wunderlich has +pointed out, during the algid stage temperatures taken in the mouth do +not give an accurate idea of the general temperature; the rectal and +vaginal temperatures are more nearly correct. The following are some +results of thermometry in 74 cases of cholera: Lorain found the +minimum rectal temperature in 1 case 93.2 degrees F., in 2 cases 95 +degrees, and in 10 cases 96.8 degrees. In 47 cases the normal +temperature was preserved; in 27 it rose to 100.4 degrees; in 15 cases +to 102.2 degrees; and in 1 to 104 degrees F. Leubuscher gives the +average temperature in the armpit 92.7 degrees F.; under the tongue, +90.5 degrees; upon the tongue, 81.5 degrees, in the nostrils, 79.2 +degrees; and on the palm of the hand, 84 degrees F. These numbers, +however, only represent averages. It should be noted that the low +temperature of the mouth and nostrils is caused not only by the +evaporation from the surface of those cavities, but also by the +relative coldness of the expired air, due to the partial suspension of +the passage of blood through the lungs, and therefore to the heating +of the air contained in them. According to Leubuscher also, the lowest +temperature is found in the nostrils, and next under the tongue, and +at the latter point it may vary from 79 degrees F. to 90.5 degrees F. +In death by asphyxia the vaginal and rectal temperatures may rise to +104 degrees-108 degrees F. The axillary fluctuates less than the +internal temperature. It is remarkable that during the algid stage the +patients, at least before the temperature has reached its minimum, are +not conscious of their coldness, but, on the contrary, complain of +internal heat, precisely as happens in the congestive forms of +periodical fever. When the febrile reaction assumes a typhoid type the +temperature in many cases is normal or only slightly elevated, and it +is of serious import if the temperature then sinks again below the +normal grade (Wunderlich). On the whole, the maintenance of a uniform +temperature, neither much above or below 90 degrees F. in the axilla +or under the tongue, may be regarded as favorable, yet recoveries have +taken place even when the temperature at these points has fallen to 79 +degrees F. If the temperature of the parts just mentioned should rise +rapidly to 104 degrees F., it may be regarded as a very unfavorable +sign. + +The skin, as has elsewhere been described, is pallid, bluish, +shrunken, and cold, and quite destitute of its natural firmness and +elasticity, so that when it is pinched into folds they subside very +slowly, as if they had been made on the skin of a corpse. It is +curious that, although the drain of liquids through the bowels is so +great, the skin not only remains moist, but generally is bathed in a +profuse cold sweat. Although the secretion of urine is reduced or +quite suspended, that of milk is said to be not {737} always so. Large +quantities of urea have been found in the urine, and in some cases it +has been visible upon the skin in the form of white scales. During +convalescence the skin may be the seat of the various eruptions +already enumerated. Of a graver nature, but, fortunately, of rarer +occurrence, are erysipelas, boils, abscesses, ulcers, and gangrene. +These several affections seem to result from the alternate obstruction +and freedom of the cutaneous circulation. They commonly appear first +upon the limbs, and afterward upon the face or trunk; they may affect +even the cavity of the mouth. Some observers have noted a relatively +frequent occurrence of diphtherial exudations in this disease, while +others do not allude to their existence. The former describe the false +membrane as affecting not only the mouth and fauces, but also the +stomach, the intestine, and the female organs of generation. A case is +reported by Joseph of a young man who, after an attack of cholera, was +affected with a blenorrhoea, due to a diphtherial inflammation of the +urethra. + +The character of the heart- and pulse-beats in this disease is quite +peculiar. Their rate does not increase indefinitely, as it does after +hemorrhage; the pulse usually varies from 90 to 110, and indeed seldom +exceeds 120, but its volume, tension, and force progressively decline +until the beats become imperceptible at the wrist, and even in the +brachial and femoral arteries. At the same time, the rhythm of the +heart is interrupted, the energy of its impulse declines until it can +no longer be felt, and its sounds grow weaker and weaker until they +become quite inaudible. Sometimes, it is said, a pericardial friction +sound may be heard, which is attributed to the dryness of the +pericardium. That the decline and suspension of the heart's sounds and +impulse are due not only to the weakness of the cardiac muscle, but +also to the lessened volume of the circulating blood, is proved by the +fact that they persist, sometimes for many hours, after reaction has +commenced, and only become audible again when the arteries have been +replenished with blood. + +In the description of the symptoms of cholera it has been mentioned +that the cyanotic color of the skin is produced by an accumulation of +blood in the veins. Many years ago Magendie, and after him +Dieffenbach, on examining the arteries of persons in the advanced +stage of cholera, found those vessels empty of blood. It might be +supposed that, under the circumstances, not only the right side of the +heart, but also the lungs, would be gorged with blood, and that +extreme dyspnoea would result. But, in point of fact, the respiration +in cholera is hurried and shallow rather than oppressed and labored, +while after death the lungs are not engorged with blood, but rather in +a bloodless condition. The pulmonary artery and its branches are also +empty, although the right side of the heart may be filled with dark +and soft coagula. These singular conditions seem to be due, on the one +hand, to the greatly diminished mass of the blood in the vessels, and +to its accumulating and stagnating in various parts of the venous +system, and, on the other hand, to the weakness of the heart, which is +shown by its suppressed impulse and sounds, and which lessens its +power to propel the venous blood into the lungs. The infarction of the +systemic veins and the threatening suspension of the circulation +necessarily impair the activity of all the functions, including those +of nutrition and disintegration, so that the effete detritus of the +economy tends to accumulate in the blood. This tendency is {738} +doubtless counterbalanced not only by the diarrhoea, but also, more or +less, by the almost total suspension of nutrition, due to the +inability of the cholera patient to digest or even to retain food, as +well as by the diminished oxidation of the blood in the lungs. It has +already been observed that, to a certain extent, the impediment to the +passage of the blood from the right side of the heart into the +ramifications of the pulmonary artery tends to prevent congestion and +infarction of the lungs. But this obstruction is precisely what occurs +during the stage of reaction in many cases, which then terminate +fatally by asphyxia, as in the previous stage still more perish by +apnoea. + +In the milder attacks of cholera vomiting may not occur, and in the +most severe it not unusually is suspended for some time before death, +although the diarrhoea may continue. In the most malignant cases, +indeed, there may be no vomiting at all, in consequence of the extreme +muscular exhaustion, although the stomach may be distended with +liquid. When rejected, the liquid has the general aspect of +rice-water, which the stools also present. Its reaction is alkaline or +neutral, and it is said to contain a less proportion than the stools +of solid matter, but a larger proportion of urea. The act of vomiting +is strictly one of regurgitation, which is performed without effort or +pain. Sometimes, indeed, it seems to relieve the sense of weight +caused by the accumulated contents of the stomach. It is readily +excited by attempts to drink, and even by slight changes of posture. +The vomited liquid at first contains the various articles of food the +patient may have eaten. Their half-digested remains have sometimes +suggested the announcement of strange specific forms of cholera germs. +The liquid, after ceasing to be colored brownish or greenish, becomes +gray, and subsequently, in favorable cases, more or less green again; +while during the stage of reaction in grave and ultimately fatal cases +it is more or less reddened by an admixture of blood. Its most usual +and characteristic appearance is that of a grayish liquid containing +whitish flocculi. The nature of this liquid, whether discharged by +vomiting or by purging, has been variously estimated. Formerly, some +persons held the white granules to be leucocytes, but the greater +number agree that they are mainly epithelial fragments. When the +vomited liquid is allowed to stand, a sediment forms in it which is +composed almost entirely of epithelial scales, more or less modified +in their appearance by the accidental contents of the stomach, and a +film covers its surface in which globules of fat and phosphatic +crystals may be detected. They are frequently associated with +sarcinae, produced by fermentation in the contents of the stomach, and +after standing for some time the liquid becomes crowded with vibrios +(Lindsay). + +Although the propensity of the sick to discover a cause for every +symptom often leads cholera patients to attribute their diarrhoea to +some particular exposure to cold, error of diet, etc., yet, in fact, +this symptom, so far as it belongs to cholera, is primarily an effect +of the cholera poison alone, although it may be aggravated by causes +like those mentioned. It is of great practical importance to bear in +mind that a specific choleraic diarrhoea--that is to say, a diarrhoea +produced by the cholera poison alone--may continue to be very slight +as long as it lasts, which may be for several weeks; and hence, as +elsewhere insisted upon, a person who is not suspected of being +affected with cholera may, quite ignorantly, sow {739} the seeds of a +deadly epidemic of the disease. The danger in cholera is proportioned +to the volume of the discharges rather than to their frequency, just +as a single profuse hemorrhage is more serious than the loss of an +equal amount of blood divided among several successive days. The +special danger, however, is not, as in hemorrhage, from syncope, but +from the progressive loss by drainage of the water of the blood, +rendering it unfit to circulate, and therefore causing it to stagnate +in the veins. The spoliative operation of the diarrhoea has +occasionally been productive of benefit instead of injury, as in the +following case of Barlow: A man suffering from dropsy was attacked +with cholera, "and passed gallons of liquid by stool, had cramps, and +became livid and clammy, but his pulse did not disappear, as in +profound collapse, and he eventually rallied, and left the hospital +apparently well. When he began to recover from cholera his appearance +was almost ludicrous, from the manner in which the integument hung +loosely about him." + +The stools pass through a series of changes corresponding to those of +the matters vomited, being fecal at first, and then becoming colorless +and watery. During reaction, if that occurs, they regain more or less +of their proper color, but if typhoid febrile symptoms prevail they +are usually bloody. Decomposed blood sometimes renders them dark, +tarry, and fetid; this condition has caused them sometimes to be +described as being composed of vitiated bile, which is, however, a +product not of the liver, but of the imagination. + +In the intestine after death considerable quantities of epithelium are +found floating in the contained liquid or else loosely adherent to the +mucous membrane. It is usually in flocculi, but sometimes in fragments +large enough to form a continuous membrane. A microscopic examination +of cholera stools shows that their turbidness depends chiefly upon +desquamated epithelium, with which is mixed white corpuscles and +bacteria. It is remarkable that although the stools are drained +directly and so rapidly from the blood-vessels, they nevertheless +contain but little albumen, indeed hardly more than a trace of it. If, +however, blood is mixed with the stools, as happens in rare instances, +more albumen is present. Oil-globules are most abundant in cases that +have passed beyond the stage of collapse into that of reaction with +fever. In these it is said that oily matter may be found either in +concrete masses or as a scum of liquid oil. Of inorganic constituents +they contain crystals of the triple phosphate of ammonium and +magnesium and chloride of sodium in greatest abundance, but the +proportion of ammonium and potassium salts is small. Indeed, the total +amount of solids does not exceed 2 per cent. As the quantity of water +in the blood and solids is limited, and as in this disease the stomach +will not receive nor retain any liquid, it follows that the more +profuse the evacuations are, the shorter must be the duration of the +attack, for the sooner then does the blood become too thick to +circulate. + +It has several times been stated that in cholera the urine is +diminished, and that, therefore, the blood retains a larger proportion +of effete products than in health. But it has also been remarked that +the amount of these products is abnormally small, on account of the +interference with nutrition of the abnormal state of the circulation. +Doubtless, as in other cases of renal obstruction, an increased +proportion of effete matter is eliminated by the skin, if not by the +bowels. When the amount of {740} urine excreted is only diminished, +its specific gravity may vary between remote extremes, as 1.012 and +1.030. Usually, however, when its quantity is very greatly reduced, +symptoms which are described as uraemic are apt to arise, and the +urine is found to contain the usual products of renal congestion--viz. +albumen, sometimes traces of blood, hyaline and granular casts, and +epithelial scales, with less chloride of sodium and more urea than +normal. It is remarkable that at the beginning of convalescence the +urine, which had been suppressed or greatly diminished, may become for +a time abnormally abundant. Rarely, if ever, does the derangement of +the kidneys now described denote or produce an organic lesion in those +organs. Like the disorders elsewhere, these are due to the loss of +balance between the arterial and the venous sides of the circulation; +both, indeed, have lost their functions more or less, the one by lack +of blood, the other by an excess of blood unfit for circulation. + +The occurrence of cramps in cholera, which has bestowed upon the +disease one of its titles, spasmodic, has, however, no distinctive +relation to the Asiatic disease. Spasmodic phenomena occur in many +cases of poisoning by corrosive and irritant agents and in ordinary +cholera morbus, and in cholera infantum they are among the most +alarming symptoms, assuming, as they often do, the character of +general convulsions. In most of these cases they are clonic and +general, and therefore probably of central origin, primary or +reflected; but the spasms of cholera are tonic, and affect the muscles +of the upper and lower limbs, and most frequently the flexor muscles +of these parts, and especially those of the fingers and toes, which +become rigidly bent. The larger muscles contract into hard lumps, and +even those of the chest and abdomen do not escape the terrible spasms. +When they are severe they extort cries from patients who at other +times seem quite apathetic. It is stated by Macnamara that the natives +of Southern Bengal and other people of relatively loose fibre are much +less apt to be attacked by them than the natives of the upper country +or than Europeans. It may be debated whether their immediate cause is +a reflex irritation emanating from the gastro-intestinal mucous +membrane; or whether it is due to the rapid diminution of the supply +of blood to the nervous centres, or to the infarction of those centres +with thick and imperfectly oxygenated blood; or, finally, whether it +is occasioned by a diminished supply of blood, and that blood of bad +quality, to the muscles themselves. Probably all of these factors are +associated causes in producing the spasmodic phenomena of cholera. It +is well worthy of notice, however, that spasms, which are so frequent +in all infantile diseases, and especially in those affecting the +stomach and bowels, rarely attack children suffering from cholera. +This would seem to prove that the spasms in question are not reflex, +but either central and spinal, or else muscular--an inference which is +strengthened by their being tonic and not clonic. As stated, the +spasms, or cramps, frequently affect the limbs, but comparatively +seldom involve the muscles of the chest or abdomen, and those of the +face hardly ever. They are almost the only causes of pain in the +disease, which in not a few instances runs its whole course, even to a +fatal termination, without their occurrence. + +As a rule, the abdomen is not so much retracted as might be expected +from the profuse discharges. Probably in some degree its form is +maintained by the constantly recurring accumulation of liquid in the +{741} gastro-intestinal cavity. In protracted cases, however, the +abdomen becomes sunken and hollowed. At all stages of the disease it +is somewhat sore under pressure, especially at the epigastrium, and it +generally has a doughy feel. As to the functions of the digestive +organs, they are completely suspended during a typical attack of the +disease. Not only are these organs incompetent to digest food, but +they cannot even retain it. + +Throughout such an attack not only is sleep apt to be prevented by the +pain of the cramps and the frequent evacuations, but, as a rule, the +patient is wakeful, and yet, apart from the restlessness which +accompanies the paroxysms of pain, there is, on the whole, a tendency +to a placid quietness. Mental excitement and delirium are probably +unknown during the primary attack, but sometimes a degree of +somnolence or of apathetic tranquillity exists, which, however, is +quite distinct from coma. When the attack is prolonged, and especially +when it merges into a typhoid state, the eyes become inflamed by their +exposure to the air. The conjunctiva then grows blood-shot, and +occasionally the cornea is ulcerated. + +MORBID ANATOMY AND PATHOLOGY.--The appearance after death of a person +who has died in the collapse of cholera is very characteristic. It +comprises a shrunken aspect of the whole body, its prevalent grayish +or leaden pallor contrasting with the livid hue of the abdomen and +back, the fingers and toes, the lips and eyelids, and ears; the eyes +are sunken deeply in their orbits; the nose is sharp and bent, the +temples are hollow, and the skin seems to cling tightly to the bones +beneath it. The connective tissue is very dry, and the muscles are +hard as well as dry, and, owing to the wasting of the softer parts, +stand prominently out. In consequence of the absence of moisture +decomposition takes place very slowly. Cadaveric rigidity is very +marked and persistent. A very notable phenomenon is the occurrence of +muscular contraction after death. It may be excited mechanically or +may occur spontaneously. A case is related (Eichhorst) in which three +hours after death the fibres of the biceps were observed to move +tremulously, and then the entire muscle contracted, causing flexion of +the forearm. Even the fingers performed movements like those made in +piano-playing. The lower jaw has also been observed to move, causing +the mouth to open and shut repeatedly. The late Sir Thomas Watson long +ago described this singular phenomenon as follows: "A quarter or half +an hour, or even longer, after the breathing had ceased, and all other +signs of animation had departed, slight, tremulous, spasmodic +twitchings and quiverings and vermicular motions of the muscles would +take place, and even distinct movements of the limbs, in consequence +of these spasms."[38] It was carefully studied by Barlow, from whose +narrative the following is taken: The patient was a strong man; the +course of his attack was rapid, and he suffered most cruelly from +cramps. "Within two minutes of his ceasing to breathe muscular +contractions began, becoming more and more numerous. The lower +extremities were first affected. Not only were the sartorius, rectus, +vasti, and other muscles thrown into violent spasmodic movements, but +the limbs were rotated forcibly and the toes were frequently bent. The +motions ceased and returned; they varied also: now one muscle moved, +now many. Quite {742} as remarkable were the movements of the arm: the +deltoid and biceps muscles were peculiarly influenced; occasionally +the forearm was flexed upon the arm--flexed completely, and when I +straightened it, which I did several times, its position was recovered +instantly. The fingers and thumbs were now and then contracted, and at +times the thumbs were separately moved. The fibres of the pectoral +muscles were often in full action; distinct bundles of them were seen +at intervals beneath the skin.... After I had taken leave of the body +the nurse was horrified by a movement of the lower jaw, which was +followed by others; and I thought for a moment that the man was alive. +The facial muscles became generally affected, and at length all was +still."[39] These muscular contractions succeed one another in a +regular order, beginning in one lower extremity and extending to the +other, then to the upper limbs, and finally to the face. Their degree +varies from a slight quivering to a powerful contraction, and their +duration from a minute or less to an hour and a quarter. Cases have +occurred in which the legs were so forcibly retracted that they could +with difficulty be straightened again. In one case, six hours after +death movements took place in one leg, and the hand was drawn across +the chest; in another, "the forearms were powerfully flexed, and the +hands, approximating, gave the attitude of praying to the body."[40] +Again, Mr. Ward reports: "I saw the eyes of my dead patient open and +move slowly in a downward direction. This was followed, a minute or +two subsequently, by the movement of the right arm (previously lying +by the side) across the chest." In the same paper Barlow says: "Mr. +Lawrence mentioned to me that a gentleman who died in 1832 of rapid +cholera was turned after death completely on the side by a strange and +forcible combination of muscular contractions."[41] These muscular +phenomena after death form an interesting feature in the history of +cholera, but they are by no means peculiar to that disease. They have +been observed in other diseases, and especially in yellow fever--an +affection in which the pathological condition is quite unlike that of +cholera. In both diseases they have been manifested in robust persons +and when the course of the fatal attack was both rapid and severe. +Thus, Dr. Dowler of New Orleans not only found that they could be +developed in such cases of yellow fever by striking the muscles, but +he observed their spontaneous occurrence in several, of which the +following is a remarkable example: "Not long after the cessation of +the respiration the left hand was carried by a regular motion to the +throat, and then to the crown of the head; the right arm followed the +same route on the right side; the left arm was then carried back to +the throat, and thence to the breast, reversing all its original +motions, and finally the right hand and arm did exactly the same."[42] +In 1860, Drasche alleged that not unusually the skin covering the +contracting muscles became reddish, while the local temperature rose +1/2 degree, and that as soon as the contractions ceased the +temperature fell below the normal and cadaveric rigidity set in. +According to the same observer, analogous contractions affect the +unstriped muscular fibres, in those of the skin producing a projection +of the papillae, and in the genital organs a discharge of semen. This +phenomenon is said to have occurred an hour and a half after death. + +[Footnote 38: _Lectures_, Am. ed. of 1872.] + +[Footnote 39: _London Med. Gaz._, Nov., 1849, p. 798.] + +[Footnote 40: _Ibid._, Jan., 1850, p. 185.] + +[Footnote 41: _Ibid._, pp. 185, 186.] + +[Footnote 42: _Experimental Researches_, 1846.] + +{743} On opening the abdominal cavity of persons who have died in the +collapse of cholera one is struck by the general pink or rose tint of +the peritoneal coat of the intestines. It is produced by a repletion +of the minute branches of the portal venous system. Sometimes the +color is rendered very dark by the pitchy blood contained in the +veins. The surface of the peritoneum, like all the tissues, is +singularly dry, and often has a soapy or sticky feel, caused by a +layer of albuminous matter, which forms a lather when rubbed between +the fingers, and causes the intestinal folds to adhere to one another. +If death takes place during the stage of reaction, these appearances +are less distinct, and the intestines, which in collapse are usually +retracted, are then somewhat distended. + +The stomach generally contains a thin, partially transparent liquid of +a greenish or grayish color, and occasionally reddish, holding in +suspension portions of coagulated mucus and an unctuous substance of +an albuminous nature, which adheres to the walls of the cavity. Fatty +globules may be observed floating in the liquid, which under the +microscope reveals epithelial debris, granular corpuscles, and +fragments of gastric glands. Under heat and nitric acid coagulation of +the liquid occurs, and on chemical examination it is found to contain +urea. The gastric mucous membrane is of a dark violet or pale pink +color, according to the stage of the disease; its follicles are +enlarged, and patches of superficial abrasion may be observed on it. + +The intestinal canal of those who die during the collapse of cholera +is, in the majority of cases, partially filled with liquid which has +the aspect of turbid serum, more or less mixed with the previous +contents of the bowel if death has taken place very rapidly, but +otherwise it is almost colorless. On the whole, however, it is less +pale and watery than the stools. It contains, like these discharges, +more or less epithelial flocculi, and generally more than were +observed during life in the dejections. The mucus scraped from the +lining membrane of the intestine and mixed with water renders it +turbid with epithelial debris. The same mucus examined microscopically +contains fragments, larger or smaller, of epithelium. These conditions +are said to predominate in the large intestine. Indeed, the proportion +of liquid increases from above downward. Hence in the more prolonged +cases the contents of the bowel at its upper part are less liquid and +are darker in color. There is, indeed, a striking contrast between the +appearance of the intestine in cases which have terminated in collapse +and its aspect in persons who have died during the stage of reaction. +It has been clearly presented by Dr. Sutton.[43] When death took place +in "the cold stage the mucous membrane was unusually pale in three +cases; in two it was healthy-looking; in other two it was pale +throughout, excepting that one or two of Peyer's patches were +congested; and in the remaining three there was more or less +congestion of the mucous membrane. When the mucous membrane was pale +throughout the entire intestine, the valvulae conniventes looked +swollen and oedematous, and the color of the membrane was dead white. +The solitary glands were very distinct and prominent. Those of the +duodenum were remarkably so. In cases of imperfect reaction the mucous +membrane of the intestine was usually found very much congested and +ecchymosed. The congested portions were sometimes {744} granular, and +apparently denuded of epithelium. The mucous surface had often a dark +port-wine color, due to the extravasated blood and the hyperaemia, and +here and there the surface was covered with a dirty gray membranous +substance, likened to a diphtheritic deposit. I have, however, seen no +decided false membrane, such as could be peeled off, as in diphtheria. +The surface was also occasionally bile-stained, and the +greenish-yellow color of the bile and the deep red color of the +congested surface presented a very striking appearance. The solitary +glands were very prominent, and in some cases apparently enlarged." +The general paleness of the intestinal mucous membrane in the stage of +collapse, and its congestive redness whenever the signs of reaction +have existed before death, have a very important bearing upon the +pathology of this disease, for they demonstrate conclusively that the +gastro-intestinal evacuations in cholera have no relation whatever to +inflammation. On the other hand, they render it altogether probable +that the serous flux is in the nature of a sweat, an intestinal +ephidrosis. + +[Footnote 43: _London Hosp. Clin. Lect. and Reports_, iv. 497.] + +The nature of the exfoliation found in the intestinal canal has been +the subject of much discussion. As long ago as the first American +epidemic of cholera (1832-35) Dr. W. E. Horner, Professor of Anatomy +in the University of Pennsylvania, described an exfoliation of the +epithelial lining of the alimentary canal, whereby the extremities of +the venous system of the part are denuded, as being characteristic of +cholera alone. In 1849, Dr. Samuel Jackson, Professor of the +Institutes of Medicine, and Dr. John Neill, Demonstrator of Anatomy in +the University, in conjunction with Dr. William Pepper and Dr. Paul B. +Goddard, presented a report to the College of Physicians of +Philadelphia, in which they, too, showed that the "epithelial layer of +the intestinal mucous membrane was either entirely removed or was +detached, adhering loosely." This important fact--the most important, +perhaps, in the mechanism of cholera--was confirmed seventeen years +later by the eminent pathologist Dr. Lionel S. Beale,[44] who, when +referring to "the remarkable characters of the matter discharged from +the intestinal tube, and to the fact that the small intestines almost +always contain a considerable quantity of pale almost colorless +gruel-, rice-, or cream-like matter," added: "This has been proved to +consist almost entirely of columnar epithelium, and in very many cases +large flakes can be found, consisting of several uninjured epithelial +sheaths of the villi.... In bad cases it is probable that almost every +villus, from the pylorus to the ilio-caecal valve, has been stripped +of its epithelial coating during life.... These important organs, the +villi, are, in a very bad case, all or nearly all left bare, and a +very essential part of what constitutes the absorbing apparatus is +completely destroyed.... It is probable that the extent of this +process of denudation determines the severity or mildness of the +attack.... It seems probable also that the epithelium may become +detached in consequence of the almost complete cessation of the +circulation in the capillaries beneath, but the death of the cells may +occur in consequence of their being exposed to the influence of +certain matters in the intestine or in the blood, in which case they +would simply fall off." + +[Footnote 44: _Med. Times and Gazette_, Aug., 1866, p. 109.] + +In this connection, and as complementary of the statements now made, +should be considered the further description by the same author--viz.: +{745} "Remarkable changes have occurred in the smaller vessels, +especially in the capillaries and small veins of the villi and +submucous tissue. The blood-corpuscles appear to have in a great +measure been destroyed in the smaller vessels, and in their place are +seen clots containing blood-coloring matter, minute granules, and +small masses of germinal matter evidently undergoing active +multiplication. Some of the arteries are contracted, but here and +there small clots destitute of blood-corpuscles may be seen at +intervals." Hence, the gastro-intestinal lesions in cholera, according +to their extent and degree, they remove the natural obstacles to +exhalation in the mucous membrane, and also, and in the same degree, +prevent the absorption of the contents of the alimentary canal. It +must not, however, be forgotten that this lesion is not altogether +peculiar to the intestinal mucous membrane. Dr. Beale long ago called +attention to the fact that in this disease there seems to be a +tendency to the removal of epithelium from the surface of all soft, +moist mucous membranes, but not from the follicles of the glands. The +first statement appears to be explicable by the shrinkage of all the +mucous membranes during cholera collapse, for by this merely +mechanical agency the inelastic epithelium must necessarily become +detached. As to the second statement, the remark may be made that the +whole follicular structure furnished with columnar epithelium is an +absorbing and not an eliminating apparatus, and that, since its +functional activity is from the beginning of the disease diminished by +an inadequate blood-supply, it can have but a small and indirect share +in generating the phenomena of the disease. + +In 1884, Dr. Koch, during his investigations of cholera in India, +found bacilli in the bowel which he believed to be peculiar to the +disease, and which presented the following characters: they were not +straight, like other bacilli, but curved or comma-shaped; they +proliferated rapidly and displayed very active movements. Bodies of +persons who died of various other diseases did not present them, +although abounding in different bacteria. The bacilli were not found, +or only exceptionally, in the stomach, but abundantly in the +intestine, and most so in the diarrhoeal discharges that occurred at +the height of the disease. As soon as the stools began to be fecal the +specific bacilli disappeared from them. After death at the height of +the disease they were most abundant in the intestinal contents, and +especially in the lower part of the small intestine. When death took +place at a later period none of them might be detected in the liquids +in the bowel, but they would still be present, in considerable +numbers, in the tubular glands. They were not found at all in cases +fatal from some sequela of the disease.[45] + +[Footnote 45: _Times and Gaz._, Mar., 1884, p. 398.] + +Other abdominal lesions in cholera possess a very subordinate +importance. The isolated and the agminated glands are both prominent, +chiefly because they are swollen by the liquid imbibed from the bowel. +A whitish substance which they sometimes contain may perhaps be the +albumen or fat which they have taken from the intestinal liquid. A +very similar condition of the mesenteric glands is probably due to a +like cause. The liver is pale and flaccid when death takes place in +collapse, and it is also described as presenting a "dirty grayish-red, +homogeneous appearance, and indistinctness of the lobular structure, +as if some glutinous matter had been poured throughout the tissues of +the organ" {746} (Sutton). This appearance would seem to be due to the +total suspension of the blood-supply through the portal vein. + +At all stages of the disease the gall-bladder is usually found full of +bile, which is apt to be dark during the collapse and more watery +after reaction has commenced. + +The spleen is small, pale, and, as a rule, firm, but occasionally it +is soft. + +The kidneys present no marked changes when death has taken place early +in the attack, or at most only exhibit a lighter color than usual of +the cortical substance and a darker one of the pyramids. They show +that the arteries are comparatively empty and that the veins are +congested. Similarly contrasted appearances are met after death from +obstructive disease of the heart and other causes that produce +obstruction of the venae cavae. In the tubules, later on, fatty +degeneration of the epithelium has been observed, and some cylindrical +casts. These alterations, especially of the tubules, are most marked +when death occurs in the stage of reaction, and are then apt to be +accompanied by more or less hemorrhagic transudation. The urinary +bladder is always contracted after death in collapse; after febrile +reaction its mucous membrane may be more or less coated with false +membrane. + +The brain and the spinal marrow offer nothing peculiar; their venous +systems are everywhere more or less engorged, and sometimes effused +blood has been found in the spinal canal. + +In the state of the respiratory organs the most important facts are +that in algid cholera the lungs are always more or less collapsed, +"shrunk and small, and lying back in the chest, toward the spine," and +that, so far from being congested, they are (with the exception of a +small portion of their posterior part rendered dense by hypostasis) +singularly bloodless, dry, and tough. As might be inferred from these +conditions, they are also lighter in weight than natural. To Dr. +Parkes belongs the credit of having first described this very +important fact in the morbid anatomy of cholera, as follows: "In +fourteen cases the lungs were completely collapsed, appearing in some +cases like the lungs of a foetus. In three cases they were +considerably, in eight slightly, collapsed, and in the remaining +fourteen cases the collapse was in some altogether, and in some +partially, prevented by old adhesions."[46] So Dr. Sutton found that +the average weight of the two lungs during collapse was about twenty +ounces, and after reaction--that is, after the passage of the blood +into the pulmonary artery had become completely re-established--about +forty-five ounces. In the latter condition also the lungs presented +the usual signs of congestion of those organs, being dark-red +throughout or in portions only. Sometimes also they contained masses +or nodules of apparent hepatization, and of these some may have +undergone partial softening. + +[Footnote 46: _Med. Times_, 1848, p. 378.] + +In absolute conformity with the condition of the lungs that has been +described is that of the heart. If the lungs are bloodless, it follows +necessarily that the left side of the heart must be empty, and almost +as necessarily that the right side of the heart must be distended with +blood. All careful investigators of the subject agree that such is the +condition of the heart when death takes place in cholera during the +stage of {747} asphyxia. All report that the pulmonary artery is +either empty or that it contains a small quantity of dark and usually +of thick blood; that the right side of the heart and the coronary +veins are distended with blood of the same description, while numerous +ecchymoses exist along the course of the coronary veins; that the +venae cavae are filled with half-coagulated blood of a tarry aspect; +and that even the femoral and splenic veins contain similar blood. On +the other hand, the left ventricle of the heart is usually contracted, +and contains a very little semi-fluid blood, with perhaps a small and +pale clot. This engorged condition of the right cavities and emptiness +of the left cavities of the heart diminish very slowly during the +passage from collapse to reaction, during which time the pulmonary +blood-vessels are being gradually replenished. Besides the thick and +tarry aspect of the blood above described, it has been observed that +when the blood is withdrawn by means of a pipette, its globules +rapidly subside and are surmounted by a transparent serum, and that +such blood may remain for a long time uncoagulated. The red corpuscles +are said to be pale and viscous, but not adhesive, and the white +corpuscles abnormally numerous and easily crushed. In the free +intervals are observed "very pale little objects, slightly elongated +and constricted in their middle," which multiplied in blood kept for +one or two days at a temperature of 38 degrees C. (100.4 degrees +F.).[47] If death does not take place until reaction is far advanced +or has merged into a febrile condition, the left ventricle is usually +found not contracted, and it contains a quantity of blood. The term +"usually" is employed to show that even to this rule there are some +exceptions, and that, as in all other diseases, the issue does not +depend absolutely and exclusively upon a definite degree of any +anatomical lesion, but upon the aggregate condition of all the +functions upon which life depends. The pericardium, like the pleura +and the peritoneum, may be covered with a saponaceous film which is +albuminous. + +[Footnote 47: _Rapport sur le Cholera d'Egypte en 1883_, par M. le Dr. +Strauss, etc.] + + * * * * * + +In looking now over the field that has been traversed in the foregoing +pages, and searching for some link that will unite in a consistent +whole the causes, symptoms, and lesions of cholera, it is evident that +only one factor can possibly be so described. That factor is the +gastro-intestinal flux. This it is that produces the vomiting and the +purging; that prostrates the patient and wastes away in a few hours +the fullest and the firmest form; that chills the limbs and afterward +the trunk; that thickens the blood so that the capillary vessels can +no longer convey it, and that spreads a cyanotic shadow over the whole +surface of the body; that cuts off the supply of blood from the lungs +and heart; that paralyzes the nervous system, ganglionic as well as +cerebro-spinal; that obstructs the kidneys and arrests their +secretion; and that, acting through the several links of this +pathological chain, becomes the cause of death. But the question still +recurs, What is the cause of the gastro-intestinal flux? To this also, +in the light of observation, it is possible to give only one answer. +It is a specific poison which originates in Hindostan, and, being +taken into the stomach and bowels, not only produces in the individual +the symptoms and lesions of cholera, but is capable of multiplying +itself and rendering infectious the discharges from the stomach and +bowels of the subjects of the disease, so that it may be transmitted +from {748} one person to another round the whole circumference of the +globe. Regarding the form and nature of that poison little or nothing +is definitely established, beyond what has already been stated as the +result of Koch's observations. As far as they go, they harmonize with +a long-prevalent opinion that the cholera poison consists of certain +microscopic germs, which, on being received into the bowels, propagate +their kind and destroy the epithelium. It is believed by some that +these bodies are products of the rice-plant on the banks of the +Ganges, and that, having once originated the disease, the germs +contained in the discharges become mixed with water or are borne upon +the wind, and enter the system of new victims, who, in their turn, +disseminate the plague. This theory will be further considered below. + +Another view, that of B. W. Richardson, is that, "as pus undergoes +changes which convert it into a septic poison, so the excreted matter +from the alimentary canal is equally capable, under peculiar +conditions of oxidation, of producing an alkaloidal organic poison, +which, soluble in water, but admitting of deposit on desiccation," +becomes the agent for disseminating the disease. In these theories a +false datum and a hypothesis are offered us in place of the fact which +we seek. The cryptogamous nature of the essential cause of the disease +has no positive proof, but only the probability of coincidence in its +favor. There is no proof, because one after another organic form has +been alleged to be the essential generator of the disease, and each +has been proved to be either not peculiar to cholera or has been shown +to be present in other diseases than cholera. + +At the present time (1884) it is the fashion to trace every disease to +specific bacteria or analogous organisms. But it may be that the +occurrence of cholera only furnishes the occasion for the development +of these organisms, just as a certain temperature, hygrometric +condition, and deficient light and air will cause mould to form on +bread and other organic substances. The judgment pronounced by Dr. +Beale in this question as long ago as 1866 appears now, as it did +then, to approach the truth upon this point: "There is no good reason +for supposing that the bacteria in such numbers in the alimentary +canal in cholera have anything to do with this disease or with the +falling off of epithelium from the intestinal and other mucous +membranes. Bacteria are developed in organic matter which is not +traversed and protected by the normal fluids of the body, and they +invade the cells and textures in cholera after those cells and +textures have undergone serious prior changes, just as they would +invade textures removed from the body altogether. Nor would it be in +accordance with known facts to infer that cholera was due to the +invasion of some peculiar form or species of bacterium."[48] + +[Footnote 48: _Times and Gazette_, Aug., 1866, p. 167.] + +We repeat, then, that while nothing can be simpler than the mechanism +of cholera viewed as a gastro-intestinal hyperidrosis, nothing is more +mysterious than the mechanism of the primary cause which gives rise to +it. That its real nature has been correctly described is rendered all +the more probable by the fact, presently to be insisted upon, that +sporadic cholera morbus, which is always the consequence of a direct +irritation of the gastro-intestinal mucous membrane, is often with +difficulty distinguishable from Asiatic cholera, which, indeed, +differs from the former {749} disease chiefly by the intensity of its +cause as measured by the gravity of its symptoms and by the nature of +the special agent that produces it. + +The above views regarding the essential cause of cholera were +substantially indited before the Egyptian epidemic of 1883, but they +are in accord with the more definite conclusions arrived at by the +German and French commissions on the subject. Before their reports +appeared, however, a communication was made by Dr. Kartulis of the +Greek hospital in Alexandria, setting forth that the drinking-water +and the stools and blood of the cholera patients contained, the first +a mass of micro-organisms, and the others bacteria and micrococci, +which, however, presented no distinctive characters.[49] The German +report was prepared by Dr. Koch, the French by Dr. Strauss.[50] The +former, alluding to the enormous quantity of micro-organisms found in +the contents of the bowels and in the stools, did not perceive any +connection between them and the phenomena of the disease. On the other +hand, he did assign this relation to a species of bacterium found in +the walls of the intestine, and which he compared to the bacilli of +glanders. They were lodged in great quantities within the intestinal +glands and behind their epithelium, as well as upon the surface of the +villi and within them, and sometimes even in the muscular coat. They +were most numerous at the lower end of the small intestine. Dr. Koch +concluded that although these bacilli, beyond doubt, are in some +manner associated with the development of cholera, they are by no +means shown to be its cause, and may indeed be themselves the product +of the morbid conditions belonging to cholera. All his attempts at +that time to develop cholera in animals by inoculating them with the +organisms gave only negative results. The conclusions of Dr. Strauss +were in entire conformity with those of Dr. Koch, but involved an +additional and very important statement--viz. that the shorter and the +more violent were the fatal attacks of cholera the fewer were the +bacteria found in the intestine. It is evident that this fact is the +very opposite of what should have been found had bacteria been +essential in the causation of cholera. The more recent investigations +conducted in Calcutta by Dr. Koch, which have already been cited, led +him, however, to attribute to bacilli of a specific form the absolute +origination of the disease. He poses the question in the following +manner: Either these "comma bacilli" are a product of the cholera +process, or "the disease only arises when these specific organisms +have found their way into the bowel." The former alternative he +rejects, because, in his judgment, it assumes that the bodies in +question must be pre-existent in every person who becomes affected +with the disease--a hypothesis which he rejects, because they have +never been found except in cholera. He therefore concludes that they +are the cause of cholera. He points out that their first appearance +coincides with the commencement of the disease, that they increase +with it, and that they disappear with its decline.[51] The statement +of Strauss quoted above does not, however, appear to harmonize with +this conclusion, since the bacteria are said by him to have been +fewest in the more violent and fatal attacks of the disease. Another +of Dr. Koch's remarks is also open to criticism. After showing how +rapidly the cholera bacteria multiply when kept moist, he states that +they die after drying more quickly than almost any other form of +bacteria. "As {750} a rule, even after three hours' drying every +vestige of life has disappeared." It is evident that this statement is +not in harmony with the numerous facts, several of which have been +cited, that cholera fomites have preserved their infectious qualities +after several weeks. Dr. Koch endeavored to produce in animals, +artificially, with these bacteria, a disease analogous to cholera, but +without success; and he adds, "If any species of animal whatever could +take the cholera, it would surely have been observed in Bengal, but +all inquiries directed to this point met with a negative result." Dr. +Vincent Edwards, who, however, is of opinion that the cholera poison +is "not an organism, but of the nature of a chemical compound of +comparatively unstable nature," reports that he produced fatal cholera +in pigs by giving them the dejections of cholera patients.[52] But the +_Times and Gazette_ inclines to question that the pigs employed in Dr. +Edwards' experiments were affected with true cholera. + +[Footnote 49: _Medical News_, xliii. 377.] + +[Footnote 50: _Archives gen._, Dec., 1883, pp. 713, 722.] + +[Footnote 51: _Times and Gaz._, Mar., 1884, p. 398.] + +[Footnote 52: _Notes on the Poison contained in Choleraic Atomic +Discharges._] + +DIAGNOSIS.--The most characteristic symptoms of Asiatic cholera have +repeatedly been mentioned in the foregoing pages. They are rice-water +evacuations by vomiting and purging, rapid emaciation of the whole +body, a cadaverous hollowness of the cheeks and eyes, a livid color of +the face, hands, and feet, a feeble, thready, and at last absent +pulse, an icy coldness of the extremities, face, and even the breath, +a loss of the elasticity of the skin, a thin and feeble voice, and +intense thirst. But every one of these symptoms may occur in cholera +morbus produced by a direct irritation of the stomach and bowels. It +is rather their nature, we repeat, than their phenomena that +distinguishes these two affections from each other. In attempting to +separate Asiatic cholera from other forms of cholera we must endeavor +to dismiss from the mind the erroneous notion that the term cholera +denotes a definite disease identical in its cause, phenomena, and +results. It is no more a disease than dropsy or fever is a disease. It +is a complex group of symptoms which have in common the fact that they +proceed directly from gastro-intestinal irritation, whose degree of +severity--_i.e._ the presence or absence of certain grave +symptoms--and, above all, its issue, depend chiefly upon the nature +and intensity of the cause of the attack, and also, necessarily, upon +the degree of resistance opposed to it by the subjects of the disease. +Nothing has led to more error in regard to epidemic cholera than the +ignorance of this pathological fact by some and the disregard of it by +others. + +In the first portion of this article it was shown that the Greek, +Roman, and Arabian conceptions of cholera morbus included a discharge +of bile, the very symptom for the absence of which Asiatic cholera is +notorious; and also that the classical cholera, or cholera morbus, +ended in recovery even more frequently than Asiatic cholera terminates +in death. But local epidemics of cholera morbus sometimes take place +which are of a severe and even of a grave type, and which also appear +to originate in some peculiar atmospheric influence, for they prevail +to a limited extent and in connection with vicissitudes of weather. +Still more circumscribed epidemics have been traced to unwholesome +food and drink, and innumerable instances of individual attacks have +been caused by irritants that are ranked as poisons and others which +are reckoned as food or medicines. Now, under these various +circumstances, which have in common gastro-intestinal irritation, +there may be produced, if the irritation is excessive, {751} a series +of symptoms closely resembling, if not identical with, those of +Asiatic cholera. + +In illustration may be cited the comparatively familiar description of +Sydenham.[53] These are his words: "There is vomiting to a great +degree, and there are also _foul_, _difficult_, and _straining +motions_ from the bowels. There is _intense pain_ in the belly, there +is _wind_, and there are _distension_, heartburn, and thirst. The +pulse is quick and frequent, at times small and unequal. The feeling +of sickness is most distressing, and is accompanied with heat and +disquiet. The perspiration sometimes amounts to absolute sweating. The +legs and arms are cramped and the extremities cold. To these symptoms, +and to others of a like stamp, we may add faintness." ... "As the +summer came to a close the cholera morbus raged epidemically, and, +being promoted by the unusual heat of the weather, it brought with it +worse symptoms, in the way of cramps and spasms, than I had ever seen. +Not only, as is generally the case, was the abdomen afflicted with +horrible cramps, but the arms and legs, indeed the muscles in general, +were afflicted also." ... At the risk of repetition an additional +passage may be quoted from Sydenham's later definition of cholera +morbus: "This is _limited_ to the _month of August_ or the first week +or two of _September_. Violent vomiting, accompanied by the dejection +of _depraved humors_, _difficulty on passing them_, _vehement pain_, +_inflation and distension of the bowels_, heartburn, thirst, quick, +frequent, small, and unequal pulse, heat and anxiety, nausea, sweat, +cramps of the legs and arms, faintings, and coldness of the +extremities, constitute the true cholera--and it kills within +twenty-four hours." + +[Footnote 53: _Works_, Sydenham Soc. ed., i. 163; ii. 8, 266.] + +In spite of the general likeness between this description and the +symptoms of Asiatic cholera, there are differences of considerable +importance which have been italicized in the quotations. These +differences are such as may be attributed to the action of a harsh +irritant in the case of cholera morbus, while in the epidemic +(Asiatic) disease the distinctive phenomena are the result of a sudden +and profuse intestinal flux. Macpherson, who had a long and extensive +experience of epidemic cholera in India, after contrasting in detail +its phenomena with those of cholera nostras, sums up the discussion in +these words: "Cholera indica is essentially a very fatal disease, +while cholera nostras is usually a mild affection and is seldom fatal, +although it was called _atrocissimus et peracutus_, and has +undoubtedly killed in from eight to twenty-four hours."[54] In regard +to the individual symptoms this very competent reporter does not +recognize a single one as being absolutely peculiar to either disease. +Even the ancients, already referred to, after describing bilious +evacuations as being characteristic of cholera nostras, add that +sometimes also they are whitish; and modern writers, both before and +since the advent of Asiatic cholera in Europe, have made a similar +observation. Thus, Quinquaud, in his description of cholera nostras, +of which a slight epidemic occurred in 1869 at the Hospital St. +Antoine in Paris, says: "The principal symptoms were vomiting and +purging, sometimes of a bilious and sometimes of a rice-water liquid; +a shrivelled and cyanotic skin, the latter appearance being sometimes +strongly marked; anxiety, coldness, cramps, altered voice, and +suppression of urine."[55] In 1875 thirty-three cases of this {752} +disease occurred at Valenciennes, near Paris, and its symptoms were +thus summarized by Manouvriez:[56] "Repeated vomiting, first of food, +and then of a dark-green liquid; diarrhoea, which was at first fecal +and then bilious, but afterward serous and like rice-water; painful +tension of the epigastrium and tenderness of this part; headache, +cramps in the legs, suppression of urine; pallor, coldness, and +dryness of the skin, especially of the limbs; pinched features, a blue +circle around the eyes, a small and scarcely perceptible pulse, and a +faltering and whispering voice." Yet of the thirty-three cases only +two were fatal--the one a child of four years and the other an infant +of as many months. The substantial identity of nature of these two +local epidemics, and the almost equally close relation of their +symptoms to those of epidemic cholera, must be quite apparent. + +[Footnote 54: _Times and Gaz._, Dec., 1870, p. 725.] + +[Footnote 55: _Archives gen._, Mars, 1870, p. 308.] + +[Footnote 56: _Archives gen._, Sept., 1877, p. 298.] + +Yet the contrasts are neither slight nor unimportant; and the most +striking and significant is the trifling mortality of the European as +compared with the Asiatic disease, notwithstanding the grave symptoms +present in the former. It may be regarded as certain, we think, that +the reason of this difference of danger lies in a corresponding +difference in the nature of the causes of the two forms of disease. +The rapid recovery from cholera morbus produced by changes of weather, +acid fruits, and indigestion renders it certain that no material +lesion of the gastro-intestinal mucous membrane has been produced; +while, on the other hand, inspection after death from epidemic cholera +or by corrosive poisoning renders it equally certain that the damage +to that membrane is substantial and widespread, as well as often +irreparable, and that, therefore, "the powers of life that resist +death" must be engaged in a very unequal and often fruitless struggle. +The cramps in cholera nostras are, as a rule, less severe than in +epidemic cholera, while the colicky, and in general the abdominal, +pains are greater in the former than in the latter disease. The reason +of this difference appears to be that muscular spasm is the natural +result of depletion, whether sanguine or serous, while colic is an +effect of irritation of the surface of the mucous coat of the bowel, +and not of its destruction, such as occurs in epidemic cholera. + +It is true only in a limited degree, and indeed only upon a +superficial survey of the symptoms, that the effects of irritant +poisoning are like those produced by Asiatic cholera. The analogy +between the two was pointed out, among others, by Sedgwick in +1867.[57] The resemblance appeared so striking to the vulgar eye that +in Paris, and perhaps elsewhere, a popular tumult followed the first +violent outbreak of epidemic cholera, and it was charged that the +wells had been poisoned. The cases that most resemble cholera are the +following: "Acute poisoning by corrosive sublimate, by arsenic, and by +mineral acids, especially nitric acid; the effects which follow the +eating or drinking of poisonous animal matters, such as tainted or +simply unwholesome meat or fish, and milk which has undergone some +injurious but yet unknown change, decomposing vegetables and some of +the poisonous fungi, and the excessive action of certain drugs, for +the most part belonging to the class of drastic purgatives," as +elaterium and croton oil. The effects produced by these agents +constitute a cholera morbus, and therefore resemble cholera, and have +been occasionally, and almost unavoidably, mistaken for it. It {753} +is remarkable that suppression of urine may occur among them, as well +as vomiting, purging, and collapse. As Griesinger and others have +pointed out, the order in which the symptoms occur is a valuable, and +generally an available, ground of diagnosis. In cholera, diarrhoea +always occurs before vomiting, while in the various irritant +poisonings mentioned vomiting precedes diarrhoea. In irritant +poisoning also there is generally severe abdominal pain--not so much +colicky and paroxysmal as constant and burning; the stools are not so +copious as in cholera, and they do not possess the rice-water aspect, +but are rather dark, bloody, and fetid, and are voided with tenesmus +or with heat in the anus; and even when the urine is suppressed it is +less persistently and completely so than in cholera, and attempts to +void it are attended with vesical tenesmus and strangury. In a +doubtful case it is important to ascertain whether a metallic or other +unpleasant taste is perceived in the mouth, whether this cavity or the +throat bears marks of corrosion, whether any unusual article of food +has been used, etc. Moreover, it is of extreme importance to learn +whether Asiatic cholera prevails, not merely in the immediate +neighborhood, but at any place from which diseased persons or infected +goods may have arrived. The instances should not be forgotten in which +cholera-infected clothing from Europe has developed the disease in the +valley of the Mississippi. Nor should those still more numerous cases +be overlooked in which travellers affected with choleraic diarrhoea +have disseminated the disease at great distances from their +starting-point, although unconscious of the nature of their own +ailment, whose seed they were sowing along their route. + +[Footnote 57: _Med.-Chir. Trans._, li. 1.] + +PROGNOSIS.--Like the diseases called septic, of which the eruptive +fevers may be taken as examples, and also like the effects of irritant +poisons, the gravity of cholera must mainly depend upon the amount and +the activity of the specific poison that is received into the system. +It is most probable that the cholera poison is organic, and that it +has a limited power of reproduction and term of existence, a period +also of intense activity and a period of exhaustion; in a word, that +either by progressive dilution as an inorganic substance or by organic +senescence it finally ceases to exist. By no other theory is it +possible to explain the numerous degrees of severity which cholera +exhibits, from a mild indisposition to a malignant and rapidly fatal +disease. On the one hand, the patients, if they may so be called, are +hardly prevented from attending to their customary occupations. They +may even be able to travel and carry the disease to distant places, +and so appear to justify the erroneous and irrational doctrine of the +atmospheric or spontaneous origin of cholera. On the other hand, the +entire apparent duration of an attack may not exceed two or three +hours, during which all the distinctive symptoms of the disease may be +crowded together in the most appalling forms. Such grave cases are +always most numerous at the commencement of an epidemic. These +statements are true not only in regard to individual cases in the +greater number of epidemics, but they represent the distinctive +character of particular epidemics, some of which are as remarkable for +their benignity as others are for their extreme malignity. For such +contrasts no plausible reason can be suggested, unless it be a +difference either in the essential virulence of the morbid poison or +in the dose of it imbibed. That they are due to the activity rather +than to the quantity of the poison seems to {754} be proved by the +progressive weakening in the gravity of the cases; for if the quantity +of the poison remained the same some malignant cases might be expected +to occur even during the decline of an epidemic. + +These considerations help to explain the extreme diversities of +mortality in different epidemics. The extremes may be stated at 10 and +90 per cent., and they would perhaps be still wider apart if all the +mild cases, which are never reported--many of which, indeed, do not +even fall under medical observation--were included in the reckoning. +The general or average mortality of cholera is about 50 per cent. +According to Allbu, the epidemics in Berlin from 1831 to 1873 gave a +total of 28,753 cases and 18,916 deaths; that is, a mortality of 65.8 +per cent. (Eichhorst). It should be noted that, as in other epidemic +diseases, there is no uniform proportion between the extent and the +mortality of cholera epidemics. Some of very limited extent have been +proportionally the most destructive. It should also be remembered that +the disease is far more fatal in infancy and old age than at any other +period of life, and for a similar reason it is very dangerous to all +who are weakened by any cause, such as an inherited morbid diathesis, +a chronic debilitating disease, etc. There seems to be a doubt whether +its male or female victims are the more numerous. In this connection +it may be suggested that while males are more likely to contract the +disease by drinking contaminated water, etc., more women are exposed +to its contagion by their intimate relations with the sick, by their +handling and washing infected fomites, by carrying away the cholera +discharges, etc. + +Undoubtedly, the class of society to which cholera patients belong is +not without influence on its prognosis. Not only is the total +mortality greater among the laboring classes, but the individual +belonging to those classes has a less chance of recovery, because he +is not apt to resort to treatment on the appearance of the premonitory +signs of the disease, and because the treatment he receives is less +intelligently and sedulously pursued by his physicians and friends. + +In regard to the particular symptoms which are favorable or +unfavorable, nothing need be added to what has already been stated in +detail, unless it be that during the height of the attack the danger +is to be measured by the degree of prostration and of the stasis of +the blood, and, during reaction, by the grade of the typhoid state. +Gradual reaction, as denoted by the state of the skin and the pulse +and a more natural aspect of the stools, is generally indicative of +improvement. + +Finally, a word of caution may be given to those who are apt to +attribute all the favorable changes in the conditions of an epidemic +to the sanitary or medicinal measures they have instituted. Cholera +epidemics are remarkable for the comparatively short period of their +duration, which may be stated at less than a month in the same place. +Doubtless, judicious sanitation and timely treatment save a great many +lives, but the qualifying fact, already insisted upon, must not be +overlooked, that the mortality occasioned by the disease in a given +place is greatest during the first period of its prevalence, and that +thenceforth it gradually declines. Yet it is of essential significance +that the disease rarely attacks a large number of persons +simultaneously; the epidemic proper is usually preceded by a few +scattering cases which are apt to become foci of ignition that +presently unite to form a widespread conflagration. The recognition +{755} of these cases, their isolation, and the proper treatment of the +localities where they occurred have frequently stamped out what might +have been the commencement of a deadly epidemic. + +PREVENTION.--The history of cholera demonstrates conclusively that +since the disease, outside of India, never arises spontaneously, it +must be more or less preventible, partly by excluding its seeds and +partly by rendering the soil in which they are planted more or less +unfit for their development; in other words, by quarantines and +sanitary cordons and by various measures of local sanitation. + +In regard to the former there would be comparatively little difference +of opinion, at least theoretically, if both measures were alike +efficacious. But there would seem to have prevailed a tendency in +official quarters to undervalue the efficiency of both. Those who made +and administered the sanitary laws relating to cholera seem to have +forgotten the emphatic question, "What will not a man give for his +life?" or at least to have considered that whatever value some men may +set upon their own lives, the lives of other men become of no account +when balanced against the needs, or even the conveniences, of +commerce. The ethics which justified the introduction of opium into +China by the English and the American gift of alcohol to the Indian to +gratify a lust for lucre or for land is only paralleled by those +contained in the official protests against cholera quarantines. At the +International Medical Congress held in 1873 at Constantinople, it was +almost unanimously resolved that "the practice of (land) quarantine as +now carried out ought not to be maintained, because, on the one hand, +it does not constitute a real protection, and, on the other hand, _it +is directly opposed to the interests of commerce and industry._" A +leading critic, in commenting upon this, remarks that if a quarantine +were possible it would give no real security, because it would be +evaded, just as customs laws are evaded by smuggling.[58] A logical +deduction from this curious argument would be that customs laws should +be abrogated. In 1880 was published the report of the German Imperial +Commission on the cholera epidemic of 1873 in Germany, edited by +Hirsch, from which we learn that "all the German medical experts agree +in condemning the employment of quarantine, for, while largely +detrimental to the _interests_, _welfare_, _convenience_, and +_happiness_ of a community, it is _quite inert_ and _inefficient_ as a +safeguard against the further diffusion of cholera."[59] Whether this +opinion refers only to land quarantine or not is left in doubt, but +the spirit of subordinating the lives of the people to the commercial +interests of a country is just the same as, and is not less worthy of +condemnation than, the spirit which has more than once blinded customs +officials to the disease on board of vessels from which it has +afterward issued to destroy thousands of lives. + +[Footnote 58: _Practitioner_, xii. 226.] + +[Footnote 59: _Ibid._, xxvi. 159.] + +It seems to be overlooked that in national as well as in personal +affairs "honesty is the best policy," and that if, instead of +concealment or false statements regarding the sanitary state of ships, +their passengers, and cargoes, and equally false assertions respecting +the contagiousness of cholera, and a contemptuous neglect of +well-tried preventive measures,--if, instead of this delusive and +disastrous policy, all nations had honestly carried out the rules +prescribed by experience for the exclusion of the disease, and for its +management after it had passed the frontiers of a country, {756} there +can be little doubt that its ravages would ere this have been confined +to the region in which it originated. As we have seen, there is urged +against the enforcement of a rigid quarantine by land or sea the +singular argument that it has not always excluded the disease. A more +logical inference would seem to be that since it succeeded, not +completely, but yet partially, its inefficiency should be charged to +its imperfect execution; or, even granting that the absolute exclusion +of cholera is impracticable in every instance, including cases of +choleraic diarrhoea, contaminated clothing and merchandise, does it +therefore follow that the transit of men and things should be +unimpeded? As well might it be maintained that because one or more +houses cannot escape destruction by fire, therefore no effort should +be made to save the remainder of a threatened city; as well might it +be argued that because some men must be killed in battle, no +precautions should therefore be used to preserve the rest of the army; +as well abstain from all local sanitation intended to mitigate the +ravages of the disease, because, do what we may, some victims it will +surely have. This is taking counsel from despair; is a stupid fatalism +which one might imagine to have been imported with the disease from +the East; or it may be a sign of the unconscious blindness of +Mammon-worshippers, who, neither fearing God nor regarding man, have +as little pity for the victims of cholera, permitted, if not invited, +by them to scourge the nations, as devout Christians once felt for the +negroes who were bought or kidnapped in Africa to toil and die under +the lash of the slave-driver. + +Probably no sanitary cordon nor any quarantine will invariably and +completely exclude cholera, since it is transmissible by living men +and by water and by fomites of various descriptions, and, worst of +all, by men who neither exhibit its characteristic symptoms nor are +conscious of the poison which they conceal and disseminate. But, as +has already been urged, it is no argument against preventive measures +that they are not absolutely perfect in their efficiency. If they +sometimes succeed in arresting the progress of cholera, and if they +always, when honestly executed, lessen the number of channels through +which the infection can be conveyed, and thereby reduce to a minimum +its fatal effects, they ought to be maintained and perfected, and not +decried or abolished. It is difficult to characterize that state of +mind which concludes against the use of a salutary measure because its +efficiency is not absolute, the more so when it is admitted that its +inefficiency is not intrinsic, but due to negligent, and even +fraudulent, administration. The preponderance of official and personal +authority is altogether on the side of the necessity of a quarantine, +not in its literal, but in its technical, sense. The International +Medical Congress of 1874 declared as follows: "Quarantine ought to be +limited to the time requisite for the examination and disinfection of +the ship, the crew, and the passengers; and if there be no disease on +board the latter should be released immediately after disinfection. +But if there be cholera or sickness of a doubtful nature on board, it +will be necessary to isolate and disinfect the ship also." The same +congress, however, wholly condemned land quarantines, apparently upon +the sole ground of the extreme difficulty of rendering them +efficient--an argument, as before remarked, that touches not the +principle of the measure, but only the manner of its execution. In +this respect the congress occupied a lower position than its +predecessor of 1866, which held that the futility of {757} quarantine +in "arresting the march of cholera" arose "rather from the +unintelligent application of the measure than from any fallacy in its +principle."[60] + +[Footnote 60: _Practitioner_, xxviii. 393.] + +It would burden this narrative even to enumerate the instances in +which a strict quarantine has protected places to which cholera has +been carried by sea. In the United States numerous examples might be +given of seaports into which cholera was brought from foreign +countries, and within whose quarantine stations it was confined by +rigid sanitary regulations; but it is sufficient to cite the case of +New York, through whose quarantine at Staten Island nine-tenths of all +emigrants to America have passed. Writing in 1867, Dr. Peters said: +"There have been fourteen epidemics of cholera at Staten Island, and +only four have reached New York." A large number of illustrations has +been collected by Dr. Smart, Inspector-General, R. N.,[61] who sums up +the matter as follows: "Believing that cholera has frequently been +excluded from islands by quarantine, and as often introduced by its +non-observance, I regard it as a truly preventive measure; but, +recognizing the impracticability of exacting it under many +circumstances, I would insist on the most strict isolation of all the +first cases or units of disease, whether introduced from without or +originating from relationship to introduced cases, or persons or goods +imported from infected countries." + +[Footnote 61: _Lancet_, April, 1873, pp. 555, 659; _Times and +Gazette_, April, 1874, p. 387. Compare also Colin, _Brit. and For. +Med.-Chir. Rev._, July, 1874, pp. 42-44.] + +While experience demonstrates the efficacy, and therefore the +necessity, of quarantine against cholera in seaports, it has also +shown that the same agent of prevention need not be invariably and +rigidly applied. When quarantine meant literally a detention, and +almost an incarceration, for forty days, it often failed through its +very rigor at a time when proper methods of disinfecting ships, +cargoes, crews, and passengers were either unknown or inefficiently +applied. It is now certain that quarantine may be reduced to a +fraction of its original duration, and yet possess a much greater +degree of efficiency, its length depending upon the number and the +sanitary condition of the crew, etc., the nature of the cargo, etc. It +is evident that a ship carrying only cabin passengers is less open to +suspicion than one crowded with filthy emigrants, although both may +have sailed from the same cholera-infected port. A more liberal rule +may govern the one than the other; and in the second case a rigid +inspection and cleansing of luggage may be imperative which would be +superfluous as well as vexatious in the first case. The importance of +such a treatment of emigrants' effects has already been illustrated by +cases in which they caused an outbreak of cholera after having been +carried from a seaport into an interior town many hundreds of miles +distant. + +In regard to the time during which a vessel that has had cholera on +board within a week or ten days should be detained under sanitary +inspection and treatment, including a thorough cleansing of the +passengers and their effects, no absolute rule can be laid down; but +it would appear that if no suspicious cases arise within a week, there +need be little apprehension that any will occur. + +The sanitary measures which should be undertaken wherever there is +reason to fear an invasion of cholera are, in the first place, such as +are {758} equally appropriate in anticipation of any infectious and +contagious epidemic disease, and relate especially to the removal of +all sources of putrid emanations, whether in stagnant ponds, in +streets, markets, shambles, sewers, privies, cellars, or inhabited +rooms; for these influences, although they do not cause cholera, yet, +by lowering the vitality of persons exposed to them, create an +abnormal susceptibility to disease. Many instances in Europe might be +cited to prove that whole cities, which in the earlier epidemics were +devastated by cholera, were either spared entirely in the later ones +or suffered in a far less degree. The measures which proved most +efficient were an improved water-supply and a better system of +sewerage; and this fact strongly corroborates the belief that +contaminated water and fecal emanations are the principal agents in +propagating this disease. Cleanliness is the best disinfectant, but +during epidemics of cholera, as of other diseases, the popular faith +is very strong in numerous articles called by that name. The real +value of these preparations is commercial rather than sanitary, but, +indirectly, they are useful by prompting those who use them to be more +diligent in searching out and removing many sources of +air-contamination that perhaps invite and intensify attacks of +cholera. + +The disinfectants in common use comprise chlorine gas, chlorinated +soda, chloride of zinc, sulphate of iron, permanganate of potassium, +carbolic acid, and the fumes of burning sulphur. Some of them--and +especially the chloride of zinc, sulphate of iron, the permanganate of +potassium, and carbolic acid--are supposed to be capable of destroying +the infectious principle of the vomit and stools. Another method is to +receive such matters in vessels containing saw-dust, which, after +being dried, is consumed by fire; and still another is to mix them +with dry earth and bury them. If they are thrown into water-closets or +privies, they should have added to them a portion of sulphate of iron. +Whatever has been used by cholera patients should be destroyed, unless +of value, and in that case it should be thoroughly purified by hot air +or boiling water and long exposure to the sun. The importance of +having large and well-ventilated rooms for cholera patients is very +great, but less, perhaps, for the patients themselves than for their +medical attendants and nurses. All persons should be excluded from +them who are not required by the duties of the sick chamber, and in +case of death funeral assemblages ought not to be allowed; nor, during +a cholera epidemic, ought crowded assemblies for any purpose to be +permitted. + +During epidemics of cholera, as of some other diseases, the liability +to be attacked is greatest when the vital powers are depressed by +mental or by physical causes. Hence it is desirable that one's courage +and confidence should repose upon a consciousness of having done +whatever is recognized as proper to ward off the disease--not by a +minute, watchful, and anxious attention to rules at every step, but by +such a general care of the health as good sense and experience enjoin. +Undoubtedly, other things being equal, the weak, sickly, careless, and +imprudent are more liable to suffer than the strong and cautious, and +therefore it is incumbent upon all to maintain as high a degree of +health as possible, avoiding not only all probable sources of +contagion, direct or indirect, but excessive fatigue, catching cold, +depressing emotions, sexual excesses, etc. During the first cholera +epidemics in this country it was considered so dangerous {759} to eat +fruit and fresh vegetables that many persons lived entirely upon meat, +rice, and bread. Such a regimen intensified choleraphobia, and was +also an unsuitable midsummer diet. There is no reason to believe that +any intrinsically wholesome food need be prohibited during the +prevalence of cholera. + +The one article of diet about which the greatest and most peculiar +care should be taken is water. It is the first duty of towns supplied +with water from a common source to be sure that it is, and continues +to be, uncontaminated. Well-water should be used as little as possible +after the disease has made its appearance, and, as an additional +precaution, no water should be drunken that has not previously been +boiled. Where ice can be procured it may be used to restore the boiled +water to an agreeable temperature for drinking. Filtered water, +provided that it be properly filtered, may likewise be regarded as +innocuous. + +TREATMENT.--If regard be had to the various methods and particular +medicines which have been used in the treatment of cholera, it will +appear that in hardly any other acute disease has a greater number or +variety been employed. If, on the other hand, we endeavor to learn +what measures have been really and generally curative in cholera, and +what are they to which, on the occurrence of an epidemic of the +disease, we may turn with confidence in their power to cure, the +result of the investigation is disheartening, and adds to the +accumulated proofs that the power of medical art is exceedingly +restricted. To this conclusion we must assent at whatever cost to a +faith which is strong in proportion to the ignorance out of which it +grows. Nor, if we consider the matter rationally, ought we to be +surprised or humiliated on account of the comparative helplessness of +medicine in this disease, since, if we reflect upon it, the case is by +no means peculiar or exceptional. Every disease that may become mortal +occurs more or less frequently with phenomena which place it beyond +the resources of therapeutics as completely as cholera is in its most +malignant forms; and yet no one lays it to the charge of medicine that +the various fevers, for example, are at times utterly uninfluenced by +the most rational and judicious treatment. Nor does any one bring a +railing accusation against medicine when accident fatally damages a +part essential to life. + +One accident of frequent occurrence presents a certain analogy to +cholera in its effects, and that is a burn or scald involving a very +large portion of the skin. In cases of this sort experience assures us +that death is almost inevitable, and that the duty of the physician is +to avoid officious and meddlesome treatment, and address himself to +soothe the patient's suffering and maintain his strength, if haply the +powers of nature may triumph over the effects of the injury. This, +too, is the lesson, substantially, which experience has taught +respecting cholera. It is certain that in this disease the function of +the whole gastro-intestinal mucous membrane is reversed, and that it +is no longer a secreting and absorbing organ, but one almost +exclusively exhaling, and that through it the liquid which is +essential to carrying on the functions is rapidly running away. If the +lesion on which this symptom depends is complete, if the +gastro-intestinal mucous membrane has entirely lost its natural +function, evidently it is quite futile to address any treatment to +this organ. But if, as probably happens in a great majority of the +cases, the {760} disorganization takes place gradually, it is evident +that there is more to hope from remedies when the disease is gradually +developed than when it reaches its acme at a single bound and leaves +no time for medical intervention. The one unmistakable lesson that +experience teaches respecting the treatment of cholera is, that its +success depends upon its prompt and early application. Almost as +distinctly does observation teach that subsequently to the first (or +diarrhoeal) stage the comparative value of different methods and +individual medicines is very uncertain. And, finally, it would seem +that in this, as in other acute diseases, intelligent and careful +nursing and regimen are quite as important as any medicinal treatment +whatever. However a false notion of the power of medicine may blind us +to the fact, it is none the less a fact, that if different methods of +treatment are compared, that method gives the best results which is +least perturbative. For example, in England, on board of a hospital +ship, were 85 cases, of which 19 treated by quinine gave 12 deaths, 12 +by calomel gave 2 deaths, 12 by carbolic acid gave 3 deaths, and 37 by +"Nil" gave 1 death.[62] Or, again, in 1865, at the London Hospital, +159 patients were treated--48 with a mixture containing logwood, +ether, aromatic sulphuric acid, camphor, and capsicum, of whom 31 +died; 56 with sweetened water, of whom 28 died; 21 with castor oil, of +whom 14 died; and 20 with "saline lemonade," of whom 6 died.[63] In +the last example the deaths during the use of the astringent mixture +were twice as great as under sugar and water, and under castor oil +twice as great as under "saline lemonade." + +[Footnote 62: _Times and Gaz._, Dec., 1866, p. 590.] + +[Footnote 63: _London Hosp. Reports_, iii. 444.] + +We shall first give an account of the management of cholera in +general, and then consider some of the particular medicines used in +its treatment. + +The essential elements of all plans of treatment for this disease, as +for so many others, are rest and abstinence. Whatever else may be +done, nothing avails without them. This remark applies emphatically to +the premonitory diarrhoea; if it is neglected it may readily be +converted into the full-formed disease. It is therefore essential, +during the prevalence of cholera, that whoever is attacked with +diarrhoea should at once give up all active occupation, and confine +himself to a recumbent posture and to the use of food of the blandest +quality, such as mucilages and similar preparations, especially of +rice, which, less than any other vegetable food, is liable to +fermentation during digestion. It is prudent to drink no water that +has not been boiled. If there is reason to believe that the bowels +retain feces from before the attack, it is generally thought advisable +to administer a laxative dose of castor oil, to procure the discharge +of matters which would act as irritants. Except for this purpose +purgatives are neither indicated nor expedient. In a large number of +cases nothing more is necessary than the use of means to check the +action of the bowels, and which should consist of absorbents or +antacids, astringents, and opiates as they are contained in the +officinal chalk mixture, with the addition of tincture of kino or +catechu and a small proportion of laudanum. This medicine should be +given in dessertspoonful doses at intervals of not more than an hour. + +If, instead of a diarrhoea which differs from ordinary dyspeptic +diarrhoea chiefly by its watery character, there should also be colic +and profuse discharges, it is proper to add to the medicines just +suggested some which are of a decidedly stimulant character, such as +the essential oils of {761} cajeput, cloves, cinnamon, peppermint, +etc., with which chloroform, ether, or Hoffman's anodyne may be +associated. At the same time rubefacient embrocations may be applied +to the abdomen, which should also be compressed slightly with a broad +flannel bandage. Instead of these stimulants, and perhaps more +efficiently, may be used a simple epithem made by dipping a large +towel several times folded in cold or cool water, applying it so as to +cover the whole abdomen, and then enveloping it and the body with a +dry towel. This application is more soothing than any liniment and its +action is more constant. Instead of any of these agents dry heat may +be used, obtained from bags of hot salt or sand, or moist heat from +thick poultices of flaxseed meal or Indian corn meal or similar +substances enclosed in flannel bags and applied to the abdomen while +they are as hot as can be borne. It is difficult to determine which of +these applications is the most useful. But, on the whole, heat is +preferable to rubefacients, and moist to dry heat. The cold-water +dressing is probably best suited to young and robust persons. + +It must be remembered that between choleraic diarrhoea and cholera in +its complete form there are several grades, in one of the most common +of which a tendency to vomit, and even a certain amount of vomiting, +accompanies the diarrhoea. Anti-emetic remedies are then indicated. +They may consist externally of rubefacient and aromatic applications +to the epigastrium (especially the spice poultice); and it is claimed +that a hypodermic injection of morphia in this part is very efficient. +Internally, the best remedies are ice swallowed in small pieces and +small but frequent draughts of iced carbonated water or iced +champagne. Where these liquids cannot be procured, effervescing +powders used in the same way form a very good substitute for them. If, +notwithstanding such remedies, the diarrhoea continues or if it tends +to increase, astringent and absorbent medicines may be substituted for +them; for example, bismuth may be given instead of chalk, and if this +also fails acetate of lead may be prescribed. The last may be used by +the rectum as well as by the mouth, but with very questionable +advantage. Meanwhile, especial care should be taken to avoid giving so +much of any opiate as will induce sopor or excite nausea. + +Whoever has had the care of cholera patients has probably, at first, +felt sanguine of success in their treatment, even after the +characteristic discharges and the symptoms of collapse had set in; but +a little more experience has proved their hope to be deceptive, and +revealed the reason of it in the absolute suspension of the +sensibility and absorbent function of the digestive canal. Hence the +dismal unanimity of all medical authors, who from actual observation +of cholera have declared that no treatment avails to arrest the +fully-developed disease. And yet there is some encouragement in the +fact that recoveries sometimes occur from even the most desperate +state of collapse and under the most dissimilar methods of treatment; +so that the physician is warranted in not yielding to discouragement +and in cheering his patients with hope even to the end of life. The +popular dread of this, and indeed of all epidemics, is sure to be +exaggerated, and it therefore behooves the physician to combat the +fears of his patients, and by a cheerful manner as well as encouraging +words administer the cordial of hope, which often proves stronger than +pharmaceutic elixirs. + +{762} It may be well to enumerate, as many do, the indications of +treatment in the active stage of cholera, but they really need no such +specification. It is evident that they consist in combating the +symptoms--the vomiting, the purging, the debility, the cyanosis, the +cramps, etc.; and the only means by which the carrying out of such +indications can even be attempted are neither more nor less than would +be used to relieve the same symptoms in other affections. If the +evacuations could be controlled, evidently the cramps and the collapse +would not occur; but this essential and preliminary step cannot be +secured. The medicines introduced into the stomach or rectum are not +absorbed, but are speedily rejected; those which are administered +subcutaneously are not taken up by the stagnant blood as freely as in +other diseases; the nervous system gives little or no response to the +mechanical and physiological stimulants applied to the skin. Yet, in +spite of these obstacles, the physician must persist in the use of +rational methods, in the hope, however faint it may be, that he may +succeed in restraining, and possibly in arresting, the fatal course of +the attack. For this end he has hardly any means at command except +those, or such as those, which were recommended in the first stage of +the disease--the anti-emetic and anti-diarrhoeal medicines, which he +is only too likely to see rejected as soon as administered. Yet he +must not cease to allay the thirst by the repeated administration of +small quantities of carbonated and cold liquids, water, or champagne +wine, or morsels of ice swallowed whole. The application of pounded +ice in a bladder to the epigastrium is a measure of an analogous sort, +and is sometimes as efficient as generally it is soothing. In other +cases the aromatic poultice seems to answer better. Of irritants +little can be said that is favorable, but the combined irritant and +anaesthetic action of chloroform is useful, and morphia should be +applied to the epigastrium as well as given hypodermically. + +If the vomiting tends to become less frequent, acetate of lead may be +prescribed, in the hope that it will exert some constringing action +upon the gastro-intestinal mucous membrane. The distressing symptom, +hiccough, cannot with any certainty be controlled by medicine, but +perhaps the inhalation of chloroform is more efficient than any other +remedy, as it also is for the cramps in the limbs. For the latter +purpose it is preferable to the frictions with flannel or with +stimulating liniments which are generally employed. If such liniments +are used, care should be taken that they do not contain ingredients +that may disorganize the skin either immediately or subsequently. A +dangerous compound of the latter sort introduced during the first +epidemic of cholera in this country became officinal under the name of +liniment of cantharides. + +The loss of the water and of the salts it holds in solution in the +blood is, as has now been frequently repeated, the chief pathological +element of the disease, next after the conjectural cause which injures +the mucous membrane of the stomach and bowels. It was rationally +indicated, and therefore a method was early practised, to supply this +loss by injecting into the veins a solution of sodium salts. The +method was seductive as well as rational, for its primary effects were +extremely encouraging; it nevertheless failed, and probably for the +very reason that suggested its use. Indeed, there is no more reason, +if there is as much, to suppose that a liquid artificially introduced +into the blood-vessels will be retained when {763} the natural liquor +sanguinis cannot be so. Necessarily, the one will escape where the +other has escaped. + +Certain systematic writers prescribe a method intended, on the one +hand, for reviving the animal heat, and on the other for restoring the +movement of the circulation. It need hardly be remarked that the two +form essentially but one and the same indication. If the circulation +is restored the animal heat will revive, but not otherwise. The same +treatment leads to both ends, and it consists partly, as already +stated, in the use of stimulants, such as alcohol, camphor, coffee, +ether, etc.; but their efficacy depends upon their being taken into +the blood, and with it reaching the various nervous centres upon which +the renewal of functional activity depends. Little, therefore, can be +expected from them at the height of the disease--that is, in the stage +of collapse--but as soon as any signs of reaction are manifested they +tend to promote it, and hence may enable the functions to revive. For +this reason they are adapted to persons who are feeble by reason of +their tender or their advanced age, or who have previously suffered +from ill-health. But if they act at all, and the more they tend to +act, they must be employed with circumspection, lest they outrun the +purpose of their administration and produce a violent or excessive +reaction. Instead of, or in conjunction with, these internal remedies +the local stimulants of the skin, already enumerated, may be used with +the due precautions, and, in addition, baths at a temperature of 105 +degrees F. of water alone or with the addition of salt or mustard; but +all such remedies are of little avail until reaction has commenced. +Before that event there is reason to believe that the cold bath is +preferable, or, still better, frictions of the whole body with cold +water, or even with ice, after which the patient should be wrapped in +dry and warm blankets. Yet the efficacy of this powerful agency is by +no means comparable to that which it produces in the algid forms of +malarial fever. The two conditions, although apparently analogous, +are, in reality, very different. In the cold stage of fever the +mechanism is indeed paralyzed, but none of its mechanical elements are +wanting; but in algid cholera there is an actual subtraction of water +from the blood, that turns it from a liquid capable of circulating +through the narrowest channels into one that stagnates even in the +largest vessels. In the one case force is wanting to circulate the +blood; in the other there is no normal blood to circulate. + +The treatment of the stage of reaction when it does not exceed a +moderate degree, consists simply in strictly enforcing the rules for +the patient's repose; that is to say, in intelligent nursing. Mental +excitement must be forbidden, and neither medicine nor food allowed +that is likely to interfere with the gradual and steady progress of +convalescence. Of all articles of food, cool water is not only the +most urgently desired, but is the most imperatively necessary for +replenishing the emptied blood-vessels and restoring the normal +functions. But unless great caution is observed it will be taken too +freely and provoke a renewal of the discharges. If any food besides +water is allowed, it should be of the simplest sort--of whey first, +and then of milk in small quantities at a time, with lime-water if it +provokes nausea or retching. Afterward thin broths may be given, also +in great moderation, and by degrees farinacea in milk and in animal +broths. Only when the strength is much improved should even the most +{764} digestible meats be permitted. In proportion as convalescence is +marked or interrupted by symptoms of undue reaction is it necessary to +prolong and render stringent this regimen; and if those symptoms +unfortunately arise which oftener, perhaps, depend upon an +over-zealous stimulant treatment than upon the natural reaction of the +system, they must be combated by measures which will lessen the local +congestions, especially of the brain and the lungs, and also by such +as will tend to prevent the system from falling into a typhoid state. +For the former dry cups applied to the back of the neck, and cold +lotions and affusions upon the scalp, are to be recommended, and for +the latter dry cups and warm stimulating poultices upon the chest near +the affected region. It is probable that the general warm bath, with +cold affusion upon the head at the same time, would prove as efficient +as it does in analogous states of typhoid affections. If the urinary +secretion is suspended or remains scanty, there is not usually an +urgent need of using means for its restoration; for that will +generally occur when the blood-vessels become replenished. It should, +however, be mentioned that, according to Macnamara, if the patient +does not pass any urine within thirty-six hours of reaction coming on, +ten minims of the tincture of cantharides in an ounce of water should +be given every half hour until six doses have been taken, and the +patient encouraged to drink freely of water. If this treatment does +not cause urine to pass, we must, after the sixth dose, discontinue +the medicine for twelve hours, and then repeat it in precisely the +same way. The dose here referred to is of the British preparation, and +if the use of it were not recommended by so competent an authority its +propriety might very properly be challenged. + +After the cholera patient has become convalescent his restoration is +very apt to be retarded by dyspeptic disorders, for which, perhaps, +the best remedy is a judicious use of condiments with the food and of +bitter tonics, especially quinine, colombo, quassia, etc., before +meals. If there is constipation, it should be corrected by the +cautious use of fruits, and, if these prove insufficient, of mild +saline laxatives or small doses of castor oil or rhubarb. On the other +hand, if there is a tendency to diarrhoea, it should be met by the use +of a mild laxative, such as castor oil, magnesia, or rhubarb, followed +by chalk or bismuth, and the use for a time of simpler food and in +less than the usual quantities. + +Having thus furnished a sketch of the plan of treatment of cholera +which we regard as dictated by experience, it may be not without some +interest to consider certain elements of the method a little more +fully, and criticise, in passing, some other remedies which have from +time to time been proposed. The first of these is venesection. There +was a time when certain physicians, carried away by conceptions of the +disease evolved from their inner consciousness, maintained that it +consisted essentially of a spasm of the blood-vessels, and that the +natural and legitimate cure for it was to be found in bleeding. No +theory is so gratuitous or absurd but cases may be found which appear +to justify it, and in this instance also examples were not wanting to +illustrate at once the truth of the theory and its successful +application. Longer experience, however, and a more correct conception +of the disease, have long since condemned this method, which was +almost as dangerous as it was irrational. If any additional argument +against it were required, it would be found in the condition of the +lungs after death. These organs, we have seen, are not {765} only not +engorged, but they are empty of blood, and death is due not to +asphyxia, but to apnoea, when it takes place in collapse. + +If ever there existed any reason for the administration of an +emetic--and ipecacuanha has generally been used at the commencement of +an attack of cholera--it must be looked for, not in any clinical +experience of its virtues, but simply in the deplorable routine that +required the administration of an emetic at the commencement of nearly +all acute diseases, so that, whatever else was prescribed, the lancet +and an emetic seldom failed to be so. In this case also the proofs of +the successful administration of ipecacuanha were not wanting, and one +might be tempted to suppose, in view of the alleged facts in its +favor, that it was useful by causing an evacuation of the material +cause of the disease. Physicians were even to be found, of high +station and character, who contended that cholera is a species of +fever, and to be treated by an emeto-cathartic composed of tartar +emetic and epsom salts. If the treatment had been efficient, the +absurdity of the reasons for it might have been overlooked; but the +one was as disastrous as the other was false. But, as usual, the facts +had been misstated or misinterpreted, and emetics ceased to form a +part of the systematic treatment of cholera. The idea which possessed +those who advocated the use of evacuants was that there was either a +poison to be eliminated from the blood or one to be expelled from the +bowels. Apparently, the method was not efficacious, for the latest +phase of it, the use of castor oil in acute stage of cholera, was of +short duration. + +When cholera first appeared in Europe the tendency naturally arose to +follow in its treatment the example of the British practitioners in +India. It then appeared that one of the most eminent among them, +Annesley, gave a scruple of calomel, with two grains of opium, at the +commencement of the attack, and repeated the dose in six or eight +hours, and again upon the following day. In the decline of the disease +he ordered scruple doses of calomel for the removal of a +"cream-colored, thick, viscid, and tenacious matter exactly like old +cream cheese, which glues the gut together and obstructs its passage." +Three, four, and even five, scruples of calomel were usually taken +before this effect was produced. When it is added that this +practitioner held depletion to be the capital element of the +treatment, and that he was equally lavish of his patient's blood and +of his own drugs, we can only wonder that any subjects of his heroic +method survived. It is now conceded by all enlightened physicians that +mercurials in large or in ordinary doses are worse than worthless in +epidemic cholera. In 1832, Dr. Ayre of Hull, Eng., proposed another +method of using calomel, to which he adhered in treating this disease. +It consisted in the administration of very small doses of calomel at +short intervals, and with each of the first doses a few drops of +laudanum. Such a method, if not carried too far, certainly has the +merit of sparing the patient a great deal of the perturbative +treatment against which we have, in the preceding pages, protested. +But that was not at all the notion of its proposer. He claimed for it +positive and active virtues. He stated, as the fundamental ground of +his plan, that "the primary and leading object of the treatment must +be to restore the secretion of the liver." He did not in the least +doubt that he was able to do this by the administration of +mercury--not, indeed, by a direct action upon the liver {766} itself, +but indirectly and sympathetically through the stomach, and by the +healthy and specific stimulus imparted to it, by which the due +secretion of the bile is promoted. It is, indeed, difficult to +conceive of any stimulus that calomel could impart to the stomach that +would not be equally given by any other non-irritant and insoluble +powder--subnitrate of bismuth, for example. Indeed, Ayre himself +relates the case of a man who in an attack of cholera took during +three days no less than five hundred and eighty grains of calomel, and +recovered without any soreness of the mouth. But the plan which he +finally elaborated was different. It was to give small doses of +calomel repeatedly--in the premonitory stage one grain every half hour +or hour for six or eight successive times, or, if this failed, every +five or ten minutes--and in the stage of collapse one grain and a half +every five minutes. In a few cases of extreme severity two grains of +calomel were given every five minutes for an hour or two, and then the +ordinary dose of one grain was resumed. But this was not all: with +every dose of calomel was associated one, two, or three drops of +laudanum, so that if these doses were repeated frequently the patient +received a very efficient amount of the narcotic during the attack. +Indeed, Ayre attributed to it the virtue of sustaining the vital +powers under the depressing influence of the disease, and of removing +or abating the cramps, as well as of detaining the calomel in the +stomach.[64] From the preceding account it follows that the treatment +of cholera by small doses of calomel with laudanum is founded on an +erroneous assumption of the mode of action of calomel, and that +whatever efficacy the plan of treatment may possess may with more +justice be attributed to the opium, whose effects we know, than to the +calomel, whose action, so far as it is known at all, has no +conceivable relation to the disease for which it was given. However +this may be, if the results of Ayre's treatment are compared with +those of other plans, it exhibits very little if any superiority. In +the report of the cholera committee of the College of Physicians, +London, made in 1853, we find the statement that in 725 unequivocal +cases treated on Ayre's plan the deaths were 365, or about 50 per +cent., and also the following commentary: "In general, no appreciable +effects followed the administration of calomel, even after a large +amount in small and frequently-repeated doses had been administered. +For the most part, it was quickly evacuated by vomiting or purging, +or, when retained for a longer period, was passed from the bowels +unchanged. Salivation but very rarely occurred, and then only in the +milder cases. We conclude that calomel was inert when administered in +collapse, and that the cases of recovery following its employment at +this period were due to the natural course of the disease, as they did +not surpass the ordinary average obtained when the treatment consisted +in the use of cold water only."[65] It is of interest to compare the +mortality of 50 per cent. above stated to have occurred under this +sort of calomel treatment with the mortality noted at the London +Hospital under various kinds of treatment, including the +administration of calomel in doses varying "from five to ten and +twenty grains every quarter, half, one hour, two, four, etc." Out of +509 cases, 281 were fatal, or 54.9 per cent.[66] + +[Footnote 64: _A Report on the Treatment of the Malignant Cholera_, +Lond., 1833.] + +[Footnote 65: Dr. Gull's _Report_, p. 177.] + +[Footnote 66: _Lond. Hosp. Reports_, iii. 437, 441.] + +Every disease in which exhaustion and coldness occur is sure to be +{767} treated more or less actively with alcohol, but in the collapse +of cholera, as in the cold stage of fevers, it is generally useless, +and sometimes hurtful. We believe that the following protest of +Macnamara is sustained by almost universal experience: "I would here +enter an earnest protest against the use of brandy or any alcoholic +stimulant in this [the second] stage of cholera. I believe these, both +theoretically and practically, to be the cause of unmitigated evil. I +simply, therefore, mention brandy, champagne, and the like in order to +condemn their use most emphatically in cholera; according to my ideas +and experience, it is almost impossible to hit on a more detrimental +plan of treatment than that usually known as 'the stimulant' in this +form of disease."[67] It is true that apparent dissidents from this +judgment may be found, like Playfair, a deputy inspector of hospitals +in Bengal, who even circulated printed directions for the treatment of +the first stage of the disease by means of brandy or strong rum, +cayenne pepper, and laudanum, and had entire confidence in the +efficacy of the method.[68] Dr. Macpherson, inspector-general of +hospitals, also, after comparing the results of a stimulant treatment +with those of other methods, reaches the conclusion that the +mortality-rate of cholera is affected neither by the moderate nor by +the excessive use of alcohol.[69] + +[Footnote 67: _Op. cit._, p. 456.] + +[Footnote 68: _Edinburgh Med. Jour._, xix. 471.] + +[Footnote 69: _Med. Times and Gaz._, Jan., 1870, p. 62.] + +Upon no other point in the treatment of cholera is the agreement of +physicians more complete than upon the use of opiates in the early +stage of the disease. The premonitory diarrhoea has always been +treated by opiates alone or associated with astringents. Probably the +best rule is to give from twenty to thirty drops of laudanum, or an +equivalent dose of some other liquid preparation of opium, in a little +brandy and water, and repeat the dose as often as a stool is voided. +Opiates have also been generally employed to mitigate the symptoms of +the fully-developed disease. But, like all other medicines introduced +into the stomach or rectum, they are apt to be rejected, and even if +they are not, their absorption is very doubtful, so that at the height +of the attack they must be considered as nearly if not quite useless. +When the vomiting and purging begin to subside and reaction is about +to commence, small and repeated doses of opiates undoubtedly tend to +lessen the evacuations; but great caution must be observed not to +exceed the due degree of stimulation, lest a dangerous state of +narcotism or collapse be induced. It might be supposed that the +hypodermic use of morphia would be less open to objection than its +administration by the stomach; but it is to be remembered that the +suspension of gastric absorption is only a part of the similar +condition affecting the whole circulatory system, and that the +stagnation of the blood in the systemic veins prevents the absorption +of medicines administered subcutaneously perhaps as completely as the +state of the gastric blood-vessels interferes with their absorption +from the stomach itself. In point of fact, the utility of opiates at +any stage of cholera after the first is not easily determined, for +nearly always they are associated with other medicines, and especially +with astringents. In this disease, as in others that involve life, we +are seldom at liberty to test the powers of individual medicines, but +are bound to endeavor to save life by associating those which seem to +be required for the purpose. Opiates, then, are nearly always given in +conjunction with astringents or stimulants {768} during the first (or +diarrhoeal) stage of the attack, but after vomiting is added to +diarrhoea and a tendency to collapse is manifested they are at least +useless. + +The patient, it has already been said, should be disturbed as little +as possible, and hence, if he becomes restless, and especially if he +is rendered so by pain, he should be tranquilized by means of +anaesthetics. Chloroform has generally been employed, and is best +administered on the first accession of cramps. Much pain, with +muscular fatigue and depression, is thus saved, and the inhalation of +the medicine may be repeated as often as the pain threatens to return. +No doubt other anaesthetics, and especially ether, would answer the +same purpose. + +Camphor has been claimed to be a valuable medicine in cholera, but +there is no clinical evidence that it is so. Indeed, the only series +of cases in which it was mainly depended upon gave a large mortality. + +Acids have been employed in cholera, but chiefly on theoretical +grounds, "in the hope of destroying the specific cholera process going +on in the intestinal canal" (Macnamara). It is hardly necessary to +discuss so vague a reason. What specific process is going on? What +relation to it has the administration of acids? And, after all, only +the hope is held out of destroying the hypothetical morbid process. +The reaction of normal stools is usually acid, but sometimes it is +neutral or even alkaline. In other acute bowel complaints with profuse +diarrhoea they are acid, as in cholera infantum, but in epidemic +cholera they are alkaline, because they consist chiefly of the water +of the blood. It is far from proven that mineral acids can be useful +merely by reversing the reaction of the stools. Far more probable is +it that, in so far as they are of use, it is because they act as +astringents upon the digestive mucous membrane. This may be inferred +from the fact that, according to the advocates of these medicines, it +is always difficult, and is often impossible, to acidify the stools in +cholera. Moreover, it must be remembered that, like other medicines, +the greater part of them are rejected by vomiting. If, then, mineral +acids tend to lessen the diarrhoea of cholera, they act by their +astringency and not by their acidity. Diluted or aromatic sulphuric +acid may be given in the dose of from two to thirty minims, at +intervals of an hour, in acid water or carbonated water, or diluted +nitric acid, in doses of from twenty to fifty minims, at the same or +somewhat longer intervals. + +Intravenous injections were used in England during the first epidemic +of cholera in 1832-33, but their results were regarded as unfavorable; +subsequently, in 1849, they were tried with somewhat better success, +and in 1867 the effects were still more encouraging. The liquid +employed on the last-mentioned trial consisted of chloride of sodium +60 gr., chloride of potassium 6 gr., phosphate of sodium 3 gr., +carbonate of sodium 20 gr., alcohol 2 drachms, and distilled water 20 +ounces. The alcohol was added only when the liquid was about to be +used, and the temperature of the latter was not allowed to exceed 110 +degrees F. or fall below 100 degrees F. The liquid was contained in a +zinc vessel holding about eighty ounces, with a lamp underneath, a +thermometer hanging within, and a tap near the bottom, from which +proceeded an india-rubber tube four feet long, with a silver nozzle at +its end. The fluid was allowed to enter the vein by the force of +gravity. If difficulty was experienced in introducing the nozzle, the +vein was freely exposed, supported on a probe, and incised +longitudinally. It was found that the success of the operation +depended greatly {769} upon having an ample supply of the solution +prepared, so as to repeat the injection as often as might be found +necessary. Mr. Little, who practised this method in numerous cases, +stated as follows: "When a patient has been long pulseless clots form +in the heart, and, as I have seen, extend into the larger veins. In +one case the fluid would not flow in, and only distended the veins of +the arm injected. After death clots were found extending from the +heart into the axillary vein."[70] Five out of twenty apparently +hopeless cases recovered under this treatment. The first effect of the +injection was to revive the pulse, which had ceased to be felt; the +voice also was restored, the color and expression improved, the cramps +were relieved, the temperature rose, and the patients became convinced +that their recovery was assured. A profuse perspiration and a severe +rigor accompanied these symptoms. The rigor was evidently a nervous +phenomenon, and not a chill, for it occurred when the temperature was +rising. Other cases might be cited which unquestionably owed their +recovery to this mode of treatment. It is true, however, that much +more frequently it failed of success; and probably not only because +the injection could not reach the heart, but because, having permeated +the blood-vessels of the whole body, it escaped, as the serum of the +blood had done, from the damaged intestine. Nevertheless, it would +seem that an expedient which in a certain proportion of cases has been +quite successful might yet be rendered more certain in its results if +the operative procedure were perfected. + +[Footnote 70: _London Hosp. Reports_, iii. 470.] + +Cramps in the limbs may be lessened by active friction and shampooing, +but there is no clinical reason for believing that these measures tend +to restore the circulation. Equally ineffectual are other means used +for communicating heat to the algid body and thereby reviving its +functions. It is true that some physicians found that warm baths, at +from 90 degrees to 104 degrees F., gave relief to the cramps and +restored the failing pulse. In most cases the calming influence of the +bath was noted, but it does not seem to have been curative or to have +diminished the mortality-rate.[71] It should not be forgotten that the +patient has no perception of his coldness. In all analogous +conditions, as has already been remarked, such as frostbite and the +cold stage of periodical fevers, cold, and not heat, promotes +reaction. Still more injurious, if possible, than hot applications are +irritants and stimulants after the stage of collapse has set in. Not +only are they absolutely futile for restoring the animal temperature, +but they are liable, unless very cautiously used, to produce +intractable sores upon the skin if recovery ensues. It should also be +remembered that the cholera patient's exhaustion is exceptionally +great, and is apt to be increased by the officiousness implied in the +use of many stimulating agents. + +[Footnote 71: _Ibid._, iii. 445; _St. Bartholomew's Reports_, iii. +190.] + +As early as 1832 a marked advantage was ascribed to the use of cold +affusions in cholera.[72] One of the physicians of the cholera +hospital of Berlin said: "In these living corpses which are struck +with asphyxia, lying cold and powerless, external and internal +medicines cease to stimulate; no steam apparatus, no warm bathing, no +friction, no irritant, avails." The condition is comparable to that in +approaching death by cold, in which friction with snow is well known +to be the proper remedy. Cold affusions were employed in the second +stage of the disease. If the pulse revived, the affusions were +continued in a tepid bath, after which the patient was {770} put to +bed and gently rubbed with cold flannels. Internally, ice-water was +freely administered. Labadie-Lagrave[73] refers to forty cases treated +in this manner, with only seven deaths. Yet the cold-water treatment +does not appear to have commended itself to physicians generally. +Evidently it does not meet the prime indication, which is to restore +the wasted waters of the blood and retain it in the blood-vessels. + +[Footnote 72: Ainsworth, _Pestilential Cholera_, 1832.] + +[Footnote 73: _Du Froid en Therapeutique_, 1878.] + +Cold water ought to be given as freely as possible to assuage the +thirst that exists in every stage of cholera, and especially in +collapse. Nor should it be withheld because it will presently be +rejected, for not only does it produce a grateful sensation in the +mouth and throat, but it renders the act of vomiting easier. Yet, to +some extent at least, the thirst may be allayed by rinsing the mouth +and throat with cold water. Iced water is preferable to ice used for +the same purpose, for the latter, by its relatively intense coldness, +irritates and dries the mouth. Fragments of ice swallowed whole allay +the burning heat in the stomach. + +On the hypothesis that the cholera poison consists of organic germs +various antiseptics have been employed in this disease. Permanganate +of potassium was fortunately excluded from the list, on account of its +corrosive action, but, unfortunately, carbolic acid was conceived to +possess virtues that rendered it an eminently suitable remedy, and +creasote, which resembles it very closely, was presumed to possess +corresponding virtues. Then sulphurous acid and the sulphites, which +for a time were warranted to destroy every species of germ, were +confidently appealed to to stay the progress of cholera, and it was at +one time even a matter of dispute whether sulphite of sodium or +sulphite of potassium was the more efficacious. In truth, all of these +medicines were useless, even when they were not mischievous. + +Cholera has never prevailed in any country without giving rise to +extraordinary theoretical and practical divagations. One physician in +the earliest American epidemic gravely proposed, as the best mode of +checking the diarrhoea, to plug the anus with a soft velvet cork. +Another, in England, suggested that the "blood may be kept circulating +by putting the patient on his back on a board and keeping up a +rocking, see-saw, to-and-fro movement from eighty to one hundred times +a minute." Another had the revelation that the disease is essentially +a "paralysis of the sympathetic nerve and want of performance of the +organic functions, with deficient vitality of the mucous membranes," +and that its proper remedies are "bleeding, turpentine, and cool +drinks, without heat and stimulants;" and to this remarkable doctrine +a well-known physician gives his adhesion, thus: "The cause, I firmly +believe, is an union of the poison with the sympathetic."[74] Still +another discovered that the disease is a spinal disorder, and is to be +treated by the application of ice-bags to the spine. Were not the +evidence so palpable, it would hardly be believed that such irrational +ideas should have been published concerning a disease which had then +been under observation by the whole medical profession in Europe and +America for more than thirty years, and in Asia for a much longer +period. + +[Footnote 74: _Times and Gazette_, Aug., 1866, p. 209; _ibid._, Nov., +1866, p. 555.] + +The most important lesson to be drawn from this history of the +treatment of epidemic cholera is, that the arrest of the disease in +the diarrhoeal stage is comparatively easy, and that in the stage of +collapse its cure by any means whatever is altogether an exceptional +occurrence. + + + + +{771} + +THE PLAGUE. + +BY JAMES C. WILSON, M.D. + + +DEFINITION.--An acute specific fever of short duration and very fatal, +endemic in certain Oriental countries, and frequently epidemic; it is +characterized by buboes, carbuncles, and petechiae. + +SYNONYMS.--([Greek: plege], _plaga_, a stroke); the Pest; Pestilence; +the Bubonic, Glandular, Inguinal Plague; the Oriental, Levantine, +Levant Plague; the Indian, Pali Plague; Mahamari; Septic or Glandular +Pestilence; Pestilential Fever, Adeno-nervous Fever; Typhus +Pestilentialis, Gravissimus, Bubonicus, Anthracicus, etc. _Gr._ +[Greek: ho loimos]; _Lat._ Pestis; _Fr._ La Peste; _Ger._ die Pest, +Beulenpest. + +CLASSIFICATION.--The plague, pest, pestilence, and their equivalents +in various tongues, are terms that have been used from the earliest +historical times to designate every epidemic disease attended by great +mortality. As knowledge of diseases becomes clearer the terms by which +they are designated become more definite; those which did service for +a class are restricted to particular groups, and new names are found +for other maladies only allied to such groups by superficial +resemblances. Hence by degrees the term plague has become more +restricted in its use. To-day it is understood as designating +exclusively the specific affection defined above, the bubo plague. + +The student of medical history meets with insurmountable difficulties +in attempting to classify the recorded epidemics which have been +described under this term. Even when used in its more restricted +signification, difficulties as to the propriety of its application to +certain epidemics arise. Thus, nosologists are not in agreement as to +whether the great plague--the black death--which swept over Europe in +the fourteenth century and destroyed in three years twenty-five +millions of inhabitants, was a modification of the bubo plague or an +essentially different disease. A like difference of opinion exists in +regard to the relationship between the Indian or Pali plague which has +from time to time prevailed in North-western India during the present +century and the true plague. + +The black death of the fourteenth century and the Pali plague, though +presenting many of the characteristics of bubo plague, differ from it, +while they resemble each other, in one important particular. Among the +earlier and more common symptoms of note are those dependent upon +gangrenous inflammation of the lungs, a lesion, according to +Hirsch,[1] extremely rare in bubo plague. This author informs us that +recent observations have fully confirmed the early opinion that the +Pali plague {772} differs from that of the Levant chiefly in this +modification, and cites Pearson and Francis as saying of the former +disease that "the collective symptoms are more like those of plague +than of any other known disease.... We believe it to be in all +essential particulars identical with the plague of Egypt." + +[Footnote 1: _Handbuch der historisch-geographischen Pathologie_, Dr. +August Hirsch, 1860.] + +The three forms of plague--(_a_) the grave (or ordinary), (_b_) the +fulminant (pestis siderans), and (_c_) the larval or abortive, +observed in epidemics and hereafter to be described--do not represent +distinct varieties of the disease, but are merely expressions of +differences in the intensity of the action of the infecting principle +upon different groups of individuals in given communities--differences +to be explained here, as in the other infectious diseases, in part by +variations in the activity of the poison itself, in part by the +individual peculiarities and susceptibilities of those exposed to it. + +HISTORICAL SKETCH.--Upon the authority of Rufus of Ephesus, quoted by +Oribasius,[2] it is stated that the bubo plague prevailed as an +endemic, and at times as an epidemic disease, in Libya, Egypt, and +Syria prior to the beginning of the Christian era. + +[Footnote 2: _Medicinalia Collecta_.] + +In the year 542 A.D., according to Procopius,[3] the plague appeared +in Egypt, at Pelusium; extended westward to Alexandria; eastward to +Palestine, Syria, and Persia; passed from Asia Minor to Europe, where +it first invaded Constantinople, whence it spread in all directions +with such fury that before the close of the sixth century one-half the +inhabitants of the Eastern empire had perished, either of the plague +itself or of the universal destitution that followed in its train. + +[Footnote 3: See Hirsch.] + +With this epidemic, known in history as the Justinian plague, this +disease established itself for the first time in Europe, where it +maintained foothold for more than a thousand years. + +About the middle of the seventeenth century the wide prevalence of the +plague in Europe began to draw to an end. In Spain it was epidemic for +the last time from 1677 to 1681; in Italy the last general epidemic +came to a close in 1656, although local outbreaks continued to occur +till the beginning of the following century. In France it still +prevailed in several provinces in 1668, although it had for the most +part disappeared some years before. In Switzerland we encounter it for +the last time in 1667-68; in the Netherlands in 1677; from England the +plague disappeared with the great outbreak of 1665. In the early part +of the eighteenth century two important epidemics occurred within the +boundaries of Europe. The first spread from Turkey, through Hungary +and Poland, to Russia, thence to Norway and Sweden, and along the +shores of the Baltic Sea to the Low Countries. This epidemic came to +an end in 1714. Six years later the last great outbreak of the plague +on European soil took place. It prevailed with great fury in +Marseilles in 1720-21, and overran the whole of Provence. From this +date till the close of the century Europe remained free from the +plague, with the exception of Turkey and the contiguous countries. +During the second and third decades of the present century repeated +epidemics occurred in the Balkan Peninsula and the regions bordering +on the Lower Danube and the Black Sea. The plague appeared also in +Malta in 1813, and prevailed till 1815, and in 1816 it reached certain +of the Ionian Islands. {773} Only twice has this pest shown itself +during the present century in Western Europe--once, during the +epidemic at Malta in 1815, at Noja, a town of the Neapolitan province +of Bari; the second time, in 1820, at Majorca, whither it was carried +over from the coast of Barbary. + +Between 1552 and 1784 the plague prevailed twenty-six times in Tunis +and Algiers. Some idea of the importance assumed by this scourge in +the countries of North-western Africa may be found from the fact that +many of these epidemics lasted continuously for years, that which came +in 1784 not ceasing for fifteen years. Between 1816 and 1821 the +plague again prevailed in Tunis and Algiers, and again in 1836-37. + +During the first half of the present century a change took place in +the prevalence of the disease elsewhere. Shortly before its complete +disappearance from Europe it ceased to prevail in Western Africa (with +the exception of the Nile countries), in Mesopotamia, and in Persia. +It disappeared from Asia Minor, Syria, and Palestine in 1843, from +Egypt in 1844. + +For a short period the plague seemed to have disappeared altogether. +Those who cherished this hope were, however, destined to +disappointment. In 1853 an outbreak occurred in the Assyr country, +Western Arabia; and from that time till the present unmistakable local +epidemics of the bubo plague have occurred in isolated regions of +Africa and Asia; thus, in 1858 at Benghazi in Tripoli; in 1857 in +Mesopotamia; in 1863 in the district of Maku, Persian Kurdistan; in +1867 in the marsh district on the right bank of the Euphrates; in 1870 +in Persian Kurdistan; in 1871-73 in the Yunnan province, Western +China; in 1873 in the marsh district on the left bank of the +Euphrates. During four years following the outbreak of 1873 the +disease continued to prevail over an extensive area in the countries +bordering on the northern banks of the Persian Gulf. In 1874 it +reappeared also in the Assyr district, Western Arabia, and in +Benghazi, Northern Africa. In 1876, whilst still infesting the regions +about the Lower Euphrates, the plague appeared in South-eastern +Persia, and during this and the following years it appeared at several +isolated points on the borders of the Caspian Sea. Early in 1878 the +disease was reported as prevailing in the district of Souj-Bulak, +Persian Kurdistan, and it appeared in October of the same year at the +Cossack village Vetlanka, on the Lower Volga, district of Astrakhan, +Russia, after an absence from Europe of thirty-seven years. It has +more recently prevailed in the Assyr district, Western Arabia, and +there have been rumors of its reappearances in Persian Kurdistan. + +The Indian or Pali plague (Mahamari) has prevailed in local epidemics +of great severity on several occasions during the present century in +the North-western provinces of India. This fever was first recognized +in Kutch in May, 1815, after a season of great scarcity of food. It +spread rapidly over an extensive territory, and appeared in the spring +of the following year at various points in Guzerat, next in Merawi, +later in Rhadenpur, spreading thence westward to Sindh. Not until the +following year (1817) did the pest reach the British possessions. This +epidemic continued to prevail until 1821. The disease did not reappear +until July 6, 1836, when it broke out in Pali, the principal depot of +traffic between the coast and North-western India. It spread with +great rapidity to the {774} adjoining provinces. Toward the close of +the year 1837 the disease broke out anew in Pali, and raged until the +spring of the following year. In 1834-35, again in 1837, there were +outbreaks of this pest in Gurwal, and in 1846 and 1847 in Karmoun, +provinces of the southern slopes of the Himalayas. This destructive +pest has raged at an altitude of 10,300 feet, and we learn from Hirsch +that it has never wholly disappeared from the mountain-districts of +the Himalayas since 1823, and that its ravages in these regions have +been so great that certain settlements have been wholly destroyed. + +The fever was remittent in type, with a great tendency to become +continued; it was characterized by rapidly developing extreme +prostration, and was very fatal. In most cases there were glandular +swellings in the groins, armpits, and neck. Carbuncles and petechiae +are not mentioned as having been observed. Dyspnoea, cough, and bloody +expectoration were frequent symptoms. Vomiting, at first of bilious +matter, later of dark, coffee-colored fluid, was likewise common. + +The plague has never appeared in the western hemisphere. + +ETIOLOGY.--1. Predisposing Influences.--Whilst the present views as to +the causation of the specific diseases compel us to assume a specific +infecting principle as the real cause of every outbreak of the plague, +there are certain circumstances which are recognized as so favoring +the development and action of that principle that they have come to be +looked upon as indirect or auxiliary causes of particular epidemics. +It is more in accordance with the facts to speak of them as +predisposing influences. Chief among these circumstances is that +combination of physical and social wretchedness which goes hand in +hand with poverty and overcrowding. The plague has been termed by a +recent observer (Cabiadis) miseriae morbus, and he has thus reproduced +in 1878 a name applied to the great plague of London in 1665--the +poor's plague. All observers of recent epidemics unite in ascribing to +poverty the foremost rank among the predisposing influences of plague +epidemics. It is only necessary to enumerate the evils which form the +train of poverty, whether in cities or in villages, to complete the +list. + +With poverty come ignorance and neglect of all sanitary laws; +overcrowding and ill ventilation; personal filthiness; improper as +well as insufficient diet; indifference as to the location of +dwellings and their surroundings. The condition of the villages which +have been the scene of some of the recent epidemics beggars +description. All observers unite in testifying to such accumulations +of filth in and around the houses as requires to be seen to be +believed. In these communities latrines are unknown, and no such thing +as organized scavenging has ever existed. + +The accumulation of unburied or imperfectly buried corpses has been +looked upon as the real cause of the plague, and some of the recent +epidemics have followed the prevalence of distinctive epizootics. +Whilst it is not difficult to disprove that under ordinary +circumstances the effluvia from exposed and rotting carcasses can give +rise to outbreaks of the plague, it is more than probable that an +atmosphere charged with such emanations (together with other causes) +can so unfavorably influence a community as to increase its +susceptibility to the specific cause of this or any other infective +disease. There can be but little doubt that the {775} dead bodies of +the victims of the plague are capable of disseminating the disease, +and that the reopening of graves containing such bodies, even after a +long period of time, has given rise to fresh outbreaks of the disease. + +The season of the year does not appear to exert any very marked +influence upon the development of epidemics, if we base our deductions +upon observations made in different countries. In northern countries +the disease has prevailed as severely in mid-winter as in summer. The +epidemics of London showed a rise during July and August, their +furious prevalence in September, and a gradual decline during October +and November. In Constantinople the disease has commonly remained +dormant during the winter months, and become active as the weather +grew hotter. In Egypt, on the contrary, the activity of the outbreaks +has developed in winter, increased with the advance of spring, and +suddenly abated upon the advent of the summer. Such also has been the +case with the three general epidemics in Mesopotamia studied by +Tholozan.[4] "Their beginning took place in winter, their development +during the spring, their decline and their extinction in summer. Their +recrudescences obeyed the same laws: after an incubation during the +summer season ... revivification took place in winter and in spring." +It is added in this writer's account that the exceptional hot weather +of summer in that country, and especially that of the shores of the +Persian Gulf, has always moderated or directed the course of epidemics +of this pest. In Cairo the epidemics have usually ceased upon the +recurrence of intense summer heat in June. Dampness, and particularly +a thoroughly wet soil, are favorable to the development and spread of +the disease. The marshy regions of the Lower Euphrates, the shores of +the Caspian and the Black Seas, the valley of the Nile, have been the +scenes of repeated visitations. On the other hand, the plague has +maintained its foothold in the mountainous districts of Western +Arabia, in Yunnan, on the slopes of the Himalayas at a great +elevation, and upon a dry, non-alluvial soil even more firmly than in +the low and humid plains of Mesopotamia.[5] + +[Footnote 4: _Histoire de la Peste Bubonique en Mesopotamie_, 2d +Memoire, Paris, 1874.] + +[Footnote 5: Tholozan, _Histoire de la Peste Bubonique en Perse_, 1st +Memoire, Paris, 1874.] + +Individual predisposition to contract the disease seems to be +increased by all depressing influences, among which may be mentioned +excessive bodily or mental exertion, intense and prolonged anxiety, +fear, and the like. Previous debilitating disease also increases the +liability to the attack. Neither sex nor age exerts an influence in +this respect, save that after the age of fifty few contract the +disease. Occupation confers no immunity. Physicians, nurses, and +others occupied in the care of the sick, and those who bury the dead, +have especially suffered in recent[6] as well as in the older +outbreaks. Oil-carriers and dealers in oils and fats, and to a less +degree water-carriers and the attendants at baths, are said to enjoy a +comparative immunity from attack. Those who have suffered from the +disease and recovered also enjoy a relative immunity. Second attacks +are usually of less intensity than the first. + +[Footnote 6: See summary of a report addressed by Dr. G. Cabiadis to +the Constantinople Board of Health on the outbreak in Astrakhan in +Russia, 1878-79, by E. D. Dickson, M.D., _Medical Times and Gazette_, +1881, vol. i. pp. 4, 32, 119.] + +2. The Exciting Cause.--The exciting cause of the plague must, in +{776} the present state of our knowledge, be assumed to be a specific +infecting principle. Upon no other hypothesis can the continued +existence of a disease so specific in its characters, unchanged +through the course of centuries, disappearing when the influences +favorable to its presence cease, reappearing in certain regions when +they again arise, be explained. Capable of being transmitted by the +vehicles of commercial intercourse, of control by quarantine and +cordons sanitaires, of spreading from limited foci of contagion into +overwhelming epidemics, the plague is the very type of the infective +diseases. The nature of this infecting principle is wholly unknown. It +is probably a microphyte capable of development within the human +organism--capable also of a prolonged independent existence under +favorable circumstances outside of the body, and of again giving rise +to the disease. The plague is properly to be classed as a +contagious-miasmatic disease (Liebermeister) with cholera, dysentery, +and enteric fever. It continues to exist by the continuous propagation +of its cause, and it spreads by the transportation of that cause. + +It is conceded on all hands that the plague has never arisen +autochthonously in Europe, but has in every instance been conveyed +thither. Those who regard its reappearance after long intervals of +time in those countries where it still occasionally prevails as +spontaneous are compelled to ignore difficulties in reasoning far +greater than the supposition of an equally prolonged condition of +quiescence or an inexplicable or unsuspected reintroduction of the +cause. + +As to the disputed question of the contagiousness of the plague, to +set forth the arguments and examples adduced in favor of either view +would far exceed the limits of the present article. All the facts are +to be explained upon the theory that the exciting cause of the plague, +like that of cholera and enteric fever, consists of a miasm that must +undergo certain changes outside the body before acquiring its virulent +properties, and that the time required for these changes is +exceedingly brief. But what the physical properties of this miasm are, +or how it finds access to the body, or how it is eliminated, are alike +utterly unknown to us. + +It is certain, however, that it is incapable of being freely +transmitted to great distances in the air. Whether or not it is +conveyed or retained by the discharges from the bowel is not known. +The history of recently observed outbreaks, from which alone definite +and trustworthy facts are to be obtained, goes to show that the +exciting cause of the plague clings closely to the patients and their +immediate belongings. The closer the relation between those sick and +the healthy, the greater the risk that the latter will contract the +disease. Those in the house with the patients are more liable to fall +sick than those in the adjoining houses--those who are constantly in +their presence than those who occasionally see them. Thus, nurses much +more frequently contract the plague than doctors, though the latter +have in all epidemics been largely numbered among the victims. Among +357 deaths in the outbreak in Vetlanka, already referred to, were a +priest, his wife and mother, three doctors, six assistant medical +officers, and two Sisters of Mercy. Dr. Cabiadis remarks that the +information obtained "shows that the malady propagated itself, in the +first instance, from the sick to their relatives and to those who +lived with them or who assisted them during their illness. If, on the +one hand, these facts showed its contagious character, on the other +hand evidence is {777} still wanting to prove whether this +transmission of the malady was caused by contact with the sick and +their clothing, or by breathing an atmosphere impregnated with the +deleterious particles emanating from their morbid bodies." + +The period of incubation is from two to seven days. In the report of +the commission of the French Academy of Medicine, drawn up by Prus in +1844, the statement appears that the plague has never shown itself +among compromised persons after an isolation of eight days. The recent +outbreaks tend to confirm this conclusion. L. Arnaud concluded from +observations made at Benghazi in 1874 that the mean duration of this +period was five or six days, and that the maximum did not exceed eight +days. Cabiadis sets this stage down as three days as the rule, but as +occasionally not exceeding twenty-four hours. He found no data, +however, to show the longest period to which it could extend. Hirsch, +from information collected in his investigation of the same epidemic +(that of Astrakhan), concluded that the minimum period of incubation +observed was from two to three days, the maximum more than eight, and +that the average was five days. He states that very short or very long +periods were seldom observed. + +SYMPTOMATOLOGY.--Individual cases of the plague, as of other epidemic +diseases, differ in their onset and progress under different +circumstances and at different periods of particular outbreaks. +Besides the ordinary form, to which as a type the greater number of +the cases more or less closely conform, there are, on the one hand, +others so severe that death takes place before the characteristic +manifestations have time to appear, and, on the other hand, cases so +light that such manifestations are but partly developed, and the +nature of the malady is only to be recognized in the light of the +prevalent epidemic influence. + +Hence among the cases three forms are recognized: (_a_) The grave or +ordinary form; (_b_) the fulminant form; and (_c_) the larval or +abortive form. + +(_a_) Grave or Ordinary Form.--The plague in typical cases is a +febrile malady of the most acute kind, with localizations in the form +of buboes or carbuncles. + +The course of the attack may, for convenience of description, be +divided into four stages: 1, the stage of invasion; 2, the stage of +intense fever; 3, the stage of fully-developed localizations; and 4, +the stage of convalescence.[7] + +[Footnote 7: This formal division of the description is suggested in +some of the older accounts. (See "_Loimologia; or, An Historical +Account of the Plague in London in 1665_, by Nathan Hodges, M.D., and +Fellow of the College of Physicians, who resided in the City all that +Time, Lond., 1721.") + +The appearance of the plague in France in 1720 was the occasion of a +great number of curious and interesting publications on this subject.] + +1. The stage of invasion is marked by a feeling of lassitude, by pains +in the loins and extremities. There is extreme bodily and mental +weakness, headache, fulness and throbbing of the head, dizziness. The +patient's expression is dull, stupid; he replies to questions slowly +or awkwardly, his face is pale, his eyes languid, his gait feeble and +staggering. The appearance in this stage has been compared by several +observers to that of a drunken man. Shivering occurs, but if fever be +present it is slight. Nausea, vomiting, and diarrhoea are symptoms +sometimes {778} observed. This stage begins suddenly. It is often +imperfectly developed, and it may last only a few hours or a day or +two. + +2. The second stage is characterized by fever of the most intense +kind. It is ushered in by a chill, sometimes slight, commonly severe. +The lassitude continues, the headache increases, the dulness deepens +to stupor or gives way to delirium. The temperature rises to 102 +degrees-104 degrees F., or even to 107.6 degrees F. The pulse quickly +mounts to 120 or 130. The skin is hot and dry; the patient complains +of burning inward heat and of great, sometimes unbearable, thirst. The +eyes are sunken and injected; the tongue moist, pale, and thickly +covered with a chalk-white or grayish pasty coating; the vomiting +often continues. The delirium is commonly active or noisy, and +accompanied by great restlessness; it may, however, be mild, tending +to sopor or coma. The progress of the disease now rapidly advances. +The patient falls into the so-called typhoid state. His tongue becomes +dry, hard, and fissured; sordes collect upon the teeth and lips, +bloody crusts about the nostrils. At this time the evidences of +failure of the forces of the circulation become conspicuous. The pulse +grows feeble, small, often irregular--sometimes it can scarcely be +felt; the lips become bluish, the extremities cold. There is tendency +to collapse. During the course of this stage buboes begin to make +their appearance. Sometimes the enlargement of the superficial +lymphatics is preceded by tenderness or pain of more or less +intensity; often the glands are found to be enlarged only upon search. + +The termination of this stage is marked by a sudden fall of the +temperature to subnormal ranges (93.2 degrees F. has been observed); +at the same time copious strong-smelling sweat not infrequently +occurs. The pulse grows feebler, and falls to 100 or below it, and the +mind becomes clearer. + +3. These changes lead up to the stage of fully-developed local +manifestations. The enlarged lymphatics are most commonly situated in +the groins or on the upper part of the thighs at a point below that +commonly the seat of venereal buboes; less often they are to be found +in the armpits or the region of the angle of the jaw; as a rule, they +occupy only one or two of these positions in the same patient. They +vary in size from a little mass or kernel, only to be discovered after +careful search, to the bulk of a hen's egg or a mandarin orange. The +swelling of the gland takes place at times with great rapidity. +Suppuration is followed by the discharge of an ichorous pus, and not +rarely by ulcerative destruction of the surrounding tissues. +Suppuration occurs more frequently than resolution, but is +comparatively rare in fatal cases. Hence it has come to be popularly +regarded as a favorable prognostic sign, whilst the early subsidence +of the swelling has been looked upon as an omen of grave import. + +The time of the appearance of the buboes varies greatly. In the +greater number of cases they have shown themselves on the second, +third, or fourth day of the attack, occasionally within six or eight +hours of the beginning of the attack, and occasionally they have been +observed to precede the general manifestation of the disease; rarely +they have appeared as late as the fifth day. In many cases they are +absent altogether. + +Carbuncles demand attention as being among the characteristic local +manifestations of this stage. They are less common than buboes. Their +usual position is upon the lower extremities, the buttocks, or the +back of {779} the neck. In favorable cases the gangrene after a few +days becomes limited and the slough separates. Boils also occasionally +appear. + +Petechiae occur in the worst cases, and often at an early period in +the course of the disease. Their appearance usually indicates a fatal +issue. They occupy at times extensive areas of the body or the greater +part of its surface; at times they appear only in the neighborhood of +the buboes. They vary in size from a mere speck to spots several lines +in diameter. When very numerous they give a livid hue to the skin, and +that appearance to the cadaver to which, together with the high +mortality, was doubtless due the term black death by which severe +epidemics were known in the Middle Ages. + +Vibices and extensive ecchymoses sometimes appear shortly before +death. + +4. The stage of convalescence sets in between the sixth and tenth +days. It is often protracted by prolonged suppuration of the bubonic +enlargements. Both relapses and distinct second attacks have been +noted by recent as well as the older observers. + +In addition to the foregoing sketch of the course of the disease in +its ordinary form it is necessary to describe certain other symptoms. + +The attack has sometimes begun with a convulsive tremor, at other +times with a prolonged shaking, which has lasted from six hours to +three days, the patient remaining free from fever and not complaining +of cold. This condition has terminated in coma, followed speedily by +death. + +Sometimes the attack has come upon the patient with great confusion of +mind, so that he appears dazed, or else a curious distraction has +befallen him in the midst of his ordinary avocations. If absent from +home, such patients commonly at once set out to return, either +trembling and staggering as though tipsy, or else rushing wildly +through the streets with frantic gestures and outcries. + +The vomited matters are usually at first gastric mucus with bile, +afterward dark coffee-colored fluid; in certain cases blood is +vomited. Bleeding from the nose, lungs, bowels, vagina, and urethra +have also been observed. Cases attended by hemorrhages have in almost +all instances terminated fatally. + +Constipation has been, as a rule, present during the acute stages; +later in the attack diarrhoea has occasionally occurred. It has been +looked upon as a favorable symptom. + +The urine has been diminished and suppressed in grave cases. +Trustworthy observations, both as to its quantity and its chemical +composition, are wanting. It has been observed to contain blood. + +As has been already pointed out, the Mahamari of North-western India +has been especially characterized by lung symptoms. Other regions also +have been visited by epidemics in which acute pulmonary lesions formed +a prominent part of the morbid complexus. + +(_b_) The Fulminant Form.--Chiefly in the early days or weeks of +epidemics, but to some extent also later, cases occur in which the +intensity of the sickness is so great that the patient dies before its +usual manifestations have time to develop. The duration of the whole +attack, which ends fatally, is often not more than a few hours; its +symptoms, which differ but little if at all from those of similar +cases of other epidemic diseases--such, for example, as epidemic +cerebro-spinal fever in its fulminant {780} form--are of the most +aggravated character, and the patient perishes overwhelmed by the +infection as though struck by a thunderbolt. Profound disturbance of +the nervous centres, convulsions, coma, the rapid formation of vibices +and petechiae, collapse, are the speedy forerunners of the fatal +issue. + +(_c_) The Larval or Abortive Form.--Toward the close of an epidemic +the character of the disease usually undergoes a change. It becomes +less malignant. The cases present the essential symptoms, but in +diminished intensity. Some cases terminate in an early defervescence +with rapid subsidence of beginning local manifestations; others +present merely the evidences of a slight disturbance of the general +health, without any characteristic symptoms of the prevalent disorder; +others, again, are characterized by the appearance of buboes without +pain or fever. These swellings undergo resolution in fourteen days or +thereabout. Exceptionally they suppurate. + +The duration of the plague is from six to ten days in typical cases +running a favorable course; those of fatal cases from one to twenty +days. Clot Bey[8] found the duration of the worst cases two or three +days, of those next in point of severity five or six days, whilst in +milder cases death did not occur until the second or third week. Of +534 fatal cases noted by W. H. Colvill, 126 occurred one day after the +attack, 80 two days after it, 105 three days, 76 four days, 60 five +days, 26 six days after the attack. After six days the number of +deaths rapidly declined; on the nineteenth day 1 death, and on the +twentieth day after the attack 11 deaths, occurred. It is said that +death after the seventh day is commonly not in consequence of the +disease itself, but of sequels. Of 16 fatal cases in the village +Prischib in Astrakhan, noted in the report of Dr. Cabiadis, and of +whom the names, as well as the day of their exposure, their falling +sick, and their death are given, 1 died in one day, 4 in two days, 6 +in three days, 3 in four days, and 2 in six days. + +[Footnote 8: _De la Peste observee en Egypte_, Paris, 1840.] + +The mortality of the plague is greater than that of any other epidemic +disease. In all epidemics a large majority of those who contract the +disease die. This is especially true of epidemics at their beginning, +when it has often happened that for a time all the cases have +perished. Of this, as of other epidemic diseases, it is true that the +death-rate has varied in different outbreaks and at different periods +of the same outbreak. Colvill states that in the epidemic of 1874 in +Mesopotamia the mortality of stricken villages during the first half +of the time was 93 to 95 per cent. of those attacked, but that +afterward the majority of those attacked recovered. The same authority +states that in Bagdad in 1876 the mortality was 55.7 per cent. of +persons attacked. Arnauld gives the mortality at Benghazi in 1874 as +39 per cent. of attacks. The death-rate at Vetlanka was 82 per cent. +of those attacked. In Toulon in 1721, of a population of about 26,000 +human beings, about 20,000 were attacked, and of these 16,000 died. It +has been by no means of rare occurrence that nearly half the +population of towns have perished in an epidemic, or that small +villages have been completely depopulated by this scourge. + +COMPLICATIONS AND SEQUELS.--The appalling mortality of the plague on +its approach, the rapidity of its spread, the popular commotion upon +its appearance, its brief course, and the fact that its recent +outbreaks have {781} taken place in regions where trained European +physicians have been, with a few exceptions, beyond reach, all unite +in maintaining the gloom that has since the Middle Ages enveloped the +clinical facts of this disease. + +Of its clinical course, beyond the brief outline already given, little +is accurately known, of its complications still less. In some of the +recent epidemics, and particularly in the outbreaks of plague in +India, the evidences of pulmonary lesions have been so conspicuous +that they deserve to be classed among the essential manifestations of +the disease rather than as complications; in others pulmonary +congestion, haemoptysis, the evidences of croupous or catarrhal +pneumonia, have occurred in a small proportion of the cases. Aside +from this, there is nothing to be said as to the complications. + +Among the known sequels are protracted ulceration of the enlarged +lymphatics, boils, superficial or deep abscesses, catarrhal pneumonia, +pertussis, mental troubles, and the like. Extensive and deep +cicatrices are not infrequently found in the site of the ulcerating +local manifestations. + +MORBID ANATOMY.--The existing knowledge of the morbid anatomy of the +plague is but scanty. The observers of the early outbreaks contributed +nothing; the recent outbreaks have taken place under circumstances in +which anatomical investigations were impracticable. The knowledge +which we possess is almost wholly due to the investigations conducted +by the French in Egypt at the close of the last and the beginning of +the present century, and again during the years 1833 to 1838. + +The descriptions of Bulant,[9] Clot Bey, and others point to gross +lesions, such as are found after death in the acute stages of the +infectious diseases in general. The viscera were engorged with dark +fluid blood; ecchymoses were often found in the mucous and the serous +membranes, in the substance of the different organs, and into the +connective tissue. The spleen was in almost all cases enlarged, +softened, and of a dark color. Not rarely the kidneys were deeply +engorged, and extravasations of blood into their substance, their +pelves, and into the surrounding connective tissues were often +encountered. + +[Footnote 9: _De la peste oriental d'apres les maternaux recuilles a +Alexandrie, a Smyrne, etc., pendant les Annees 1833 a 1838_, Paris, +1839.] + +The only constant and characteristic changes relate to the lymphatic +system. The lymphatic glands were, as a rule, enlarged and deeply +injected with blood. Where no buboes existed the glands of the various +cavities of the body showed evidences of acute inflammatory processes. +In some instances the affection of the glands appeared to be general; +less frequently it was most conspicuous in, or apparently limited to, +one or more great groups. Thus, the bronchial, the mediastinal, the +mesenteric, the lumbar, etc. were severally the seat of marked changes +with or without enlargement of superficial groups, or several of these +groups were at the same time implicated. + +In no instance were symmetrical enlargements of the inguinal regions, +the axillae, or the throat met with. + +According to Runnel,[10] in 2700 cases there were inguinal buboes in +1841, axillary in 569, maxillary in 231; inguinal buboes occurred 175 +times on both sides, 729 times on the right only, 589 times on the +left only; the axillary buboes were double 9 times, right only 185, +left only {782} 163. Buboes of the neck only occurred 130 times, and +of them 67 cases were children. + +[Footnote 10: _A Treatise on the Plague_, London, 1791.] + +The connective tissue surrounding the affected glands was the seat of +an infiltration sometimes serous, sometimes cellular; it also very +commonly contained more or less extensive extravasations of blood. +Even where no buboes appeared on the surface of the body the glands +were enlarged to twice their usual size or more. The substance of the +glands in the larger swellings was at times uniformly red or violet, +again whitish or marbled or pulpy or denser, or of the consistence of +fat. It was also sometimes soft like jelly, and rarely it contained +minute collections of pus. Some observers speak of dilatation of the +lymph-vessels in the neighborhood of the enlarged glands. + +DIAGNOSIS.--The difficulties attending the recognition of the plague +at the beginning of an outbreak speedily subside. The rapid spread of +the disease, its frightful mortality, the overwhelming intensity of +the symptoms, the prompt occurrence of cases characterized by buboes, +carbuncles, or petechiae, are collectively considered diagnostic of +this, and of no other disease whatever. In regions subject to the +repeated visitations of this pest there exists a universal +unwillingness to mention even the name of a disease whose suspected +presence alone is followed by consequences of the most serious nature +to the freedom of personal and commercial intercourse. To this +unwillingness, rather than to any real likeness between the plague and +other diseases with which it has been compared, are to be traced most +of the difficulties as to the differential diagnosis that have been +raised, especially in the regions bordering on the Mediterranean Sea. + +It is not, therefore, necessary in this place to discuss the diagnosis +between the plague and malarial and other pernicious fevers, malignant +typhus, epidemic dysentery, lymphadenitis, syphilitic buboes, +parotitis, and so forth. + +TREATMENT.--Preventive.--The efficient treatment consists in +prophylaxis. The history of this disease indicates with singular +clearness the measures which, properly carried out, are capable of +controlling the spread of the epidemic diseases. These measures +arrange themselves into two groups, of which the first has to do with +the removal of the conditions familiar to the development of the +disease, the predisposing influences; and the second with the +restriction of the disease to the locality in which it shows +itself--isolation, quarantine. + +The conditions favorable to the development of the plague have already +been set forth under the heading Etiology. They relate to poverty and +ignorance, and their attendant evils, in communities. They are those +conditions which tend to disappear under the influences of +civilization, and in truth it may be said that at the present time the +plague occurs only in half-civilized countries. + +Preventive medicine has achieved no other work comparing in magnitude +and importance with the extinction of the plague in Europe. This was, +to use the words of Hirsch, "a gradual process, and kept pace in great +measure with the development and perfection of the quarantine system +with reference to the Orient and the different countries of Europe." +This author continues: "I cannot, in fact, understand how any one +criticising the facts without prejudice, and having regard to the +{783} state of the plague in the East, can for a moment hesitate to +attribute the chief cause of the disappearance of the plague from +European soil to a well-regulated quarantine system." The European has +by no means lost his susceptibility to the disease. He is liable to +attack in the East. His protection at home lies in the restriction of +the exciting cause of the disease to its present haunts. + +Any extended notice of quarantine and quarantine laws is beyond the +scope of this article. It may be said, however, that with reference to +the plague measures quite unnecessary under ordinary circumstances +assume the greatest importance when this disease makes its appearance +in countries bordering upon Europe, and that no amount of hardship to +individuals necessary to avert so great a calamity as a plague +epidemic could be looked upon as excessive. Indeed, we can with +difficulty realize the severity with which measures of isolation have +been carried into effect at times when the devastation produced by the +plague was still vividly remembered. Violation of the orders issued +during an epidemic has been punished with no less a penalty than +death. It is related that upon the appearance of the plague in the +little town of Noja in Lower Italy in 1815, troops were despatched +immediately to surround the place with a cordon. The town was +encircled by two deep ditches, and opposite the gates three ditches +were spanned by drawbridges, which served as a means for the +introduction of provisions, but no other communication was allowed. +Only letters were allowed to leave the city, and these were first +dipped in vinegar. Cannons were posted at the city gates. The ditches +were occupied by sentinels, who were ordered to shoot down any one who +approached and failed to stand still the moment he was hailed. A +plague patient who escaped while delirious and attempted to pass the +lines was, in fact, shot dead. Outside this cordon two others were +established. Those who disobeyed the orders were treated with the +greatest severity. An inhabitant of Noja, who had thrown a pack of +cards to the soldiers, together with the soldier who picked it up, was +tried by court-martial and shot.[11] + +[Footnote 11: _Ueber die Pest zu Noja_, Nurnberg, 1818, quoted by +Liebermeister in _Ziemssen's Encyclopedia_, article "Plague."] + +Lower Italy, possibly Europe also, owed its escape to the rigorous +measures carried out in this instance; nor can it be doubted that the +measures of isolation practised during the outbreak on the Volga +1878-79 restricted the disease to the district in which it appeared +and brought it to a speedy end. On this occasion three efficient +cordons were established to isolate the infected places. The first +cordon was put around every place where plague prevailed, to prevent +persons from entering or quitting that locality until forty-two days +had elapsed after the last attack of the malady there. The second +cordon was formed around the infected area, encircling all the +infected localities. Its circumference extended 800 kilometres, and +was guarded by pickets of soldiers stationed at intervals of five +kilometres. This cordon had four quarantine stations. The third and +outermost cordon was established round the whole province of +Astrakhan. It served to control the functions of the inner cordons, +inasmuch as all persons coming from within its area, who could not +prove that they had undergone quarantine at the stations of the middle +cordon, were stopped. + +{784} The complete disinfection of all clothing and other articles +used in the service of the sick is to be included among measures of +prophylaxis. It is no uncommon thing to destroy by fire the houses in +which cases have occurred, along with their contents. + +No efficient means of protection are known for those who during an +outbreak cannot escape from the infected neighborhood. It would be +without purpose other than to amuse the reader to reproduce the quaint +fancies of the older physicians in this matter, or to dwell upon the +amulets and incantations, the absurd costumes, the protective power of +tobacco, according to Diemerhoeck, or the disbelief in its virtues on +the part of Hodges, who preferred "canary, of the best sort, of which +he frequently drank while he attended the sick." + +Clinical.--"The treatment of individual cases must in the present +state of knowledge be expectant and symptomatic. Notwithstanding our +acquaintance with the symptoms that characterize plague, we are +utterly ignorant of the treatment best suited to its cases" +(Cabiadis). + +Physicians who have written from personal observation unite in +advising a treatment of the simplest kind. Ventilation, cleanliness, a +liquid diet, abundant cool drinks, are to be ordered. The initial +collapse and the evidences of failure of the circulation call for the +use of stimulants, and especially of alcohol. Cold or tepid sponging, +in accordance with the sensations of the patient, may be resorted to. +If there be high fever an energetic antipyretic treatment might be +carried out. Cold effusion is said to have been of use in many +instances. + +Purging, bloodletting, mercurials, blistering, emetics, have proved +either positively injurious or altogether without effect upon the +course of the disease. + +Of drugs, ammonium chloride, salicylic acid, carbolic acid, quinine, +have been administered without positive effect. + +It is stated that the free inunction of oil from the very beginning of +the attack was affirmed to exert a favorable influence.[12] + +[Footnote 12: See Griesinger, _Virchow's Handbuch der Speciellen +Pathologie und Therapie_, ii. 2, s. 316.] + +In early times the buboes were often incised, or even excised, as soon +as they began to swell. More recently they have been treated with +leeches or inunctions of mercurial ointment. The treatment by +poultices and the evacuation of pus as soon as it can be detected is +at present regarded with greater favor. Carbuncles are likewise to be +treated in accordance with accepted surgical procedures. + + + + +{785} + +LEPROSY. + +BY JAMES C. WHITE, M.D. + + +DEFINITION.--Leprosy is a constitutional disease of chronic course and +fatal termination, characterized by peculiar changes in the tissues of +skin, mucous membrane, nerves, and most organs of the body. + +SYNONYMS.--Elephantiasis of Greek writers; Lepra of Arabian authors; +Anssatz (Germany); Spedalskhed (Norway). The local names in use among +the numerous races in which it prevails are too numerous to be given +here. + +HISTORY.--Although great confusion has existed among the most ancient +as well as later medical writers with regard to the definition of this +disease, it having been confounded with several other affections +(elephantiasis arabum, syphilis, psoriasis, morphoea, etc.), leprosy +has prevailed in certain parts of the world from the time of the +earliest records. The biblical accounts show that it existed among the +Jews in Egypt, although it was not accurately distinguished from other +diseases resembling it in some respects. It was recognized in Greece +before the Christian era, and in the early centuries after Christ it +had extended widely over Europe. In the seventh and eighth centuries +special leper-houses were founded in Italy, France, and Germany. The +disease reached its height in Europe in the twelfth and thirteenth +centuries, when 19,000 lazarettos are said to have been in existence. +Its spread was greatly increased by the constant intercourse kept up +between Europe and the East during the Crusades. In the fifteenth +century it began to diminish, and in the course of the seventeenth it +had almost wholly disappeared from the most civilized states. It has +lingered, however, in other parts, and exists to-day in France and +Spain and Portugal, in Norway and Sweden, and in Italy, Greece, and +Southern Russia. As in ancient times, it is widely spread along the +coasts of Africa and prevails largely throughout Asia. It is found in +many of the islands of the Indian and Pacific Oceans, in Japan, New +Zealand, Madeira, the West Indies, extensively in some of the states +of Central and South America and Mexico and the Hawaiian Islands. + +It may be interesting to trace its history in the United States and +adjacent districts more minutely. It is not known just when leprosy +was introduced into North America. According to the Louisiana +historian, Gayarre, the Spaniards established leper hospitals in +several of their colonies on the Gulf of Mexico during the last +century. One existed in New Orleans as late as 1785. In 1776 the +disease was reported as existing among the blacks in Florida. It seems +to have died out, and with {786} it all remembrance of its former +existence amongst us, until within the last few years, when its +occurrence in the Southern States has again attracted attention. In +Louisiana the first case was discovered in 1866 in an old woman whose +father came from the south of France; she died in 1870. In 1871 it +appeared in one of her sons, in 1872 in two others, and in 1876 in a +nephew. A sixth case developed in a young woman who was in constant +attendance upon the first case. In addition to this group, other cases +have been observed in several parishes, amounting to twenty-one in +all, as collected by Salomon of New Orleans in 1878.[1] Two other +cases, brother and sister, in Louisiana are known to the writer, one +of whom has recently died under his care. In South Carolina the +disease is reported by J. F. M. Geddings[2] to have been observed in +sixteen cases since the year 1846; four were Jews, four negroes, and +eight whites. In none was any hereditary taint to be traced. No new +cases have developed since that report.[3] + +[Footnote 1: _New Orleans Med. and Surg. Journal_, March, 1878.] + +[Footnote 2: _Trans. Intern. Med. Congress_, Philadelphia, 1876.] + +[Footnote 3: See article on "Contagiousness of Leprosy" by writer, in +_Amer. Journ. of Med. Sciences_, Oct., 1882.] + +In Minnesota and other North-western States leprosy has been known to +exist for a considerable time among the Norwegian immigrants who have +settled in them in large numbers. Holmboe in 1863 and Prof. Boeck +later made visits to these colonies while in this country, and +published reports concerning them after their return.[4] The latter +found eighteen cases among his countrymen, most of which were leprous +before emigration; in others the disease developed after arrival in +America. It had not manifested itself in any person born in this +country. The character and progress of the affection seem to have been +little influenced by residence here. Since these observations other +cases have been collected by the committee on statistics of the +American Dermatological Association,[5] showing the continuance of the +disease in these States. In 1879 there were fifteen cases in +Minnesota. Its spread in this portion of our country is slow. + +[Footnote 4: _British and For. Med.-Chir. Review_, Jan., 1870, and +_Nord. Medic. Ark._, Bd. iii.] + +[Footnote 5: See _Transactions_.] + +Since 1871, 52 cases of the disease have been inmates of the hospital +for lepers in San Francisco, California. Of these, all, with one +exception, were Chinese, and forty-five of them had been sent back to +China. It is presumed to have shown itself after arrival in this +country, as "unproductive labor would not be imported by the Six +Companies."[6] No case of the disease known to have been acquired in +this country has yet been reported upon the Pacific Coast. One case +has developed in San Francisco after residence in the Hawaiian +Islands. + +[Footnote 6: _Trans. Am. Derm. Assoc._, 1881.] + +In Oregon, too, the disease has appeared among the Chinese immigrants, +steps having been recently taken to re-ship five lepers from the +poor-farm at Portland to China. + +Since 1815, possibly earlier, leprosy has prevailed among the poor +French settlements along the Miramichi River, near the Bay of +Chaleurs, New Brunswick. It was first noticed in a woman whose mother +came from Normandy, and has continued mainly in her descendants since. +No measures were taken to control the disease until 1844, when a +hospital was erected on Sheldrake Island. In 1849 the present +lazaretto at {787} Tracadie was established. During the first five +years (1844-49) there were admitted 32 patients; from 1849 to 1863, 67 +additional patients were received; and from the latter date to 1879, +30 more, making a total number of 129 up to the last report. The +greatest number present at any one time was 37. In 1878 there were 16 +patients in the lazaretto--6 men and 10 women. The total number of +deaths in the hospital has been, up to 1878, 123. A. C. Smith, who +resides near Tracadie, states that at the latter date but three cases +were known to exist outside the lazaretto. Residence is not +compulsory, and no sufficient measures are taken to remove patients +from their homes before they may have inoculated other members of the +family. The disease is more restricted in locality than formerly. + +Within the last two years two or three small groups of the disease +have been discovered in the island of Cape Breton, which are described +in the _Canadian Journal of Med. Science_, Sept., 1881. + +These are all the places north of Mexico where the disease exists in +an endemic form. A considerable number of cases have been reported +within the past few years from other parts of the United States, where +it has manifested itself in persons who have formerly resided in +leprous countries or in those who have wandered from the above +infected districts. A very few instances have been recorded in which +it has appeared in those who have never visited any infected locality +or have been in apparent contact with lepers. Such cases, if +authentic, establish the possibility of a sporadic origin of the +affection. The fact of so many foci already established, and the +penetration of a race so prone to the disease as the Chinese into all +parts of the country, give the study of leprosy in America a special +importance. + +ETIOLOGY.--The study of the etiology of leprosy is intimately +connected with that of its history and geographical distribution. From +the earliest times it was regarded in all parts of the world as a +contagious affection, and efforts were made by the sternest laws of +Church and State to control its spread by segregation, by interdiction +of marriage, etc. No disease has ever been regarded with an equal +degree of abhorrence by mankind; none has received greater attention +from physicians of every age. Within the present century it has come +to be regarded, almost without exception, by the profession as +non-contagious. Peculiarities of climate, soil, and modes of life have +been looked upon as predisposing, exciting, or even essential +influences in its causation; but the widespread distribution of the +disease, with the consequent diversity of diet and customs of living, +its prevalence upon the coast and in interior regions, in high +altitudes as well as at the sea-level, in Iceland as in the tropics, +show that these conditions, however they may affect the course of the +affection, have no direct relation to its causation. The theory of +heredity, as the most plausible explanation, has received its +strongest support in the investigations of Boeck and Danielssen in +Norway, where the disease can be traced for several generations in +families. The same conclusions readily present themselves where the +disease is studied in restricted localities, as in Louisiana and New +Brunswick at the present time, where, as we have seen, it manifests +itself closely in families in different generations. But this is a +narrow point of view from which to study the etiology of leprosy. It +often fails to manifest itself in the descendants of lepers in {788} +such communities, and affects persons in whose families it has never +previously existed. Moreover, in countries where it does not prevail +it not infrequently attacks individuals who have at some time visited +regions where it was endemic, and in the latter places may develop in +immigrants from parts of the world where it has never existed. + +The same class of facts which seem to demonstrate its hereditary +nature may be used in support of its infectious character. The proper +field for observation in this regard would be a virgin region where +its natural course could be studied independently of theories. +Fortunately for science, such an opportunity is afforded in the +history of the disease in the Hawaiian Islands. The exact date and +mode of its introduction there are not definitely known. The islands +have for years been the resort of the whaling-fleets manned by sailors +coming from leprous regions. The natives also shipped as sailors, and +after visiting such ports returned home. The absence of any restraint +in the intercourse of crews and native women is well known. Isolated +cases may have occurred as far back as 1830, but the disease made slow +headway until about 1860, when it increased so rapidly that the +government took stringent measures to control it, all cases discovered +being sent to the leper segregation upon an island from which there is +no escape. Since 1866, 2000 cases have been received there, and at +last report the asylum contained 750 inmates. This by no means +represents the extent of its prevalence in the islands, however. As +the native population by recent census was only 44,000, it will be +seen that the proportion affected is very large. This unwonted +rapidity of spread cannot be accounted for on the ground of heredity. +Transference from individual to individual by inoculation seems to be +the only possible explanation, and all resident physicians believe +that the disease is contagious in this sense. It affects almost +exclusively those of native descent, and their habits of life are such +as would greatly facilitate its wide dissemination in this way--viz. +their great licentiousness and absence of all fear of the disease, +which affords no bar to ordinary association or cohabitation; the +crowding of large families in small huts and sharing the same mats and +blankets; the eating of poi with the fingers from the same dish; +passing a common drinking-vessel or pipe from mouth to mouth, etc.[7] +Promiscuous and compulsory vaccination with impure virus, too, has +been generally practised during recent epidemics of small-pox. It is +evident that abundant opportunity has in many ways been presented for +the inoculation of pus or blood into the circulation from infected to +healthy persons. Where immunity from contraction has followed marriage +with a leper, it may be assumed that the conditions of an abraded +surface and the contact with pus or blood have not been fulfilled. The +wide spread of syphilis among the natives, and a consequent cachexia, +have no doubt contributed to these conditions and established a +national lack of resistance to the ravages of the disease. Nor can we +overlook the proclivity of all endemic diseases to extraordinary +manifestations of virulence in insular nations not previously +protected by gradual inoculation. Many reliable cases are cited by +resident physicians where the evidence of direct communication of the +disease seems to be reliable. Facts of the same nature may be +collected in the study of the history of {789} the disease in New +Brunswick and in Louisiana, where, as above stated, much better fields +for investigating this question exist than in the Old-World regions +where the affection has been rife for centuries. + +[Footnote 7: Dr. G. W. Woods, U.S.N., in _Hygienic and Med. Reports_ +of Navy Department, vol. iv., 1879.] + +If we admit the fact of transference by inoculation in a single +instance, there is no reason why we should not regard this as the +principal if not the only means of extension of the disease, whether +we accept or not the theory of its parasitic nature. It is not +inconsistent with our knowledge of its laws and history to believe +that leprosy is an affection communicated with difficulty, and after a +prolonged period of incubation, from one person to another by contact +with certain products of the diseased tissue; that it has in past and +present time in this way spread from nation to nation; and that its +progress as an endemic affection has been checked only by laws based +upon this theory. All the negative facts so frequently urged against +this doctrine of contagion apply as strongly to that of heredity, and +may be interpreted in support of the former. The latest investigations +into its pathology afford tangible evidence in its favor. It may at +least be claimed that the question of contagion through inoculation +must be reopened.[8] + +[Footnote 8: See article on the question of contagion in leprosy in +the _American Journal of Med. Sciences_, Oct., 1882, by the writer.] + +Leprosy affects both sexes in about equal degree, and may first show +itself in early childhood. It is apt to produce sterility, so that +marriages between lepers are rarely fruitful. This result seems to +limit the extension of the disease under the law of heredity if we +admit its action. There can be no doubt that cohabitation may take +place for years without communication of the disease where one party +alone is leprous; and such immunity may be explained by the failure of +favorable conditions for sexual inoculation, just as in syphilis. The +disease would naturally be most dangerous in its ulcerative tubercular +form. + +SYMPTOMATOLOGY.--There are two well-marked forms of leprosy--viz. the +tubercular and the anaesthetic--which are characterized by certain +easily recognized external manifestations, and which are accompanied +by symptoms indicative of disturbances of the general economy as well +as of special organs. These forms are not always sharply defined, and +often occur simultaneously or in succession in individual cases. Both +are generally preceded by premonitory symptoms, consisting of +unaccountable languor of mind and body, tingling sensations in the +skin, rise of temperature in the evening, and various disturbances of +digestion, or by the occasional outbreak of single or several blebs. +This prodromal stage affords no indication of the type of disease to +follow, and may last for days, months, or even years, with greater or +less intervals and intensity. + +TUBERCULAR LEPROSY.--This form may declare itself at once by the +characteristic tubercles, but frequently an earlier manifestation is +the appearance of macules or dull red spots, varying in size from a +pea to two or three inches in diameter. They have an indistinct +margin, a glazed and smooth surface, and become paler on pressure. The +patches, although not at all or but slightly elevated above the +general surface, are firmer, and penetrate more or less deeply into +the cutaneous tissues. They may increase in size peripherally and +undergo involution in the older central portions simultaneously. +During the latter process the color changes from a more or less dull +red to a brown, yellow, or grayish tint, and {790} finally may become +quite white. The spots also become thinner or even slightly depressed. +Their seat is principally the trunk, but also the limbs, and less +frequently the face. This condition of the skin may precede any other +changes in its tissues for months or years, the patches appearing and +disappearing or remaining as permanent stains. At last well-defined +tubercular elevations show themselves, varying in size from a small +shot to a filbert, flattened or semi-globular in form, generally +smooth and firm to the touch, and of a dull red or brown color. They +occur upon any part of the surface, but are especially abundant upon +the face, where they may cause great deformity of the features. The +forehead and eyebrows may become very greatly thickened by general +infiltration, or thrown out into very prominent folds and +protuberances by the massing of individual tubercles. The lips +thicken, the nose broadens, and the ears stand out conspicuously with +their increased bulk. All these changes in form, with the great +darkening in tint which is often present, give at times a most +repulsive expression to the face. The tubercles are sometimes to be +felt imbedded in the skin, or considerable areas are found to be +uniformly thickened and scarcely at all prominent. All forms are +capable of involution after an existence of months, and may leave +dark-colored atrophic patches to mark their seat. They are rarely +painful, and occasionally slightly sensitive. They may be transformed +into ulcers, especially upon prominent positions, as the knuckles, +elbows, knees, as the result of pressure or injury, which are +extremely indolent, although shallow, and may heal and break down +repeatedly. Occasionally they give rise to serious +complications--inflammation of the lymph-vessels, suppuration of the +joints with loss of the attendant members, as the fingers and toes. +Tubercles appear also upon the mucous membrane of the nasal cavities, +the mouth, and larynx, often in great abundance, causing a very +characteristic hoarseness or loss of voice. With these changes in the +cutaneous tissues, which may be accompanied in their periods of +greatest activity by febrile disturbances, there are developed after +months or years, with gradual failure of strength, manifestations of +changes in the internal organs, the lungs, intestines, and brain, +which may prove fatal at any time, or the patient may die of slowly +progressive marasmus. The course of the tubercular form is on the +average between eight and ten years. At any period there may supervene +manifestations of the anaesthetic type, which makes the so-called +mixed variety, in which either form may predominate. + +ANAESTHETIC LEPROSY.--This variety is characterized by the loss of +sensation in the skin over areas of varying extent, which occupy no +definite positions in relation to nerve-distribution. The anaesthetic +patches may appear upon the seat of old maculae or former tubercles or +of a preceding bullous efflorescence, or upon parts not previously +affected in any way. They may follow a reddened and hyperaesthetic +condition of the cutaneous tissues, or they may be surrounded by a +serpiginous border of this character. The degree of anaesthesia in the +affected parts is sometimes so complete that the skin and underlying +tissues may be deeply pricked or cut or burned without the patient +being aware of the injury. Such patches may possibly regain their +sensibility. Their surface appears in later stages dry, wrinkled, +shrunken, and of a brownish color, and atrophy, not only of the skin +but of the muscles, is gradually developed, {791} in consequence of +which the expression of the face undergoes a marked change. The +eyelids and lips droop, the hair falls, the hands contract, and the +joints of the fingers and toes are laid bare, so that the phalanges, +or even the whole hands and feet, drop off. Ulceration or gangrene of +the parts may develop, and whole extremities may shrivel up. With +these manifestations of local derangements of nerve-action the +functions of the brain fail, the patient becoming stupid and incapable +of action or motion, the temperature and pulse are lowered, and death +comes slowly by marasmus or the most various complications--tetanus, +disease of the lungs, pyaemia, etc. The average duration of this form +is from eighteen to twenty years. + +PATHOLOGICAL ANATOMY.--The structural changes which take place in the +tissues of parts which are the seat of the appearances above described +have received the special study of many excellent observers[9] in +recent times, and are now well understood. A section through the +thickened skin or a tubercle shows the corium and underlying +connective tissue infiltrated with round cells, as in lupus and +syphilis; in other words, converted into "granulation tissue." This +change first takes place along the course of the cutaneous vessels and +glands, penetrating more deeply and forming a firmer cell new-growth +in proportion to duration, the cells being enclosed in a coarse +meshwork of fibrous tissue, and encroaching upon the various +structures of the skin, so as to produce atrophy and finally +destruction of all its characteristic tissues. This cell-infiltration +may of itself undergo later changes, as fatty degeneration and +softening (ulceration). The lymph-glands and corpuscles assume a +special fatty metamorphosis. An examination of the tubercles upon the +mucous membrane reveals the same small-celled new-growth. In the +nerve-tissues also marked structural changes are found, both in the +central and peripheral systems, in the anaesthetic form of the +disease. In many cases the posterior segments of the gray cornua and +the fibres of the commissure, as well as the nerves of the +extremities, have been found altered by inflammation, which will +account for the disordered sensibility and the subsequent disturbances +of nutrition, muscular atrophy, etc. The nerve-trunks are often to be +felt beneath the skin, thickened and sensitive on pressure. The +chronic cell-infiltration affects the fibrous structure of the outer +sheath, the neurilemma, and the septa between the nerve-bundles, +producing fatty metamorphosis and atrophy of the nerve-bundles. +Similar cell-infiltrations are found also in the connective tissue of +all the internal organs of the body, which lead to destructive +processes in their respective structures. + +[Footnote 9: Boeck and Danielssen, _Traite de la Spedalskhed_, Paris, +1848; Virchow, _Die Krankhaften Geschwulste_; Kaposi in _Hebra's +Lehrbuch der Hautkrankheiten_; Monasterski, _Vierteljahressch. fur +Derm. u. Syph._, 1879, p. 203; Hansen, _Virchow's Archiv_, Band 79, +1880; Neisser, _Virchow's Archiv_, Band 84, 1881; Cornil et Souchard, +_Annales de Derm. et de Syph._, 1881, No. 4.] + +Within the last two years repeated observations have been made which +confirm the statement published by Hansen in 1873, that a peculiar +bacterium occurs in leprous tissues, which, it is claimed, establishes +the parasitic nature of the affection. These examinations have been +carried on with leprous material derived from many parts of the world, +and the results have been uniform. Within the round cells which +characterize the cutaneous neoplasms, both in the distinct tubercles +and the diffused {792} infiltrations, small agglomerations of minute +rod- or staff-like bodies (bacilli) are found, arranged in parallel +rows or placed end to end. Their length is one-half or three-fourths +the diameter of a red blood-globule, and their breadth is one-fourth +their length. With them minute granular particles are seen in the +cells. They occur in greatest numbers in the cells of the upper layers +of the true skin, which are considerably swollen by their presence. +They never penetrate the epithelial layer, nor are they found in +epithelial cells in any position. When the protoplasm of the cell is +interfered with by the later tissue-changes of the disease, the +bacillus perishes. They are found not only in the leprous cells, but +also in those of the connective tissue running between the +agglomerated masses of the former. Between the leprous cells and the +filaments of connective tissue but few free bacilli are seen. The +neoplasms of the mucous membrane and of many organs of the body have +been found to contain them also. In the blood they have been detected +by some observers. Their presence in the nerve-tissues is of +importance as throwing light upon the question of the specific or +inflammatory nature of the morbid processes above described as +affecting them. If we regard the bacteria as pathognomonic of leprous +tissue-changes, their occurrence, recognized in the cells penetrating +between the fibres of the peripheral nerves, would seem to make all +primary structural changes identical, and the anaesthetic as much as +the tubercular form the direct result of their presence. Neisser draws +the following conclusions from his investigations: "Leprosy is a real +bacterial disease, caused by a special kind of bacterium. The bacilli +appear in the tissues as such, or more probably as spores, and remain +for a longer or shorter time in a state of incubation, according to +circumstances, in depots, perhaps in the lymph-glands. This period, +much longer than in other infective diseases, is in proportion to the +physiological resistance of the human organism compared with the +feeble developing power of the bacilli. It, as well as the course of +the disease, is more rapid in tropical countries than in Europe. From +these depots the disease extends throughout the body in those portions +of the skin most exposed, the face, hands, elbows, knees, and into the +peripheral nerves. The other organs are less freely invaded. The +bacilli excite inflammation, and by a specific action transform the +migrating cell into the leprous cell. Leprosy is probably an +infectious disease, and its specific products are contagious--viz. the +leprous cells of the tubercles, the tissue-fluids, and the pus +containing bacilli or viable spores. On the other hand, the pus may +not always be infectious, as the fluid contained in the bullae is +not." + +It must be said that the bacterial nature of leprosy, if established +in accordance with the above observations, furnishes a satisfactory +basis of explanation of all facts, historical, clinical, and +pathological, which have so long been awaiting solution. The inability +of the parasite to penetrate the epithelial layer of the skin and +mucous membrane explains why contagion is so difficult, and why the +ulcerative tubercular form would be more favorable to such +transference than the anaesthetic variety. + +DIAGNOSIS.--Leprosy in some of its early appearances may be readily +confounded with vitiligo, morphoea, pemphigus, lupus, and syphilis. In +some cases its prodromal manifestations cannot be positively +diagnosticated until other symptoms have developed, which by +concurrence establish their true significance. Such are the +pemphigus-like bullae, the {793} pigment-changes, and the smaller +tubercular efflorescences. In regions where the disease occurs only by +importation, and in the so-called sporadic cases, it is not at all +strange that it should fail of recognition, even in well-advanced +forms, unless the observer is acquainted with its whole +symptomatology. On the other hand, there is no disease which presents +more strikingly characteristic features in its advanced stages. + +PROGNOSIS.--Leprosy is almost uniformly a fatal affection, and its +course toward this termination varies but slightly under the most +diverse conditions of life. Its development and progress are naturally +more rapid under circumstances of least individual resistance, where +food is poor and scanty, where extremes of climate are most felt, +where the constitution of the individual or nation is debilitated by +previous disease, as that of the Hawaiians by syphilis, or where no +proper professional care is employed. It has been believed that a +change of residence from infected to non-leprous regions would retard +its advance or avert its appearance in those supposed to be +hereditarily disposed; but the former effect follows probably only so +far as the general condition of the patient is affected by the change, +as in other constitutional disorders, and the latter is necessarily a +matter wholly of conjecture. No case of leprosy in the Norwegian +colony in our North-western States has ceased to progress after +arrival toward its fatal ending, even if this has been somewhat +delayed in individual cases under more generous ways of living. If it +could be known that a child born in Norway had escaped leprosy by +removal to America, we should not, if we accept the bacterial origin +of the disease, consider that climate or other mysterious influences +had overcome its inherited tendencies, but that it had been taken away +from the chance of direct inoculation. It is stated that very rarely +cases cease to progress beyond certain stages even in countries where +the disease is endemic. The course, as has been stated, varies +according to the clinical form, the duration of the tubercular variety +being on an average but one-half that of the purely anaesthetic type. +Leprosy may be called the slow disease, its period of incubation, so +far as this can be determined, extending from one to several years, +its prodromal stage lasting often several more years, and its +well-developed forms requiring at times more than twenty years to +destroy the patient. Cases sometimes prove fatal, however, in a single +year. + +TREATMENT.--In a disease which affects so many of the races and such +great numbers of mankind, which has been for centuries the object of +special attention on the part of physicians, and of late years of +government commissions and of eminent pathologists, it is evident that +every remedy which the materia medica includes, as well as those of +merely popular reputation in the widely-diverse geographical regions +in which it prevails, must have been employed in its treatment. None +of them exert any specific action upon it; it remains incurable. Every +year some new article is employed with the usual claims of success +which accompany the introduction of new remedies, but they merely +swell the long list of failures in the therapeutics of the affection. +Still, leprosy is influenced somewhat by medical care; life may be +prolonged and made more comfortable. To this end we may employ +remedies which are capable of improving and maintaining the +constitutional powers of resistance to the disease, such as are found +of service in other chronic wasting affections. {794} The patient is +to be put in as healthy ways of living as possible, removed from +debilitating localities, and given generous diet and tonics, as iron +and quinia. Several new drugs which seem to stimulate the nutrition +and produce temporary improvement in the local and general symptoms +have lately been widely employed, as Gurjun balsam and chaulmoogra +oil, but they have wrought no cure. Digestion is to be aided, +diarrhoea to be checked, and disturbances of respiration to be +alleviated. Local treatment is also of service. The tubercles may +sometimes be made to disappear--partly, at least--by stimulating +applications, and ulcers made to heal by cauterization and other +well-known methods of dressing. These ulcers and their secretions +should be regarded as possible sources of infection by attendants and +members of the patient's household. For the anaesthetic alterations in +the tissues but little can be done locally. If the bacterial origin +and causation of the disease be eventually established, its future +extinction must be based upon studies directed to the nature and mode +of protection against this organism. Collectively, the disease should +be treated by every nation by thorough segregation, and importation +should be prevented by the most rigid quarantine laws. + + + + +{795} + +EPIDEMIC CEREBRO-SPINAL MENINGITIS. + +BY ALFRED STILLE, M.D., LL.D. + + +DEFINITION.--A febrile, and often malignant, but non-contagious +disease of unknown origin; usually occurring as a local epidemic; +confined hitherto to the North American and European continents, and +to the vicinity of the latter; characterized by its rapid and +irregular course, and usually by a tetanic rigidity or retraction of +the neck, a tendency to disorganization of the blood, and the +formation of inflammatory exudates beneath the membranes of the brain +and spinal cord. + +SYNONYMS.--Spotted fever; petechial fever; malignant purpuric fever; +malignant purpura; pestilential purpura; black death; typhus +petechialis; typhus syncopalis; febris nigra; febbre +soporoso-convulsivo; tifo apoplettico tetanico; fievre +cerebro-spinale; typhus cerebro-spinale; phrenitis typhodes; epidemic +meningitis; epidemic cerebro-spinal meningitis; malignant meningitis; +typhoid meningitis; meningite cerebro-spinale epidemique; meningite +cerebro-rachidienne; Genickkrampf; Genickstarre. + +The names which have been given to this disease convey more or less +distinctly one or the other of two ideas: 1st, that the disease is +essentially a blood-disorder; and 2d, that it is an inflammation of +the cerebro-spinal meninges. Under the first head belong the following +names: Malignant purpuric fever; malignant purpura; pestilential +purpura; petechial fever; spotted fever; febris nigra; black death, +etc. Under the second head belong epidemic cerebro-spinal meningitis; +epidemic meningitis; malignant meningitis; typhoid meningitis, etc. As +partaking of the qualities of both categories may be cited the names +cerebro-spinal fever and fever with cerebro-spinal meningitis. In +regard to all those of the first class it is sufficient to repeat the +criticism made by the early American writers who described this +disease after having largely studied it. One only of them need be +cited, because he expresses the opinion of all. Miner, writing in +1822, said: "It is quite unfortunate that a single symptom +(petechiae), and one, too, that is wanting in a great majority of +cases, should have been seized upon to give it the odious and +deceptive name of spotted fever, as that name has been applied by +European writers to a very different kind of fever." Among the names +given to the disease, cerebro-spinal fever is perhaps the least +suitable and the least in harmony with the principles of scientific +nomenclature. It is one of those terms which may be pardoned when used +by the laity, but which educated physicians ought not tolerate. +Parallel examples may be found in such compounds as brain-fever, +lung-fever, gastric-fever, and, most unfortunate of all, enteric +fever. The first three of these are {796} inflammations, pure and +simple, of the brain, lung, and stomach; and, after their example, +cerebro-spinal meningitis would be, what it is not, merely an +inflammation of the membranes of the brain and spinal marrow. The name +of the remaining disease has only to be turned into English and called +intestinal fever to demonstrate its defects. It is evident that other +diseases--and dysentery in particular--are equally entitled to be +called enteric fever. Moreover, there are cases of enteric fever in +which death takes place so early that the intestinal lesion is +undeveloped, and the fatal issue must be attributed to the +fever-poison in the blood or else to the changes it has wrought in +that fluid. Analogous illustrations abound in the history of the +eruptive fevers. The disease we are studying presents another +affection in which the septic element sometimes so far overrides the +inflammatory as to destroy life before the latter has developed +characteristic tissue-changes. There may be no valid objection against +classing it among the fevers, but there can be no excuse for +denominating it cerebro-spinal fever. The very reasons that militate +against its being regarded as a meningitis forbid its being considered +as a meningeal fever. But if it is a meningitis, inchoate or complete, +then the prefix epidemic denotes its constitutional nature and its +probable blood origin, and a term is employed which is descriptive and +accurate, and not misleading. Moreover, the term epidemic indicates, +or at least implies, the characteristic type of the disease, which is +asthenic and sometimes more or less typhoidal, just as other +inflammatory diseases become so in their epidemic form--_e.g._ +pneumonia, bronchitis (influenza), dysentery, etc. + +There ought to be no doubt whether epidemic meningitis should be +classed with general diseases or with inflammations. It is excluded +from the latter class by the total absence of any tangible external +cause from its causation, as well as by its frequent fatal termination +before the characteristic signs of inflammation have had time to form, +or because the peculiar type of the disease prevents their +development. It belongs to the former class because it is epidemic in +the largest sense, its outbreaks occurring simultaneously in remote +parts of the earth and independently of all cognizable celestial or +terrestrial influences. In this as in other elements of its pathology +the disease stands absolutely alone. While the acute affections of the +pulmonary and digestive organs, which were just now alluded to, affect +large districts, and even sweep over a whole continent, epidemic +meningitis breaks out in limited localities, and may for years prevail +in a populous city within a hundred miles of another still more +populous which during that time may altogether escape its ravages. Of +this curious fact the cities of Philadelphia and New York present a +striking illustration. Since, then, we are ignorant of the +circumstances under which the disease arises, and since, as will more +distinctly appear later on, its several forms really include quite +various morbid conditions, we are compelled to consider it as +occupying a peculiar and exceptional nosological position. + +HISTORY.--Previous to the present century the existence of this +disease can hardly be demonstrated. And yet Dr. B. W. Richardson +believed that some faint traces of it could be discovered, as in the +following statement:[1] "The great plague which visited Constantinople +in 543, and which Procopius and Enagrius described, the plague of +{797} hallucination, drowsiness, slumbering, distraction, and ardent +fever, with eruption on the skin of black pimples the size of a +lentil,--this plague, which usually killed in five days, and left many +who recovered with withered limbs, wasted tongues, stammering speech +or such utterance of sound that their words could not be +distinguished,--this plague, which had passed into mythical learning +under the name of cerebro-spinal meningitis, has also in our time +reappeared." The concluding statement in regard to the name of the +plague is quite erroneous, and there is nothing in the description +which distinctively applies to the disease we are examining. On the +other hand, we know that Procopius wrote a history of the Oriental +plague, which invaded Europe for the first time at the very date above +given. It had as a distinctive symptom the well-known inguinal bubo, +and there is no mention whatever, in the descriptions of it that have +survived, of the tetanoid symptoms belonging to epidemic meningitis. +In 1802 an epidemic occurred at Roetlingen in Franconia which had a +certain resemblance to the subject of this article, for it was +characterized by lacerating pains in the back of the neck. According +to Hecker, this was the sweating sickness which had ravaged various +parts of Europe during the Middle Ages, and of which limited outbreaks +still recur. In 1880 such a one took place at l'Ile d'Oleron in +France, and many of the patients were affected with tonic or clonic +spasms, both general and local, but not, apparently, opisthotonic.[2] + +[Footnote 1: _Diseases of Modern Life_, p. 16.] + +[Footnote 2: Pineau, _Archives gen. de med._, tom. i., 1882, pp. 25, +169.] + +If epidemic meningitis occurred before the nineteenth century, it must +have been confounded with other affections, but when we consider its +characteristic symptoms such an error seems improbable. The +comparatively rare resort at that time to post-mortem examinations, +particularly of the cranial and spinal cavities, may in part account +for such a confusion of ideas; and even when dissections were made, +the skill to interpret the discovered lesions was possessed by few. It +has been thought that in the latter part of the last century some +cases of this disease were seen and described, although their +nosological value was unrecognized. Thus, Stoll[3] speaks of a young +soldier who was seized with a pain in the back of the head and neck, +and who was affected with opisthotonos before he died. On examination +pus was found between the arachnoid and the pia mater. The first clear +and unquestionable description of epidemic meningitis was published in +1805, first by Vieusseux and directly afterward by Mathey.[4] The +disease appeared at Geneva in the spring of the year, in a family +composed of a woman and three children, of whom two of the latter died +within twenty-four hours. A fortnight later four children in a +neighboring family died of it after fourteen or fifteen hours' +illness, and a young man in an adjoining house, being attacked, died +the same night, with his whole body of a violet color. The disease +ceased during the spring, after having destroyed thirty-three lives. +Its distinctive features were an abrupt attack during the night, +bilious vomiting, excruciating headache, rigidity of the spine, +difficult deglutition, convulsions, nocturnal paroxysms, petechiae, +and death in from twelve hours to five days. Vieusseux calls it "a +malignant non-contagious fever," and Mathey gives as the lesions +revealed by dissection a gelatinous {798} exudation covering the +convex surface of the brain, and a yellow puriform matter upon its +posterior aspect, upon the optic commissure, the inferior surface of +the cerebellum, and the medulla oblongata. + +[Footnote 3: Quoted by Boudin, _Hist. du typhus cerebro-spinal_, p. +5.] + +[Footnote 4: _Journ. de Med., Chirurg. et Pharm., etc._, an. xiv., +tom. xi, pp. 163, 243.] + +After its first appearance at Geneva the disease does not seem to have +extended in any direction from that place as a centre, but we next +hear of it at two points remote from it and from one another--Germany +and the United States. From the former it extended to the conterminous +countries, Bavaria, Holland, and the east of France, where, however, +it prevailed neither extensively nor fatally, and soon died out; while +in America it first appeared at Medfield, Mass., in 1806. The European +epidemic was faintly felt in England the following year, and between +that time and 1816 it prevailed at several places in the east of +France, and slightly at Paris, while during the corresponding period +it had extended through New England into Canada, New York, +Pennsylvania, and several Western and South-western States. It is a +noteworthy fact that on both sides of the Atlantic it ceased in the +same year (1816). During the six following years we can discover no +trace of its existence, but in 1822-23 it reappeared at Vesoul in +France, and at Middletown, Connecticut, and does not seem to have +extended beyond those places. Again, after an interval of five years, +in 1828 it was heard of in Trumbull co., Ohio, two years later at +Sunderland in England, and three years afterward (in 1833) at Naples. + +After four years of quiescence the disease entered upon a wider and +more destructive career than ever before, which was almost +uninterrupted from 1837 to 1850. During the first two years of its +recurrence in Europe it was confined almost wholly to France. It began +in the southern departments, with Bayonne as a centre, and extended +gradually westward and northward, in some places attacking only +military garrisons and in others only civilians. Elsewhere the +predilection was reversed, or, again, civilians and soldiers were +equally affected. As Boudin has pointed out, "it located itself in +certain districts; in garrison-towns it seemed to affect certain +barracks only, and in them only certain rooms. In one place it broke +out in a prison and spared the soldiers; in another its victims were +among the soldiers and the citizens, while the prisoners were +untouched." Thus the disease spread over the whole of France, and was +more fatal almost everywhere else than in Paris itself. Almost at the +gates of the capital, at Versailles, and among the garrison, it was +very destructive in 1839, causing a mortality among those attacked of +from 50 to 75 per cent. About the same time it occasioned a great +mortality at other military posts, especially at Rochefort and Metz, +and in 1840-41 at Strasbourg. In 1843 the disease had almost ceased to +prevail in France, but in 1846 it reappeared at Lyons, and in the +following years, and until 1849, affected the garrisons of Orleans, +Cambrai, Saint-Etienne, Metz again, Luneville, Dijon, Bourges, and +Toulon. In some of these places the military experienced five, and +even seven, successive epidemics. Meanwhile, the disease spread to +Algeria (1839-47), and to Italy in the former year--not, however, on +the confines of France, but at Naples and in the Romagna, whence it +extended to Sicily and Gibraltar, and did not cease there until 1845. +In 1839 it first showed itself in Denmark, and remained for about +three years, while in 1846 it "appeared in the {799} majority of the +workhouses of Ireland," and in the spring of the same year it occurred +in England, at Liverpool and Rochester. + +While the disease was thus spreading throughout Europe, it again, in +1842, appeared in the United States, but at places as remote as +possible from Transatlantic communication and hundreds of miles +distant from one another--_e.g._ in Louisville, Kentucky, in +Rutherford co., Tennessee, and in Montgomery, Alabama. In the +following year it prevailed in Arkansas, Mississippi, and Illinois. In +1848 it occurred again at Montgomery, Ala., and simultaneously, in +Beaver co., Pa.; in 1849 it existed in Massachusetts and in Cayuga +co., N.Y., and in 1850 at New Orleans. + +Between 1850 and 1854 epidemic meningitis ceased to be heard of, but +in the spring of the latter year it began to appear in the southern +provinces of Sweden, whence it rapidly spread over the greater part of +the kingdom, reaching an extreme degree of fatality in 1858, and not +finally disappearing until 1861. It is said to have caused more than +four thousand deaths. It was not until the height of the Swedish +epidemic in 1858 that it invaded Norway, where it seems to have been +even more malignant and extensive. Between 1850 and 1860 local +outbreaks of the disease took place in Ireland, and isolated cases +were observed in various parts of England, but in that country it has +never prevailed as a general epidemic. This fact alone is sufficient +to defeat all the attempts that have been made to trace the origin of +the disease to any of the conditions associated with a crowded +population. In Scotland, where such conditions exist in their greatest +intensity and fulness of development, it has never occurred as an +epidemic. During the decade under consideration (in 1856 and 1857) +epidemic meningitis again appeared in the United States, and, as +before, at points very remote from one another. In the former year it +occurred for the first time in North Carolina, and in the latter year +in the central portions of New York and Massachusetts. + +Hardly had the disease subsided in the Scandinavian peninsula and in +the United Kingdom when it reappeared in Holland during the winter of +1860-61. In the following year and at the same season it occupied a +large extent of Portuguese territory, including the cities of Oporto +and Lisbon, and now for the first time it spread over Germany. +Beginning slightly during the summer of 1863 in Prussia, it acquired +new vigor during the succeeding winter, and in the two following years +it devastated almost every part of Northern Germany, and in 1864-65 +extended throughout Bavaria except in its southern and western +provinces. Strange to relate, the disease appears to have passed +almost wholly by Austria proper, and to have prevailed, although not +extensively nor fatally, in Hungary, and in the latter part of the +decade in Istria, Greece, Turkey, and Asia Minor. + +The American counterpart of this epidemic first appeared in Livingston +co., Missouri, in the winter of 1861-62, and during the same season it +invaded Indiana and Kentucky in the West and Connecticut in the East. +From about the same date, and until 1864, it prevailed in Ohio, and +during the last-named year in Illinois. Cases occurred at Newport, +Rhode Island, in 1863, and in Vermont in 1864. In the winter and +spring of the latter year it broke out at Carbondale, Pa., and in a +population of 6000 caused the death of 400, principally among children +and {800} very young persons.[5] In the winters of 1863-64 and of +1864-65 it prevailed in the U.S. army, and in the early part of this +period in the Confederate army which at the time was stationed near +Fredericksburg, Va. In North Carolina also, from 1862 to 1864, the +disease assumed a very malignant type, and affected citizens and +soldiers equally, and the latter in the Union and Confederate armies +alike. During the winter of 1864-65 a limited but very fatal epidemic +of the disease prevailed at Little Rock, Arkansas. About the same time +it existed as an epidemic in Maryland, Alabama, and other Southern +States, and throughout the Civil War affected both whites and negroes, +but showed, as in France, an exceptional gravity among the military. + +[Footnote 5: Burr, _Trans. Med. Soc. State of N. York_, 1865, p. 40.] + +The first appearance of the disease in Philadelphia took place in +1863, and from that date until the present (1884) it has never failed +to appear among the causes of death in the reports of the Health +Office. A table compiled by Dr. C. F. Clark, and printed in a paper on +the subject by Dr. James C. Wilson,[6] exhibits the difficulties of +obtaining accurate statistics, even from official reports, on this +subject. The medical profession of the city, having had but little +knowledge of the disease either by reading or observation, reported +deaths from it which occurred in their practice under various +denominations. At first it was spotted fever, which continued to be +used by many for a year or two, when it was superseded almost entirely +by cerebro-spinal meningitis. There can be no doubt that both of these +terms were used to designate the same disease, and therefore no error +will be committed in merging the deaths charged to each of them, and +in estimating by their annual totals at least the relative mortality +of the disease in the successive years of the period. But in the +Health Office reports there are at least three other rubrics that +suggest doubt. One is typhus fever, which seems to have presented a +sudden and remarkable increase of mortality during the first years, +and the most fatal, of the existence of cerebro-spinal meningitis. It +should also be observed that typhus fever is applied by many German +physicians in this country, as in their native land, to typhoid fever. +A second is malignant fever, and a third is congestive fever, neither +of which has claimed many victims in the health reports of +Philadelphia except while meningitis was epidemic. It seems probable, +therefore, that nearly all of the deaths charged under these heads +belong to the disease under consideration. + +[Footnote 6: _Phila. Med. Times_, xiii. 88.] + +_Deaths in Philadelphia from Cerebro-Spinal Meningitis from 1863-82._ + + | Brought over 1136 + 1863 49 | 1873 246 + 1864 384 | 1874 82 + 1865 192 | 1875 83 + 1866 92 | 1876 85 + 1867 109 | 1877 56 + 1868 55 | 1878 90 + 1869 37 | 1879 62 + 1870 36 | 1880 78 + 1871 49 | 1881 90 + 1872 133 | 1882 41 to Sept. 23d. + ---- ---- + 1136 Total 2049 + +If to these deaths are added those charged to malignant fever, 111, +and to {801} congestive fever, 279, we obtain a total of 2439 deaths, +nearly all of which may be set to the account of epidemic meningitis. +It may also be remarked that up to the date at which this computation +was made (May, 1883) hardly a week passed in which the Health Office +did not register several deaths from this cause. Hence it would appear +that the disease continues to linger in this locality longer than has +been reported of any other place from which information has been +obtained. + +In the city of New York it appears to have been much more limited both +in extent and duration. The first recorded death from it was in 1861; +in 1866 the deaths were 18; in 1867 the deaths were 32; in 1868 they +were 34; in 1869, 42; in 1870, 32; in 1871, 48. In 1872 the disease +became epidemic, and "from January 6 to May 31, inclusive, 632 cases +were reported to the City Sanitary Inspector, and 469 deaths to the +Bureau of Records of Vital Statistics" (Clymer). After this period the +disease seems to have declined very rapidly, and not to have +reappeared, since no notice is taken of its recurrence by the medical +journals of New York. + +It was mentioned above that about 1870 some traces of the disease were +observed in Asia Minor, and in 1872 several cases are said to have +occurred at Jerusalem,[7] but beyond that time and place it does not +appear to have extended as an epidemic. In 1879, Cheevers said: "I am +not aware of the existence of any report of an outbreak of the disease +in India." He refers, however, to several cases occurring in Calcutta +as possibly representing this affection.[8] + +[Footnote 7: _Berlin klin. Wochensch._, May, 1872.] + +[Footnote 8: _Times and Gazette_, Aug., 1879, p. 121.] + +In 1867-68 sporadic cases occurred at Little Rock, Ark., and in the +former year in Madison co., N.Y., thirty-three cases were reported.[9] +In Chicago, between February and April, 1872, Dr. Davis reported forty +cases observed in his own practice in seventy-two days. In the same +year the disease occurred at Elizabethtown, Ky.,[10] and at +Louisville, Ky., in December of the same year. It existed in Michigan +between 1868 and 1874, but only in the latter year epidemically, and +not to a very great extent. + +[Footnote 9: _Trans. Med. Soc. State of N.Y._, 1868, p. 251.] + +[Footnote 10: _Richmond and Louisville Journ._, Nov., 1872, p. 555.] + +Of later occurrences of the disease the following may be mentioned: +Several cases were reported in London in 1867, 1871, 1876, and +1878.[11] In 1870 four cases were observed in Providence, R.I.[12] In +1882 cases were met with in Boston, New York, Philadelphia, Pittsburg, +Western Ohio, Indianapolis, Detroit, Louisville, Memphis, New Orleans, +Richmond, Milwaukee, St. Louis, Salt Lake City, San Francisco, etc., +but in none of these places did the disease become epidemic. + +[Footnote 11: _Times and Gazette_, July, 1867, pp. 58, 59; Nov., 1867, +p. 511; _Guy's Hospital Rep._, 3d Ser., xvii. 440; _St. Bart's +Reports_, xii. 267; _Times and Gaz._, Aug., 1878, p. 167.] + +[Footnote 12: _Boston M. and S. Jour._, Oct., 1870, p. 261.] + +ETIOLOGY.--Epidemic meningitis has occurred in Europe and America in +every portion of the temperate zone, but its greatest prevalence and +mortality have undoubtedly been in the northern rather than in the +southern portions of that region. One of its most interesting features +consists in its appearing simultaneously at points very remote from +one another and having no connection with each other save through the +atmosphere. Of this statement several illustrations have already been +presented. Another {802} peculiarity of the disease consists in its +occurring with hardly any relation to external natural conditions or +to those of its victims. It affects localities as diverse as possible +in their geological, meteorological, and sanitary states, the rich and +the poor, the old and the young, and both sexes, and (as it is +certainly not in a strict sense contagious) its rise and spread must +necessarily be attributed to some occult cause pervading the +atmosphere. + +It is evident that the prevalence of the disease has some relation to +meteorological agencies, for not only is it greater, on the whole, in +_cold_ than in warm climates, but it is also greater in cold than in +warm seasons. Thus, if we examine the epidemics in Europe and America +we shall find that they almost invariably were most severe in the +winter and spring. Yet the rule presents several exceptions on both +continents. In France, out of 216 local epidemics, more than +one-fourth took place during the warm months of the year, and in +Sweden the proportion was about the same. It is evident, therefore, +that cold is not an essential cause of the disease. Among the problems +that remain unsolved in regard to this disease none is more obscure +than the apparent immunity of Russia from its ravages, although the +climate seems adapted to favor it, and the domestic habits of no +people are fitter to intensify it if individual conditions entered +into the etiology of the disease; but, in truth, no such causes are +related to epidemic meningitis. Localities of every sort, high and +low, dry and moist, those saturated with marsh miasmata and those +fanned by pure mountain-breezes, have been alike visited by this +disease. It has passed by large cities reeking with all the +corruptions of a soil saturated with ordure and populations begrimed +with filth, as Vienna, Berlin, Paris, London, and New York, to +devastate clean and salubrious villages and the families of +substantial farmers inhabiting isolated spots. + +By far the greatest number of the subjects of epidemic meningitis are +young persons. In Sweden, according to Hirsch, of 1267 fatal cases of +the disease, 889 occurred in persons under fifteen years of age, 328 +between sixteen and forty years, and 50 in persons of forty years and +upward. In 1866, in the Kronach district (Germany), of 115 cases, 75 +occurred under the seventh year, 22 between the seventh and twelfth +years, and 10 between the thirteenth and twentieth years (Schweitzer). +During 1865 a local outbreak of the disease in Bavaria affected 53 +persons, of whom 22 were children under ten years of age, 18 between +ten and twenty years, and 11 between twenty and thirty years. Under +the fifth year few were attacked (Orth). Dr. J. L. Smith[13] found +that, according to the reports of the Board of Health of the city of +New York, out of 975 cases, 771 occurred in persons under fifteen +years of age, the greatest number for any quiquennial period being 336 +in children under five years. Of the 469 deaths occurring in this +epidemic, 216 were of children under five years of age, and the next +largest number for an equal period was 99, which represented the +deaths between the ages of five and ten years. Of adults or persons +beyond the age of twenty, the whole number was but 39. The peculiar +liability to the disease of the young recruits in the French army has +already been alluded to. The proportion of male victims to this +affection is rather larger than that of females in the civil +population, but in France especially the excess was greatly on the +side of males, owing to the prevalence of the disease in the army. In +other places, as {803} in Sweden and Germany, the number of deaths +among females equalled, or even exceeded, that of males, and in +Leipsic the garrison remained exempt while the disease prevailed among +the citizens. In 1847 a fatal epidemic of it affected the second +regiment of the Mississippi Rifles, and was entirely confined to that +corps (Love). During the Civil War of the United States the disease +affected particular corps or regiments in the South or in the North, +yet it never became epidemic in the army, even when the disease +prevailed among the adjacent civil population. + +[Footnote 13: _Amer. Jour. of Med. Sci._, Oct., 1873, p. 320.] + +Various depressing or debilitating causes, such as lowness of spirits, +home-sickness, mental or bodily strain, over-eating, drinking alcohol, +the action of excessive cold or heat, checking perspiration, etc., +have been enumerated as causes of this disease. It is unnecessary to +dwell upon such gratuitous assumptions. All of these influences are +constant, but epidemic meningitis is the rarest of epidemic diseases, +and the agencies referred to have no further operation than to lessen +the resistance of the body to morbid influences of every description. +If there be one peculiarity about this disease which is more +surprising and inexplicable than another, it is that its peculiar +victims are not the feeble and delicate, but the vigorous and +active--not the old and decaying, but the young and stalwart. + +No one of authority has claimed that this disease can be propagated by +_contagion_. All of its early American historians are of the same +opinion upon this question, and nearly all European authorities are in +perfect accord with them. The apparent exceptions to this all but +universal judgment are so insignificant in number and weight as not in +the least to diminish its validity. A case has been published in which +a pregnant woman at full term died of the disease after giving birth +to an apparently healthy child. "Two hours later the infant presented +symptoms of meningitis, followed rapidly by death."[14] Supposing the +concluding statement to be accurate, the case only shows that the +cause of the disease which destroyed the mother's life infected the +system of the child also. If there is one point in the history of the +disease established by the concurring testimony of American and +European writers, it is the extreme rarity of its attacking either the +physicians and nurses in attendance upon patients affected with it, or +those laboring under other diseases and occupying beds adjacent to +persons ill with epidemic meningitis. That, nevertheless, there is a +material morbific principle which inheres in certain localities, so +that those who occupy them successively are liable to suffer from this +disease, and that also this principle may be carried from place to +place so as to render certain houses (barracks) infectious, seems to +be demonstrated by the history of the disease in the French army. +Between 1837 and 1850, when the disease prevailed in various parts of +France, it did so not indiscriminately, but it usually followed the +ordinary routes of communication, and especially the movements of the +military in their transfers from one post to another, and the course +of navigable streams. Strangely, also, it attacked soldiers much +oftener than civilians. The most curious fact of all is one already +referred to--viz. that although the disease prevailed in almost every +part of the provinces, and although then as ever an incessant stream +from them was flowing into the capital, neither its civil nor its +military population was generally affected, nor, {804} indeed, at all +so, until near the close of the period mentioned. Meanwhile, however, +the disease extended to several countries conterminous with France or +in close and frequent intercourse with it--to Italy (1839-45), Algeria +(1839-47), England, Ireland, and Denmark (1845-48). These events seem +to point to a certain transmissibility of the disease until we examine +the negative facts that bear upon the question. They are such as +these: The epidemic did not spread at all from France into two of the +adjacent countries, Belgium and Switzerland, with which the +first-named country maintained an incessant intercourse by travel and +traffic, but, on the other hand, it broke out at an early date within +the period mentioned at places very remote and absolutely independent +of all influence emanating from France or any other European +source--in the south-western portions of the United States. It is by +numerous facts of this description that we are compelled to remove the +disease from the category of endemic and even epidemic diseases, and +relegate it, along with influenza, to that of pandemic affections. + +[Footnote 14: _Med. Record_, xxii. 547.] + +There seems to be some reason for thinking that the epidemic cause of +this disease may affect the lower animals as well as man. It was +stated by Gallup in 1811 that during the epidemic of meningitis in +Vermont "even the foxes seemed to be affected, so that they were +killed in numbers near the dwellings of the inhabitants;" and of the +epidemic in 1871 in New York, Dr. Smith relates that "it was common +and fatal in the large stables of the city car and stage lines, while +among the people the epidemic did not properly commence until January, +1872." It would be desirable to learn more precisely the characters of +these vulpine and equine epidemics before associating them with the +disease we are studying, the more so that we have been unable to +discover a similar relation between any epizootic and other epidemics +of meningitis. In this connection may be recalled the statement of Dr. +Law of Dublin, that while he was attending a lady suffering from +cerebro-spinal meningitis "nine rabbits, out of eleven which her son +had, died, all in the same way: their limbs seemed to fail them, they +fell on their side, and then worked in convulsions, and died." On +examination of the bodies of several of them congestion of the vessels +of the base of the brain was found, and also "vascularity of the +membranes of the spinal marrow, indicating inflammation."[15] + +[Footnote 15: _Dublin Quarterly Journ._, May, 1866, p. 298.] + +TYPES.--No disease presents a greater variety--and, indeed, +dissimilarity--of symptoms than epidemic meningitis. Some of its +epidemics are sthenic and even inflammatory in their type, while +others have the malignant aspect of rapid blood-poisoning. These +contrasts have been exhibited on a large scale, for while upon the +continent of Europe the disease for the most part has presented +sthenic phenomena, it has been more generally asthenic and adynamic in +Ireland. One might be inclined to attribute the latter peculiarity to +the permanent prevalence of typhus fever in the latter country, or +rather to the special causes producing typhus, were it not that in the +United States both types of the disease have been observed at +different times and in different places. Such contrasts of type are, +however, not unusual in other diseases that occur as epidemics, +including not only the eruptive fevers, but inflammations, or +affections involving inflammation, such as pneumonia, dysentery, {805} +diphtheria, etc. Hence it is evident that certain epidemics, and +certain cases in each epidemic, may exhibit on the one hand a +predominance of inflammatory, or on the other of adynamic or ataxic, +symptoms, and each of them in every conceivable degree and +combination. It is this variation of type that has led to such +different conceptions of the nature of epidemic meningitis, many +physicians regarding it as a fever, and many others as an +inflammation, while, as we believe, it is both the one and the other, +and acquires from either element, according to its ascendency, the +typical character of the particular epidemic under observation. + +As illustrative of these statements we may mention in this place the +several _forms_ of the disease as they have been seen and interpreted +by different observers. Forget classified them as follows: (_A_) +CEREBRO-SPINAL; 1, _Explosive_ (_foudroyante_); 2, +_Comatose-convulsive_; 3, _Inflammatory_; 4, _Typhoid_; 5, +_Neuralgic_; 6, _Hectic_; 7, _Paralytic_. (_B_) CEREBRAL: 1, +_Cephalalgic_; 2, _Cephalalgic-delirious_; 3, _Delirious_; 4, +_Comatose_. In the first of these divisions three-sevenths belong to +the first and fourth varieties. But "there were slight and severe +cases; violent and hectic forms; cerebral symptoms predominant in some +and spinal in others, etc." + +In his excellent paper on the epidemic of 1848 in New Orleans, Ames +arranged his cases in two categories--the _Congestive_ and the +_Inflammatory_, subdividing the former into the _Malignant_ and the +_Mild_. Malignant congestive cases were distinguished by prostration, +coma or delirium, or both; opisthotonos; and a pulse varying extremely +in its degree of frequency. In _mild congestive_ cases a good degree +of strength was preserved; the pulse was below 90; there were marked +pain in the head and tenderness of the spine, but no coma, delirium, +or stiffness of any muscles besides those of the neck. The purely +_inflammatory_ cases were, in general, distinguished by a temperature +of the skin above that of health and a full, firm pulse, but the +_malignant inflammatory_ were marked by the early occurrence of +delirium or coma, great irregularity of pulse, opisthotonos, +convulsive spasm, strabismus, and occasional amaurosis, with vomiting +and a rapid and fatal course; the _grave_, by a slighter development +of the same symptoms, except coma and delirium; and the _mild_, by a +lower grade of febrile excitement, the preservation of a good degree +of strength, a tendency to become chronic, and by the absence of coma, +drowsiness, delirium, and a cold stage. + +Wunderlich adopted the simple plan of arranging the cases in three +categories: 1, the _gravest_ and most rapidly fatal cases; 2, the +_less grave_; and 3, the _lightest_. The arrangement of Hirsch had +more significance, as well as a clinical foundation--viz. 1, the +_abortive_; 2, the _explosive_ (_m. siderans_, the same as _m. +foudroyante_ of Tourdes); 3, the _intermittent_; 4, the _typhoid_. + +Dr. Bedford Brown,[16] who observed the epidemics in North Carolina +from 1862 to 1864, arranged the cases under the following heads: 1, +the _inflammatory_ form, in which the fever is high, the pain very +acute, and the delirium furious, but which is exceedingly rare; 2, the +_neuralgic_ form, which is stated to be the most frequent and +protracted, with moderate fever and a pulse but slightly accelerated, +and giving a favorable prognosis; 3, the _ataxic_ form, in which great +nervous depression is {806} associated with a low and busy delirium, +and the temperature "is generally much reduced below the natural +standard.... This is always a dangerous form;" 4, the _paralytic_ +form, in which stupor and insensibility are early and prominent +features, with a very slow and feeble pulse, blanched skin, and death +by syncope. + +[Footnote 16: _Richmond Med. Jour._, ii. 1.] + +Dr. Purcell of Cork[17] furnished a classification which is one of the +best for practical and clinical purposes--viz. 1, the _rapid_ variety, +attended with purple blotches, embarrassed respiration and +circulation, followed by sopor, insensibility, and coma; 2, the +_cerebro-spinal_ form, with retraction of the head, pain and cramps of +the muscles, hyperaesthesia of the skin, delirium, etc., accompanied +by fever, herpetic eruptions, etc. These two forms are apt to be more +or less associated in the same case. + +[Footnote 17: _Dublin Quarterly Jour._, Aug., 1870, p. 243.] + +Of the various forms admitted by different authors, and of which we +have seen examples, we would class together--(_a_.) The abortive, in +which the characteristic phenomena are often faintly defined, and yet +to the practised eye distinctive. (_b_.) The malignant, in which the +symptoms, of whatever kind, are exaggerated, the attack sudden, the +course short, and the issue fatal. (_c_.) The nervous, including 1, +the _Ataxic_--viz.--1, the _delirious_; 2, the _cephalalgic_; 3, the +_neuralgic_; 4, the _convulsive_; 5, the _paralytic_; and 6, the +_adynamic_ (_comatose_ and _typhoid_). (_d_.) The inflammatory. (_e_.) +The intermittent. Of these the _abortive_ and _intermittent_ call for +a brief explanation. Abortive meningitis is observed only during the +prevalence of the disease in a more characteristic form. Thus, the +mother of a boy who had died of the fully-developed disease +"complained of the head and back and limbs, and of chilliness, and +presented a petechial eruption. After active purgative and +counter-irritant treatment she was about her work on the second +day."[18] The late Dr. Burns of Frankford, Philadelphia, while +attending patients affected with the disease suffered from headache, +severe pains along the spine and in every joint of the body, and a +general languid feeling.[19] Kempf during the decline of an epidemic +observed "a great number of individuals, especially adults, who +complained of headache, malaise, neuralgic pains in various parts of +the body, and pain in the nape of the neck or other parts of the +spine."[20] In a case observed by the writer (June, 1867) most of the +characteristic symptoms were present in a mitigated form, and the +pulse was at 60. Within five days restoration was complete.[21] The +_intermittent_ and _remittent_ types are apt to be quotidian or +tertian, and in fatal cases the former has been taken for malignant +intermittent fever, which it resembles by a periodical febrile +movement, with pains, cramps, delirium, etc. This type sometimes first +manifests itself during the decline of an attack. + +[Footnote 18: Sargent, _Amer. Jour. of Med. Sci._, July, 1849, p. 35.] + +[Footnote 19: _Amer. Jour. of Med. Sci._, April, 1865, p. 339.] + +[Footnote 20: _Ibid._, July, 1866, p. 55.] + +[Footnote 21: _Epidemic Meningitis_, p. 42.] + +SUMMARY OF THE SYMPTOMS.--Like other fatal epidemic diseases, +meningitis is sometimes sudden and sometimes gradual in its +development. In the former case the patient, who has gone to bed +apparently in perfect health, awakes suddenly from a sound sleep about +the small hours of the night to find himself in a severe chill. In the +case of young children a convulsion attends the awakening. Or the +patient, while {807} pursuing his ordinary avocations, may be seized +with a chill, prostration, vomiting, and headache, of which symptoms +the last is often intensely distressing. In this, as in other epidemic +diseases, such violent seizures are most common during the earlier +periods of its prevalence, but later in its course premonitory +symptoms are more frequently observed. They may last for an hour or +two, or may extend to several days; and, in general, it may be stated +that the longer their duration the milder will be the subsequent +attack. But the symptoms in either case are essentially the +same--prostration, chilliness, feverishness, and sometimes vomiting +and sharp pains in the head, back, and limbs. The character of the +vomiting, as well as the absence of all gastric lesions in fatal +cases, proves that it is occasioned by an irritation of the central +nervous system. + +In the cases which are regularly developed these phenomena more or +less gradually assume a graver aspect or usher in a heavy chill, which +in its turn is followed by alarming symptoms, and especially by an +excruciating pain in the head, a livid or pale and sunken countenance, +and extreme restlessness. The pulse is as often slow as frequent, and +the skin is rarely hot, and, indeed, is generally but little, if at +all, warmer than natural. The vague pains that began with the attack +are now concentrated, and seem to dart in every direction from the +spine, which is also, at its upper part, the seat of severe aching; +and in some cases hyperaesthesia of the skin is very marked. In a +large proportion of cases the spinal muscles become more or less +rigidly contracted, so that the head is drawn backward or the whole +trunk is arched as in tetanus. Trismus is not uncommon, and clonic +spasms frequently affect the limbs. Even general convulsions are +occasionally observed. As these phenomena grow more decided delirium +of various degrees is often manifested, from mere wanderings and +hallucinations during the sleepless watches of the night to violent +maniacal ravings or incoherent mutterings, or the stertor of coma. +Frey and others have noted a remission of the symptoms occurring on or +about the third day in cases of a regular type. The rigidity of the +cervical muscles becomes relaxed, the headache subsides, and the +mental condition improves. But this amelioration lasts but a short +time, and then the normal course of the symptoms is resumed. + +As the attack advances the pulse gradually or rapidly rises above the +normal rate, and sometimes becomes very frequent, and the skin, +although it grows warmer, does not often acquire the temperature +observed in idiopathic fevers or sustain it as they do. In many cases +eruptions appear upon the skin. During some epidemics the only one +observed is herpes labialis; in others the eruption resembles roseola, +measles, or the mulberry rash of typhus, or from the first it consists +of petechiae, vibices, or extensive ecchymoses. The tongue presents +the characters which belong generally to the typhoid state. At first +moist and coated with a whitish fur or a mucous secretion, it +afterward, if life is prolonged, grows red and shining or brown and +fuliginous. There is usually a complete loss of appetite, and the +thirst is not commonly urgent. One or two liquid stools at the +commencement are generally followed by constipation, which continues +throughout the attack, although in very grave and protracted cases +diarrhoea may persist, and even become colliquative. When the attack +tends to a fatal issue the patient generally, but by no means always, +sinks into a soporose condition, in which {808} muscular relaxation, +debility, and tremulousness, such as are common in the typhoid state +of fevers, are associated with paralysis of the sphincters and of +other muscles. But we have seen rigid opisthotonos continue until +within a few hours of death in a case of more than the average +duration. + +In cases that tend toward recovery the typhoid condition is rarely so +grave, but patients have often survived very severe nervous symptoms. +It is true that the return to health may be tedious and uncertain, and +not unusually a perfect restoration of all the functions is very long +delayed, or, it may be, is never attained. + +INDIVIDUAL SYMPTOMS.--Pain in the head is one of the most +characteristic symptoms of epidemic meningitis. It is always present, +except in those malignant cases in which the morbid poison seems to +spend its fatal power upon the blood. In some, however, of a less +rapid but still malignant type, in which after death no exudation is +found, but only an extreme venous congestion of the membranes, or it +may be an effusion of blood beneath them, this symptom may be more or +less marked. It is generally an excruciating pain, sometimes darting +apparently through the head from the nuchae to the forehead, extorting +cries and groans, and is variously described by the sufferers as +throbbing, boring, lancinating, sharp, or crushing, "as if the head +were in a vice or nails or screws were being forced into the brain." +Its paroxysms arouse the patient from his apathetic stupor or his +coma, and cause him to become restless or violent or to shriek with +agony. Even when this evidence of anguish is wanting the patient often +attests his suffering by contortions or cries, or by frequently +carrying his hands to his head. That it depends upon mechanical +pressure upon the sensitive ganglia within the cranium and upper part +of the spine is shown by the relief which revulsive and +counter-irritant measures afford when applied to the occipital region +and the back of the neck. Identical in cause and quality with this +pain is the spinal pain proper. No better description of it has been +given than that of Fiske in 1810. It is in these words: "Its bold and +prominent features defy comparison.... In some a pain resembling the +sensation felt from the stinging of a bee seizes the extremity of a +finger or toe; from thence it darts to the foot or hand or some other +part of the limbs, sometimes in the joints and sometimes in the +muscles, carrying a numbness or prickling sensation in its progress. +After traversing the extremities, generally of one side only, it +seizes the head, and flies with the rapidity and sensation of +electricity over the whole body, occasioning blindness, faintings, +sickness at the stomach, with indescribable distress about the +praecordia--a numbness or partial loss of motion in one or both limbs +on one side, with great prostration of strength. The horrible +sensation of this process no language can describe."[22] These spinal +pains are always aggravated by pressure made on either side of the +spinous processes of the vertebrae, and, like the cephalic pains, are +more or less mitigated by revulsive applications. Accompanying the +pains is a hyperaesthesia or morbid sensibility of the skin, rendering +it painfully sensitive to the slightest touch; in the advanced stages +of the disease, when the spinal phenomena predominate, the irritation +of the nerves by the pressure of the exudation on their roots is +exchanged for numbness or {809} absolute insensibility, due to the +increase and continuance of that pressure. Moving the limbs or +separating the closed eyelids will sometimes provoke resistance, and +even extort cries; and especially is this true of attempts to +straighten the rigidly bent spine or the flexed extremities. Lewis +states that such outcries were so often excited by slowly introducing +the thermometer into the rectum that he was forced to believe that the +anal and perhaps the rectal surface was hypersensitive. + +[Footnote 22: North, on _Spotted Fever_, p. 176.] + +The physical causes that give rise to the pains which have just been +described likewise occasion the spasmodic and tetanoid phenomena that +are so peculiar to this disease. In general terms, they are most +marked in cases attended with inflammatory exudation, and least so +when, instead of this lesion, there is only vascular congestion of the +meninges of the spinal cord. But the rule is, of course, not absolute, +for individuals are so differently constituted that one will remain +impassive under an irritation that will throw another into +convulsions. There is no doubt that spinal rigidity may be produced by +mere congestion of the cord, and, on the other hand, that it may be +absent even when plastic exudation is abundant. This symptom is, +however, more than any other one, characteristic of the disease. It +existed in the original epidemic at Geneva, attracted the attention of +the earliest American observers of the disease, and elsewhere has +marked a greater or a smaller proportion of the cases in every +epidemic. It was described by such terms as these: "a drawing-back of +the head;" "a corpse-like rigidity of the limbs;" "the form of tetanus +called opisthotonos;" "spastic rigidity of the muscles of the lower +jaw and the posterior muscles of the neck;" "rigidity of the posterior +cervical muscles, retracting the head considerably backward." The +historians of the disease in Europe are, if possible, still more +emphatic in their elaborate descriptions of this phenomenon, and, on +the Continent at least, it seems to have been more uniformly present +than it was in Ireland or in this country. Tourdes, in describing the +epidemic of 1842 at Strasburg, said: "The decubitus of the sick was +distinguished by a backward flexion of the head and spine; most +frequently the neck alone was affected, but sometimes the whole trunk +was arched." And again: "The contraction often involved all of the +extensor muscles of the spine, and the trunk formed an arch opening +backward and resting upon the occiput and sacrum." In Ireland, Gordon +says of a patient, "Her spine presented a most wonderful uniform curve +concave backward; her head was also curved backward on the spine of +the neck." During an epidemic at Birmingham in 1875 in one case "the +retraction was so marked that a slough formed from the occiput +pressing between the scapulae."[23] In some cases rigid flexion of the +body forward or laterally has been noticed. The rigidity persists, as +a rule, until death, but sometimes ceases a short time before that +event. If recovery takes place, this symptom gradually subsides, and +disappears within a few days; but, on the other hand, more or less +stiffness of the spine may last for several weeks. In one case it +continued for more than two months, and in another until death on the +forty-ninth day. + +[Footnote 23: Hart, _St. Bart's Rep._, iv. 141.] + +The same physical cause that occasions rigidity, when acting less +intensely or when a special susceptibility of the nervous system +exists, also excites clonic convulsions. They are oftenest observed in +patients of the {810} age especially liable to spasmodic +affections--in children before the completion of the first dentition. +They vary in degree from twitching or subsultus affecting particular +muscles, as of the eyes, the face, a limb, etc., to general +epileptiform convulsions with loss of consciousness. They may be +associated with paralysis, as where the two halves of the body are, +the one convulsed and the other paralyzed. A case occurred in Dublin +which "presented the very striking phenomenon of continued and violent +convulsions during the whole of the brief course of the illness."[24] +These convulsions, like others occurring at the commencement of acute +diseases, are by no means always fatal, even when they are general. In +the case of a robust adult convulsions occurred repeatedly during the +first two days, and less frequently during the two following days, but +the patient ultimately recovered.[25] + +[Footnote 24: _Dublin Quart. Jour._, xlvi. 187.] + +[Footnote 25: _Boston Med. and Surg. Jour._, Feb., 1884, p. 121.] + +Paralysis, it may be inferred from the statements already made, is an +incident of this disease, for an excess of the action causing tonic or +clonic spasm must induce paralysis. Paralysis of an arm or leg or of +the muscles of deglutition was long ago noticed among even the initial +symptoms of the attack. In Dublin (1865) it was said of a patient, +"All his members seemed to be paralyzed; he could move neither arms +nor legs." Wunderlich describes the case of a man who "on the second +day of the disease lost both sensibility and motility in the lower +limbs and over the greater part of the trunk, while his left arm also +was partially paralyzed." In another case complete paralysis of the +right side occurred on the third day, the left side being rigid.[26] +Baxa relates the case of a soldier in whom paralysis of the left side +persisted after recovery from the disease,[27] and that of a woman in +whom paralysis of the left lower limb continued along with right +ciliary paralysis. Ptosis, strabismus, paralysis of the bladder and +rectum, of the muscles of deglutition, and even general paralysis, +have been observed. Aphasia also has been recorded by Hirsch and by +Hayden.[28] + +[Footnote 26: _Dublin Quart. Jour._, 1867, p. 431.] + +[Footnote 27: _Wiener med. Presse_, No. 29, p. 715.] + +[Footnote 28: _Dublin Quart. Jour._, xlvi. 187.] + +The condition of the eyes and of vision in this disease is directly +due to pressure of the exudation at the base of the brain upon the +nerves and blood-vessels that supply these organs. One of the most +striking peculiarities of the countenance of a patient at the +beginning of an attack is the diffused and uniform redness of the +conjunctivae. In children it has a light tint, but a darker one in +adults, and in some cases the eye becomes suffused with an +extravasation of blood. The conditions of the pupil are also very +peculiar. Very long ago it was observed to undergo sudden changes from +contraction to dilatation, or the reverse. Dilatation is, however, its +ordinary condition, especially in the fully-formed attack. Very often +the pupils of the two eyes are in opposite states. In cases of long +duration, with great exhaustion, they are almost invariably dilated. +Photophobia is not uncommon, and oscillation of the pupils and +spasmodic movements of the eyeball have frequently been observed. +Strabismus is a symptom of very ordinary occurrence, particularly when +other paralytic or spasmodic phenomena exist. It may be convergent or +divergent, but most commonly is the former, and may be either a +transient or a {811} permanent symptom. Like other individual +symptoms, it may be present rarely or frequently in a particular +epidemic. + +Blindness has been repeatedly observed. At first it seemed to be +noticed as a transient symptom only. Fish (1809) states that it was +sometimes the first deviation from health, and then was followed by +paralytic spinal symptoms. He also observed that sight was sometimes +restored in a few hours, and in no case did he know it to be +permanently lost. American as well as European physicians, however, +have met with many cases in which the sight was seriously and +permanently impaired or altogether destroyed. In 1873 the changes +affecting the eye were more fully and accurately described, especially +those which tend to the structural injury of the organ. The abnormal +appearances included cloudiness of the media, discoloration of the +iris, irregularity of the pupils, and their obstruction with exudate. +In exceptional cases the cornea ulcerated, and the globe collapsed +after losing its contents. Ordinarily, however, says Lewis, "no +ulceration occurs, and as the patient convalesces the oedema of the +lids, the hyperaemia of the conjunctiva, the cloudiness of the cornea +and of the humors gradually abate, and the exudation in the pupils is +absorbed. The iris bulges forward, and the deep tissues of the eye, +viewed through the vitreous humor, which had a dusky color from +hyperaemia, now present a dull white color. The lens itself, at first +transparent, after a while becomes cataractous, and sight is lost +totally and for ever." + +Impairment or loss of hearing has been occasionally observed during +the successive epidemics of this disease, even from the beginning of +its history, and it was early noticed that the symptom was often quite +independent of any cognizable lesion of the ear itself. It was also +observed that the sense of smell sometimes became impaired or was lost +at the same time with that of hearing. More recently, Collins reported +a case in which the patient lost the sight of one eye and became +permanently deaf in both ears. Knapp states that in all of thirty-one +cases examined by him the deafness was bilateral, and, with two +exceptions of faint perception of sound, complete. Among twenty-nine +cases of total deafness only one seemed to give some evidence of +hearing afterward.[29] This surgeon holds that the deafness results +from a purulent inflammation of the labyrinth, and his judgment has +been confirmed by Keller and Lucas. When the impairment of hearing +occurs simultaneously, or nearly so, in both ears, it is probable that +the chief cause of the deafness is the pressure of the plastic +exudation in which the auditory nerve is imbedded. Such deafness is +rarely permanent. When the loss of hearing, whether complete or +partial, does not improve, there is reason to believe that the +internal ear has suffered great and incurable changes of structure. +Sometimes this follows a distinct attack of suppurative inflammation +of the middle ear; but as complete and permanent deafness sometimes +occurs without being preceded by any such affection, it must be +inferred that atrophic changes have taken place in some portion of the +nervous apparatus of hearing. It is stated by Moos that of sixty-four +cases of recovery from cerebro-spinal meningitis, which showed +disturbance of hearing as a sequel, one-half manifested in addition a +more less disordered equilibrium. Of these twenty-nine were totally +deaf on both sides, two totally deaf on one and hard of hearing on the +other side, and one case had merely {812} impaired hearing in both +ears. The disturbance of locomotion had existed for periods varying +from three weeks to five years from the inception of the disease, and +was chiefly characterized by a staggering or waddling gait.[30] In the +deaf-mute institutions at Bamberg and Nurnberg it is said that out of +91 pupils, 80 owed their infirmity to this disease (Ziemssen). Salamo +states that some awake out of sleep totally deaf, and remain so for a +long time, or, it may be, permanently (Moos). + +[Footnote 29: Smith, _loc. cit._] + +[Footnote 30: _Mening. Cerebro-spinal epid._, p. 11.] + +The expression of countenance in this disease is peculiar. When the +pain in the head is severe and paroxysmal the features are apt to be +violently distorted; when it is more persistent the face assumes a +fixed or rigid expression, or is at the same time dull, particularly +after a long continuance of the pain. In the apoplectic form the +expression may be set and stupid, but the features have neither the +dark, dull, swollen, and duskily-flushed aspect of typhus, nor the +languid, sleepy expression, and circumscribed flush on the cheek which +are so characteristic of typhoid fever. Except during absolute +insensibility in rapidly fatal cases there is a look of greater +intelligence than belongs to either of the diseases mentioned. Indeed, +in the beginning of the attack in regular cases the distinctive facies +presents pale and sunken features, with paleness of the skin over the +whole body. + +Delirium in this disease exhibits a great many degrees and varieties. +It may occur among the earliest symptoms in certain rapid cases not of +the congestive type, but is more apt to arise on the second or third +day in those more typically developed. It may be mild, reasoning, +hysterical, or maniacal, or it may change from one to another of these +forms during the same attack. Fish states that it is apt to be violent +if it comes on at the commencement of the illness, but that when it +begins at a later period it is milder, and sometimes playful, the +patient being sociable and humorous. All good observers have furnished +similar descriptions of this symptom; some have added that the mental +condition is often desponding and apprehensive, and others that +certain patients remain sombre and silent; and it sometimes happens +that the delirium comes on abruptly, as when a patient "woke suddenly +in the middle of the night and began to hum tunes, to fancy that +people were conversing with him," etc. (Gordon). + +Coma is met with sooner or later in nearly all fatal cases, but rarely +in a marked degree until the approach of death. If anything is +surprising in epidemic meningitis, it is the absence of that deep and +prolonged stupor that characterizes the typhoid state, notwithstanding +the pressure of the exudation upon the brain in most cases, and in +others such a profound alteration of the blood that it exudes through +the tissues as water passes through a porous body. Another striking +phenomenon of the disease is that the patient after recovery has +generally a complete oblivion of all that happened to him between the +beginning of the attack and convalescence. This is true even of cases +in which the brain symptoms are far from being conspicuous. + +Another symptom closely related to the local lesion and the +blood-change in this disease is vertigo. As originally described by +Miner in 1823, it occurred from the very commencement of the attack, +and was even then regarded as denoting a deficient supply of the blood +to the {813} brain, so that when the patient rose to an erect posture +it was felt along with uneasiness in the stomach, acceleration of the +pulse, dimness of sight, nausea, and fainting. Tourdes, speaking of it +as it occurred in the Strasburg epidemic, says that it confused the +mind and rendered walking impossible. In two cases patients were +seized with a giddiness which compelled them to whirl around, when +they fell and did not rise again. According to Moos (1881) unilateral +affections of the labyrinth give rise to vertigo, and bilateral +lesions to a staggering gait. Bilateral hemorrhage or acute +suppuration of the ampullar terminations of the auditory nerve +occasions paralysis and staggering. Children, and those who at the +same time have the sight impaired, are apt to remain affected for a +long time. Otherwise, prolonged and systematic muscular exercise may +remove the tottering walk. + +To the same causes must doubtless be attributed the debility which is +so early and so conspicuous a symptom in this disease, and which gave +it one of the names, typhus syncopalis, by which it was first known in +this country. It was manifested by the vertigo already noticed, by a +sense of sinking in the epigastrium, by a quick, frequent, feeble, and +irregular pulse, and by a sudden and extreme loss of muscular power, +so that the patient found himself unable to raise his hand before he +was sensible of being ill. This state of asthenia is conspicuous +throughout the whole of the disease, and is the immediate cause of the +slow and irregular convalescence which is characteristic of it. + +Of the symptoms peculiar to the digestive apparatus hardly any belong +to it directly. They are nearly all the effect of reflex influences. +The condition of the tongue is for the most part quite unlike that +which belongs to the typhoid state. The fuliginous condition of the +tongue, gums, cheeks, and lips which characterizes that state is +seldom met with in epidemic meningitis. The older writers agreed that +even when the tongue does grow dry and brown the condition is not of +long continuance, and later observers have confirmed their statements. +Thus, J. L. Smith (1872) says, "Occasionally, in cases attended with +great prostration, the fur of the tongue is dry and brown, but only +for a few days, when the moist whitish fur succeeds." We have +generally found it moist, whitish in the centre and at the tip and +edges. + +Nausea and vomiting are very constant among the initial symptoms of +the disease, and, as already pointed out, are due to irritation of the +cerebro-spinal ganglia. Very often the vomiting is not preceded by +nausea, and is brought on by the patient's raising himself, etc. The +stomach itself undergoes no change. Both symptoms are usually +accompanied by faintness or giddiness, and are more decided in the +initial than in the later stages of the attack. The matters vomited, +varying with the contents of the stomach and the urgency and duration +of the symptom, consist of ingesta, mucus, serum, or bile, and in some +grave cases of a dark grumous matter taken to be altered blood. In +some epidemics, apparently, more than in others, this symptom is very +distressing, as it was at Birmingham in 1875.[31] The inability of the +stomach to retain food necessarily leads to a rapid wasting of the +flesh, which is aggravated by the patient's suffering, restlessness, +and want of sleep. Nevertheless, no sooner is the vomiting appeased +than a desire for food is felt, and when {814} it is retained it +generally undergoes digestion. Indeed, in no other disease is the +return of a good appetite and digestion so prompt and complete. It is +true that the recovery of flesh and strength is not always in +proportion to the appetite. As might be expected in a disease in which +fever plays so subordinate a part, there is seldom urgent thirst. But +epidemics differ in this as in so many other respects. In that which +we witnessed in the Philadelphia Hospital in 1866-67 the patients were +clamorous for liquids. Constipation is the rule among patients with +this disease, as, indeed, might naturally be expected, for no lesion +affects the bowels and little or no food is retained by the stomach. +Yet in a few cases diarrhoea accompanies persistent vomiting. + +[Footnote 31: Hart, _St. Bart's Rep._, xii. 112.] + +The fauces appear to have been more or less inflamed in some +epidemics; swelling of the parotid glands is an occasional occurrence, +and sometimes they undergo suppuration. Aphthae have also been met +with. + +The secretion of urine is not affected in any uniform manner. +Sometimes it is diminished and sometimes increased in quantity. The +latter symptom has occasionally long survived the disease. It retains +its normal acidity. In rare cases either albumen or sugar has been +detected; the former may have been due to the action of blisters of +cantharides used in the treatment of the disease. + +One of the most curious and unintelligible phenomena occasionally met +with in this disease is a peculiar affection of the joints, which +first was observed in this country. Jackson (1810 and 1813) wrote: "In +some cases swellings have occurred in the joints and limbs. They have +been very sore to the touch, and their appearance has been compared to +that of the gout. The parts so affected feel as if they had been +bruised. These swellings arise on the smaller as well as on the larger +joints, and are often of a purple color." So Collins[32] reports: "The +joints sometimes become swollen, red, and tender; at other times red +and painful without any swelling; while, again, intense pain and rapid +enlargement from effusion have occurred unattended with redness. The +joints most usually attacked are the knee, elbow, wrist, and the +smaller articulations of the fingers and toes." In an epidemic which +occurred in Greece in 1869 articular swellings similar to those of +inflammatory rheumatism were observed.[33] These descriptions, which +apply to some cases in most epidemics, are of more than casual +interest, for they demonstrate conclusively, as we think, the truth +which the whole history of the disease confirms--viz. that it is a +systemic and not a local affection, and is dependent for its existence +upon a specific poison which is absolutely unlike every other morbid +poison known to pathology. + +[Footnote 32: _Dublin Quart. Jour._, Aug., 1868, p. 170.] + +[Footnote 33: _Archives generales de med._, Mai, 1883, p. 622.] + +The act of respiration is variously modified in this disease, as +might, indeed, be expected from the seat and nature of the +cerebro-spinal lesions. It is sighing, labored, and interrupted. +Burdon-Sanderson describes its differences from the so-called +Cheyne-Stokes respiration; it is, he says, "marked by a slow, labored +inspiration, followed by a quick expiration and a long pause." When +opisthotonos is very great and persistent, it necessarily interferes +with the dilatation of the lungs, and leads to oedema of those organs, +and even to sanguineous effusions into them. {815} Pneumonia is not an +unusual complication of the disease when it prevails in cold weather. + +The distinguishing characters of the pulse are diminished force and +volume, and a tone so much impaired that slight causes produce extreme +variations in its rate and rhythm. If the disease be a fever, as is by +some maintained, then it is the only fever in which the pulse-rate is +often far below the normal, and at the same time neither full nor +tense, unless transiently and in altogether exceptional cases. In no +other disease attended with inflammation do the rate and quality of +the pulse vary so greatly within short intervals. It may be said, in +general terms, to be variable in rate and strength even in the most +sthenic cases of the disease, and in those which tend to a fatal issue +to be small, thready, weak, intermittent, or imperceptible for a +longer or shorter time before death. It is no uncommon thing for the +pulse-rate at the beginning of an attack to fall as low as 40, or even +27, and afterward rise to 120 or even more, in a minute, without +necessarily indicating a fatal issue. Muscular exertion, rising from a +recumbent posture, etc., will sometimes double its frequency, besides +producing irregularity. Read, describing the pulse as he observed it +in Boston in 1873-74, speaks of cases in which "both the rhythm and +the force of the beats are entirely destroyed; ... one moment, while +beating very fast, it will suddenly drop to a much lower rate.... +These conditions also may outlast apparent convalescence." Some fatal +cases are attended by distressing palpitations of the heart. + +Nothing is more remarkable in the early histories of this affection +than their unanimous statement that it is not distinguished by a +febrile temperature. It is true that the observers of those days had +not the advantage of using clinical thermometers, but they were too +nearly agreed in their judgments and harmonious in their descriptions +to permit any serious doubt of the substantial accuracy of their +conclusions, which were expressed in such terms as these: "A +diminution of heat may be considered as among this most striking +symptoms of this disease" (Strong); or, "the temperature never +exceeded the standard of health in more than three or four cases, ... +and a great majority of the patients had no fever at all" (Miner); or, +again, "A high febrile movement took place only in a limited number" +(Gilchrist); or, "The heat of the surface was less in all cases than +is usually observed in acute diseases" (Jenks). It will be observed +that these statements, and very many others which agree with them, +were founded upon the perception of the patients' temperature by the +hand, which was of course applied to the most accessible parts of the +body--the face, neck, arms, and hands--but they have more real value +and significance than the more recent measurements taken in the mouth, +axilla, rectum, or vagina, for we know that, however valuable the +temperatures of these parts may be for comparative studies, they do +not really indicate the condition of the individual who presents them. +It is a familiar fact that the difference of temperature in cholera +when taken in the rectum and the axilla may be 4 degrees F., or even +more than this. + +Since the thermometer has been used in the study of epidemic +meningitis greater accuracy of results has been attained, and yet the +general statements of the earlier observers have been confirmed. Thus, +Githens has shown that the temperature of the body in this disease is +lower than that recorded of any other fever or inflammatory affection; +the average, {816} indeed, of his cases was lower by four or five +degrees than that of typhus or typhoid fever, pneumonia, etc. In 2 +cases only did the thermometer in the axilla reach 105 degrees. The +highest temperature in 15 cases was between 104 degrees and 105 +degrees; in 12, between 103 degrees and 104 degrees; in 7, between 102 +degrees and 103 degrees; in 6, between 101 degrees and 102 degrees; +and in 2 it was below 100 degrees.[34] Tourdes, Niemeyer, and others +have noted the slight rise of temperature during the first and second +days of the attack, and Wunderlich found fever of very unequal degrees +and with very variable maxima, but the highest temperatures were +observed by him as well as others in fatal cases and immediately +before death. In one instance it reached 107.5 degrees F. +Burdon-Sanderson and others have found that an increased temperature +always attended exacerbations of pain. Von Ziemssen gives the average +temperature as varying from 100.4 degrees to 103 degrees F., but with +variations between higher and lower points, and particularly notes the +persistence of a normal temperature while the other symptoms are +undergoing a variety of changes, as well as the fact that, unlike +other febrile affections, this disease has no representative +temperature curve. In his clinical observations Hart found for several +successive days as much as six degrees of difference between the +morning and evening temperatures. A morning rise for several days was +noticed in four cases, and usually there was no relation between the +pulse and the temperature, nor any uniformly between the temperature +and the gravity of the attack.[35] But not rarely it has been noticed +that the daily exacerbations, if any, did not occur in the afternoon, +but with great irregularity, so that the maxima and minima might occur +on successive days and at the same hour of the day. Dr. J. L. Smith, +whose thermometric observations in this disease seem to have been +carefully made, used the thermometer in the rectum, and thus obtained +temperatures higher that the average of other observations, such as +105.4/6 degrees to 107.2/6 degrees in several cases. Yet he found the +fluctuations of rectal temperature remarkable, though less so than the +surface temperature, of which he states that sometimes it rose above +or fell below the normal standard several times in the course of the +same day. + +[Footnote 34: _Amer. Jour. of Med. Sci._, July, 1867, p. 38.] + +[Footnote 35: _St. Bart's Reports_, xii. 112.] + +Nothing can be more irregular, uncertain, or various than the +eruptions and other cutaneous symptoms that have been met with in this +disease. When it first appeared in New England a large proportion of +the cases, and especially of the grave cases, exhibited petechial +eruptions and ecchymotic spots, whence the disease presently received +the name of spotted fever. Yet even then, North and the other +historians of its epidemics were careful to state that spots on the +skin were by no means characteristic of the disease, and very often +were not present at all, especially in cases that terminated +favorably. Woodward, for example, wrote (1808): "An eruption on the +skin so seldom appeared that it could no longer be considered a +characteristic symptom of the disease." In various American local +epidemics an eruption of some kind seems to have existed in about +one-half of the cases. In one that we observed in the Philadelphia +Hospital no eruption whatever was observed in thirty-seven out of +ninety-eight cases. In the epidemic at Chicago in 1872, N. S. Davis +says:[36] "About one-third of the cases presented some red +erythematous spots" between the third and the seventh day. In mild +cases they were few and {817} bright red; in grave cases, darker and +larger, with some swelling of the skin; and in the worst cases, purple +spots one or two or more inches in diameter. In that of +Louisville,[37] Larrabie states that the eruption "was generally +herpetic in its character, and accompanied by sudamina; but in several +instances an urticarious eruption suddenly appeared and disappeared." +Nothing is said of petechiae or ecchymoses. In the New York epidemic +of 1873[38] the skin in grave cases presented dusky mottlings, +especially when the animal temperature was reduced; also a punctated +red eruption, bluish spots a few lines in diameter, and large patches +of the same color. Herpes also was common. It is chiefly in cases of a +malignant type and rapid and fatal course that ecchymoses have been +observed. Of this statement illustrations will be given in the +paragraph relating to the duration of the disease. + +[Footnote 36: _Louisville Med. Jour._, June, 1872, p. 705.] + +[Footnote 37: _Louisville Med. Jour._, Dec., 1872, p. 782.] + +[Footnote 38: _Amer. Jour. of Med. Sci._, Oct., 1873, p. 329.] + +In continental European epidemics of meningitis the proportion of +cases in which a general eruption existed seems to have been smaller +than it was in this country. In the Geneva epidemic of 1805 a +considerable number of cases at the point of death presented purplish +spots, some earlier than this, and some after death only. In the +Neapolitan epidemic of 1833, and in that which occurred in Dublin in +1867-68, ecchymoses were often present, and in a very marked degree. +Stokes and Banks mention that in some rare instances the spots ran +together and coalesced over some portions of the body, so as to cover +a large extent of the skin and render it completely black, as though +it were wrapped in some dark shroud. The entire right arm and half of +the right side of the chest in one case, and in the other the whole of +the lower portion of one leg and foot, were thus affected.[39] In +Strasburg, on the other hand, only three cases of petechiae were +observed by Tourdes; at Rochefort and Versailles, in 1839, they were +rarely noticed; at Gibraltar, in 1844, they do not seem to have been +observed; in 1848-49, at the Val de Grace Hospital (Paris), they +appear not to have attracted attention; and at Petit Bourg they were +not noticed, although the state of the skin was fully described. In +Prussia, in 1865, neither Burdon-Sanderson nor Wunderlich mentions +petechiae or vibices as occurring during life; and Hirsch, after +noting their occasional presence, is obliged to draw upon American +authors for an account of them. + +[Footnote 39: _Dublin Quart. Jour._, xlvi. 199.] + +Of the eruptions other than petechiae and ecchymoses, several of which +have already been mentioned, it is necessary to take some notice here. +They are, chiefly, and in general terms, exanthems, including +erythema, roseola, and urticaria, and in addition herpes, particularly +of the lips. The last has no special relation to this affection, as it +is met with in almost every febrile disease, but it has sometimes +extended to the whole face in this one. The former may be connected +pathologically either with the altered condition of the blood or with +the irritation produced by the exudation in the spinal nervous +centres. They have frequently been compared to measles and to +scarlatina, but sometimes they have assumed the form of bullae. Thus, +in the case of a child four years old, described by Grimshaw,[40] an +eruption of pemphigus occurred over the whole body. Jackson long +before had mentioned, as one of the eruptions belonging to this +disease, "large bullae, as if produced by cantharides." Jenks {818} +described "large elevated spots of a very dark color, presenting +outside of the dark color a blistered appearance." In some cases +gangrene of the skin has been observed when the spots have been +exceptionally dark, and occasionally has been produced by pressure. + +[Footnote 40: _Jour. of Cutaneous Med._, ii. 37.] + +The cause of death in many of the more rapid cases is coma, which is +often preceded by convulsions, especially in children; but in many +others, even when attended with all the marks of dissolution of the +blood, consciousness may be but slightly impaired until the actual +imminence of death. In many other cases, which are fatal in the midst +of an attack with spinal symptoms, death is due to asphyxia, partly +owing to pressure on the medulla oblongata, and partly to the +interference with the respiratory act due to this pressure, and +occasioning excessive bronchial secretion. Again, death may occur +through a gradual exhaustion of the powers of life, without marked +spasm, blood-change, or complication. In these cases also the +intelligence remains unimpaired almost until the moment of +dissolution. Death is not very rarely due to pneumonia, and when the +disease is greatly prolonged or the convalescence from it is imperfect +a fatal termination by dropsy of the brain is still among its dangers. + +Hirsch once declared that the duration of epidemic meningitis "is +between a few hours and several months," and, however hyperbolical the +phrase may seem, it is quite accurate. Such inequalities are more +characteristic of acute blood diseases than of inflammations, and in +this case the coexistence of elements of both kinds doubtless accounts +for the extreme irregularity of the symptoms and duration of the +attack. The early American writers insisted strongly on this as a +characteristic feature of the disease. They record an unusually large +proportion of cases that were fatal within the first day, and even +after an illness of five hours, although they agree that the most +usual date of death was between the fourth and seventh days--a result +that has been confirmed by subsequent observation. Dr. N. S. Davis +gives the duration of the disease, as seen by him, as between twenty +hours and twenty-eight days. Out of 469 fatal cases in the city of New +York in 1872, 334 are said to have terminated within eleven days, and +of this number 270 were fatal in the first six days of the attack, +including 52 who died on the first day, and 51 in from one to two +days. It is perhaps worthy of note that while from the eleventh to the +fourteenth day only 11 deaths occurred, 20 took place on the +fourteenth and fifteenth; and while from the fifteenth to the +twenty-first day only 16 died, yet from the twenty-first to the +twenty-second 12 deaths were reported. This would seem to indicate a +peculiar danger on the days represented by multiples of seven. Of +cases that recover, the duration is even more indefinite than that of +fatal cases, owing to complications that occur in many, and especially +such as involve the cerebro-spinal centres. When death takes place +within a few hours it usually, if not always, is attended with +symptoms that denote a disorganization of the blood. In 1864 we +attended a young man previously in perfect health, but who died in +twenty-one hours after the first seizure. His mind was unclouded +throughout his brief but fatal illness. Within seven hours of death a +purpurous discoloration of the skin began, and about an hour before +that event the surface everywhere assumed a dusky hue. The forearms +and hands were almost uniformly purple and the face turgid; many +ecchymotic spots on the trunk and lower limbs were nearly black and +measured {819} one or two inches in diameter.[41] In the case of a +child of five years death in convulsions took place after an illness +of ten hours, the skin presenting purpurous spots, some of them very +large and of a deep bluish livid hue. On post-mortem examination there +was not the slightest appearance of any meningeal lesion, except a few +dark spots like sanguineous effusion under the arachnoid. The heart +was full of dark blood in a semi-coagulated state, and the white +corpuscles were three times as numerous as the red.[42] A case is +reported by Gordon[43] in which the entire duration of the illness +until death was five hours. This is probably the shortest case on +record. A lady aged twenty-two years died in sixteen hours, the skin +covered with livid ecchymoses, some of them measuring an inch or an +inch and a half in diameter.[44] + +[Footnote 41: _Amer. Jour. of Med. Sci._, July, 1864, p. 133.] + +[Footnote 42: _Dublin Quart. Jour._, 1867, ii. 441.] + +[Footnote 43: _Loc. cit._] + +[Footnote 44: _Med. Press and Circular_, May, 1866. For other cases +see _ibid._, pp. 296, 298-300.] + +The character of the convalescence from epidemic meningitis must +evidently be affected by the causes that determine its duration, the +grade of the disease, the development and extent of the lesions, etc.; +but it is certain that, except in those imperfect and, as it were, +shadowy cases which denote a very slight action of the morbid cause, +its subjects do not recover rapidly. The essential lesion of the +fully-formed disease requires time for its removal, just as in typhoid +fever the intestinal ulcers are often slow of healing, and hence +become a cause of tardy recovery and even of unlooked-for death. The +convalescence, then, from the disease we are now studying is slow and +irregular, is attended often with debility and emaciation, and +sometimes with persistent headache, neuralgia, convulsions, stiffness +of the neck and pain in moving it, hyperaesthesia of portions of the +skin, palpitation of the heart, dyspepsia, etc. Relapses are very far +from being uncommon. + +Among the causes of tardy convalescence in this disease are those +lesions and disorders which may be embraced by the term sequelae. +Impaired vision, due to various affections of the eyes, has already +been considered among the symptoms proper of the disease, but they are +not infrequently developed after the acute attack has subsided. Thus, +in a case reported by Larrabie:[45] "Just as convalescence seemed +beginning the left eye became affected in all its parts, with entire +loss of vision and also complete deafness. After a short remission +hydrencephaloid symptoms appeared, followed by the same changes in the +hitherto sound eye, complete blindness and deafness, general cachexia +and marasmus, rigid flexion of the right limbs, and death by +exhaustion at the end of sixteen weeks." The impairment of hearing, +which also was described as a symptom of the acute attack, is apt to +become more marked after the acute stage has passed by, and, as before +stated, is very often permanent. Occurring in young children, it then +involves deaf-mutism. It is in many cases associated with defective +vision, weakness or loss of memory, mania, impairment of intelligence, +persistent pains in the head or chronic hydrocephalus. Sometimes to +one or more of these symptoms is added more or less general paresis or +complete paralysis. Southhall[46] mentions the case of a child two +years old whose attack was followed by incomplete paralysis, and death +at the end of eight months with softening {820} of the brain. Gordon +thus describes the conclusion of a case: "The man has gradually passed +into a state of almost organic life; he eats, drinks, and sleeps well; +he passes solid feces and urine without giving any notice, yet, +evidently, not unconsciously; ... he seems to understand, but cannot +answer; ... he can draw up his legs and arms, but he cannot use his +hands at all." Hirsch has remarked that disorders of speech are met +with, due apparently to an inability to articulate certain sounds. Von +Ziemssen regards chronic hydrocephalus as not a rare consequence of +epidemic meningitis, and as one not absolutely or immediately fatal. +Its symptoms include severe paroxysmal pain in the head or neck or +extremities, with vomiting, loss of consciousness, convulsions, and +involuntary evacuation of excrements. Between the paroxysms, which +sometimes occur periodically, the patient generally suffers from +neuralgic pains, hyperaesthesia, and various motor and even mental +disorders; but in other cases the intervals are free, or nearly so, +from all morbid manifestations. Davis (1872) and many others speak of +severe neuralgic pains following this disease; according to Dr. D., +they are most frequent at the heads of the gastrocnemii muscles, in +the abdomen, and the head; a very fretful disposition, variable +appetite, and disturbed sleep are often observed. Relapses have been +noticed in almost all the epidemics, and it seems probable that they +are often due to the influence of accidental exciting causes, mental +or physical, in renewing the inflammation around the cerebro-spinal +lesions. Miner (1825) remarked that they were most apt to occur within +the first week, but that when the disease had once run its course +there were very few relapses during convalescence. But, he adds, there +were several repeated attacks after the most perfect recovery, and +several of the patients had had the disease the preceding year. + +[Footnote 45: _Richmond Journal of Med._, Dec., 1872, p. 779.] + +[Footnote 46: _Ibid._, Aug., 1872, p. 141.] + +Like other epidemic diseases, meningitis presents itself with every +possible degree of gravity between that of a slight indisposition and +that of a malignant and deadly malady. The mortality in a number of +epidemics compared by Hirsch varied between 20 per cent. and 75 per +cent. It changes with the locality. Thus, nearly at the same time that +the death-rate from this disease in Massachusetts was 61 per cent., it +was but 33 per cent. in the Philadelphia Hospital. In 1872 the whole +number of deaths caused by it in Philadelphia was 133, while at St. +John's College, Little Rock, Ark., 21 cases out of 29 were fatal +(Southhall). It differs, also, at different periods; for while ten +epidemics in various places, occurring between 1838 and 1848, +presented an average mortality of 70 per cent., a similar number, +occurring between 1855 and 1865, gave an average mortality of only 30 +per cent. It must, however, be confessed that such statistics cannot +be relied upon as accurate, for in private practice many cases occur +that are never reported unless they end fatally. + +MORBID ANATOMY.--The lesions found after death from epidemic +meningitis consist essentially of congestion or inflammation of the +cerebro-spinal meninges, but they also include in many cases +hemorrhage, serous effusion, plastic exudation, and tissue-changes in +the brain and spinal marrow, and in many other cases an impaired +constitution of the blood. As the signs of the latter, and not the +former, alterations are met with in the more malignant cases, it is +evident that, looking at the disease as a {821} whole, it must involve +a toxic element of whose operation the various post-mortem lesions are +only effects. These lesions, on the whole, vary with the type of the +disease, and also with its duration, but some are chiefly met with in +cases of a malignant and others in cases of an inflammatory type. + +The exterior of the body after death in the early stages of this +disease almost always presents the marks of transudation of the +contents of the blood-vessels. The dependent parts of the body exhibit +large livid patches or a uniform discoloration of the same hue. In +acute cases the muscles are more deeply colored than natural, and when +the attack is prolonged they are said to have their cohesion impaired +by fatty degeneration. Congestion of the brain is an unfailing +accompaniment of the first stage of the disease; its blood-vessels are +all distended with dark blood; the sinuses of the dura mater are +usually filled with coagula of the same hue, though sometimes very +dense. Serum abounds in the arachnoid cavity and in the ventricles of +the brain; it may be clear or milky, and sometimes it is quite +purulent. It is alleged by one reporter that no less than three pints +of turbid serum escaped in a case in which, however, death did not +occur until the thirty-fifth day. Craig found eight and twelve ounces +of a limpid fluid in two cases; and Tourdes found pus in more than +one-half of his cases, either unmixed or forming a milky liquid. J. L. +Smith refers to the case of an infant who had the disease at the age +of five months, and two months subsequently great prominence of the +anterior fontanelle, and other symptoms which indicated the presence +of a considerable amount of effusion within the cranium. In a case in +Dublin,[47] there was no meningeal lesion except in a "few dark spots +like sanguineous effusion under the arachnoid." White[48] mentions the +case of an adult that terminated fatally in thirty-six hours, in which +the vessels of the pia mater were very much congested, and sanguineous +effusions existed above and below the cerebellum, and a clot of blood +three inches long and external to the theca extended downward from the +lowest portion of the medulla oblongata. In all of these instances, +then, congestion, the first stage of inflammation, existed. That such +was its real nature is proved by what follows. + +[Footnote 47: _Dublin Jour._, July, 1867, p. 441.] + +[Footnote 48: _Med. Record_, iii. 198.] + +The most characteristic lesion is a fibrinous or purulent exudation in +the meshes of the pia mater. American physicians described it as early +as 1806 in such terms as these: "The dura mater and pia mater in +several places adhered together and to the substance of the brain; ... +between the dura mater and the pia mater was a fluid resembling pus" +(Danielson and Mann). In 1810, Bartlett and Wilson found "an +extravasation of lymph on the surface of the brain;" and in the same +year Jackson and his colleagues, after describing the congestion and +serous effusion found within the cranium "in those who perished within +twelve hours of the first invasion," state that the arachnoid and pia +mater present an effusion between them of "coagulated lymph or +semi-purulent lymph" both on the convexity and at the base of the +brain. These descriptions correspond in all respects with those of +Mathey relating to the epidemic at Geneva in 1805, for he says: "The +meningeal blood-vessels were strongly injected. A jelly-like exudation +tinged with blood covered the surface of the brain; ... on its lower +surface and in the ventricles a {822} yellowish puriform matter was +found." Such lesions have been described by a long line of +observers--by Wilson in 1813, Gamage in 1818, Ames and Sargent in +1848; by Squire, Upham, and a host of others since 1860 in the United +States, and by Tourdes, Gilchrist, Ferrus, Wilks, Gordon, Banks, +Gaskoin, Niemeyer, Burdon-Sanderson, and many more in Europe. + +It is evident, therefore, that in a certain number of fatal cases only +sanguineous congestion of the membranes of the brain and spinal cord +are found, and in certain others--constituting, it may be added, +nine-tenths of the whole number--evidences exist of cerebro-spinal +meningitis. Hence the natural conclusion is that the congestive +lesions represent the first stage of a process which if prolonged and +perfected occasions the lesions peculiar to inflammation. For the +development of the latter two factors would seem to be essential--not +only a fibrinous condition of the blood, but also sufficient time for +exudation to occur. But when we come to study the actual results of +examinations post-mortem, it is found that the duration of the attack +does not determine absolutely the nature of the lesions. On the one +hand, in a case which terminated fatally after a week's illness there +was found reddish serum between the arachnoid and the pia mater and in +the lateral ventricles, with intense injection of the pia mater of the +base, medulla oblongata, and upper part of the spinal cord, but no +exudation of lymph.[49] And, on the other hand, numerous cases have +been published in which, although death occurred within twenty-four +hours from the onset of the attack, coagulated lymph and also pus were +found upon the brain and spinal marrow. For example, during the winter +of 1861-62, in the army, that then lay near Washington, D.C., a +soldier was attacked with a chill, severe fever, and headache, +followed by opisthotonos and repeated convulsions before his death, +which occurred in about twenty-four hours. No eruption or +discoloration of the skin is mentioned in the history. On examination +there was found beneath the arachnoid a thin layer of lymph and +abundant exudation over the posterior lobes of the cerebrum, and also +at the base of the brain and on the medulla oblongata.[50] In a case +reported by Gordon[51] the entire duration of the illness was under +five hours, and after death the cerebral arachnoid was more or less +opaque, and in some spots had a layer of very thin purulent matter +beneath it. And, again, not only may the symptoms belonging to +blood-dissolution be consistent with a certain prolongation of life, +but also with decidedly inflammatory tissue-changes. Thus, in another +case of Gordon's the duration of the illness was at least six days, +and the patient presented all the characteristic symptoms of the +disease, including "a most wonderful and uniform curve of the spine +and head backward," "spots black as ink," "bullae which rapidly became +opaque and dusky," "herpetic eruption, etc." After death the body had +a very frightful appearance. It was still prominently arched forward. +It was of a dusky blue color, with a copious eruption of black spots +of various sizes, and one or two of them were gangrenous.... When the +theca vertebralis was opened purulent matter flowed out, and a +purulent effusion was found in patches on the brain. {823} The +cerebral arachnoid was all opaque, the lateral ventricles were filled +with serum, and the blood in all the cavities was very fluid and dark +colored. From all that precedes, therefore, it must be inferred that +the nature of the lesions in this disease depends not on the type +alone, nor on the duration merely, of the attack--that a very brief +course is compatible with marked inflammatory lesions, and a prolonged +one with profound alterations in the condition of the blood. In other +words, it seems that there must be something besides the appreciable +lesions that influences, if it does not determine, the issue of an +attack of this affection. While bringing forward prominently this +proposition, and the facts on which it rests, we have no intention of +under-estimating the relative significance of the two most conspicuous +types of the disease, the purely inflammatory and the adynamic, or +calling in question the fact that the evolution of the former is most +usually comparatively slow and regular, and of the latter rapid and +irregular. In the one, when death takes place early, congestive +changes are found, and when later these have merged into exudative +lesions; in the other or adynamic cases congestion and liquid +transudation prevail, and the results of complete inflammation are +seldom seen. When the disease has been very much prolonged the +exudation becomes tough, adherent, and shrivelled. + +[Footnote 49: Davis, _Richmond Med. Jour._, June, 1872, p. 709.] + +[Footnote 50: Frothingham, _Amer. Med. Times_, Apr., 1864, p. 207.] + +[Footnote 51: _Dublin Quart. Jour._, May, 1867, p. 409.] + +The brain-tissue has generally been found softer than natural, and, +although in some cases this diminished consistence might be attributed +to post-mortem changes, yet on the whole it must be associated with +the inflammatory lesions of the meninges. As a rule, it is greater the +longer the attack has lasted, and is by no means equally diffused, but +is more marked where the meningeal alterations are greatest. Ames +found softening in nine out of eleven cases, and chiefly in the +cortical substance, but also in the fornix and septum lucidum; and +Chauffard states that in protracted cases "the interior surface of the +ventricles, the fornix, and septum lucidum, were reduced to a +pultaceous and creamy consistence." But it is by no means true that +softening is met with in all cases of long duration. + +The lesions of the spinal marrow and its membranes correspond with +those of the brain. The dura mater is often very dark, its +blood-vessels engorged, its arachnoid cavity distended with serum more +or less bloody, turbid, or purulent. Two ounces of pus have been +removed from it through a puncture. Fibrinous and purulent exudation +fills the meshes of the pia mater, and is usually most abundant in the +cervical and dorsal portions, and generally upon the posterior rather +than upon the anterior surface of the organ; but sometimes large +accumulations of lymph and pus are found at the lower end of the cord. +Gordon[52] relates of a case that "when an opening was made into the +lower part of the theca vertebralis purulent matter flowed out, and +the entire surface of the pia mater was covered with a coating of thin +purulent matter, which, like a thin layer of butter, remained adherent +to it." Occasionally the cavity of the spinal arachnoid contains +blood. Softening of the spinal cord has been often noticed. Chauffard +states that in some cases of particularly long duration it was reduced +to a mere pulp, and he adds, "in the place of portions of the spinal +marrow, completely destroyed, was found only a yellowish liquid, or +the empty membranes fell into contact where it was {824} wanting." +Similar disorganization has been described by Ames, Klebs, and others. +Fronmuller reports the case of a girl aged fourteen years in whom the +central canal of the spinal cord was distended with pure pus. + +[Footnote 52: _Dublin Quart. Jour._, xliii. 414.] + +The lesions of the internal auditory apparatus consist of softening in +the fourth ventricle and of the root of the auditory nerve, yet such +lesions are said to have been found even when no defect of hearing had +existed. In other cases in which deafness did occur the lesions +consisted of inflammatory changes in the cavity of the tympanum and +suppuration of the labyrinth. They probably arose from an extension of +inflammation from the pia mater along the trunk of the auditory nerve +(Von Ziemssen). In like manner, the inflammatory and destructive +changes in the eye which have been elsewhere described arise from an +analogous cause affecting the optic nerves. + +It is unnecessary to dwell upon the condition in which other organs +are found after death from epidemic meningitis. In cases that present +a typhoid type, and even in such as are rapidly fatal with ecchymotic +discoloration of the skin, the various organs present no distinctive +tissue-change, but only such engorgement as is common to all diseases +of a similar type. It deserves to be particularly mentioned that in +this affection the spleen is not enlarged, as it always is in a +greater or less degree in diseases whose primary stage involves an +altered condition of the blood. This fact becomes all the more +important in view of the remarkable contrast which the constitution of +the blood presents in epidemic meningitis and in various typhous +affections. + +The state of the blood in this disease is one of peculiar interest, +dominating as it does its whole pathology and determining its +nosological position. It is the blood of a phlegmasia rather than of a +pyrexia. This fact was early established by American physicians who +observed the disease, and the opportunities for doing so were not +wanting, since venesection was used by every one who treated it. In +1807-09 a rapidly fatal case or two was found in which the "blood was +darker and had a larger proportion of serum than usual," but in others +"it did not present any uncommon appearance, and no inflammatory buff, +nor was it dissolved" (Fish). In 1811, Arnell stated that "the blood +drawn in the early stage appeared like that of a person in full +health; there was no unusual buffy coat, neither was the crassamentum +broken down or destroyed." In the epidemic studied by Mannkopff (1866) +he found that blood obtained by venesection gave a clot with a thick +buffy coat. Andral, seeking to establish the law that in every acute +inflammation there is an increase in the fibrin of the blood, remarks +that in a case of cerebro-spinal meningitis it was very marked.[53] +Ames states that "the blood taken from the arm and by cups from the +back of the neck" "coagulated with great rapidity." "Its color was +generally bright--in a few cases nearly approaching to that of +arterial blood; it was seldom buffed; in thirty-seven cases in which +its appearance was noted it was buffed in only four." Analyses were +made in four cases, "the blood being taken early in the disease from +the arm, and was the first bleeding in each case. They furnished the +following results: {825} + + Fibrin. Corpuscles. + I 6.40 140.29 + II 5.20 112.79 + III 3.64 123.45 + IV 4.56 129.50 + +The first was from a laboring man thirty-five years old; the second +from a boy twelve years old, while comatose; and the two others from +stout women between thirty and thirty-five."[54] Tourdes, whose +analyses follow, states that "blood drawn from a vein was rarely +buffed; if a buffy coat existed, it was thin, and generally a mere +iridization upon the surface of the clot."[55] + + Fibrin. Corpuscles. + I 4.60 134.00 + II 3.90 135.54 + III 3.70 143.00 + IV 5.63 137.84 + +Maillot gives, as the result of an analysis of six cases, an increase +of fibrin to six parts and more in a thousand. This summary +represents, as far as is known, all of the analyses of blood taken +from living patients in this disease, and it shows that in every case +the proportion of fibrin exceeded that of healthy blood, and +corresponded exactly to that observed in the blood of inflammatory +diseases, while the proportion of red corpuscles varied within the +normal limits. How different is this condition of the blood from that +of typhus fever, in which there is a marked diminution of fibrin, and +a falling off in the red corpuscles as well, or from that of typhoid +fever, in which neither element declines until the disease affects the +body by inanition! (Murchison). + +[Footnote 53: _Path. Haematology_, p. 73.] + +[Footnote 54: _New Orleans Med. and Surg. Jour._, Nov., 1848.] + +[Footnote 55: _Epidemie de Strasbourg_, p. 160.] + + * * * * * + +In regard to the condition of the blood after death the historians of +the disease are not so well agreed; nevertheless, the preponderance of +the testimony is in favor of the statement that the blood presents +appearances resembling those belonging to the continued fevers rather +than to the inflammations. It is true that even in this the agreement +is neither general nor complete. Tourdes, for example, states that in +an autopsy "the blood was remarkable for the abundance and toughness +of the fibrinous clots," but the greater number have reported it as +being dark and liquid. Such was its condition in the epidemic which we +studied at the Philadelphia Hospital in 1866-67, and it has been +correctly described by Dr. Githens as follows: "The blood was fluid, +of the color and appearance of port-wine lees; under the microscope +the corpuscles were shrivelled and crenated, and there was a space +apparent between them as they were arranged in rouleaux. There were in +two cases white, firm, fibrinous heart-clots extending through both +ventricles and auricles and into the vessels leading to and from the +heart."[56] It may be added that the red corpuscles are often crenated +and shrivelled when the case has been protracted, and it has been +stated--from limited observation, indeed--that "the white corpuscles +are three times more numerous than the red."[57] The blood has been +scrutinized to discover, if possible, some of those bodies which are +judged by Koch and his disciples to differentiate {826} general +diseases, but it is stated that the investigation has been without +definite result.[58] + +[Footnote 56: _Amer. Jour. of Med. Sci._, July, 1867, p. 23.] + +[Footnote 57: _Dublin Quart. Jour._, May, 1867, p. 441.] + +[Footnote 58: Jaffe, _Phila. Med. Times_, xii. 599.] + +It does not seem difficult to reconcile the conflicting statements now +given of the condition of the blood in epidemic meningitis. One of +them points to an excess and the other to a loss of the spontaneously +coagulable element of the blood. It is evident that venesection, which +was necessary for procuring the living blood for analysis, would only +be performed when the type of the disease authorized it--that is, when +the type was sthenic; whereas the blood examined after death had +necessarily undergone changes which tended to, if they did not +actually, occasion death. Hence we find among the former cases, when +fatal, the most extensive and massive exudation, and always among the +latter less evidence of inflammation, but, on the other hand, a +greater or less manifestation of those appearances which denote a loss +of the vitality and organization of the blood. In the one case death +may fairly be attributed, above all other causes, to the pressure +upon, and the disorganization of, the cerebro-spinal organs essential +to life; in the other, primarily, to the death of the vital elements +of the blood produced by the specific cause of the disease. It is +probable that the post-mortem fluidity of the blood exists under two +conditions. In the one the morbid cause is powerful enough from the +very commencement rapidly to destroy the life of that fluid, and in +the other it acts less violently, but continuously, to exhaust the +powers of life. + +Our conception of the pathology of epidemic meningitis is implicitly +contained in the foregoing discussion. Of its essential cause and of +the conditions that call it into existence nothing whatever is known. +The disease is most probably due to some atmospheric agency that is +capable of acting at the same time upon widely separated localities. +Its specific cause appears to enter the blood first of all, and +doubtless through the lungs, and to be capable of destroying life by +its action upon the blood alone. Failing this effect, its force is +spent upon the cerebro-spinal pia mater, and it may become fatal by +the mechanical interference of the products of inflammation with the +nutrition of those parts of the central nervous system which are +essential to life. An inflammatory and a septic element together +constitute the fully-developed disease; either may be in excess and +overshadow the other. According to the relative predominance of one or +the other, the disease assumes more of a typhoid or more of an +inflammatory type, and it is doubtless this diversity in its +physiognomy, as well as in the lesions that attend it, which has led +to the most opposite doctrines respecting its nature and its +nosological affinities. + +DIAGNOSIS.--The most distinctive phenomena of epidemic meningitis are +suddenness of attack and rapidity of development of the following +symptoms: acute pain in the head, neck, spine, and limbs; faintness, +vomiting; stiffness or spasm of the cervical or spinal muscles; +hyperaesthesia of the skin; delirium, alternating with intelligence +and merging afterward into dulness or coma; occasional convulsive +spasms; paralysis of the face or of one side of the body. The +evidences of associated blood-poisoning are, the epidemic prevalence +of the disease, various eruptions upon the skin (herpes, roseola, +petechiae, etc.), ecchymoses, debility out of proportion to the +evidences of local disease, redness of the eyes, {827} foulness of the +tongue and mouth, and more or less of the other conditions which +characterize the typhoid state. To these features must be added the +rate of mortality, which is greater in most epidemics of meningitis +than that of any disease with which it is liable to be confounded. + +It is distinguished from sporadic meningitis by the fact that the +latter disease is never primary, but is always either an epiphenomenon +of some other and previous malady (various fevers and chronic blood +diseases) or is traumatic in its origin. The thermometer readily +distinguishes it from various functional nervous affections, chiefly +hysterical, in which the temperature remains normal. + +From typhoid fever it differs as widely as possible by its rapid +onset, the exquisite pain in the head, the neuralgic pains, the +opisthotonos, and the convulsions. The alternate delirium or coma and +clearness of mind in meningitis contrast with the persistent hebetude, +stupor, or muttering delirium and the muscular relaxation in typhoid +fever. The sordes on the tongue, the diarrhoea, the meteorism, the +intestinal hemorrhage of the latter, instead of the moist or merely +dry tongue and the transient vomiting and torpid bowels of the former; +high or continuous fever on the one hand, slight or variable increase +of temperature on the other; diffluence of blood in the one and an +increase in the proportion of its fibrin in the other; in the one +suppurative inflammation of the cerebro-spinal meninges, in the other +specific lesions of the intestinal and mesenteric glands,--these, as +well as the very different modes of origin of the two affections, draw +a broad and manifest line of distinction between them. + +It would scarcely be necessary to point out the contrasts between +epidemic meningitis and typhus fever were it not that, notwithstanding +the abundance of instruction on the subject in medical treatises and +lectures, a large number of physicians confound typhus fever, typhoid +fever, and the typhoid state of inflammatory diseases with one +another. The confusion was intensified at one time by designating the +disease we are studying as spotted fever--a term originally applied +and properly belonging to typhus fever (typhus petechialis). It is +true that New England physicians soon became aware of their error, +which was distinctly pointed out and condemned by North, Strong, +Miner, Foot, Fish, and others in the early part of this century. A +similar error was at first committed both in Ireland and England, but +was corrected by maturer experience. In order to contrast the two +diseases as strongly as possible, we place their distinctive features +side by side in the following table: + + EPIDEMIC MENINGITIS. | TYPHUS FEVER. + | + A pandemic disease. Occurs | An endemic disease, due to local + simultaneously in places remote | causes and spreading by + from one another and without | intercommunication. + intercommunication. | + | + Attacks all classes of society. | Attacks the poor, filthy, and + Is never primarily developed by | crowded alone. + destitution, squalor, or | + defective ventilation. | + | + Is not contagious. | Contagious in a high degree. + | + Attacks more males than females.| Both sexes equally affected. + | + Attacks more young persons than | More adults than young persons. + adults. | + | + Generally occurs in winter. | Epidemics irrespective of season. + | + Eruptions are absent in at least| Eruption rarely absent, and + half of the cases; they occur | appears about the fifth day. + within the first day or two. | {828} + | + The eruptions are various; they | Eruption always roseolous, and + include erythema, roseola, | then petechial. Ecchymoses are + urticaria, herpes, etc. | rare. + Ecchymoses are common. | + | + Headache is acute, agonizing, | Headache dull and heavy. + tensive. | + | + Delirium often absent; often | Delirium rarely absent; usually + hysterical, sometimes vivacious,| muttering. Rarely begins before + sometimes maniacal. Generally | the end of the first week. + begins on the first or second | + day. | + | + Pulse very often not above the | A slow pulse exceedingly rare. + natural rate; often | Its rate usually between 90 and + preternaturally frequent or | 120. + infrequent. Is subject to sudden| + and great variations. | + | + "The temperature is lower than | The temperature is always + that recorded in any other | elevated, and does not fall until + typhoid or inflammatory | the close of the attack. "The + disease." It is also very | skin is hot, burning, and pungent + fluctuating. | to the feel." + | + The body has no peculiar smell. | The mouse-like smell is + | characteristic. + | + The tongue is generally moist | The tongue is generally dry, + and soft, and if dry is not | hard, and brown, and the teeth + foul. Sordes on teeth rare. | and gums fuliginous. + | + Vomiting is an almost constant | Vomiting is rare and not urgent. + and urgent symptom, especially | + in the first stage. | + | + Pains in the spine and limbs of | The pains, if any, are dull, and + a sharp and lancinating | apparently muscular. + character are usual. | + | + Tetanic spasms occur in a large | Tetanic spasms are unknown in + proportion of cases and within | typhus. Convulsions sometimes + the first two or three days. | occur, due to pyaemia. + They are due to an exudation on | + the medulla oblongata and | + spinalis. | + | + Cutaneous hyperaesthesia is a | The sensibility of the skin is + prominent symptom. | generally blunted. + | + Strabismus is common. | Strabismus is rare. + | + The eyes, if injected, have a | The blood in the conjunctival + light red or pinkish color. | vessels is dark. + | + The pupils are often variable | The pupils are equal and + and unequal. | contracted. + | + Deafness and blindness are often| Deafness almost always ceases + complete and permanent. | with convalescence. Blindness + | never follows typhus. + | + Duration very indefinite, but | Duration from twelve to fourteen + generally from four to seven | days. + days. | + | + Relapses are common. | Relapses are rare. + | + The blood is often fibrinous. | The blood is never fibrinous. + | + The lesions, except in the most | In typhus no inflammatory lesions + rapid cases, consist of a | exist. + plastic or purulent exudation in| + the meshes of the cerebro-spinal| + pia mater. | + | + Mortality from 20 to 75 per | Mortality from 8 to 40 per cent. + cent. | + +PROGNOSIS.--In the section relating to the mortality of epidemic +meningitis it has been seen that its death-rate varies at different +times and places between widely remote extremes. This fact must be +borne in mind in estimating the influence of various circumstances in +controlling the issue of the disease. The relative as well as the +aggregate mortality is far greater in childhood than in adult life. +After the age of thirty or thirty-five it decreases rapidly until old +age, when recovery from the disease is quite exceptional. A sudden or +rapidly developed attack is generally unfavorable, especially when the +symptoms are adynamic and there is a purplish discoloration of the +skin. Indeed, even apart from evidences {829} of blood-change, +cerebral are, on the whole, of graver importance than spinal +phenomena, and the more so the more typhoidal their type. Of still +more serious significance is a want of perception of the gravity of +the situation or unconcern about its issue. A preternaturally slow and +compressible pulse implies danger, and so does coolness of the skin, +especially if it grows purplish from a diffusion of blood beneath it +or even from venous stasis. The various eruptions that have been +described including petechiae, are not necessarily dangerous signs. +Profuse sweats during a soporose state, bullae and gangrenous spots, +obstruction of the bronchia with mucus or serum, pneumonia or +pericarditis,--these are all grave indications. So, too, are a dry, +fissured, shrivelled, and pale tongue or a fuliginous state of the +mouth, swelling of the parotids, obstinate vomiting, and profuse +diarrhoea at an advanced stage of the disease. Among the most +unfavorable nervous symptoms are great restlessness, rigid retraction +of the head, spasms of other than the spinal muscles, general +convulsions, extensive hyperaesthesia, deep coma, dilatation and +insensibility of the pupils or their rapid change from a dilated to a +contracted state, retention or incontinence of urine, and all cerebral +paralyses, including that of the muscles of deglutition. The favorable +indications comprise a general mildness of the symptoms, a moderate +loss of strength, a slight degree of pain and muscular stiffness, the +absence of petechiae or vibices (although in many grave epidemics they +are of rare occurrence), a desire for food and the ability to digest +it. Yet it is imprudent to make an absolute prognosis in any grave +case of this disease. Recovery has sometimes occurred when it appeared +impossible, and some have died when the period of danger seemed to +have passed on the sudden accession of cerebral or spinal nervous +symptoms. + +TREATMENT.--The difficulties that attend the solution of therapeutical +questions regarding diseases which are comparatively regular in their +evolution, and are produced by definite causes acting in an +intelligible manner, are very numerous and often insuperable. They +become multiplied in relation to a disease which, like this one, +stands alone in many respects; whose causes, phenomena, and +lesions--in a word, whose laws--are specific; and whose varieties of +type are as numerous as can be formed by the combination, in a +constantly varying proportion, of a special (hypothetical) alteration +of the blood, deranging the molecular actions of the economy, and at +the same time of an inflammation of the cerebro-spinal meninges, and +even of the substance of the great nervous centres. These reasons are +sufficient to account for the diverse and often opposite methods of +treatment that have been applied to the disease. As in almost all +other cases, the methods have consisted in using remedies to +counteract certain symptoms--now a stimulant or tonic regimen to +combat the debility which conferred the name of "sinking typhus" on +the disease; now an antiphlogistic course to allay the inflammation of +the brain and spinal marrow denoted by the neuralgic pain and the +tetanoid phenomena; and, again, large doses of narcotics to blunt the +pain and subdue the spasm. Still other medications have been used with +a similar purpose, and some, as we shall see, with more or less +theoretical views. It may be said, with Von Ziemssen, "that we are far +from having it in our power to decide whether a rational treatment of +the symptoms has cured the disease or lessened its mortality;" but a +review of the methods {830} that have been employed and their results +leads to no doubtful conclusion that some are mischievous and others +more or less salutary. + +Emetics were among the first medicines used in the treatment of this +affection, and were probably suggested by the vomiting which is one of +its most constant initial symptoms. But we can readily understand why +they failed to afford relief. The vomiting and retching are not +gastric symptoms at all, but, as already stated, are due to the +irritation of the congestive or inflammatory process at the base of +the brain. These medicines may therefore be omitted. The employment of +purgatives is even less rational; they debilitate without affording +any relief. + +Venesection was probably employed as a part of a routine treatment +which neither sound reason nor clinical experience justified. It was +generally found to fail of its curative purpose, and often induced, +especially in young persons, dangerous exhaustion. No better +illustration is needed to show that the disease we have been studying +is far more than a local inflammation of the cerebro-spinal meninges. +On the other hand, local depletion is often of marked utility. Our own +experience would lead us to conclude that in the more sthenic cases +scarified cups, applied to the nape of the neck and along the cervical +vertebrae, are of essential service in mitigating--and generally, +indeed, in wholly removing--the neuralgic pains which form so +prominent and severe a symptom in many cases of this disease. When any +abstraction of blood appears to be contraindicated by the patient's +debility, even dry cups will afford him signal relief. Leeches have +been applied to the parts mentioned, and over the mastoid processes +have sometimes been used with advantage, but their depletory surpasses +their revulsive action, and is, so far, injurious. Cold to the head +and spine is among the most efficient means of relieving certain +symptoms. In the Massachusetts Medical Society's Report of 1810 we +read: "Cold water, snow, and ice have been applied to the head when +there was violent pain in that part with heat and flushed face, and +when there was violent delirium. They afforded great comfort to the +patient, and mitigated or removed those important symptoms." It is +probable, however, that the value of the remedy is almost entirely +restricted to the forming--or at least the early--stage of the attack, +when the pain in the head is most intense. Its soothing influence is +then very marked, as well as its indirect action in promoting sleep. +Heat of head is not an essential condition for its use, for even in +the most violent cases it is rarely extreme, and is often entirely +wanting. Pain calls more distinctly for the application, and when that +symptom has subsided cold is apt to be more annoying than grateful to +the patient. Cold is best applied to the head in the form of pounded +ice enclosed in a bladder or rubber bag; but cold affusions are also +very valuable, especially for children. For the application of cold to +the spine the most efficient apparatus is the long, flat rubber bag, +either single or double. + +From the earliest history of epidemic meningitis in this country +blisters formed a conspicuous element in the treatment. They were +used, as they had been in other forms of meningitis, to relieve the +pain and diminish the congestion in the cerebro-spinal centres. The +results of their use were by no means uniform, for not only were they +employed in many of the cases which must almost necessarily have been +fatal before inflammation could be established, but even in the +inflammatory cases {831} they were often applied when time enough had +elapsed to allow the exudation to be fully formed, and when, +therefore, they were too late to be useful. Again, they were sometimes +used so as to vesicate too deeply, and thus by the pain they caused at +first, and by the exhaustion that resulted from the excessive +discharges they maintained, the patient was more injured than +benefited. Our own experience proves that in the early stage of the +inflammatory form of the disease blisters applied below the occipital +ridge and upon the back of the neck, and only allowed to vesicate +superficially, not only remove the pain in the head, but diminish the +delirium, spasms, and coma, and therefore contribute as directly as +other remedies, if not more so, to the favorable issue of the attack. +But such salutary effects are not to be looked for when the disease +assumes a malignant type nor after its constitution has become +definitely fixed. The application of stimulant and even vesicating +agents to the spine below the neck has not been generally practised +because, probably, the seat of the spinal lesions was known to be +chiefly at the upper part of the organ. Still, the neuralgic pains +felt in the spinal nerves may be mitigated by stimulant and anodyne +liniments applied with friction to the spinal column. + +American physicians early recognized coolness of the skin among the +most striking phenomena of the disease; and this probably suggested +their use of diaphoretic remedies, among which were the external +application of moist heat in baths and warm wrappings, as well as +"bottles of hot water or billets of wood heated in boiling water and +wrapped in flannel," or the patient "was wrapped in flannel wrung out +of boiling water, sinapisms were applied to the feet, while hot +infusions were administered, made from the leaves of mint, pennyroyal, +and other similar plants, and also wine-whey, wine and water, wine, +brandy, and other ardent spirits more or less diluted, camphor, +sulphuric ether, and opium. It was not generally thought useful to +excite profuse sweating, but important to maintain the activity of the +skin from twenty to forty hours, and even longer in some instances. +Soup and cordials were at the same time administered. Under this +treatment most commonly the violent symptoms, and not very rarely all +the appearances of disease, have subsided" (Jackson). Beyond all +doubt, this method was a rational one, for it tended to promote an +elimination of the morbid poison, while it depleted the blood-vessels +and acted revulsively upon the local inflammation of the +cerebro-spinal meninges. Yet it seems not to have been revived during +the more recent epidemics of the disease, unless, partially, by Gordon +(1867), who says: "What I have seen most useful in the stage of +collapse is external warmth applied to the entire surface by means of +flannel bags containing roasted salt, applied along the spine, along +the chest, inside the arms, and to the feet and legs and between +them." + +Except typhus fever, there is no disease in which a due administration +of alcoholic stimulants may become more important. In cases of the +inflammatory type they are rarely needful, and are frequently hurtful, +but in those which exhibit signs of blood disorder with nervous +exhaustion they are often indispensable. Nothing demonstrates their +necessity more clearly than the extraordinary tolerance of alcohol +exhibited in some cases of the disease. Among the earlier American +authorities may be found many illustrations of this statement. +Woodward (1808) {832} observed that very large quantities of wine or +ardent spirits may be given without injury. Arnell said: "In some +cases I have given a quart of brandy in six or eight hours with the +happiest effect." Haskell maintained that "the bold and liberal use of +diffusible stimuli is the only safe and efficacious mode of +treatment." In Ireland the habitual use of alcohol in the treatment of +typhus fever no doubt suggested its liberal employment in this +disease, but such stimulants have never been in vogue among the +physicians of France or Germany. This difference may in part be +accounted for by the generally asthenic type of the disease in the +first-named country and its more inflammatory character in the others. +Similar contrasts of type mark different epidemics, and individual +cases during the same epidemic. We have no doubt that while these +agents are indispensable in the treatment of cases of the former type, +they must even then be exhibited discreetly, for their too lavish +exhibition entails the gravest peril by intoxicating the patients and +oppressing instead of arousing their vital energies. In 1866, on +taking charge of the medical wards in the Philadelphia Hospital, we +found that the patients were using as large quantities of alcohol as +are given in typhus fever, but a very short period of observation +showed that this use of the stimulant was excessive; consequently the +dose of it was first reduced, and finally it was omitted altogether +unless special indications for it arose. This change was followed by a +manifest improvement in the general aspect of the sick and the +subsidence of symptoms which, it then became evident, were due to a +lavish use of stimulants rather than to the gravity of the disease. +Alcohol is no more essential to the treatment of epidemic meningitis +than of any other acute affection; it is a cordial to be held in +reserve to meet those signs of failure of the heart and nervous system +which may arise in all acute diseases attended with changes in the +condition of the blood. + +The use of opium in the treatment of this disease was strongly +advocated by nearly all of the early American writers upon the +subject, and by many of them enormous doses were given. It was +observed not to produce narcotic effects in ordinary doses. In one +case, marked by excruciating pain in the head and maniacal delirium, +sixty drops of laudanum were given every hour until nearly half an +ounce had been taken within eight hours (Strong). Haskell states: "We +have been obliged frequently to exhibit ten grains of opium for a dose +in some of the violent cases attended with strong spasms, and have +never known it to produce stupor in a single instance." Miner relates +that "a few cases imperiously required half an ounce of the tincture +of opium in an hour, or half a drachm [of opium] in substance in the +course of twelve hours, before the urgent symptoms could be +controlled, and even some cases required a drachm in the same time. +All these patients recovered." In Europe, Chauffard administered opium +in doses of from three to fifteen grains, and Boudin frequently +prescribed from seven to fifteen grains at a single dose at the +commencement of the attack, and subsequently one or two grains every +half hour, until the patient grew sleepy or his symptoms subsided. +This tolerance of the drug is remarkable, and so is the fact that it +does not cause constipation. These and many similar statements agree +entirely with our personal experience. We were in the habit, during +the epidemic above referred to, of prescribing one grain {833} of +opium every hour in very severe and every two hours in moderately +severe cases, and in no instance was narcotism induced, or even an +approach to that condition. Under the influence of the medicine the +pain and spasm subsided, the skin grew warmer and the pulse fuller, +and the entire condition of the patient more hopeful. It seemed +probable, however, that the benefit of the opium treatment was most +decided in the early stages of the attack, and hence in those in which +the inflammatory and spasmodic elements predominated. The hypodermic +injection of morphia is to be preferred before the internal +administration of other preparations of opium, not only on account of +its prompter action, but because it avoids the rejection of the +medicine by vomiting. On the whole, Von Ziemssen is within the bounds +of truth when he says, "Beyond all doubt morphia may be considered the +most indispensable medicine in the treatment of epidemic meningitis." + +There is no evidence sufficient to show that epidemic meningitis has +ever been cured by quinia alone. In the early prevalence of the +disease it was treated by large doses of cinchona, but unavailingly, +and subsequently smaller doses were given during the convalescence, as +it was in that of other acute diseases. In some parts of this country +where miasmatic diseases prevail, and epidemic meningitis, like all +other acute, and especially febrile, disorders, displayed more or less +of a periodical or paroxysmal type, quinia was used in large doses, +but the expected result was not realized. Upham states that in some +instances it was given to the extent of sixty, or even eighty, grains +within twelve hours from the beginning of the attack, but without +effect. In Europe it was extensively tried and unanimously condemned. +It may very properly be left out of the list of medicines suitable for +this disease, particularly since it is no longer probable that any +physician would be rash enough to employ it in the so-called +antipyretic doses with or without their usual associates, cold baths. +According to Karl Jaffe, the medicinal antipyretics (quinia, salicylic +acid, and also sodium benzoate) may be entirely discarded, because +they ruin the already weakened digestion.[59] + +[Footnote 59: _Phila. Med. Times_, xii. 600.] + +Common sense has also proved stronger than theory in excluding +mercurials from the treatment of epidemic meningitis. At one time they +were extensively used, especially when it was learned that the disease +in its full development included a paramount inflammatory element. But +it was soon found that the results of their use were far from uniform, +and farther still from being demonstrably beneficial. In this, as in +many other similar cases, it is quite impossible to reach a definite +judgment unless it were known what was the type of the cases in which +the medicine was given, whether they were asthenic or inflammatory, +and again whether it was used during the active or during the +declining stage and toward convalescence. In the absence of any +trustworthy testimony upon the subject it is only possible at present +to state that in the treatment of this disease mercurials should not +be used. This conclusion is all the more imperative because the +medicine is not an indifferent one. If it is not necessary--and it +certainly is not--it is too dangerous in its immediate and ultimate +effects for its employment to be warranted. + +Since belladonna and ergot were shown to diminish vascular action in +the cerebro-spinal axis by contracting its capillary blood-vessels, +they have {834} been put forward as having a specific virtue in this +disease. If the fact be so, how is that other fact--a clinical one, +moreover--to be disposed of, which is that opium, the physiological +antagonist of belladonna and ergot, is more efficient than they are in +curing the disease? It is possible, indeed, that they may have that +curative power, and that opium possesses it also, and that the +explanation given of the action of all of these agents is erroneous. +Upham states that, in 1863, Haddock recommended ergot upon theoretical +grounds, and that during an epidemic at Newbern, N.C., several cases +treated by it recovered. Three cases recovered in which it was +prescribed by Borland. Read used it in 1873-74 at Boston, Mass., and +out of 19 cases 16 recovered and 3 died.[60] This mortality of about +15 per cent. is not more than half of that which has generally been +met with, and if it can be attributed to the treatment would go far to +prove the efficacy of the latter. One grain of ergotine, with +one-tenth of a grain of extract of belladonna, was administered every +three hours. Considering the exiguity of the dose of belladonna, it is +not surprising that, except in one case, it did not dilate the pupil; +and the dose of ergotine is likewise far smaller than the average +medicinal dose of that preparation. Moreover, all of the cases except +the fatal ones appear to have presented the disease in a subacute, and +certainly not in an aggravated, form. + +[Footnote 60: _Philadelphia Med. and Surg. Reporter_, Jan., 1875, p. +68.] + +In 1872, Dr. S. N. Davis,[61] moved by the success of Calabar bean in +tetanus, employed it in this disease. A mixture of one ounce of +tincture of Calabar bean with one and a half ounces of fluid extract +of ergot was administered in doses of half a teaspoonful every two +hours, and with better results than had followed other remedies. Here, +again, it is to be noticed that the analogy suggesting the use of +physostigma is not a logical one. That drug indeed relieves the spinal +spasms of tetanus--a disease in which there is an irritation of the +spinal axis, but no exudation from its meningeal vessels, as in the +affection we are studying. Moreover, it is a disease of extraordinary +power, as shown not only by the spasms, but by the exceptionally high +temperature, and thus again is in direct contrast to epidemic +meningitis. If, therefore, Calabar bean benefits that disease, it +cannot do so in the manner suggested by the author. + +[Footnote 61: _Richmond and Louisville Med. Jour._, xiii. 711.] + +Bromide of potassium and hydrate of chloral have also been employed to +allay the spasmodic symptoms; but the former is too feeble for the +purpose, and the depressing action of the latter upon the heart +renders it dangerous. Bromide of potassium has been given to children +of two and five years in doses of four and six grains every two hours; +but these doses appear to be quite too small even for the purpose in +view--viz. to prevent convulsive attacks. Whatever remedies may be +suggested hereafter, none should be employed that tend to reduce the +power of the heart, which, as we have seen, is dangerously depressed +by the disease. + +During the decline and convalescence of the affection it is probable +that iodide of potassium may be advantageously used to promote the +removal of the exudation-matter on the brain and spinal marrow, and +probably to prevent the hydrocephalus which sometimes follows the +attack, and is attributable to the pressure of effused lymph upon the +cerebral veins. + +DIET.--The mildly febrile character of epidemic meningitis, and the +{835} remarkable debility which characterizes so many cases of the +disease, and which, as was before pointed out, conferred upon it the +name typhus syncopalis, plainly justify what experience has taught, +that appropriate food for the subjects of this affection is at once +the most digestible and nutritious that can be taken. It is true that +this regimen is interfered with by the vomiting, but, as that symptom +is of cerebral and not of gastric origin, it is more apt to be allayed +by suitable food than by abstinence. It has been our custom to observe +in this disease the same rules respecting diet that are recognized as +the most suitable in typhus fever. In doing so, indeed, we did, +without at the time knowing it, follow the example of the early +American physicians. Strong, who wrote in 1811, advised "soup made +from chicken, veal, mutton, and beef, richly seasoned with pepper and +savory herbs." These articles were prescribed by him during the height +of the disease. Later on he says: "The stomach soon begins to crave +something more solid than soup; oysters, beefsteak, cold ham, or +neat's tongue are received with peculiar relish. Often I have seen +convalescents, when they had hardly strength enough to raise +themselves in bed, make a hearty meal of the above-mentioned articles, +which were received with great satisfaction, sat well upon the +stomach, and were well digested and assimilated." This method is +substantially the same that was found successful in the earlier, as it +has been in the later, epidemics in this country, and we have no +hesitation in attributing to it and the appropriate use of opium and +blisters the degree of success we enjoyed in the treatment of the +disease in the Philadelphia Hospital and elsewhere. + +During convalescence from epidemic meningitis the patient should +carefully abstain from physical exertion and mental excitement, and +before this state is fully established he should even very cautiously +change his position from a recumbent to an erect posture. And, +finally, he should return to his ordinary occupations, mental or +physical, as late as possible, on account of the danger of a relapse, +which has already been described. + + + + +{836} + +PERTUSSIS. + +BY JOHN M. KEATING, M.D. + + +HISTORY.--A careful study of this disease from the various writings +since the time of Hippocrates leaves little doubt in the mind of the +reader as to its antiquity, so little indeed has it changed in its +various characteristics. Whether the affection passed to continental +Europe from Africa, or whether its starting-point was India, are +questions difficult to solve, and, except for the medical historian, +of little import. Desruelles probably truthfully asserts that the many +differences which mark the descriptions of the disease, especially by +the early Grecian writers, may be due, not to the non-existence of the +disease as we know it, but to the influence which climate exerted then +as now, and to the unrecognized fact that it is only fatal in its +complications. The writings of Hippocrates, Galen, and Avicenna, +though undoubtedly referring to the many affections in which +paroxysmal cough is a prominent symptom, contain many expressions that +would point clearly to the existence of a specific disease. Dr. Watt +believed that the disease was not known to the Greeks, and other +writers claim that it came from the north and spread southward over +Europe about the sixth century; nevertheless, it first appears on +record as a distinct affection, disentangled from the confused mass +with which it was involved for centuries, about the middle of the +seventeenth century. Steffen mentions the first well-established +accounts as coming from Baillou in the year 1600, and Schenck in 1650, +and Ettmuller in 1685. Sydenham casually mentions it in 1670. Since +the time of Willis the definition of the disease has remained +unaltered, and so accurate was the description then given of it that +we can but naturally conclude that for many centuries at least it has +varied but little. + +In studying affections of this kind, occurring in epidemic form +especially, and which are increased in intensity by whatever means the +contagious element, whether gaseous or parasitic, is made more +virulent, much allowance is to be made for the climate, customs, and +habits of the people whence our data are derived. Thus, most of the +diseases of antiquity, the descriptions of which have reached us, have +been drawn from types modified by mild climates where the people have +led an out-door life, and though the disease we see at the present day +is one and the same so far as its causation is concerned, the indoor +life and close confinement, the bad ventilation, and the artificial +existence in our large cities must weaken the individual, intensify +the poison, and exert an influence on the disease. + +DEFINITION AND DESCRIPTION.--Whooping cough has been {837} +characterized as an acute contagious affection, occurring usually in +childhood, though it may occur at any age, and lasting several weeks. +It is manifested usually by malaise, catarrh of the respiratory tract, +and subsequently by a convulsive cough occurring in paroxysms, the +peculiarity of which consists of a series of forcible expirations, +followed by a sonorous inspiration or whoop, which may be repeated +several times. + +At the beginning of these paroxysms of coughing, there are evidences +of slight laryngeal irritation, attended by an effort at suppressing +the cough; then follow gradually increasing and more audible +inspirations, which become more and more difficult. The child is +agitated, the face becomes pale, and the countenance has a mingled +expression of supplication and fear. If it is old enough it will seize +the nearest object for support. As the spell advances, the eyes become +suffused and prominent and the loose tissue surrounding the orbits +appears puffy and congested. Finally, the paroxysm reaches its height; +the child, with a livid countenance, with veins standing out like +cords, gives a succession of violent expiratory efforts, followed by a +long inspiratory whoop. The same is repeated several times, until +finally almost complete cyanosis takes place; the spasm relaxes, a +glairy, tenacious mucus runs from the mouth, the contents of the +stomach are vomited, and the child falls back exhausted. The lividity +of the countenance is succeeded by a deathly pallor; the face still +appears swollen and puffy beneath the eyes; the tears course down the +cheeks, and frequently hemorrhage occurs from the eyes, nose, ears, or +throat, owing to the terrific strain upon the circulation. As soon as +the child has recovered from the fatigue of the paroxysm all is +apparently over, and were it not for the characteristic expression of +the eye, which is pathognomonic in a well-advanced case, nothing would +be noticed to even suggest the disease when uncomplicated. The voice +is clear; there is little or no elevation of temperature. + +The paroxysms which have given the name to this disease can only be +likened to an epileptic convulsion, which by gradually increasing +cyanosis is self-curable, the carbonized blood finally bringing about +an anaesthetic effect. The severity of the paroxysms is by no means in +proportion to the local catarrh, which latter may be superficial and +slight, not to be detected during life by the most careful laryngeal +examinations, and only after death by the aid of the microscope. The +frequency and intensity of the paroxysms are dependent in a measure +upon the degree of excitability of the nervous system, which of course +differs in individuals. It is evident that the success of treatment +must be powerfully influenced by this circumstance, and it is partly +owing to it that there are so many opinions as to the value of +remedies in this disease. + +The complications are usually dependent upon outside causes, and have +nothing to do with the poison proper of whooping cough, as far as we +can tell. There are some which depend on an inflammation of the mucous +membrane, which may be limited to any portion of the respiratory tract +or may extend throughout it. Complications may arise from mechanical +obstruction to inspiration by the swollen mucous membrane or from +plugs of tenacious mucus, which may cause pulmonary collapse and favor +the development of catarrhal pneumonia, and later even of phthisis; or +from impediments to free and easy expiration, whether from spasm of +the bronchioles, from forcible compression of the thorax through +reflex {838} nervous irritation, or from other obstructions, all of +which tend to produce emphysema. Disturbances of the circulation, in +the brain or elsewhere, may proceed from thrombi or emboli and give +rise to complications which will render fatal an otherwise mild form +of the disease. The invariable disturbance of nutrition which +accompanies every disease affecting the nervous system is apt to show +itself in the breaking down of products which are simply inflammatory. +Vomiting may be a most serious complication, both from its immediate +and remote effects. It may be due to gastric catarrh, or more +frequently to irritation of the pneumogastric nerve. + +ETIOLOGY.--Very numerous theories have been advanced as to the nature +of this interesting disease. Hufeland, Lebenstein, Pinel, Jahn, Todd, +Cullen and a host of others have regarded it as essentially a +neurosis. By many others it has been supposed to be due to a lesion of +the brain or of its membranes, but careful investigation has +established the fact that there is no lesion in whooping cough at all +constant or characteristic. By still others, and especially by Gueneau +de Mussy, it has been regarded as essentially an affection of the +tracheo-bronchial glands, a bronchial adenopathy, causing irritation +of the pneumogastrics and of their bronchial branches by pressure of +the enlarged glands. We have, however, seen many post-mortem +examinations of the bodies of children who have died of measles, where +marked enlargement of these glands was constantly found, but where no +symptoms of whooping cough had been present. There are indeed many +features of the disease which seem inexplicable on any other theory +than that the essential cause of whooping cough is a specific poison, +and such is the view now generally adopted. This poison is capable of +being carried by fomites, though as it is highly infectious it is +often communicated through the atmosphere, and is most frequently +conveyed from individual to individual. Dolan,[1] who has recently +published a very interesting and valuable monograph on this affection, +quotes Linnaeus, who ascribed it to the irritation of insects, as the +author of the modern view that whooping cough is due to the presence +of a peculiar microbe, though it must be conceded that as yet it has +not been discovered. Most observers hold that the contagium is not in +the blood, but that it resides in the secretions of the respiratory +passages, and is most virulent during that stage of the disease when +the secretion is abundant. Letzerich states that he has {839} +succeeded in producing whooping cough in rabbits by inoculating the +trachea with the sputa of the human subject. Dolan obtained similar +results by injecting the nasal secretions, and also by compelling +rabbits to inhale air impregnated with decomposing sputa and vomit of +patients suffering with the disease. + +[Footnote 1: Dolan, Thos. M., _Whooping Cough_, London, 1882. + +The following brief statement of his conclusions may be quoted as +presenting the most important facts concerning the pathology of the +disease: + +1st. Pertussis depends on a specific poison or contagion; this is +universally admitted. + +2d. This contagion is active and highly infectious; this is also +granted. + +3d. The contagion is analogous to the contagia which produce splenic +fever, measles, scarlatina, variola, etc. + +4th. It has a peculiar determination to the lungs. + +5th. Like all other contagia, it has its period of activity and +decline. + +6th. The period of greatest activity is in the first and second +stages. + +7th. Pertussis runs a regular course like measles, scarlatina, +variola, etc., and rarely attacks a person but once. + +8th. It may thus be classed among zymotic diseases. + +9th. The fact that there is no primary pathognomonic morbid change +supports this view. + +10th. There are various secondary lesions which are characteristic, as +ulcerations of the fraenum linguae. + +11th. The mode of death harmonizes with this view.] + +I do not, however, feel entirely satisfied in adopting the view that +the contagium of whooping cough resides alone in the mucous membranes +of the air-passages.[2] Children have been known to be born with the +disease, the mother having suffered from it some time previous to +confinement. The following case occurred under my own observation: +Mrs. F----, the mother of two children, was in her eighth month of +pregnancy; the two children had at the time a very severe attack of +whooping cough, which required the constant attendance of the mother. +She, though an extremely intelligent woman, belonged to the poorer +classes, and had no one to assist her at this trying time. One day she +complained that the movements of her child in utero had entirely +changed. Suddenly, without any previous motion, the child would become +very active; the force of its movements was such as to make hazardous +any attempt on her part to walk in the street. The suddenness with +which the movement would come on would oblige her to seize the nearest +object for support. This continued until the child was born. Shortly +after labor my attention was called to the infant, which had a curious +attack, it became deeply cyanosed, seemed asphyxiated, as it were, for +a moment, had no convulsions, and within a few seconds resumed its +normal breathing and the circulation seemed once more established. I +saw the child in several of these attacks; its health did not seem to +be impaired, and without treatment, within a few weeks they +disappeared altogether. The mother insisted upon the fact that the +child had whooping cough, and the absence of the characteristic whoop +was the only thing that prevented the diagnosis from being positive. +This would show--and there are enough cases on record to warrant our +basing an opinion upon them--that the contagium of whooping cough is +found not alone in the matters expectorated, notwithstanding the +statement of Dolan and others that their experiments failed to show +its existence in the blood. + +[Footnote 2: Colson, _Lancet_, July 2d.] + +It must not be forgotten, in reference to cases which seem to have +arisen without any exposure to the specific poison, that the +characteristic whoop is not always present, and that consequently the +true nature of mild cases of the disease which may infect other +individuals may have been overlooked. Childhood probably acts as a +predisposing cause, though the disease occurs at all periods of life, +and as it usually occurs but once in the same individual, it is clear +that the apparent diminution of susceptibility in later years may be +largely due to the fact that most persons have had the disease in +childhood. More children are attacked from one to five years, and the +disease is more prevalent in summer and fall months. Causes which, +like exposure to inclement weather, give rise to irritation of the +bronchial mucous membrane, or diseases which, as measles, are +accompanied with catarrhal symptoms and susceptibility of the +bronchial mucous membrane, also may serve as predisposing causes. Sex +appears to exert some positive influence. Of 360 cases of pertussis by +Dessau,[3] the total number of males were 154, that of females 206. +Girls are more {840} frequently attacked than boys, in proportion of 2 +to 1.50; this seems true at all ages; this statement is substantiated +by Unruh of Dresden, based on an analysis of 1952 cases. + +[Footnote 3: _N.Y. Jour. of Obst._, 1881, xiv. 490-503.] + +SYMPTOMS.--The disease begins usually with an ordinary catarrh, +preceded by malaise and slight laryngeal irritation, which may be +overlooked; in fact, during the first stage there is nothing to +attract special attention, unless a direct history of exposure be +known and suspicion be aroused on that account. Meigs and Pepper state +that the earliest period at which they have known the distinctive +whoop of the disease was three days, though in a great many instances +it was delayed as late as three weeks. The same authors state that the +ordinary duration of a paroxysm or kink is from one-fourth to +three-fourths of a minute. They mention a case where the paroxysm +lasted fifty-five minutes. Ordinarily they number about thirty-five or +forty during the twenty-four hours at the height of the disease, +differing greatly in individuals. Their number is most frequent in the +course of the third or fourth week, after which they remain +stationary, and then gradually decline. The paroxysms may occur +spontaneously, or they may follow some irritation, either direct or +reflex, or they may be induced by nervous excitement. Toward the end +of the attack, after the catarrhal irritation has greatly subsided, or +in fact has entirely disappeared, the paroxysmal kinks may be provoked +by irritation of the fauces, and also by nervous excitement; and there +is no question but that at this time they can be controlled by +will-power. In many cases a distinct relapse occurs after the disease +has been apparently cured. + +Dolan believes the phenomena of the cough or kinks to be due, as +suggested by Laennec, to a "spasmodic condition of the muscular or +contractile fibres of the bronchi and their branches." He remarks that +the lungs are supplied from the anterior and posterior pulmonary +plexuses, formed chiefly of branches from the sympathetic and +pneumogastrics. The filaments from these accompany the bronchial tubes +upon which they are lost. Irritation of these nerves is said to have +the effect of producing contractions of the bronchial canals +sufficient to expel a certain quantity of air. If this theory is true, +it helps us in explaining why the large, mediate, and smaller bronchi +are closed during the expiratory stage of the paroxysmal cough of +pertussis. The general opinion seems to be that the pneumogastric +nerve is not inflamed, as has been asserted by some. + +The highly sensitive condition of the nervous system, which is +probably in a great measure intensified by the anaemia, and by the +interference with nutrition due to the disturbance of the circulation +by the cough, will show itself in many ways, and even when no +secondary nervous affections complicate the attack or follow it. Some +time will elapse after the disease has passed away before the child +will recover its self-control, or its nutrition will show the +influence of a healthy nervous system. The total duration of the +affection is said to vary from six weeks to three months in ordinary +cases; though probably, if active treatment could be instituted early +enough and kept up with thoroughness, there is no specific disease +more capable of being shortened in its course than the one under +consideration; this remains, however, for future statistics to decide. + +During the second stage of the disease the symptoms are sufficiently +{841} marked to attract attention and render a diagnosis easy to make. +Frequently the catarrh seems to extend to the bronchioles, and gives +rise to symptoms that are alarming; and the intensity of the paroxysm +will cause the engorgement of the blood-vessels to get relief in +profuse hemorrhage; this is the period for caution. Complications may +arise, the strength may fail, the secretions may become too abundant, +and asphyxia may ensue; emphysema may show itself, or catarrhal +pneumonia may gradually supervene. + +The period of decline is very gradual; the secretions become less in +quantity and more viscid, the paroxysmal cough is less frequent, but +may at times be equally severe, the child's strength is usually +exhausted, and its nutrition is greatly impaired. The expected +paroxysm throws it into a state of intense nervous excitement; it is +sleepless--in fact, worn out. Probably at this period of the disease +treatment will show the most marked results, and the long lists of +sedatives, tonics, etc. which are presented to us by their zealous +advocates owe much of their popularity to their value at this stage of +the disease. The catarrhal symptoms are the first to subside; the +nervous disturbances remain for some time, and gradually fade, and the +constitutional symptoms, or those from exhaustion, are the last to +leave the patient. + +Strange as it may seem, the heart appears to suffer but little in the +long run from the great strain upon it; the palpitation and +irregularity of its actions are not followed by structural changes as +a rule, though we may state that feebleness of the circulation has +remained in most of our bad cases for some months after recovery. + +As regards the ulceration of the fraenum linguae, which has given rise +to so much discussion as to its exact value as a symptom of this +disease, our own experience leads us to believe that though it is +nearly always present in the severe cases, its almost invariable +absence before dentition and in milder cases shows it to be of +traumatic origin. Roger's exhaustive report before the French Academy +supported this view, and showed how clearly it is caused by the +violent rubbing of the fraenum on the free border of the incisors. On +the other hand, Delthil of Paris and Blake of England believe that it +is a pathological feature of the disease. The former reported cases in +which it occurred before dentition. The ulcer is not always found on +the fraenum linguae, but is found on either side of it. Bouffier noted +severe cases of ulceration in children who had no teeth, but he +attributed it to the injury produced by the mother in detaching the +mucus with the finger. + +Examinations of the urine have been carefully made by many observers. +The appearance of sugar, about which so much has been said, does not +seem to be constant, or even very frequent. Out of 50 cases, Dolan +found traces of it in but 13. This coincides with our experience also, +for we have frequently tested the urine in seven cases with negative +results. Since, as is well known, irritation of the pneumogastric +centre may cause glycosuria, it was at one time attempted to show that +the paroxysms in whooping cough were due to congestion of the +pneumogastric nerves, a condition which is said to have been +occasionally found in this disease. Dolan says he has never seen +hemorrhage from the kidneys during the course of whooping cough, nor +blood in the urine. + +MORTALITY.--It is an extremely difficult matter to reach, with any +{842} degree of certainty, the true mortality of this affection. Meigs +and Pepper say: "Of the 208 cases observed by ourselves, 143 were +simple, all of which recovered;" and, again, "Some form of +complication occurred in the 65 of the 208 cases observed by +ourselves; of these 65, 12 died." The mortality seems greater under +five years; thus: Of the 9008 deaths attributed to it in the United +States during the census year ending June 1, 1870, the number of +persons under one year of age was 4424, and 8396 were under five +years. There were 1784 deaths from it recorded in Philadelphia from +1860 to 1876; of this number, 1724 were under five years of age. The +census of the United States for 1880 gives a return of 11,102 deaths +from this disease. + +Females seem more liable to die of it than males; of the 1784 deaths +in this city, 766 were males and 1018 females. As we have already +seen, females are more liable to the disease than males. + +Robt. J. Lee, M.D.,[4] says that from the Registrar-General's report +of 1876 it is seen that in a total mortality in England of 510,315, +whooping cough was returned as the cause of death in 10,554 cases, or +nearly 2 per cent. + +[Footnote 4: In a paper in the _British Med. Jour._, 1879, vol. i. p. +307.] + +As for the time of year, we quote the following: "Thus, according to +the census statistics, most deaths occur in the spring, there being a +rise up to the middle of May. From the middle of May the number +lessens largely until August, when a rise occurs and continues until +October, when a decline sets in and continues until December, when a +rise begins and goes on increasing until the middle of May. This rise +in mortality from August to October is attributed to the wear and tear +of a hot summer and the intestinal troubles then so prevalent." + +The mortality statistics of this disease are uncertain. It is fatal in +its complications or by inducing a debilitated condition which invites +degenerative processes. The severity of the symptoms is no guide for +prognosis as far as uncomplicated cases are concerned, and there is no +doubt but that at present we are able to greatly reduce the +mortality-rate by care and medical treatment, as well as to shorten +the attack. Sporadic cases are apt to be neglected until they become +complicated. When the disease occurs in epidemic form, measles is +often prevalent simultaneously, and in consequence children who become +affected by both diseases have a greater tendency, from debility, to +become the victims of those affections of the respiratory organs which +are such frequent and fatal complications of both maladies. + +Instead of surprise at the mortality of this affection, the marvel is +that so large a percentage of recoveries take place, when we consider +that we are dealing with a disease whose lesion is a catarrh of the +air-passages which seldom lasts less than two months, with a tendency +to involve the lungs in one way or another, and then witness the +carelessness with which, among the lower classes, the child is often +treated--exposed to all weathers, under-clothed, under-fed, and +probably allowed to pass through the whole attack without medical +treatment. Taking this into consideration, the probability is that the +mortality of this disease could be reduced to a very small figure by +careful management, even if the investigations of those now seeking +the microbe of pertussis do not lead to any plan, in accordance with +Pasteur's teachings, which will still further lessen the gravity of +the disease. Until {843} then, we can but insist upon a rigid +quarantine of schools, a registration of all cases, and the seclusion +of them, as we have done to-day in the case of variola and scarlatina. + +MORBID ANATOMY.--Although whooping cough is a serious disease, the +cause of death is generally found to be dependent upon its +complications, and there is no lesion at all characteristic of it. The +chief complications and sequelae are--bronchitis, which may become +capillary; lobular collapse, which, according to Alderson,[5] is +frequently found; emphysema, usually marginal, probably due, as +suggested by Jenner, to violent expiratory exertions; rupture of +air-vesicles, with subcutaneous emphysema; catarrhal pneumonia, +pleurisy, phthisis, acute tuberculosis, croup, cerebral apoplexy, +meningitis, etc. As any of these complications, and others which may +arise from debility, may be the cause of death, independent of the +action of the specific poison itself, it is usual to divide the +post-mortem appearances into those that are the result of the +extension of the catarrh itself and those produced by the interference +with the circulation and with nutrition from mechanical violence. Of +the former, the usual causes of death are pneumonia, gastritis and +enteritis. Of the latter, we have thrombosis of the cerebral sinuses, +hemorrhages, emphysema, and exhaustion following constant vomiting. + +[Footnote 5: _Medico-Chir. Trans._, pp. 90, 91, 1830.] + +Tubercular disease of the lungs or of the brain is apt to be a cause +of death. Convulsions carried off 5 of the 12 fatal cases reported out +of 208 by Meigs and Pepper. This may be due to congestion of the +brain, especially in teething children. Spasm of the glottis with +sudden death is occasionally found. In such cases there is found +intense congestion of the brain, also of the liver and kidneys, and at +times of the mucous membrane of the stomach and intestines, as well as +of that of the respiratory tract. + +In all cases, especially at the teething age, sudden death may occur +because effusion into the ventricles of the brain or the formation of +heart-clot has taken place. It is important to know this, that active +treatment applied early enough may save the patient. + +PROPHYLAXIS.--Should the interesting and seemingly conclusive +statements of Dolan and the microscopic investigations of Carl +Bruger[6] receive the endorsement of future workers, the subject of +prophylaxis will assume a degree of importance which hitherto it has +only maintained with the medical profession. No one has doubted that +the disease was contagious, and yet there is no affection which has +attached to it a corresponding fatality that is so carelessly dealt +with as pertussis. + +[Footnote 6: Bruger of Bonn, in the _Berliner klinische Wochen._, +describes at length the special micro-organisms of pertussis. They +appear as small elongated elliptical bodies of unequal length, the +smallest being double as long as broad. High powers show subdivisions +in the largest specimens. They are generally isolated, but may appear +in groups. They bear some resemblance to _Leptothrix buccalis_, the +spores of which are often found in whooping-cough sputa. Occasionally +the bacillus is seen inside the mucous corpuscle in the sputum. They +stain in the usual way, fuschin and methyl violet. This bacillus is +not found in any other kind of sputum, is very abundant in pertussis, +and increases in direct proportion to the severity of the disease.] + +Within the past few days we have heard on two occasions in crowded +railway-cars the characteristic paroxysm of the third stage of the +disease, and yet people will endeavor to convince themselves that +unless contact with the child takes place the danger is little. + +{844} The atmosphere in school-rooms, railway-cars, and places of +amusement which are badly ventilated, is an excellent medium for the +propagation of the contagious matter, and many extraordinary cases are +on record of momentary exposure being sufficient to contract the +disease. Believing that the contagium or virus resides in the mucus +and air thrown off by the child, and also in the vomited matters, +which contain a large amount of ropy mucus, and also that it gains +entrance by means of the respiratory organs, protection from contagion +divides itself as follows: thorough disinfection of the exhaled air, +of the mucus remaining within the bronchial tubes and air-passages, +and of the clothing, together with exposure to fresh air and thorough +cleansing of all furniture and household utensils, including cups, +silverware, and toys, used by the child. Oxygen is said to have this +effect, and thorough, constant ventilation, with the breathing of +fresh air by the child, the thorough washing of its surface, and +disinfection of its clothing, are the first indications; while the +impregnation of the atmosphere with the spray of well-known germicides +by means of the steam or other atomizer and the frequent inhalation of +such materials by the patient are no less important. Every case of +whooping cough should be compelled to use two or three times daily the +spray impregnated with a substance of this sort, either carbolic acid, +the oil of eucalyptus, a solution of quinia, or thymol. Chlorine (from +chloride of lime) used thus has of late been followed by excellent +results, and the spray of a solution of corrosive sublimate or of +ammonium chloride has been found very useful. The protective treatment +should be applied to those exposed to contagion. Such children should +be guarded from exposure to colds; their diet should be simple and +nourishing, their clothing warm; they should be kept as much as +possible in the open air. The breathing of air impregnated with such +substances as above mentioned will no doubt act upon the virus before +it comes in contact with the mucous membranes so as to be absorbed, +and probably the severity of the attack might be mitigated by +modifying the germ of the disease. + +TREATMENT.--As can be readily imagined, a disease which is so +universal, so distressing, and at the same time so obscure in its +pathology, as the one under consideration, would have in its +literature a mass of recommendations for treatment from zealous +advocates, based upon theory or experience, as numerous as the authors +themselves. It would be impossible for us to dwell at length upon all +of these, but we will confine ourselves especially to the +consideration of a few of the most important. It will be convenient to +consider first those remedies which have been used with the view of +relieving the congestion and irritability of the respiratory mucous +membrane and of promoting more free secretion. It will also be +observed that many of these remedies may now be regarded as of value +for destroying the special germ which is thought to be the essential +cause and real virus of pertussis. Allusion has been made above to the +importance of inhalations as a prophylactic for those who have been +exposed to the contagion, as well as for the purpose of rendering the +secretions less contagious; and so too we find that the inhalation of +various substances has received favor with many as a method of +treatment. Thus, hyoscyamus, belladonna, ammonium bromide have been +used. Helenke and Serbaud say that bromide of {845} potassium is best +for inhalation. Letzerich recommended the insufflation of quinia twice +daily, using the quinia muriate with potassium bicarbonate and +gum-arabic. Forchheimer[7] reports 97 cases of whooping cough treated +by the insufflation of the quinia muriate; of the 97 cases, 52 were +females, 45 males--the youngest three weeks, the oldest nine years +old. Five cases gave no results, while in the others benefit was shown +by a shortening or amelioration of the disease. The vapor of benzole +has been used with good results. The vapor of carbolic acid has of +late been highly recommended, either administered with the atomizer +several times daily, or used by saturating flannels in carbolic acid +solution and placed around the child's bed at night. It is said that +the inhalation of the vapor of a few drops of carbolic acid on some +hot coals will ensure a night of freedom from violent coughing. +Probably in this way we may account for the belief that proximity to +gas-works is beneficial to a child with this disease. As is well +known, Niemeyer and others in the north of Germany believed in the +value of the inhalation of oxygen, and the experience of every one who +has had much to do with this disease favors an out-door life. We may +here also mention the value of a small quantity of chloroform or +ether, by inhalation, in allaying the severity of the paroxysms of +cough. We have also tried the nitrate of amyl, but without marked +result. + +[Footnote 7: _New York Jour. Obstet._, 1882.] + +Others have recommended the use of solutions of various substances, +applied directly by a brush to the interior of the larynx. Quinia has +been used in this way also by Hagenbach; but the most satisfactory +results have been obtained by the application of very weak solutions +of nitrate of silver, as first recommended by Watson in 1849. + +After the secretions have been fully established and the +characteristic whoop has appeared, the indications in the treatment +are to relieve the respiratory tract of its burden by occasional +emesis with alum or ipecacuanha, to give freely antispasmodics and +sedatives, as belladonna, chloral, the bromides, hydrobromic acid, or, +as recommended by some, digitalis; to give quinia freely, and to use +counter-irritants to the neck and chest with liniments composed of oil +of amber, croton oil, or turpentine. + +The value of emetics has been long recognized in this affection, +although we are told by Vogel that the continuous use of emetics in +the early stage for several days causes harm. Copeland ordered an +emetic every third day in ordinary cases. All writers agree that the +milder emetics should be used by preference; that tartar emetic should +be avoided, except as an external application where a counter-irritant +is desired; and that ipecacuanha is the safest, though alum is also +safe and as an astringent useful. Trousseau preferred the sulphate of +copper. In the earlier stages of the disease emetics are not, as a +rule, indicated; it is only when the secretion has become extremely +tenacious, and the paroxysms so frequent and severe as to greatly +strain the patient and endanger his lungs, that they are of value. +There seems to be a close connection between the amount and tenacity +of the secretion and the severity of the paroxysm. The potassium +carbonate has been recommended as an active agent in the amelioration +of this affection; it is probably valuable in rendering the secretion +less tenacious. Alum has been used with success, as has tannin, +probably owing to their local action on the mucous membrane. +Macartan[8] says that in the East {846} Indies the disease is treated +in the first stages by astringent and tonic gargles. + +[Footnote 8: _Dictionnaire des Sciences Med._, 1813, vol. vi.] + +Belladonna certainly receives the endorsement of the greatest number +of writers. Vogel considers it superior to all other drugs, and +regards dilatation of the pupil as the only sure guide in its +administration. He says it does not cut short the attack, but +mitigates the paroxysm. Trousseau was also an advocate of this form of +treatment. When combined with alum[9] it is considered by Meigs and +Pepper to be one of the most valuable drugs recommended. They also +advise the use of potassium carbonate. Seiner trusted belladonna more +than any other remedy; so also Rilliet and Barthez. William Lee, in an +interesting paper in the _New York Medical Journal_, 1883, advocates +the use of atropia hypodermically; he believes that atropia chiefly +acts in these cases on the laryngeal branches of the pneumogastric +nerves, and that it is probable that it has a decided effect also on +the medulla oblongata itself, and renders it less capable of exciting +reflex action. Kroon's experiments led him to conclude that the +valerianate of atropia was the most useful. Evans[10] gave the 1/120 +of a grain of atropia to a child aged three years until the pupils +were dilated, then reduced the dose; this stopped the paroxysm in +twenty-one days. At the commencement of the treatment the child had +twenty-three paroxysms in the day, and twenty-seven at night. Case No. +2 under same circumstances recovered in fourteen days. In case No. 3 +the paroxysms were reduced from twenty-six to two or three a day. +Arthur Wiglesworth[11] used a solution of sulphate of atropia, +administered in the morning fasting; the dose he advises for children +from one to four years is gr. 1/120, given only once a day except in +some cases. The results are as follows: There is a steady diminution +in the number of paroxysms; a change in the character of the whoop as +if the vocal cords were not so closely approximated. If atropia is +withheld, the beneficent effect derived from it subsides. + +[Footnote 9: Golding Bird, _Guy's Hosp. Rep._, April, 1845.] + +[Footnote 10: _Glasgow Med. Jour._, 1880.] + +[Footnote 11: _Lancet_, April 12, 1879.] + +West advises dilute hydrocyanic acid, and many writers agree with him, +ranking it next to belladonna. + +Harley and others are strong advocates for the bromide of ammonium; it +is supposed to have a local anaesthetic action on the pharyngeal and +laryngeal mucous membrane. Fordyce Grinnell[12] during four months +treated 223 cases with this remedy, and highly recommends it. The +doses were in accordance with those of Dr. Kormann--3/4 to 4 grains, +as indicated by age, three or four times a day and at night when the +paroxysms were severe. No other treatment was used in these 223 cases, +except camphorated oil to the throat and chest in some cases. +Potassium bromide has been recommended by Helenke, Beaufort, +Erlenmeyer, and others. Henry Field[13] recommends sodium bromide. + +[Footnote 12: _Med. News_, 1882.] + +[Footnote 13: _Brit. Med. Jour._] + +Probably next to belladonna in the treatment of this disease we should +place chloral hydrate. + +Hebner, after an elaborate study of the relative value of potassium +bromide, quinia, salicylic acid, chloral, and belladonna, says: +"Salicylic acid and chloral tend to relieve the paroxysms--belladonna +and quinia to shorten the disease." Kennedy[14] writes: "I cannot +doubt {847} its specific effects on the cough. Chloral seems to me to +yield the best and most constant results. The advantage of chloral +hydrate seems to exist in producing sleep; it should be given in from +2- to 5-gr. doses, at night." If there is much irritability or +fretfulness, or any premonition of eclampsia, it should be associated +with potassium bromide. + +[Footnote 14: _Dublin Jour. M. S._, 1881.] + +Croton chloral has received much praise from those who have used it; +we have had no experience with it. + +We have already alluded to the value of quinia, which has been used +largely in this disease, both internally and as a local application. +Originally recommended in the latter manner on account of its power of +controlling the development of low organisms, it has not proved so +satisfactory or valuable as when given internally. Binz in 1870 was +perhaps the first to recommend quinia given frequently and in +solution, and Dawson in 1873[15] reports excellent results from the +sulphate or muriate of quinia given in full and frequent doses, and in +such solutions as will not prevent its acting on the mucous membrane +in its passage through the pharynx. Breidenbach[16] gives the quinia +muriate in larger doses--one and a half to fifteen and a half grains +per diem. The effects were surprising as soon as the proper dose for +each person had been determined; this, he says, is the keynote of +success. To prevent complications he continued it for a long time in +small doses. + +[Footnote 15: _Am. Jour. Obstetrics._] + +[Footnote 16: _Practitioner_, Feb., 1871.] + +Our own experience favors the view that quinia, when given in solution +or suspended in mixture, is valuable in many cases of this disease; it +can be ordered in powder, and given in a spoonful of simple syrup or +of the preparation known as the syrup of yerba santa, which makes an +excellent vehicle. Liquorice also disguises the taste of quinia +admirably for children. + +Albrecht[17] has found from an experience of ten cases of whooping +cough in children between the ages of one and a half and nine years, +all of a marked scrofulous type, much benefit from the muriate of +pilocarpine, given in small doses after every fit of coughing. To +prevent collapse, he advises that it should be given in a mixture +containing a little brandy. After twenty-four hours of its +administration an obvious change for the better takes place in the +appearance of the mucous membrane of the throat, velum palati, and +uvula, which becomes paler, less swollen, and more moist; +laryngoscopic examination shows a similar improvement. During the +catarrhal period cold compresses to the neck and sweetened milk +containing potassium chlorate are used instead of the pilocarpine, +which is to be resumed as soon as a whoop recurs. + +[Footnote 17: _London Med. Rec._, March 15, 1882, p. 110.] + +Dr. Tordeus, of the Hospice des Enfants Assistes, Brussels, states +that he has found the sodium benzoate useful in whooping cough, +diminishing the frequency and violence of the paroxysms, and by its +action on the pulmonary mucous membrane preventing those pulmonary +complications which so frequently supervene and constitute the danger +of the disease. + +Sulphur has been largely used by the Germans in two- or three-grain +doses, and is said to be greatly esteemed by them. Cantharides has +been recommended, and it is stated that when strangury is produced the +whoop will cease; we should consider this rather severe treatment. The +{848} fluid extract of castanea is used by many with undoubtedly good +results, though this also has been somewhat of a disappointment in the +way of treatment, as at one time it was looked upon almost as a +specific. Many claim that an infusion of the fresh leaves gives a +better result. Dewar[18] regards ergot with great favor in the +treatment of pertussis. Certainly in those cases where, from violent +straining, hemorrhages have taken place we have found it to be highly +valuable. We have had no experience with it in the treatment of +ordinary cases, though Dewar claims that it shortens the attack. The +ammonium picrate, and recently resorcine, have been used with success. + +[Footnote 18: _The Practitioner_, London, May, 1882.] + +Counter-irritation to the neck and chest has always been found useful +in the treatment of this disease. Autenreith[19] recommends tartar +emetic to the epigastrium till vesicles appear and even ulcerate. +Milder forms of counter-irritation over the chest seem equally +efficacious if continued for some time. The oil of amber, when used in +liniment with camphor or turpentine, is by some considered almost a +specific. Great care should also be observed in the dress of children +with whooping cough. Warmth about the chest is always indicated, while +there should be nothing close or tight about the throat allowed. + +[Footnote 19: _Dict. des Sciences Med._, 1813.] + +In the third stage, when there is the nervous element remaining, +tonics, such as cod-liver oil, iron, the phosphates and +hypophosphites, are required. + +The diet should be nutritious, easy of digestion, and abundant, and +the bowels should be kept regular by fruits or laxatives. Over-feeding +should of course always be avoided, and the attempt at weaning a babe +with this disease would certainly meet with unfavorable results. + +Bicarbonate of soda or lime-water should be given freely with the milk +taken by children with this disease. Milk certainly should form the +basis of the diet of children with pertussis, and reliable +meat-extracts are to be recommended in this disease even for older +children, who from the severity of the attack would vomit more solid +food. If the vomiting be so severe as to affect nutrition, the child +should be sustained by peptonized milk, soup, or gruel, given by the +bowel. + +The importance of a proper regulation of the temperature of the air +which the patient breathes is especially recognized in France. If the +attack occurs in mid-winter and the seashore be inaccessible or +inexpedient, the child should be restricted to a well-ventilated +nursery or suite of rooms, the temperature of which should be kept +uniform. + +Salt air is recognized to be of great value in advanced cases of this +disease; this has been attributed partly to the effects of stimulation +of the mucous membrane in rendering less viscid and more copious the +bronchial secretions, and also to the balmy softness and great purity +of the atmosphere at the sea-shore. But probably there is another +element in the local action of the chloride of sodium, either in +establishing a resistance on the part of the patient or in modifying +the germ of the disease. + +The most serious complication of whooping cough is pneumonia. It +occasionally happens that an attack of croupous pneumonia may develop +during the course of whooping cough, but in the vast majority of cases +the disease is of the catarrhal type. When, indeed, it is remembered +that a bronchial catarrh, which is the invariable precursor or +accompaniment {849} of catarrhal pneumonia, is a constant factor in +whooping cough, and, further, that all conditions of debility, and +especially of enfeebled or embarrassed respiration, dispose to this +form of pneumonia, it is not surprising that this complication should +be of such frequent occurrence. It is not impossible that in aiming at +securing sufficient fresh air and out-door exercise to maintain the +general health, an injudicious degree of exposure may be permitted +which will aggravate the existing bronchitis and induce an extension +of inflammation to the alveoli. But usually the catarrhal pneumonia +develops in a subacute and more or less insidious manner, and without +being traceable to any such exposure. It may happen occasionally that +in the violent inspiratory efforts at the close of the paroxysms +irritating secretions may be sucked from the bronchioles into the +alveoli, and there excite inflammation. Or, again, it doubtless +happens frequently that, with the existence of swelling of the +bronchial mucous membrane and of viscid secretions in the bronchial +tubes, collapse of portions of lung tissue is developed by the +forcible expulsion of air during the paroxysms of cough, which cannot +be replaced owing to the relative weakness of inspiration and to the +ball-valve action of the plugs of mucus in the obstructed bronchioles. +The intimate relation between pulmonary collapse and catarrhal +pneumonia is familiarly known. It is not to be considered that the +mere occurrence of collapse will induce pneumonia in the areas +affected, but certainly it will aid in rendering effective the other +irritating causes. As a consequence, it usually happens that when +catarrhal pneumonia occurs in whooping cough it is associated with +more or less collapse. When, then, especially in children of +debilitated or rachitic constitution, or in those who are subjected to +unfavorable hygienic influences, such as overcrowding, bad air, and +the like, there is a rather gradual development of dyspnoea, with +increasing debility, emaciation, and evidences of impaired oxygenation +of the blood, it is to be feared that this serious complication has +developed. The physical signs are often difficult of interpretation, +but if careful examination of the chest be conducted, together with +thermometric observations, the approach of this danger or its actual +presence may be detected. The result is fatal in a large proportion of +cases, so that suitable treatment--for the details of which reference +is made to the appropriate section--must be instituted without delay. + + * * * * * + +Our investigations of this disease have led us to the conclusion that +we have to deal with an affection caused by a specific germ, which is +usually, after a period of incubation, made manifest by a catarrh of a +portion of the air-passages; that this catarrh, existing for an +indefinite period, is capable of being influenced by medication, +applied either by means of inhalation or by acting on the mucous +membrane after absorption by the stomach. In this way we have known +the administration of quinia and of alum diminish the number of +paroxysms, to all appearance checking the excessive secretion to a +marvellous extent. The other element of the disease, the neurosis, +which soon follows the initial catarrh, and seems to last for an +indefinite time after the mucous membrane has regained its normal +appearance, is also capable of being controlled by the use of drugs, +especially belladonna, chloral, the bromides, and hydrocyanic acid, +not to speak of the other antispasmodics and sedatives, and by the +{850} analgesic effect of carbonic acid gas, or by the spray of +bromide of ammonium, carbolic acid, and other substances upon the +larynx. + +Vogel tells us in his classical work on children, "If now, as a +resume, I would give an explanation of my views, it would go to show +that there never has been, and most probably never will be, a remedy +by which whooping cough may be abridged, any more than we are able to +cut short the acute exanthemata or typhus fever or pneumonia." And yet +the experience of many whom we have quoted in this article tends to +support the view that by a form of treatment calculated to act on the +two elements of the disease which we have just noted, the affection +can be greatly modified in its intensity, and probably the attack be +somewhat shortened. Certain it is that the recent studies of this +disease give us hope that the day is not far distant when the cause, +whatever it is, will be definitely known, and if it is found to reside +in the secretions from the larynx, that treatment by inhalation or +atomization will modify or destroy it, and prevent its dissemination. + + + + +{851} + +INFLUENZA. + +BY JAMES C. WILSON, M.D. + + +DEFINITION.--A continued fever, occurring in widely-extended +epidemics, and due to a specific cause; it is characterized by early +catarrh of the mucous membrane of the respiratory tract, and in many +cases also of the digestive tract; by quickly oncoming debility out of +proportion to the intensity of the fever and the catarrhal processes; +and by nervous symptoms. There is a strong tendency to inflammatory +complications, especially of the lungs. Uncomplicated cases are rarely +fatal except in feeble and aged persons. An attack does not confer +immunity from the disease in future epidemics. + +SYNONYMS.--Febris catarrhalis; Defluxio catarrhalis epidemicus; +Catarrhus a contagio; Rheuma epidemicum; Cephalalgia contagiosa; +Epidemic catarrhal fever; Tac; Horion; Quinte; Coqueluche; Ladendo, +also written La Dando; Baraquette; Generale; Coquette; Cocotte; +Allure; Follette; Petite poste; Petit courier; Grenade; La Grippe; +Ziep; Schaffhusten and Schaffkrankheit; Huhner-Weh; Blitz-Katarrh; +Modefieber; Mal del Castrone. There are also several names indicating +its supposed origin; thus it has been called in Russia, Chinese +catarrh; in Germany and Italy, the Russian disease; in France, Italian +fever, Spanish catarrh, and so forth. + +It is a remarkable fact that in two instances at least the popular +name for the disease under consideration has found its way widely into +medicine and medical literature, almost to the exclusion of the +studied terms by which science has sought to designate it; these are +influenza and la grippe. + +Such obsolete and now meaningless terms as Peripneumonia notha +(Sydenham, Boerhaave), Peripneumonia catarrhalis (Huxham), Pleuritis +humida (Stoll), have been omitted from this list of synonyms as being +of interest rather to the student of medical history than to the +student of medicine. + +Febris catarrhalis, Defluxio catarrhalis epidemicus, Rheuma epidemicus +are terms which no longer retain the place given them in the +literature of influenza by the older medical authorities. + +Catarrhis a contagio (Cullen) and Cephalalgia contagiosa are derived +from a view of the nature of the disease, which has been the cause of +no little controversy. + +Epidemic catarrhal fever is, with its Latin equivalent, the most +satisfactory of the so-called scientific names by which the disease is +at present known. + +In the popular names for the affection there is to be noted an {852} +indication of the national character of some of the peoples who have +suffered from its frequent visitations. + +Among the English it is known as cold or epidemic cold, or, in +deference to medical authority, as catarrh or epidemic catarrh; and at +present, both among the folk and the doctors, as influenza. Englishmen +are neither quick to see in the disease a resemblance to some common +circumstance or thing, nor are they disposed to make a joke about it. + +The Germans find obvious resemblances. In the labored respiration and +the character of the cough they find a suggestion of a common +epizootic affecting the sheep, hence Schaffhusten and Shaffkrankheit; +or, because the cough is like the crowing of a cock and the +disturbance of respiration and rapid prostration suggest some +resemblance to a common disease of the domestic fowl, it has been +called Huhner-Weh (chicken disease, whooping cough), and Ziep, which +is about equivalent to pip. They call it also, from its rapid +invasion, Blitz-Katarrh, and from its diffusion, Modefieber. + +The French are disposed to make a jest of everything, and the more +serious the subject the better the joke. Hence they have found a new +name for almost every great epidemic, and each more trivial than the +last. Thus, tac (rot); horion (in jest, a blow); quinte, because the +spells occur at intervals of five hours (sic); coqueluche (a hood or +cowl), from the cap worn by those suffering from the malady; and so on +through the long list given above. + +La grippe is said to be derived from the Polish Chrypka (Raucedo); it +may, however, be derived from agripper (to seize). + +Influenza is of Italian derivation. It is said that the disease +received this name because it was attributed to the influence of the +stars, or from a secondary signification of the word indicating +something fluid, transient, or fashionable. + +HISTORICAL SKETCH.[1]--Epidemics of influenza have been clearly +recorded only since the beginning of the sixteenth century. There are +numerous accounts of earlier epidemic diseases resembling it, but they +are not sufficiently particular to warrant us in inferring its +undoubted existence. It is supposed to be referred to in the writings +of Hippocrates, who, however, gives no exact description.[2] An +outbreak in the Athenian army in Sicily (415 B.C.), recorded by +Diodorus Siculus, has been supposed to have been influenza. Despite +these statements, and those of others to the effect that it is a +disease known from a remote antiquity, it may be said that no accounts +can be confidently established, as referring to the disease now known +as influenza, in the writings of classical antiquity.[3] + +[Footnote 1: See also _The Continued Fevers_, by the author of this +paper, New York, 1881.] + +[Footnote 2: Parkes, _Reynolds's System of Medicine_, vol. i., 1868.] + +[Footnote 3: Zuelzer, _Ziemssen's Cyclopaedia of Medicine_, vol. ii., +1875.] + +As early as the ninth century several epidemics of catarrhal fever, +Italian fever, and the like, which were probably influenza, were made +matter of history. In the year A.D. 827 a cough which spread like the +plague was recorded. In 876 there appeared in Italy a similar +epidemic, which spread with great rapidity over all Europe. It is +related that dogs and birds suffered with symptoms not unlike those +characterizing the affection in man. In 976, Germany and all France +suffered from a fever of which the chief {853} symptom was cough. No +further epidemic is noted until two centuries later, when, in 1173, a +widespread malady, of which the symptoms were chiefly catarrhal, raged +throughout Europe; while less important epidemics of a like character +are recorded as having occurred during the following century +(1239-99). + +In the medical writings of the fourteenth century there are to be +found records of six epidemics, and in the fifteenth seven great +visitations of influenza are described (Parkes). + +Aitken[4] speaks of a very fatal prevalence of influenza throughout +France in 1311, and of an epidemic in 1403 in which the mortality was +so great that the courts of law in Paris were closed in consequence of +the deaths. + +[Footnote 4: Aitken's _Practice of Medicine_, vol. i., 1872.] + +Influenza is mentioned in the _Annals of the Four Masters_ as having +prevailed in Ireland in the fourteenth century, and a disease +characterized by similar symptoms is alluded to in early Gaelic +manuscripts under the name of Creatan (creat, the chest). The disease +is described also in an Irish manuscript of the fifteenth century +under the terms Fuacht and Slaodan.[5] + +[Footnote 5: Theophilus Thompson, _Annals of Influenza_, 1852.] + +The earliest epidemic that prevailed in the British Isles of which any +accurate description remains is that of the year 1510. The disease +came from Malta, and invaded first Sicily, then Italy and Spain and +Portugal, whence it crossed the Alps into Hungary and Germany as far +as the Baltic Sea, extending westward into France and Britain. Its +track widened over the whole of Europe from the south-east to the +extreme north-west, and it is said that not a single family and scarce +a person escaped it. It was attended by a "grievous pain in the head, +heaviness, difficulty of breathing, hoarseness, loss of strength and +appetite, restlessness, retchings from a terrible tearing cough. +Presently succeeded a chilliness, and so violent a cough that many +were in danger of suffocation. The first day it was without spitting, +but about the seventh or eighth day much viscid phlegm was spit up. +Others (though fewer) spat only water and froth. When they began to +spit, cough and shortness of breath were easier. None died except some +children. In some it went off with a looseness, in others by sweating. +Bleeding and purging did hurt."[6] Blisters were commonly +employed--two each upon the arms and legs, and one to the back of the +head. The description is sufficiently clear to place the nature of +this epidemic beyond all doubt. + +[Footnote 6: Thomas Short, _A General Chronological History of the +Air, Weather, Meteors, etc._, London, 1749; quoted in the _Annals of +Influenza_.] + +The epidemic of 1557, starting westward from Asia, spread over Europe, +and then crossed the Atlantic to America. The malady broke out in +England, after a season of unusual rain and great scarcity of corn, in +the month of September. "Presently after were many catarrhs, quickly +followed by a more severe cough, pain of the side, difficulty of +breathing, and a fever. The pain was neither violent nor pricking, but +mild. The third day they expectorated freely. The sixth, seventh, or +at the farthest the eighth day, all who had that pain of the side +died, but such as were blooded on the first or second day recovered on +the fourth or fifth; but bleeding on the last two days did no +service." "Some, but very few, had continual fevers along with it; +many had {854} double tertians; others simply slight intermittent. All +were worse by night than by day; such as recovered were long +valetudinary, had a weak stomach, and hypped." Gravid women either +aborted or died. This epidemic spread with frightful rapidity. +Thousands were attacked at the same time. The entire population of +Nismes, with scarcely an exception, fell ill of it upon the same day. +It was extremely fatal. In Mantua Carpentaria, a small town near +Madrid, it broke out in August, and so fatal were the bloodletting and +purging which constituted the treatment at first, that, of the two +thousand persons who were bled, all died. The disease raged in some +parts till the middle of the following year (1558), and carried off, +in Delft alone, five thousand of the poor. In all cases mild treatment +was called for, with warm broths and speedy immersals, "to recall the +appetite and keep the vessels of the throat open." + +In 1580 a great epidemic of influenza spread from the south-east +toward the north-west over Asia, Africa, and Europe. From +Constantinople and Venice it overran Hungary and Germany, and reached +the farthest regions of Norway, Sweden, and Russia. It spread into +England, and has been described by Dr. Short. In Italy it prevailed +during August and September, in England from the middle of August to +the end of September, and in Spain during the whole summer. In most +places its duration was about six weeks. As a rule, the termination +was favorable, although the disease ran a somewhat protracted course. +In the account of Dr. Short it is stated that "few died except those +that were let blood of or had unsound viscera." In some places, on the +contrary, the course of the disease was very severe. In Rome two +thousand died of it, according to the author just cited, but Zuelzer +informs us that the victims of this epidemic in the Eternal City were +not less than nine thousand, and adds that Madrid must have been +almost depopulated by it. This high mortality has been attributed to +the bloodletting practised in the treatment of the disease. The +symptoms were similar to those of the previous epidemics, with a +greater shortness of breath, which continued in many cases for some +time after the disappearance of the catarrhal trouble. There was great +sweating at the end of the attack. The plague, measles, and small-pox +prevailed also, and with considerable violence, during the year 1580. + +Influenza, unfelt for several years, reappeared in Germany in 1591; an +epidemic extending from Holland through France and into Italy occurred +in 1593. In 1610 catarrh is said to have prevailed throughout Europe. +In 1626-27 epidemic catarrhal fever made its appearance in Italy and +France; in 1642-43 in Holland; in 1647 in Spain and in the colonies of +the Western World; and again, in 1655 in North America. According to +Webster,[7] this epidemic of 1647 was the first catarrh mentioned in +American annals. + +[Footnote 7: Noah Webster, _A Brief History of Epidemic and +Pestilential Diseases_, London, 1800.] + +In 1658 and 1675 it again visited Austria, Germany, England, etc. The +first of these two epidemics is described by Willis,[8] and the second +by Sydenham,[9] as they occurred in England, and the accounts are to +be {855} found in the _Annals of Influenza_. It is about this period +that the disease began to be known as influenza, and it is not without +interest to observe that the influence of the stars suggested itself, +in connection with its sudden appearance and wide prevalence, to the +minds of the physicians of this date. Willis writes that "about the +end of April (1658), suddenly a distemper arose, as if sent by some +blast of the stars, which laid hold on very many together; that in +some towns in the space of a week above a thousand people fell sick +together." + +[Footnote 8: Dr. Willis, _The Description of a Catarrhal Fever +Epidemical in the Middle of the Spring in the Year 1658: Practice of +Physick_, 1684.] + +[Footnote 9: _The Epidemic Coughs of the Year 1675, with the Pleurisy +and Peripneumony that supervened_: from the _Works_ of Thomas +Sydenham, M.D.] + +Epidemics are recorded as having occurred in Great Britain and Europe +in 1688, 1693, and in 1709. The disease raged in 1712 widely over +Europe from Denmark to Italy. + +In 1729-30 a widespread epidemic swept over Europe. In five months it +extended over Russia, Poland, Germany, Sweden, and Denmark. In Vienna +sixty thousand persons fell ill of it. In the autumn it spread to +England, and reached France and Switzerland; from there it extended to +Italy, and by February it had reached Rome and Naples. Spain did not +escape its ravages, and it is said to have found its way to Mexico. +The symptoms did not differ in any important respect from those +already described as characterizing previous epidemics. Pains in the +limbs and fever marked the onset of the attack; catarrh, oppression, +hoarseness, cough followed. In some cases delirium, drowsiness, and +faintings occurred. A petechial eruption was observed, in some +instances, between the fourth and seventh days. This renders it +probable that typhus or cerebro-spinal fever prevailed at the same +time. Turbid urine, copious sweats, bilious stools, and nose-bleeding +were often noted. In Switzerland only children and old persons died. +The disease was not very fatal. + +Two years later (1732-33) an epidemic, starting from Saxony and +Poland, overran Germany, Switzerland, and Holland, and invaded Great +Britain in the month of December. Toward the end of January it spread +in a south-easterly direction to France, Italy, Spain, and westward to +North America, thence southward to the islands of the West Indies, and +on to South America. The course of the disease in this epidemic was +favorable. The attack terminated in from three to fourteen days, with +sweating, bleeding from the nose, or an abundant discharge from the +nasal passages. The aged and those suffering from chronic pulmonary +diseases mostly perished. In Scotland three forms of the affection +were described--namely, the cephalic, the thoracic, and the abdominal. +The epidemic slowly spread over Eastern Europe and in a south-easterly +direction, and may be said to have lasted till 1737. + +Concerning this epidemic John Huxham of Plymouth wrote as follows:[10] +"About this time a disease invaded these parts which was the most +completely epidemic of any I remember to have met with; not a house +was free from it; the beggar's hut and the nobleman's palace were +alike subject to its attacks, scarce a person escaping either in town +or country; old and young, strong and infirm, shared the same fate." +The malady had raged in Cornwall and the western parts of Devonshire +from the beginning of February; it reached Plymouth on the 10th, which +was on a Saturday, and that day numbers were suddenly seized. The next +day multitudes were taken ill, and by the 18th or 20th of March +scarcely {856} any one had escaped it. "The disorder began at first +with a slight shivering; this was presently followed by a transient +erratic heat and headache and a violent and troublesome sneezing; then +the back and lungs were seized with flying pains, which sometimes +attacked the heart likewise, and though they did not long remain +there, yet were very troublesome, being greatly irritated by the +violent cough which accompanied the disorder, in the fits of which a +great quantity of a thin, sharp mucus was thrown out from the nose and +mouth. These complaints were like those arising from what is called +catching cold, but presently a slight fever came on, which afterward +grew more violent; the pulse was now very quick, but not in the least +hard and tense like that in a pleurisy; nor was the urine remarkably +red, but very thick, and inclining to a whitish color; the tongue, +instead of being dry, was thickly covered with a whitish mucus or +slime; there was an universal complaint of want of rest and a great +giddiness. Several likewise were seized with a most racking pain in +the head, often accompanied by a slight delirium. Many were troubled +with a tinnitus aurium, or singing in the ears; and numbers suffered +from violent earaches or pains in the meatus auditorius, which in some +turned to an abscess. Exulcerations and swellings of the fauces were +likwise very common. The sick were in general very much given to +sweat, which, when it broke out of its own accord, was very plentiful +and continued without striking in again, and did often in the space of +two or three days wholly carry off the fever. You have here a +description of this epidemic disease such as it prevailed hereabouts, +attacking every one more or less; but still, considering the great +multitude that were seized by it, it was fatal to but few, and that +chiefly infants and consumptive old people. It generally went off +about the fourth day, leaving behind a troublesome cough, which was +very often of long duration, and such a dejection of strength as one +would hardly have suspected from the shortness of the time. + +"On the whole, this disorder was rarely mortal, unless by some very +great error arising in the treatment of it; however, this very +circumstance proved fatal to some, who, making too slight of it, +either on account of its being so common or not thinking it very +dangerous, often found asthmas, hectics, or even consumptions +themselves, the forfeitures of their inconsiderate rashness." + +[Footnote 10: _Observations on the Air and Epidemical Diseases, +translated from the Latin_, London, 1758.] + +Arbuthnot also described this visitation of the disease.[11] He +regarded the uniformity of the symptoms in every place as most +remarkable, and tells us that during the whole season in which it +prevailed there was "a great run of hysterical, hypochondriacal, and +nervous distempers; in short, all the symptoms of relaxation." + +[Footnote 11: _An Essay concerning the Effects of Air on Human +Bodies_, London, 1751.] + +During the years 1737-38 influenza again swept over England, North +America, the islands of the West Indies, and France; in 1742-43 it +prevailed in Western Europe and the British Isles; in 1757-58 in North +America, the West Indies, France, and Scotland. In 1761 it overran the +North American colonies and the West Indies. + +The epidemic of 1762 extended very generally over Europe and Great +Britain. In Germany nine-tenths of the population were attacked by the +disease. + +Widely extended epidemics prevailed in Europe and America in 1767 +{857} and 1775; in 1772 it raged in North America; in 1778-80, in +France, Germany and Russia. Noah Webster found influenza prevalent in +North America in 1781; the next year one of the most remarkable +epidemics of this disease (described as the epidemic of 1782) appeared +in Europe. It came from the East, from Asia into Russia. From St. +Petersburg it spread during the winter and spring over Sweden, +Germany, Holland, and France. In the autumn it was in Italy, Spain, +and Portugal. The crews of Dutch and English ships were taken ill with +the disease upon the high seas. + +In Vienna three-fourths of the population fell ill of it with such +suddenness that it got here for the first time its name of "Blitz +Katarrh" (lightning catarrh). It was characterized by great pain in +the back, breast, and throat, and by extraordinary enfeeblement. +Relapses occurred, and inflammation of the lungs and bowels was +common. Children remained relatively exempt from its seizure. This +epidemic broke out in England about the end of April and raged until +the end of June. "The duration of the malady in some was not above a +day or two, but it usually lasted near a week or longer. In a few the +symptoms seemed to abate in two or three days, but some returned and +raged with more violence than at first."[12] The disease was not +regarded as in itself fatal, and few could be said to have died of it +"but those who were old, asthmatic, or who had been debilitated by +some previous indisposition." + +[Footnote 12: _An Account of the Epidemic Disease called the Influenza +of the Year 1782. Collected from the Observations of several +Physicians in London and in the Country, by a Committee of the Fellows +of the Royal College of Physicians in London. Read at the College, +June 25, 1783._] + +Numerous recurring outbreaks took place in Europe and America during +the years 1788-90. One of these, as it occurred in America, is well +described by Dr. John Warren[13] of Boston in a letter to Lettsom. +This letter is dated May 30, 1790, and among other matters of great +interest respecting the disease it is stated that "Our beloved +President Washington is but now on the recovery from a very severe and +dangerous attack of it in that city" (New York). + +[Footnote 13: _Memoirs of the Life and Writings of J. Coakley +Lettsom_, Thomas Joseph Pettigrew, 1817.] + +Webster mentions an epidemic in America in 1790, one in Europe in +1795, and another in Europe in 1797, but there seems to have been no +general epidemic of sufficient importance to attract the attention of +other writers upon the subject until 1798, when the malady again broke +out in Russia and spread over the greater part of Europe, continuing +to prevail in various regions till 1803, when it again appeared in +England, and is described by several writers of that country. + +From 1805 to 1827 influenza prevailed (according to Zuelzer, who tells +us that few years during this interval were free from it) in +frequently-recurring epidemics in Europe and America. Thompson +mentions no visitation in England between 1803 and 1831. + +In the year 1830 began a series of epidemics remarkable for their wide +diffusion and the rapid succession with which they followed one upon +another. The disease began in China; in September it reached the +Indian Archipelago; it swept into Russia, and invaded Moscow in +November; in January, 1831, it was raging in St. Petersburg; March +found it in Warsaw; April in Eastern Prussia and Silesia; in May it +prevailed in Denmark, Finland, and a great part of Germany, and in +{858} the same month it fell upon Paris; in June it affected England +and Sweden; it was still creeping about Middle Europe and lingering in +Great Britain at the end of July; in the early winter it swept +southward into Italy, and westward across the Atlantic to North +America, and was still harassing the inhabitants of certain regions of +the United States in January and February, 1832. Meanwhile it +continued in the East, spreading to Java, Farther India, and the +Indian Archipelago. It continued in Hindostan after it had died out in +Europe. But in January, 1833, it again visited Russia, and rolled +thence southward and eastward over the most of Europe. It is recorded +that by February it had reached Galicia and Eastern Prussia; in March +it was in Prussia, Bohemia, and Warsaw, and had extended to Syria and +Egypt; in April to many parts of Germany and Austria and to France and +Great Britain. Midsummer found the disease yet prevailing in some +districts of Germany and Northern Italy, and in the early autumn it +was in Switzerland and Eastern France; in November it visited Naples. + +Epidemics so frequent, so widespread, and so unsparing of individuals +wherever the disease appeared could not fail to excite a deep and +general interest. From this period the literature of the subject has +been voluminous. + +A brief period of repose ensued. For three years no epidemic occurred +which was of sufficient importance to attract the attention of medical +historians. + +In December, 1837, influenza reappeared, and first, as so often +before, in Russia; Sweden and Denmark were almost simultaneously +affected; in January, 1837, it broke out in London, and rapidly swept +over all England and into France and Germany. In January it appeared +in Berlin, and shortly afterward in Dresden, Munich, and Vienna. The +disease spread by February into Switzerland, and into Spain as far as +Madrid by the end of March. In London almost the whole population was +attacked, and the mortality was enormous. It is stated that the deaths +were quadrupled during the prevalence of the disease. Large +populations suffered most. This epidemic spread into the southern +hemisphere, and prevailed at the same time, and consequently at +exactly the opposite season that it prevailed north of the equator, in +Sydney and at the Cape of Good Hope. + +From 1837 to 1850-51 numerous epidemics of influenza occurred. Few +years were exempt from them. The epidemic of 1847-48 has been +described by many writers, and more particularly, as it occurred in +London, by Peacock[14] with great exactitude. It is estimated that +one-fourth of the entire population of that city were more or less +affected by the disease. The epidemic prevailed in London for six +months, and, although the deaths registered for the entire period as +from influenza amounted to only 1739, it is stated in the report of +the registrar-general that during the six weeks the epidemic was at +its height not less than five thousand persons died, in the +metropolitan districts, in excess of the average mortality of the +period, the excess showing itself in nearly every class of disease, +the local maladies which had been the predominant affections being +doubtless in many cases assigned as the cause of death. This {859} +epidemic affected between one-fourth and one-half of the population of +Paris, and in Geneva the proportion of those attacked was not less +than one-third of the entire population. + +[Footnote 14: _On the Influenza, or Epidemic Catarrhal Fever of +1847-48_, Thomas Berill Peacock. M.D., 1848.] + +More or less widespread epidemics of influenza are recorded as having +occurred in 1857-58 and 1860; in 1864 in Switzerland; in 1867 in Paris +in the spring; and at various times in the United States and Canada. + +A mild epidemic occurred in 1874 in Berlin. + +Influenza prevailed over a wide area in the United States during the +early months of 1879. The characteristics of this visitation have been +well described by Da Costa.[15] + +[Footnote 15: "The Prevailing Epidemic of Influenza--Its +Characteristic Phenomena--Pulmonary, Gastro-intestinal, Cerebral, and +Nervous--Its Wide Distribution, Mortality, and Treatment," _Medical +and Surgical Reporter_, Philadelphia, March 8, 1879.] + +The disease, since the great epidemic of 1847-48, has affected a +smaller proportion of the inhabitants of the localities visited, and +has run a less dangerous course, than in the earlier epidemics. It has +for this reason occupied a less conspicuous place in the medical +literature of recent years. It is nevertheless true that even in the +mildest epidemics, when a relatively small number of persons are +seized and the symptoms are in most cases almost insignificant, cases +do here and there occur which are of a serious or even fatal +character, and that the death-rate from other diseases is for the time +considerably increased. + +Catarrhal affections have often prevailed among the domestic animals +when influenza has been epidemic. Horses, dogs, and cats are subject +to these disorders; neat cattle, goats, and sheep have been less +commonly affected; chickens and pheasants have suffered, and it is +stated by some of the older writers that birds, and particularly the +sparrow, have deserted localities in which influenza was prevailing, +and that migratory birds have taken flight earlier than usual. + +These epizootics have sometimes preceded the appearance of influenza +among men by a period of some weeks or days; in other instances they +have appeared at the same time; and in a widespread outbreak among +horses in the United States in 1872, in which the symptoms and morbid +anatomy, accurately observed, were undoubtedly those of influenza, the +disease did not affect man except to a very limited extent. A want of +fulness of description, and the inaccuracy of diagnosis too common in +the consideration of the general diseases of the lower animals, leave +the precise nature of most of the epizootics described by the earlier +writers doubtful. + +An extensive influenza of moderate intensity prevailed as an +epizootic, chiefly affecting horses, during the latter part of the +summer and the autumn of 1880 in Canada and the United States east of +the Mississippi River. Dogs were also affected, but less generally, +and human beings to a still slighter extent. In several localities +where this invasion was observed by the writer the horses were first +affected, the dogs next, and after the lapse of some weeks, as the +animals were recovering, the disease became epidemic; but those +persons who took care of horses and were much in contact with them +neither suffered earlier nor more severely than others not so exposed. + +ETIOLOGY.--1. Predisposing Influences.--There are no {860} +well-established facts pointing to the existence of individual +peculiarities that can be regarded as predisposing influences. When +the disease appears a large proportion of the population is attacked +without distinction of age, sex, social condition, or occupation. +Previous illness, whether acute or chronic, local or constitutional, +affords no protection. Aged and infirm persons and those of nervous +temperament are peculiarly liable to attack, but the robust possess no +immunity. All races and dwellers in every climate are the victims of +influenza. In a community invaded by the disease females are apt to be +the first attacked, adult males next, and children last. It has been +observed that in some epidemics children are but little liable to +contract the disease. + +An attack confers no exemption from the disease in another epidemic, +and independently of relapses, which are not infrequent, persons have +been known to experience a second attack during the prevalence of the +same epidemic. + +Persons dwelling in overcrowded and ill-ventilated habitations and in +low, damp and unhealthy situations have, in certain epidemics, +especially suffered, and the increase of deaths by influenza is +proportionately much greater in districts in which there is ordinarily +a high mortality than in healthier places. + +Influenza appears at all seasons of the year and affects the +inhabitants of every latitude. It has no connection with known +atmospheric conditions. Many of the earlier writers sought to +establish a relation between low temperatures and sudden variations of +temperature and influenza, and by reason of the confusion among the +people between these diseases and common "colds" there has always +existed an opinion that such a relation obtains. There is, however, no +evidence to sustain this view; neither low temperature nor abrupt +changes give rise to the affection. It has prevailed in hot and dry +seasons, in the West Indies, on the coast of Java, in India, in Egypt, +at the Cape of Good Hope, on the Riviera in summer. + +The condition of the air as regards moisture, or dryness, does not +influence the spread of the disease. It has occurred at sea, on low +sea-coasts, and in the dryest climates, as, for example, in Upper +Egypt. + +Its spread is not much influenced by local winds. It does not travel +with the same velocity, and even sometimes advances against them. In +several well-authenticated instances a dense and foul fog has preceded +and attended the local outbreak of epidemics. The much greater number +of epidemics that have occurred altogether without such manifestations +make it in a high degree probable that this has been a coincidence. +Ozone in large quantities artificially produced may give rise to the +symptoms of ordinary catarrh, but it is not a cause of influenza. The +disease is not in any way connected with the condition of the soil, +elevation, volcanic eruption, or any other local cause. The history of +every epidemic may be adduced in proof of this statement. + +Before taking up the consideration of the exciting causes of +influenza, it is important to review the known facts concerning the +march of epidemics and the spread of the disease in affected +localities. It has prevailed with greater or less frequency in almost +every region of the globe. Epidemics recur at irregular periods. It +was at one time supposed that the course of the disease was cyclical, +with a return at intervals of about one hundred years. This view was +long ago proved to be unfounded. About every {861} twenty-five or +thirty-five years great epidemics have swept over vast areas of the +globe, and influenza may be said to be, at such times, pandemic. +Less-widely extended epidemics have taken place with greater or less +frequency in the intervals between the great outbreaks. But it is not +possible to establish anything like a regular periodicity in the +returns of the disease. + +It has been supposed in some instances to prevail within restricted +localities, as, for example, in a single city. Such local epidemics +are without doubt due to local causes, and are of the nature of simple +ordinary catarrhal fever, rather than true influenza. + +The epidemics have extended over great areas, usually in a direction +from the east or north-east toward the west and south. At other times +they take the opposite course, and in some years they have appeared to +radiate in various directions from several centres. It is in +consequence of these facts that two views have arisen concerning the +origin of the affection. The first of these is, that each epidemic +starts out from some single unknown source, and spreads thence from +point to point, invading more distant localities successfully as it +advances, until at length it dies out in regions remote from the +starting-point. This opinion is in accord with the popular belief. +Thus, the Italians have called it the German disease; the Germans, the +Russian pest; the Russians, the Chinese catarrh. The geographical +relation of these nations indicates the usual track of the great +epidemics, as shown in the foregoing historical sketch. The other +opinion is, that it arises not from some single particular place, but +that it may start anywhere, and that widespread epidemics are due to +the successive outbreaks of the disease at many distinct points of +origin. + +The evidence that the great epidemics of influenza are due to some +general and pandemic influence is conclusive. The point of origin of +the great epidemics has not yet been indicated with precision, and +must remain beyond conjecture until further facts bearing upon the +question of their source are brought to light. When it has prevailed +over a large portion of the earth's surface its progress from place to +place has usually been rapid. In this respect, however, the epidemics +show a great diversity. It sometimes travels exceedingly slowly. It is +said to have overrun Europe in six weeks, and it has again taken six +months to do so. It sometimes attacks places widely remote from each +other within short intervals of time, and it has appeared at the same +time in different quarters of the globe. It does not follow the great +lines of travel and commercial intercourse. + +When influenza enters a city it continues to prevail, as a rule, from +four weeks to two months, but exceptionally it remains a longer time; +for example, the epidemic of 1831 was prevalent in Paris for the +greater part of the year. It in all instances finally disappears, and +sporadic cases do not occur in the intervals between the epidemics. + +In rare instances the epidemics are heralded by scattered cases. But +as a rule this disease attacks simultaneously great numbers of the +inhabitants of affected districts, so that, when the epidemic is +severe, the sick are in a short time to be counted by thousands and +business is paralyzed as by a blow. Epidemics rapidly reach their +height, and subside almost as suddenly as they began. In a large city +the disease frequently, perhaps always, makes its appearance nearly at +the same time in several {862} different localities, affecting certain +streets and quarters solely or more generally than others for a time, +and spreading thus from several centres through the entire community. +Large towns and cities are generally affected earlier than the +villages around them, and the latter, though closely adjacent, +sometimes escape for weeks. The crews of ships upon the high seas, not +sailing from an infected port, are said to have suffered from the +seizure, and epidemics have many times crossed the Atlantic from the +Old World to the New, and more than once in the opposite direction. + +2. The Exciting Cause.--Large as has been the place in medical +literature occupied by the histories of epidemics of influenza, the +nature of the "epidemic influence" which gives rise to the disease is +still unknown. + +The question of the contagiousness of influenza is one of grave +interest, and has been the subject of much controversy. The great +rapidity of the spread of epidemics, the vast area they overrun, the +fact that they do not follow the lines of human intercourse, the +suddenness with which great numbers of the inhabitants of an invaded +district or city are seized, the fact that the most complete seclusion +from intercourse with affected persons, or even the shutting up of +houses, affords in most instances no protection whatever,--all go to +show that the disease spreads, in the main, independently of direct +contact. This opinion has been almost universally entertained. There +is evidence, however, to show that the disease is to some extent +contagious; and so convincing have the facts bearing upon this point +appeared to some that they have believed it to be propagated entirely +by human intercourse. Haygarth[16] declares, as the result of his +observations during the epidemics of 1775 and 1782, that the influenza +spreads "by the contagion of patients in the distemper;" and +Falconer,[17] writing of the epidemic of 1803, says, "I have no doubt +that it is contagious in the strictest sense of the word." Watson[18] +regards the instances in which the complaint has first broken out in +those particular houses of a town at which travellers have arrived +from infected places as too numerous to be attributed to mere chance. +Very often those dwelling near the invalids are attacked next in the +order of time, and when the disease affects a household all do not +usually manifest the symptoms at the same time, but one member after +another is stricken down with it. + +[Footnote 16: John Haygarth, M.D., F.R.S., _On the Manner in which the +Influenza of 1775 and 1782 spread by Contagion in Chester and its +Neighborhood._] + +[Footnote 17: William Falconer, M.D., F.R.S., _An Account of the +Epidemic Catarrhal Fever, commonly called the Influenza, as it +appeared at Bath in the Winter and Spring of the Year 1803_, Bath, +1803.] + +[Footnote 18: _Principles and Practice of Medicine_.] + +In a few rare cases the isolation or seclusion of a community has +appeared to give protection, as in cloisters, prisons, garrisons, and +the like; at all events, there are instances on record where +segregated communities of this kind have escaped attack. + +The following observation, conducted under unusual circumstances, +establishes the fact that influenza may be brought from an infected +city in such a way as to give rise to a localized outbreak in a remote +community. Drs. Guiteras and White[19] narrate that, influenza +prevailing in Europe, and particularly in Paris and London, an +American gentleman in bad health contracted the disease in London, +improved, suffered a relapse {863} shortly afterward in Paris, and +died there at the end of December, 1879. His body was embalmed and +sent home. Following the exposure of the remains of this person to the +view of his family in Philadelphia there was an outbreak of influenza +with characteristic symptoms, which affected, in the first place, +members of that family; afterward, friends living in close intercourse +with them; next, the medical attendant of some of them; and finally, +the housekeeper and a patient or two of one of the physicians who +wrote the paper, the whole number affected in Philadelphia being +eighteen at the time of the publication of the account. Subsequently +two or three other cases were developed, but the disease did not +extend beyond the immediate circle of those in direct communication +with the invalids. + +[Footnote 19: John Guiteras, M.D., and J. W. White, M.D., "A +Contribution to the History of Influenza, being a Study of a Series of +Cases," _Philadelphia Medical Times_, April 10, 1880.] + +It was at one time thought that influenza developed at once, without a +period of incubation, persons in perfect health being struck down with +it as by lightning-stroke. It is, however, now known that a period of +incubation, varying from a few hours to several days, and usually +without subjective symptoms, exists. Many instances are recorded in +which persons coming into an infected city have remained well for one, +two, or three days, but have eventually shared the sufferings of those +into whose midst they have come. There are cases also in which the +period of incubation could not have been less than two or three weeks. + +There is no sufficient evidence of a causal relation between influenza +and any other epidemic disease. The statement that other prevalent +diseases abate in frequency and intensity upon its outbreak is not +sustained by well-observed facts. Graves[20] holds that those +suffering with acute diseases are less liable during the febrile +stage, but that they are attacked as convalescence sets in. + +[Footnote 20: _Clinical Medicine_.] + +The facts in reference to the spread of epidemics of influenza and the +course of the disease in infected localities are comprehensible upon +no other theory than that of a specific infecting principle as its +exciting cause. What this principle may be is not yet known; where it +originates is equally unknown; and our knowledge of the influences +that from time to time call it into activity and send it forth in +definite directions over the earth is no less negative. + +So general a disease can only be disseminated by the most general +medium, the atmosphere, and its exciting cause must be capable of +reproducing itself in that medium, otherwise it would be lost by +dispersion in traversing distances measured by the boundaries of +continents and oceans. The rapid diffusion of influenza, sweeping over +continents in a few weeks at one time, its slow migration, creeping +about a city and its environs for months, at another, are to be most +easily explained upon the theory of a living miasm capable of being +transmitted by the air, and possessing at the same time an independent +existence. Such an entity would find certain localities more favorable +to its growth, reproduction, and prolonged existence than others. From +this point of view influenza is a miasmatic disease. The infecting +principle of this disease is also, to a slight extent, capable of +being reproduced in or about the human body and transmitted by +personal intercourse, as well as conveyed from place to place by the +persons or clothing of those affected or those travelling from +localities in which the disease prevails. We are thus led to the +conclusion that it is also contagious, though feebly so. + +{864} CLINICAL HISTORY.--Influenza, in individual cases, presents the +greatest variation as regards intensity, from the most trifling +indisposition to an illness of the gravest kind, terminating in death. +These variations are dependent upon--1st, the previous health of the +individual, his age, and the power of resisting depressing influences +which he possesses; 2d, the energy and the amount of the specific +cause of the disease to which he has been exposed--in other words, the +dose of the fever-producing poison; and 3d, the character of the +prevailing epidemic. + +It is important to observe that cases of very great severity are +occasionally encountered during the prevalence of mild epidemics. In +every epidemic, on the contrary, a considerable part of the community +suffers from influenza in the mildest, or what has been called the +rudimentary, form. This is characterized by general malaise, an easily +oncoming weariness upon bodily and mental effort, a disinclination for +business, some inability to fix the attention, and slight mental +confusion; to these nervous disturbances are added catarrhal symptoms, +as coryza, sore throat, a tickling cough, and the like; but the +indisposition is subfebrile--it does not amount to a fully-developed +fever. Other cases present the symptoms of an ordinary attack of acute +coryza, laryngitis, bronchitis, pharyngitis, with unusual +constitutional disturbance, distressing headache, and pains in the +back and limbs. The fever in this class of cases does not range high, +yet the patients are ill enough to betake themselves to bed. + +In severe cases the onset is usually abrupt. The attack begins with +shivering or a chill, or with fits of chilliness alternating with +heat. Fever is rapidly established. It is usually moderate; sometimes +it reaches a high grade. It shows a tendency to morning remissions. +Sensations of chilliness occur; they are called forth by slight +changes in the external temperature. They are often followed by +flushes of heat, and are, in many cases, attended by annoying sweats. +The febrile outbreak is sometimes preceded by intense frontal +headache, with pain in the orbits and at the root of the nose. In +other cases these pains quickly follow the chill. Sneezing, redness of +the eyes and edges of the nostrils, a more or less abundant thin +discharge from the nose, and lachrymation, now occur. In some +instances there is bleeding from the nose. The throat becomes sore; +there is a tickling sensation in the upper air-passages; a dry cough +sets in, attended by more or less hoarseness and shortness of breath. +The cough is paroxysmal, hard, distressing. It sometimes causes +vomiting, like that which occurs in the paroxysms of whooping cough. +Chest-pains, stitches in the side, frequent sneezing, loss of the +sense of smell and of taste, attend the development of the general +catarrhal manifestations. + +The fever is attended by great depression, pains in the limbs, loss of +appetite, thirst, constipation, and diminished secretion of urine. The +pulse is full, but, as a rule, only moderately increased in frequency. +There is in many cases slight, or even decided, blueness of the lips +and finger-tips. The patient is distressed by restlessness and want of +sleep. At the end of four or five days the febrile symptoms decline, +at times gradually, oftener rapidly, with copious sweats or +spontaneous flux from the bowels. The fever continues, however, when +severe complications have taken place, ten or twelve days. The +defervescence is marked by {865} an increased flow of sedimentary +urine and considerable amelioration of the subjective symptoms. The +catarrhal symptoms outlast the fever two or three days, but cough and +expectoration may not disappear for some time. + +With these symptoms are associated the evidences of functional +disturbance of the nervous system. There is remarkable nervous +depression; loss of strength and lowness of spirits are combined with +mental weakness, or even stupor and delirium. In some cases slight +convulsions take place. Cutaneous hyperaesthesia occasionally occurs, +and areas of burning pain in the skin are to be met with. Neuralgia, +muscle-pain, and aching referred to the bones are very common and +often severe. + +In other cases abdominal symptoms are prominent, while those referable +to the head and chest are less urgent. The disease assumes the guise +of a more or less severe catarrh of the gastro-enteric mucous +membrane, with disturbance of the functions of the liver. The fever +and the peculiar nervous depression are, however, the same. Cases +likewise present themselves in which but little of the usual tendency +to localization of the catarrhal processes is to be observed; there is +fever of varying intensity, with great depression, and simultaneous +and equal implication of the head and the organs of the chest and +abdomen. + +Many writers have sought to arrange the foregoing different forms of +influenza in definite categories. It would be a useless task to +reproduce their views upon the subject, or even to enumerate the +varieties that have been described. In practice, the various described +types merge so gradually into each other, and are so modified by the +individual peculiarities of the sick, and by the complications which +arise in the course of the attack in consequence of such peculiarities +or of previously existing diseases or tendencies to special forms of +disease, that, in point of fact, particular cases cannot usually be +referred to theoretical categories. Hysterical persons and those of a +nervous constitution are prone to suffer especially from the peculiar +nervous symptoms of influenza. The disease is also modified by the age +of the subject of the attack; children manifest in a high degree the +signs of cerebral congestion, while old persons are subject in a +peculiar manner to dangerous pulmonary complications, and those of a +gouty or rheumatic constitution suffer more than others from muscular +pains. + +The duration of the mildest form of influenza is from two to three +days; in well-developed cases without complications convalescence sets +in between the fourth and tenth days; while severe cases with +complications last much longer, several weeks often elapsing before +recovery is complete. + +SYMPTOMATOLOGY.--ANALYSIS OF THE SYMPTOMS.--For the purpose of +separate consideration it is convenient to take up the symptoms +belonging to the fever first, then those of the special catarrh, and +finally those more particularly referable to the nervous system; but +we encounter in the present state of our knowledge of the pathology of +influenza--or our ignorance of its pathology--no little difficulty in +deciding under which of these headings particular symptoms are +properly to be classed, by reason of the close interdependence of the +chief processes of the disease and the anomalies of its phenomena +viewed as a whole. + +The Fever.--The fever is of the sub-continuous or remittent type, +{866} but its range is very irregular. Irregularity of temperature is +characteristic of influenza and may assume diagnostic importance. + +The intensity of the fever is variable. As a rule, it is moderate or +slight; occasionally it is severe. I observed in several cases during +the epidemic of 1879 in Philadelphia an evening temperature of only 39 +degrees C. (102.2 degrees F.). Da Costa in the same outbreak found the +febrile movement not high; the highest temperature he observed was 40 +degrees C. (104 degrees F.). Biermer found a temperature of over 39 +degrees C. in moderate cases of catarrhal fever, and does not doubt +that under certain transient conditions the temperature may reach the +height of that of pneumonia or typhus. In weakly persons and the aged +the fever is adynamic. + +The pulse has no constant characters. Its frequency is moderately +increased; it is apt to be less forcible than in health, is generally +compressible, sometimes full, often irregular, changing in character +in the course of a few hours. + +The urine is usually diminished; sometimes its secretion is +temporarily suppressed; as a rule, it shows little change, and is +rarely, as in other fevers, concentrated and high-colored. It deposits +on cooling a sediment of urates, which toward the close of the fever +is often very abundant. The defervescence is in many instances +attended by a copious secretion of urine. Albumen is not present +except as a result of some complication. + +At first the skin is hot and dry; later, frequent sweats occur; +sweating generally attends the febrile remissions and the +defervescence not rarely sets in with copious, acid, ill-smelling +sweats. In some cases a tendency to sweat shows itself early and +continuous throughout the attack. Sudamina occur in great numbers. + +The face is often flushed, and irregular mottlings of the skin, +especially upon the neck and chest, have been frequent in some of the +epidemics. An outbreak of herpes about the lips is occasionally seen. + +Disturbances of the digestive tract are more or less prominent in +almost all cases. Only in a rudimentary and sub-febrile form are they +absent. In many cases they are such as are usually seen in febrile +disorders--namely, loss of appetite, thirst, impaired taste, pasty +tongue, tenderness in the epigastrium, and constipation. Nausea and +vomiting sometimes usher in the attack. In other cases (the so-called +abdominal form) all the above symptoms are more severe, and diarrhoea, +colicky pains, and vomiting are superadded. In certain epidemics the +intestinal catarrh has shown a tendency to run into dysentery. + +The expression of the countenance is changed, in part by the +appearance characterizing an ordinary attack of coryza of considerable +or great severity, and in part by anxiety and depression. It is pale. +Where the pulmonary catarrh is excessive and dyspnoea great the lips +become bluish. The facies sometimes suggests that of typhoid fever. + +The Catarrh.--A more or less extensive hyperaemia of the mucous +membrane of the respiratory tract is invariably present, and may be +said to characterize the disease. + +There is cold in the head, more severe in most cases than ordinary +simple coryza. The eyelids are swollen and reddened, there is +lachrymation, sneezing is frequent, and the discharge from the nose is +abundant. Epistaxis is not rare. Sore throat, with tickling sensations +and difficulty {867} in swallowing, is due to inflammation of the +pharynx and neighboring parts. In many instances the catarrhal +symptoms are due to a pharyngitis and tonsillitis only, the lower +air-passages escaping. Hoarseness is common. + +Cough is a prominent symptom. It is apt to be frequent and +distressing--sometimes paroxysmal from the beginning of the sickness, +almost always so at some period of its course. Its spasmodic character +in some of the older epidemics led to the confounding of epidemic +catarrhal fever with whooping cough. It is apt to be worse toward +evening and at night, but the sick are often tormented day and night +by the loud racking cough. It often leads to vomiting, and by its +violence and persistence gives rise to pain and soreness in the +muscles of respiration (myalgia), and occasionally to hernia. It is at +first dry or attended with a scanty muco-serous expectoration; later +on the sputa become opaque and muco-purulent, and in consumptive or +full-blooded persons or those having mitral disease they are sometimes +streaked or mingled with blood. Toward the close of the attack the +cough becomes less urgent and loses its spasmodic character. In some +epidemics cough is not a prominent symptom, and a few cases are +encountered in most epidemics in which well-developed influenza runs +its course without unusual, peculiar, or excessive cough. If the cough +be due to bronchitis, we find on auscultation the physical signs of +that affection. They are of course wanting when it is due simply to +laryngo-tracheal irritation. Hence we frequently detect sonorous and +sibillant or mucous and subcrepitant rales upon both sides of the +chest in the course of the attack, as in non-epidemic acute +bronchitis; and, on the other hand, cases occur where the auscultatory +signs are but little or not at all altered from those of health. It is +scarcely necessary to add that there are no special physical signs +that can be regarded as diagnostic of influenza. + +Many patients suffer from dyspnoea. Although due in some instances to +complications, it occurs with remarkable frequency in those in whom +none of the objective signs of any pulmonary lesion can be discovered. +It is here of nervous origin. Graves assumes a direct disturbance in +the function of the vagus as its cause. This view is sustained by the +observation that the dyspnoea is now and then intermittent, or shows +rhythmically recurring remissions, which are unattended by alteration +of the physical signs. To Biermer it appears more probable that the +congestions so common in influenza, not attended by marked physical +signs until they lead to oedema, are to be regarded as the cause of +the dyspnoea. It varies greatly in intensity. In many patients it goes +on to marked oppression, great shortness of breath, precordial pain, +and the like. In certain epidemics orthopnoea and suffocative attacks +were very common. Stitches in the side and pain under the sternum are +observed without appreciable physical signs. + +Symptoms Referable to the Nervous System.--Great prostration of +muscular strength is a very early symptom, and constitutes, in most +epidemics, one of the remarkable features of the disease. Patients +from the onset feel extremely weak, and are exhausted by the slightest +bodily effort. The ordinary strength is not regained until +convalescence is far advanced. + +Headache is a constant symptom. Severe frontal pains are scarcely +{868} ever absent. They extend across the brow and deeply about the +orbits and at the root of the nose, having their seat in the +Schneiderian mucous membrane and its prolongations lining the frontal +sinuses and the nasal ducts. Sometimes the pain is referred also to +the region of the antrum of Highmore and to the Eustachian tube and +the middle ear. It occasionally extends over the whole head. Cutaneous +hyperaesthesia of the head and neck and stiffness of the neck-muscles +are also met with. The headache is often most intense; it lasts +commonly till the end of the attack, and may even outlast it. It +increases in severity with the fever and mental agitation toward +evening. The occurrence of epistaxis affords some relief. + +Among the more constant symptoms of influenza are very severe pains in +the limbs. Patients experience sensations of soreness and bruising, +such as follow the most severe and unaccustomed muscular effort. Dull, +tearing, and burning pains are felt sometimes in particular muscles or +tendons; sometimes they are diffused over the whole body. Distressing +pains of a dragging or boring character in the loins and calves of the +legs are complained of. These pains are neither relieved nor +aggravated by gentle movement or by moderate pressure. A sense of +contraction of the chest and precordial distress also occurs, and +stitches in the side (pleurodynia), substernal pain, and pains in the +throat and nape of the neck are common. When the attack is severe the +patient is usually restless, sleepless, and anxious. Dizziness and a +tendency to faint occur on rising, particularly in women. Mild +delirium is not uncommon, but the more intense forms are occasionally +observed. Active delirium was thought to be a mortal symptom in some +of the older epidemics. + +The inability to sleep bears no direct relation to the intensity of +the fever. It is seen in some cases where fever is slight or even +absent. + +Somnolent states also occur. Great hebetude and torpor have marked +some epidemics. That of 1712 was called the sleepy sickness, by reason +of the prevalence of these symptoms. + +In grave cases painful muscle-cramps, subsultus tendinum, twitchings +of particular muscles, and tremblings of the hands occur. + +The mental power is enfeebled, and the acuteness of the special senses +is diminished. + +COMPLICATIONS AND SEQUELS.--The most important complications of +influenza are inflammatory diseases of the lungs. The hyperaemia and +intense bronchitis already described as occurring in the severer cases +cannot properly be looked upon as complications. They constitute +rather essential processes of particular forms of the disease. But +capillary bronchitis, catarrhal pneumonia, and less frequently +croupous pneumonia, arise as complications in the course of the +disease. Satisfactory statistics are wanting, but Biermer estimates +that from 5 to 10 per cent. of the whole number of patients suffer +from inflammatory lung-complications, and holds that the bloodletting +so frequently practised by the older physicians was due to a desire to +combat inflammation. The comparative frequency of chest complications +in different epidemics varies greatly, but the estimate of Biermer may +be accepted as an approximate average. + +Owing to the masking of the physical signs in the early stages and the +pre-existing pulmonary oedema, it is not always easy to recognize at +once {869} the occurrence of capillary bronchitis. This complication +is attended with increasing dyspnoea, decided lividity of the face and +extremities, and great prostration. Crepitant and subcrepitant rales +at the lower portions of the posterior dorsal regions, rapidly +spreading to all parts of the chest, without dulness at first and with +increased resonance later, instead of the signs of consolidation which +are met with in pneumonia, are the signs which attend its appearance. + +Catarrhal pneumonia occurs insidiously, with gradual intensification +of the bronchitic symptoms about the fourth or fifth day, but it may +set in as early as the second day, or much later, during +convalescence. It is, as a rule, developed without chill or great +increase in the fever. + +Old persons and those of feeble constitutions are most liable to the +foregoing complications. + +Lobar pneumonia is less common. It is a late complication, occurring +toward the close of the attack or even when the patient is beginning +to get about. It is easily recognized, and differs in no wise from +acute lobar pneumonia occurring under other circumstances. + +In October, 1880, influenza being prevalent in Philadelphia, both +epizootic and epidemic, but very mild both among horses and men, I +attended a medical student who, having had what he regarded as a cold +for about a week, had kept at his work without treatment, until, upon +the occurrence of a chill followed by grave thoracic symptoms, he was +obliged to betake himself to bed. I first saw him the following day in +the hospital of the Jefferson College. There were the symptoms of +acute lobar pneumonia, with the signs of extensive consolidation of +the left lung and pleurisy of the right side. Moreover, there were +delirium and jaundice. The urine was non-albuminous. The next evening +he died. At the same time many members of the class suffered from +influenza, and a careful inquiry into the history of the case of this +young gentleman satisfied me that the pneumonia had arisen as a +complication in a neglected and moderate severe catarrhal fever. Until +the eighth day before his death he was in excellent health. No +examination of the body was permitted. + +Graves[21] thought that a kind of paralysis of the lungs, with great +oedema, takes place in some cases, and attributed it to an affection +of the vagus. It was his conviction "that the poison which produced +influenza acted on the nervous system in general, and on the pulmonary +nerves in particular, in such a way as to produce symptoms of +bronchial irritation and dyspnoea, to which bronchial congestion and +inflammation were often superadded." + +[Footnote 21: _Annals of Influenza_.] + +It is certain that localized collapse of the lung often occurs. White +and Guiteras attributed the consolidations of the lung to congestive +collapse due to enlargement of the tracheal and bronchial glands and +"disturbance of the great nervous tract about the root of the lung." +They were enabled to satisfy themselves of the existence of glandular +enlargement--adenopathie bronchique--in nine of their eighteen cases +by percussion practised in the method of M. Geneau de Mussy,[22] who +was the first to call attention to the importance of percussing the +spinous processes of the vertebrae over the course of the trachea. +Following this line in the healthy subject, a distinct tubular +(high-pitched and slightly {870} tympanitic) sound is elicited by +percussion down to the point of bifurcation of the trachea on the +level of the fourth dorsal vertebra. Opposite the fifth and downward +we get the lower-pitched pulmonary resonance. When the tracheal and +bronchial glands are enlarged, the tubular sound over the upper dorsal +vertebrae is replaced by dulness, which may contrast sharply, above +with the tracheal, and below with the vesicular resonance. + +[Footnote 22: _Chirurgie medicale_, Paris, 1874.] + +Some well-recognized peculiarities of the so-called pneumonias of +influenza give weight to the view that the consolidations are not, in +the beginning, pneumonic at all. Thus, we have at first weakness of +the vesicular murmur, then its absence; the respiration soon becomes +bronchial, without being preceded by dulness or the crepitant rale; +the extension of those consolidations from one part of the lung to +another is very irregular; the process is more apt to involve both +sides than one; the disappearance of the consolidation is frequently +very rapid. + +The relations of cause and effect between collapse and catarrhal +pneumonia are so close that it is not difficult to see how the +condition spoken of may lead to secondary lobular or catarrhal +pneumonia. In truth, this is a frequent result of collapse from any +cause. + +White and Guiteras do not adduce any post-mortem facts in support of +their theory. Peacock, however, observed in the epidemic of 1847 +softening and enlargement of the bronchial glands in several cases, +and in one instance where there was no antecedent disease of the +lungs, and where the physical signs corresponded to some extent with +those of the cases upon which White and Guiteras base their views. + +Gangrene of the lungs must be named as one of the less common +complications. + +These complications are the chief cause of the danger of influenza in +the aged, the debilitated, and those suffering from previous disease +of the thoracic organs. + +Pleurisy is rare except where there is coexisting inflammation of the +lungs. It may be associated with pericarditis. In old persons serous +effusions into the pleural sac are now and then encountered. + +Troublesome laryngitis and chronic bronchitis may follow the attack. +In consequence of the extension of the catarrhal processes along the +Eustachian tube an actual inflammation of the middle ear is, in rare +instances, set up. Parotitis with salivation sometimes occurs, +likewise aphthous inflammations of the mouth. + +Herpes labialis occasionally occurs toward the end of the attack; it +is then a favorable indication. + +Phthisis may be developed in consequence of an attack of influenza, +and if phthisis be already established it is apt to run a more rapid +course. Emphysematous affections are aggravated; diseases of the heart +are unfavorably influenced; chronic nervous affections are made worse, +and, in particular, neuralgias are aggravated. Old neuralgias, that +have long ceased to give trouble, occasionally reappear during the +convalescence. + +Persons subject to latent or chronic Bright's disease are especially +liable to the more serious manifestations of influenza. The fatal +termination of such cases not unfrequently occurs in consequence of an +attack. + +Many of the older observers speak of the intermittent character of +{871} influenza in certain epidemics, and its tendency to run into +intermittents, particularly of a certain type, during convalescence. +This has not been observed in the outbreaks of later years, and it is +probable that in such instances an endemic malaria has modified the +epidemic catarrhal fever, or the former has broken out as the latter +passed away. + +Pregnant women are in danger of aborting. + +PATHOLOGY.--Our knowledge of the pathology of influenza is as yet very +imperfect. Biermer has described it as the sum of a series of +catarrhal manifestations developed under a common epidemic influence. +The close association of the various local affections arises from +their almost simultaneous occurrence as results of primary +pathological processes common to them all. Each of the three groups of +symptoms which make up the clinical picture of the disease--namely, +the fever, the catarrh, and the symptoms referable to the nervous +system--constitutes a distinct factor of influenza, and is a direct +outcome of the action of the infecting principle. There is no constant +interdependence among these groups, either in the order of their +succession or in their intensity. Thus, while all three groups are +commonly present from the beginning of the attack, any one of them may +be the first to appear or have an intensity out of all proportion to +each of the others. The fever is not a result of the catarrhal +inflammation, nor are the nervous symptoms the result of both the +others. They all spring directly from the action of the same cause. + +This view is at variance with the opinion--based upon the fact that +ordinary acute local inflammatory diseases, tonsillitis, bronchitis, +and the like, sometimes run their course in a similar way to +influenza, with fever, nervous depression, and a serious sense of +illness--that influenza is a simple epidemic catarrhal inflammation. + +The sudden onset of influenza, its not infrequent abrupt termination, +which suggests crisis, its unsparing seizure of great numbers of the +population, the severity of the nervous symptoms, and the amount of +laryngo-bronchial irritation, often out of measure with the lesions of +the mucous membranes,--all point to the action of a morbid agent +affecting the body at large. The severity of the symptoms also, in +many cases, is much greater than in similar acute non-specific local +affections, while the complications, and in particular the +recrudescence of fading neuralgias and the tendency to abortion, and +the sequels, as cough, weakness, headaches, flying pains, which often +remain long after convalescence, are evidences of its belonging to the +group of infectious diseases rather than to that of simple acute +inflammatory diseases. + +In conclusion, it must be urged that the similarity of the symptoms in +many epidemics, occurring during the course of several centuries and +under different social conditions, and even different degrees of +civilization, forcibly demonstrates the specific and definite +character of the causes which give rise to influenza. + +Very little light is thrown upon the pathology of the disease by the +anatomical changes found after death. Uncomplicated influenza is +rarely fatal. As a rule, the unfavorable termination is due to lung +complications. The essential lesions are congestion and catarrhal +swelling of the mucous membrane of the upper air-passages and the +bronchial tubes. These changes may be restricted, in the lungs, to the +trachea and larger {872} bronchi, or they may extend to the finest +twigs. They may amount to great thickening and deep capillary +injections of the mucous lining of the tubes, which contain clear, +frothy mucus or thick, viscid masses of muco-purulent secretion +unmixed with air. + +More or less congestion of the gastric mucous membrane, and more +rarely of that of the intestine, is also met with. The solitary and +agminate glands of the intestine are not affected, save as the result +of special complications. A few observations relate to the finding of +enlarged and softened bronchial glands. More extended researches are +needed, not only upon this point, but also in the whole domain of the +pathological anatomy of the disease. + +Hyperaemia, oedema, hypostatic congestions, splenization, catarrhal +pneumonia, and hepatization affect the lung-tissue in cases fatal by +the complications which are associated with such changes. The +tissue-changes of diseases existing prior to the attack of influenza, +such as old consolidations, tubercle, brown induration, emphysema, and +so forth, are of course frequently discovered. + +DIAGNOSIS.--The discrimination of influenza from other affections +having some points of resemblance to it is, under ordinary +circumstances, unattended with difficulty. The march of the epidemic, +the number of persons attacked, the prominence of the nervous +symptoms, the rapidly developed debility, and the character of the +cough, usually severe out of proportion to the physical signs, +distinguish it from all other epidemic diseases. + +It is to be differentiated from non-specific catarrhal affections +attended by fever, malaise, weakness, severe headache, and pain in the +extremities by a due regard to the causative relations of the two +affections. Simple catarrhs not rarely present the group of symptoms +which characterize epidemic catarrhal fever, but they occur almost +constantly as the result of great and sudden changes in the weather, +and are therefore met with in greatest frequency in bad seasons, and +are particularly common at the end of winter and in the spring. +Influenza is not in any way dependent upon the vicissitudes of the +seasons, and may occur, as has been shown, at all times of the year, +in wet or dry, mild or cold seasons equally, and in every variety of +climate. It is of course diagnosticated without difficulty from the +sporadic catarrhal fevers, which lack the characteristic depression, +neuralgic and rheumatoid pains, the irritative cough, dyspnoea, and so +on. + +Cases of influenza are met with that bear a strong resemblance to +beginning enteric fever. The malaise, headache, obtunded hearing, +mental depression, high fever, coated tongue, tender belly, diarrhoea, +are symptoms to be observed in both affections. But influenza lacks +the temperature curve, the splenic enlargement, and the eruption of +enteric fever, and the progress of the disease will in a few days +clear up the most doubtful case. + +PROGNOSIS AND MORTALITY.--Death is rare in uncomplicated cases. The +very young bear influenza badly; the old bear it more badly still. +Nevertheless, children have in some epidemics enjoyed a considerable +proportionate immunity. Healthy persons in the middle periods of life +bear it well. Certain pre-existing diseases modify its course +unfavorably; among these are chronic bronchitis, emphysema, fatty +heart, and Bright's disease. {873} The debility of advanced phthisis +and other exhausting diseases renders influenza dangerous. Death takes +place, in by far the greater number of cases, as the result of the +complication of the attack, either by some pre-existing affection or +by an acute disease arising in its course. The commonest of the latter +are inflammations of the parenchyma of the lungs. + +Patients presenting very severe symptoms generally recover if they be +not the subjects of complicating maladies or very young or very old. + +Relapses are not uncommon; independently of relapses, second attacks +have been known to occur during the continuance of an epidemic; it is +often the case that an individual in the course of his life passes +through several epidemics of influenza, and is the subject of the +disease in each of them. + +The prognosis is greatly modified by the character of the prevailing +epidemic. In some epidemics the deaths are few, and the mortality from +other diseases does not appear to be greatly augmented. In others many +die of the epidemic disease, and the death-rate of certain endemic +affections is much increased. In some of the older epidemics the high +mortality was doubtless due to injudicious measures of treatment, +among which bloodletting and other depressing agencies were +conspicuous. Some of the older accounts also warrant the suspicion +that a coexisting typhus had to do with the high death-rate. It is +estimated that in the epidemic of 1837, which was a very severe one, 2 +per cent. of those attacked died. The proportion of fatal cases in +particular epidemics varies in different countries, and even in +different quarters of the same city. + +TREATMENT.--Efficient measures of prophylaxis are as yet unknown. +Unfavorable hygienic surroundings, overcrowding, a damp, unhealthy +locality, appear to increase the prevalence and severity of influenza. +The opposite conditions of living do not, however, secure immunity +from the attack. During an epidemic aged persons, those enfeebled by +chronic diseases, and in particular those subject to chronic +bronchitis, consumption, emphysema, fatty heart, and Bright's disease +should be cared for with unusual diligence and solicitude, since they +constitute the classes most prone to the graver complications of the +disease, and from which its fatal cases are almost wholly derived. +Such individuals should be warmly clad; they should shun, so far as +possible, the vicissitudes of the weather, even, if practicable, +keeping within warmed and well-ventilated apartments; they should +exercise unusual prudence in diet and lead a carefully regulated life, +with long hours of sleep. It is true that these measures are not +preventive of the attack. Families not quitting the house, living in +the greatest seclusion, even the bedridden, do not always, or even as +a rule, escape. Yet it has frequently been observed that those whose +occupations are carried on in the open air are attacked earliest and +in greatest numbers. On the other hand, in rare instances, persons +isolated from the community with strictness--in prisons, cloisters, +hospitals--have remained free from the disease prevailing around them. +It therefore appears probable that, under certain favorable +circumstances not as yet perfectly understood, the avoidance of the +open air and of the direct influences of the weather may confer some +degree of immunity from the attack, and it is desirable that the class +of persons most liable to the graver consequences of the disease +should avail themselves of even the most uncertain precautions. + +{874} The treatment of influenza is expectant and supporting. Not only +is the epidemic self-limiting, tending to exhaust the susceptibility +of a community, in most instances, in the space of a few weeks, but +the attack is also of definite duration, and the perturbations set up +by the action of the influenza-poison upon the individual subside +spontaneously in three or four, or at most ten or twelve, days. The +susceptibility of the individual is also, for the time being, +exhausted, for second attacks in the same epidemic are not very +common. In cases where the duration of the attack is prolonged beyond +the period indicated, it is kept up by complications, and we have to +do not so much with the pathological processes of influenza as with +secondary diseases that the influenza has excited either by the +intensity of its action or by reason of some peculiarity of the +subject of the attack. + +By far the greatest number of cases are light and unattended by +danger. The treatment is therefore, for the most part, an extremely +simple one. These lighter cases seldom require medical measures. The +patients are uncomfortable and anxious, easily fatigued, and unfitted +for business. It is best that they keep the house, and, if willing, +the bed or sofa, for the space of two or three days. The diet should +be restricted to a few simple and easily-digested dishes. Meat should +be avoided. The common custom of taking hot beef-tea is an extremely +bad one; it often increases the headache and languor. Moderate +quantities of cold drinks may be taken. The fruit-syrups, lemonade, +raspberry vinegar, a weak solution of citrate of potash or of cream of +tartar, and barley-water with lemon, are useful. Very weak wine-whey +is often liked. The effervescing mineral waters or Apollinaris are +preferred by many persons. The best of such drinks is a mixture of +equal parts of Seltzer-water and milk, iced. If the stomach be +irritable, koumiss will be found an excellent beverage and food. In +the mild cases stimulants are not necessary. Sound claret, with or +without Seltzer-water, is not contraindicated. In all cases the amount +of fluid taken should be moderate. + +Quinine in moderate doses should be taken from the onset. The +head-pains are not increased by it. Dover's powder, if well borne, +should be administered at night. Some form of opiate may be required, +even in mild cases, to counteract wakefulness. A compressed pill, +containing extract of opium 0.030 gramme (gr. 1/2), camphor 0.15 (gr. +ij), and ammonium carbonate 0.15 (gr. ij), will be found useful when +Dover's powder cannot be employed. During convalescence iron and barks +are often requisite. + +The coryza, tonsillitis, laryngitis, bronchitis are to be treated +according to general principles, if they require treatment at all. In +most mild cases the catarrhal symptoms call for no special measures of +treatment. + +Free inunctions of fatty substances about the brow and over the bridge +of the nose are of use as regards the coryza. For this purpose animal +fats, washed lard, simple cerate, cold cream, and the like are to be +preferred to cosmoline and vaseline. + +Morphine dissolved in cherry-laurel water, one part in fifty or sixty, +is useful for the relief of the head-pains associated with the coryza. +A few drops may be snuffed up from time to time. These pains are +mitigated to some degree by wearing a flannel cap or wrapping the head +in a silk handkerchief. Warm applications sometimes give comfort, +while cold almost invariably add to the distress. + +{875} Distress in the upper air-passages and the tickling cough call +for steam inhalations, and the air of the apartment may be rendered +moist by the evaporation of water kept boiling in a broad, shallow +vessel. Gargles of potassium chlorate, or potassium chlorate with +sumac, exert a soothing influence upon the congested tonsils. + +Severe cases call for more energetic measures of treatment. The most +prominent indications are the control of the fever; the diminution of +the hyperaemic fluxion to the mucous tracts; measures of support; the +mitigation of pain and the induction of sleep; and, finally, the +prevention of the pulmonary congestion, to which the depression leads +by enfeeblement of the circulation. The last indication is especially +urgent in infants, the very old, and those previously debilitated from +any cause. + +Inflammatory complications require special treatment or modifications +of treatment. + +The febrile movement is not, as a rule, high; grave nervous symptoms +and serious catarrh may be associated with moderate fever. + +An anti-febrile regimen is to be observed. The moderate duration of +this fever, as compared with enteric fever, renders it less important +that large amounts of fever-food should be given, while the tendency +to depression makes it of the utmost importance that the +administration of food be systematic and carefully looked after by the +medical attendant. The disinclination to take food is so great that it +is often with difficulty that a sufficient quantity can be given in +the early days of the attack, and it is to be doubted whether benefit +follows anything in excess of the most moderate amount. It is +necessary to observe regular hours, as in the management of all the +low fevers. As soon as convalescence begins the patient should be +urged to eat; the quantity of food taken at one time is to be +augmented, and the intervals between the meals may be longer. + +A favorable action upon the excretory function of the skin and kidneys +will result from the moderate drinking of water or of the beverages +already spoken of. At least enough fluid should be taken to relieve +thirst. + +Diaphoretics have been much used, upon the theory that by +determination to the skin they correspondingly diminish the tendency +to hyperaemia of the affected mucous tracts. Dover's powder, solution +of the acetate of ammonia, and other mild diaphoretics are to be +selected. Jaborandi should be employed with caution. The wet pack and +other hydrotherapeutic measures have been employed to act upon the +skin and to effect a direct reduction of temperature in influenza. For +old and feeble persons warm packs are employed. A profuse sweating at +the onset of the attack is said to occasionally cut it short. Early +diaphoresis often brings about a rapid and lasting amelioration of the +symptoms. It is to be borne in mind that the fever is rarely +excessive, and that sweating is not infrequently a troublesome +symptom. In some epidemics it has been a very troublesome one. + +General bloodletting is not to be resorted to in influenza. Its danger +was apparent to some of the early writers. As has been pointed out, +the high mortality of some of the older epidemics is to be explained +by the venesections practised at the beginning, and even during the +course, of the attack. It has no favorable effect upon the catarrhal +processes, and but little upon the subjective symptoms. The fever is +not relieved by it; the {876} nervous depression is increased and the +risk of lung-congestion is augmented. Bleeding is not likely to be +practised in epidemic catarrhal fever while the present views of its +place in therapeutics continue to influence practice. Cautious local +bloodletting for the relief of local inflammatory trouble is spoken of +in most of the modern books. The occasions for its employment are so +rare in the treatment of this disease that even this statement should +be henceforth omitted. In influenza, as it is known to medical men of +the present from the descriptions of the old and personal experience +of the few recent and milder epidemics, bloodletting, either general +or local, is clearly uncalled for. + +Emetics hold a high historical place. It was of old customary to begin +the treatment with a vomit. As late as the epidemic of 1837, Lombard +of Geneva believed that they shortened the attack and lessened the +intensity of the symptoms when administered at the beginning. In cases +attended by early gastric disturbance and nausea they are said to be +especially of use. They sometimes set up great irritability of the +stomach, with vomiting that it is difficult to control. On the whole, +the cases in which an emetic would do good are extremely rare. + +Purgatives were formerly regarded as important in the treatment. This +view no longer prevails. In case of constipation gentle purgation, ex +indicatione symptomatica, is a necessary part of the proper management +of the case. For this purpose the laxative mineral waters, as +Friederichshalle, Hunyadi, Pullna, are excellent. Castor oil may be +given, and calomel is in some cases, and particularly in childhood, of +great service. Simple enemata of warm water or soap and water will +often suffice. The tendency in some cases to exhausting and +troublesome diarrhoea, and the fact that diarrhoea occurs +spontaneously some time in the course of most cases, should inspire +caution in the use of purgatives. Repeated purgation during the +progress of the attack is not only useless--it is also positively +injurious. + +In the severe cases quinine is to be given early and in full doses. It +exerts at the same time a powerful influence upon the temperature, +upon the tendency to local hyperaemias, and upon the nervous symptoms, +and in particular the headache. Rawlins,[23] as early as 1833, found +that excellent results followed its administration, the effect being +the better the earlier it was given. It has even been lauded as a +specific for influenza. + +[Footnote 23: _London Medical Gazette_, May, 1833.] + +The mineral acids may be given with a view to realizing their tonic +effects. + +For the most part, the foregoing measures, directed against the fever, +will exert a favorable influence upon the catarrhal processes. +Expectorants are of advantage; ipecac is useful. The preparations of +antimony are inadmissible by reason of their tendency to depress. +Ammonium chloride is indicated in the earlier stages of the +bronchitis. Among recent drugs, yerba santa (Eryodiction glutinosum) +and the oil of eucalyptus are of use in mitigating the symptoms in +epidemic catarrh, as they do in certain forms of simple sporadic +catarrh. + +The peculiar dry, racking cough so often present in the early days of +the attack should be relieved. It is not useful in removing bronchial +accumulations, being, as has been shown, in most instances out of +proportion to the lesions of the bronchial mucous membrane; on the +other {877} hand, it tends to increase the hyperaemia of the upper +air-passages by the mechanical violence of the cough-paroxysms. +Further, it is distressing and exhausting, and contributes to the +muscular and nervous prostration. Benefit will be derived from keeping +the air of the apartment moist, and from the occasional inhalation of +the steam from hot water, either used alone or poured upon the +compound tincture of benzoin, a pint to the teaspoonful, or upon +paregoric, a pint to the tablespoonful, in a proper vessel or inhaler. + +No drugs are more potent to this end than opium and its derivatives, +and in particular morphia and codeia. The hypodermic use of the +morphia salts, judiciously resorted to, constitutes our most valuable +therapeutic resource in fulfilling the threefold indication of +relieving cough, alleviating both the head-pain and the pains in the +extremities, and in procuring sleep. The old-time dread of opium in +influenza was not well founded. The administration of this drug in +moderate doses is attended with advantages that far outweigh any +danger of increasing the tightness across the chest and retarding +expectoration. It is necessary to observe the same caution in giving +it to infants and aged persons in influenza that is necessary under +other circumstances. The influence of carbolic acid in restraining +cough makes it a useful addition to soothing draughts in this disease. + +The substernal and other chest-pains may be combated with sinapisms, +turpentine stupes, repeated inunctions of fatty substances containing +extract of belladonna, and the like. Pleurodynic stitches call for +similar measures; a long strip of machine-spread belladonna plaster, +about five centimetres (two inches) in width, applied very firmly to +the side of the chest from the spine in a direction downward and +forward parallel with the ribs, and reaching to the median line in +front, affords great relief to the lateral chest-pains. + +The control of the debility must be regarded as the most important +indication in old and feeble persons. Wine, spirits, milk-punch, +ammonia, spirits of chloroform, are to be used, not in accordance with +fixed rules, but as occasion may require. In many cases wine or +whiskey will be indicated from the beginning, the quantity being +determined rather by the effect upon the circulation and the general +condition of the case than by rule. Women and others unaccustomed to +the use of alcoholic drinks often take wine and brandy in considerable +quantities, with striking benefit and without flushing or other +evidences of its disagreeing. + +Chloral is inadmissible as a hypnotic by reason of its depressing +effect upon the heart. Paraldehyde may be used, or the bromides in +connection with opium if the latter alone is not well borne. + +Diarrhoea must be managed in accordance with general principles. If +slight, it does not require special treatment. It is apt to occur at +one period or another in the course of most cases, and not +infrequently marks the beginning of convalescence. Colic may be +treated with warm fomentations and carminatives; if it be due to +constipation, mild laxatives are to be combined with them. + +Severe cases of influenza demand the careful attention of the +physician, who must be on the alert to detect the inflammatory lung +complications which so often lead up to the fatal issue as early as +possible. Their treatment must be regulated by the circumstances of +the case, the nature {878} of the particular complication, the age of +the patient, and so on, in accordance with general therapeutical +indications. + +Finally, all measures, of whatever kind, that tend to depress the +general nervous system or the functional activity of the respiration, +and especially the heart-power, are to be sedulously avoided in the +management of influenza. During the convalescence unfavorable +influences of the weather are to be guarded against. It is important +to warn the patient that a severe attack of influenza renders him +liable for some time afterward to pulmonary disorders. The sequels, +and in particular those implicating the respiratory tract, are to be +appropriately treated. After severe cases a course of tonics is +commonly of advantage, and a change of climate often necessary to +re-establish the health. + +As bearing on what is stated in the foregoing pages on the causation +of influenza, reference may be made to the investigations of +Seifert,[24] who claims to have found in the mucus expectorated by +patients with influenza numbers of a peculiar micrococcus. It is +evident, however, that no conclusions can be based upon these +observations until the results have been subjected to careful +examination in other epidemics. + +[Footnote 24: _Volkmann's klinische Vortrage_, No. 240, June 20, +1884.] + + + + +{879} + +DENGUE. + +BY H. D. SCHMIDT, M.D. + + +SYNONYMS.--Break-bone fever, Dandy fever. + +HISTORY.--The history of this disease dates only from the second half +of the last century, though it appears very probable that previous to +this time dengue existed in the tropical regions of Africa and Asia, +whence it was carried to Europe and America. + +In Spain the disease has been known since 1764, when, up to 1768, it +prevailed in Cadiz and Seville under the name of la piadosa or la +pantomina.[1] In 1780 it appeared in the form of an epidemic in +Philadelphia, where it was first noticed and described by Rush under +the name of bilious remitting fever, commonly called break-bone fever +on account of the violent pains attending it. Next it prevailed in +Calcutta in 1824, and two years afterward it made its first appearance +on the southern coast of the United States, in Charleston and +Savannah, where it prevailed to 1827. Toward the close of 1827 another +dengue epidemic broke out in the West Indies, whence the disease +proceeded to the American continent, reaching New Orleans in the +spring, and visiting Charleston and Savannah in the summer and autumn +of 1828.[2] In 1844 it showed itself in Mobile, and in 1848 in +Natchez, whilst in 1850 it reappeared along the Southern seacoast, +particularly in Charleston, from which it proceeded even to inland +towns, such as Augusta, Ga.[3] In 1865 dengue appeared in Teneriffe +and other Canary Islands, whilst at the same time and through the +years 1866 and 1867 it prevailed in Andalusia and in some other +Spanish provinces.[4] + +[Footnote 1: R. H. Poggio, _La calentura roja observada in sus +apariciones epidemicas de los anos 1865 y 1867_, Madrid (reported in +_Virchow und Hirsch's Jahresbericht fur das Jahr 1871_, vol. ii. p. +200).] + +[Footnote 2: G. B. Wood, _Practice of Medicine_, 4th ed., vol. i. p. +444.] + +[Footnote 3: S. H. Dickson, _Elements of Medicine_, 2d. ed., p. 747.] + +[Footnote 4: R. H. Poggio, _Virchow und Hirsch's Jahresbericht fur das +Jahr 1871_, vol. ii. p. 200.] + +One of the most extensive epidemics of dengue prevailed from July, +1870, to January, 1871, in Zanzibar,[5] on the East Coast of Africa, +whence it extended to Aden in Arabia and Port Said in Egypt. In +December, 1871, the disease appeared simultaneously at Bombay and +Calcutta,[6] to which place it had been carried by transport-ships +from Aden. Proceeding from Bombay in a northern direction along the +railroad, it spread {880} over the central regions of the +North-western Provinces, the Rajputana states, Cashmir, and the +Punjaub. From Calcutta it passed over Assam and Bhotan to Thibet, and +thence downward into Burmah and to all the large cities along the +coast; while it also extended along the coast of Malabar over +Visigapatam to Madras and Pondichery, finally arriving at Mysore. Thus +the disease had actually spread over the whole Peninsula from Cape +Tutikorin to the foot of the Himalayas, attacking equally all races or +nationalities without regard to age, occupation, or position. Forty +years previously, however, an epidemic of dengue had prevailed in +Burmah. In 1873 it appeared on the island of Mauritius, to which it +had been carried from India by an emigrant ship. In the same year a +considerable number of cases of dengue were observed in New Orleans. +In 1877 it appeared again in Egypt, where it prevailed in Ismailia. + +[Footnote 5: J. Christie, "Remarks on Kidniga Pepo, a peculiar form of +exanthematous disease epidemic in Zanzibar, East Coast of Africa, from +July, 1870, to January, 1871," _Brit. Med. Journal_, July 1, 1872, p. +577 (reported in _Virchow und Hirsch's Jahresbericht fur das Jahr +1872_, vol. ii. p. 203).] + +[Footnote 6: _Virchow und Hirsch's Jahresbericht fur das Jahr 1873_, +vol. ii. p. 208.] + +Finally, in 1880, dengue, in the form of a very extensive epidemic, +prevailed once more along the Southern coast, visiting equally +Charleston, Savannah, and New Orleans. A number of valuable +observations concerning the nature and symptoms of the disease were +made during this epidemic by Drs. D. C. Holliday of New Orleans, J. G. +Thomas of Savannah, and F. T. Porcher and J. Forrest of Charleston.[7] +At the same time it prevailed at Alexandria[8] (Egypt) to such an +extent as to affect nearly the whole population. + +[Footnote 7: The papers of Drs. Holliday, Thomas, and Porcher were +read before the American Public Health Association at its annual +meeting, December, 1880, and published in the _Proceedings_ of the +Association. Dr. Forrest's paper was published in the _American +Journal of Med. Science_, April, 1881.] + +[Footnote 8: A. Vernoni, "Le Dengue a Alexandrie d'Egypte en 1880," +_Gaz. hebd. de med. et de chir._, 41, 42 (reported in _Virchow und +Hirsch's Jahresbericht fur das Jahr 1880_, vol. ii. p. 5).] + +Dengue has been known under various popular names which it received +from the people of the particular localities where it appeared in +epidemic form. Even the designation, dengue, itself, by which the +disease is at present generally known to the medical profession of the +leading civilized nations, is of popular origin,[9] for it is supposed +to be a Spanish corruption of the word dandy, the name of dandy-fever +having been jocosely conferred on the disease by the negroes of St. +Thomas from the stiff carriage of those affected with it. At Zanzibar +it received the popular name of kidniga pepo, signifying spasmodic +pains. + +[Footnote 9: G. B. Wood, _Practice of Medicine_, 4th edit., vol. i. p. +444.] + +DEFINITION.--Dengue is a peculiar febrile disease, generally appearing +epidemically in tropical or semi-tropical regions, and characterized +by a single paroxysm with or without remissions, severe pains, and +stiffness in the joints and muscles, a peculiar exanthematous +eruption, and almost never terminating fatally. + +SYMPTOMS, COURSE, AND DURATION.[10]--Dengue never commences with a +decided chill, though in many cases the attack of the disease is +preceded by a feeling of general uneasiness and depression, vertigo, +and headache, or even by a slight chilliness--a condition which may +last from a few to twelve or even eighteen hours. In the majority of +cases, however, the disease appears suddenly, very frequently at +night, and announces itself at once by pains and a feeling of +stiffness in the muscles, joints, back, and loins; in severe cases the +pain may even extend to the {881} bones.[11] The larger and smaller +joints are equally affected, either simultaneously or successively, +and frequently swollen, those of the hands and feet generally before +the others. The pain in the joints is increased by motion, and is +therefore justly regarded by most authors as rheumatic in nature. The +same may be said of the muscles. Sheriff even observed redness of the +skin covering the joints. According to the degree of severity of the +case these pains may be more or less intense. In some cases +hyperaesthesia of the skin of the palms of the hands and of the soles +of the feet has been observed. + +[Footnote 10: Judging from the various accounts rendered by a +considerable number of observers, it appears that the clinical +symptoms of dengue had been the same in all the different localities +on the globe where it has hitherto prevailed epidemically.] + +[Footnote 11: M. Sheriff, "History of the Epidemic of Dengue in Madras +in 1872," _Med. Times and Gazette_, Nov. 15, p. 543 (reported in +_Virchow und Hirsch's Jahresbericht fur das Jahr 1873_).] + +Simultaneously with the affection of the joints and muscles the fever +commences; its duration is from four to five days on the average, with +one or, in exceptional cases, even more remissions. The temperature of +the body during the first and second days of the fever rises to 102, +103, or even to 105 degrees F; it then declines, to return to the +normal standard on the fifth day. According to the measurements made +by the late Dr. D'Aquin[12] of New Orleans, the temperature curves of +dengue showed a continuous and steady rise until the highest point was +reached on the first, second, or third day of the attack; then comes a +short stadium of a few hours, and then a remission, soon to be +followed by another rise of temperature, which, however, never reaches +the maximum point of the first. The pulse rises with the temperature +of the body, generally to from 80 to 120 beats a minute, and +subsequently declines with the temperature. Delirium is very rarely +observed in adults, but frequently in children, though without +aggravation of the other symptoms. The face is generally flushed, the +eyelids swollen, and the eyes injected and watery. The tongue in the +beginning of the disease is covered with a white fur; its edges are +red and its body swollen. As the disease advances the coating +increases in thickness and assumes a dirty yellow color. The appetite +is lost, without excessive thirst. In many cases there is slight +irritability of the stomach, accompanied sometimes with nausea, though +vomiting rarely takes place. The condition of the bowels is variable. +The urine is small in quantity, and highly colored in some cases, +whilst in others it has been reported to be pale and copious, and rich +in phosphates in the beginning of the disease; it seldom shows any +sediments and very rarely contains albumen. The disease generally +reaches its acme on the third or fourth day, when the fever commences +to subside, and an amelioration of the other symptoms takes place, so +that the patient feels greatly relieved. This, however, is only of +short duration, for not many hours afterward the fever rises again, +while the other symptoms also increase in severity. At this time an +exanthematous eruption appears upon the upper part of the body, the +face, neck, breast, and shoulders, which in the course of two days +extends over the whole body. Simultaneously with the appearance of the +eruption the lymphatic glands of the back of the head and those of the +neck, axillae, and groins commence to swell; in severe cases the +mucous membranes of the nose, mouth, and pharynx also become +congested. The eruption, which is attended with much heat, itching, or +even pain, is not uniform in character; for while in some cases it may +{882} represent a simple rash or erythema, it resembles in others the +eruptions of scarlatina, rubeola, lichen, or urticaria. Frequently it +is very light and evanescent, showing itself only for a few hours, and +perhaps in the majority of cases it does not appear at all. In the +severer cases it generally remains two days, when it commences to fade +and disappear with desquamation, while at the same time the fever +subsides and disappears entirely, though the stiffness and soreness in +the joints and muscles, together with the inflammatory condition of +the superficial lymphatic glands, may persist for many weeks. In +exceptional cases the eruption, after an intermission of a few days, +reappears, generally with greater intensity and with an aggravation of +the other symptoms. In others, again, it has been observed to remain a +whole week. + +[Footnote 12: D. C. Holliday, "Dengue or Dandy Fever," read before the +Amer. Publ. Health Assoc. at New Orleans, December, 1880.] + +Hemorrhages from the nose and gums are also occasionally observed. +Holliday even observed the occurrence of black vomit in the cases of +two female children, aged respectively six and twelve, in the same +family, who had suffered from yellow fever in 1878; they both +recovered from the attack of dengue, though they were extremely ill +and much prostrated. In female patients an attack of dengue not +unfrequently causes the reappearance of the menstrual flow, while the +pains attending the disease equally predispose to premature labor in +pregnant women. + +In severe cases of dengue the prostration following upon the +subsidence of the fever is very great, for the patient is affected +with a general weakness both of body and mind, indicating a great loss +of nervous energy. In some cases observed by Slaughter the memory for +names and words, as well as the ability for correctly writing even +short sentences, was lost for one or two weeks after the commencement +of convalescence. In children also cases are reported in which the +mind remained affected for a short time after the attack. The +convalescence in dengue, therefore, is comparatively slow, +particularly as the pains in the muscles and joints, as already +mentioned, pass away only gradually. + +The duration of the disease, including the stage of convalescence, of +course depends upon the degree of intensity of the attack, and +accordingly varies in different cases. In a great number of cases +dengue manifests itself only in its milder form. The average duration +of the disease is from three to six days. + +PATHOLOGY.--The pathological changes taking place in the different +organs during the course of dengue are unknown, on account of the +almost constantly favorable termination of the disease. From the +peculiar features of some of the clinical symptoms accompanying the +disease, however, we may speculate to a certain extent upon the nature +of the pathological processes to which they are due. The sudden +appearance of the characteristic pains in the muscles and joints, but +particularly those in the head, neck, and loins, accompanied by a +comparatively high fever, evidently point to the presence of an +infectious poison in the system, though the question whether the +noxious influence of this poison primarily affects the blood or the +nervous system will be difficult to answer. But, judging from the +early appearance of the pains, as well as from the physical and mental +depression of the patient, we may presume that the nervous system is +involved from the very beginning of the disease, and that the pains +depend upon a hyperaemic condition of the affected parts, probably +caused by a vaso-motor paralysis. The great resemblance of the painful +{883} affection of the muscles and joints in dengue to that of acute +articular rheumatism leads to the supposition that the pathological +condition in these joints is the same in both diseases; this view +appears to be held by the majority of medical observers. In dengue, as +in rheumatism, the pain due to the pressure of the hyperaemic and +swollen tissues upon the irritated sensory nervous filaments is +increased by motion--a phenomenon generally absent in neuralgia. The +persistent headache, restlessness, and want of sleep, as well as the +delirium and loss of memory observed in the severer cases, furthermore +indicate a hyperaemic condition not only of the pia mater, but even of +the brain-substance. + +It is to be regretted that the literature of dengue within our reach +shows no record of a quantitative analysis of the urine, from which we +might have learned the quantity of urea secreted during the different +stages of the disease, and which might have enabled us to form some +idea of the extent of the destruction of the albuminous substances +during the febrile stage, though, judging from the high grade of fever +observed in the severer cases, we may well presume that the +interchanges of matter are considerably augmented during this stage; +while, on the other hand, the great nervous prostration of the patient +directly after the subsidence of the fever, as well as the tardy +convalescence, sufficiently shows that a large part of this waste is +derived from the nervous tissues. The exanthematous eruption, +representing a hyperaemia, or even an inflammation, of the skin, +furthermore contributes to depress the nervous system by the pain and +itching which it causes. This eruption, together with the inflammation +and swelling of the superficial lymphatic glands, we are inclined to +associate with the final elimination of the infectious poison from the +organism. + +Very little also is definitely known about the condition of the +remaining organs, such as the kidneys, liver, and alimentary canal. +The examinations of the urine in dengue recorded in literature are +very few in number, and appear too unreliable for drawing any definite +conclusions from them with regard to the condition of the kidneys. As +albuminuria is met with in other infectious diseases, it is not +impossible that it has also occurred in severe cases of dengue; though +from the favorable termination of the disease it appears quite +improbable that organic changes take place in these organs. In the +same way may the liver be functionally deranged, or, judging from the +destruction of matter during the febrile stage, a slight fatty +infiltration of the organ may even occur--conditions which are apt to +pass away with the exciting cause. The gastric irritability, whenever +present, may be of nervous origin, though the vomiting, and +particularly that of black hemorrhagic matters, observed in +exceptional cases, evidently depends upon a hyperaemia of the stomach. + +ETIOLOGY.--There is nothing positively known of the origin of dengue, +but in perusing the accounts given by a number of medical observers +from the different localities of the globe where it prevailed, we may +presume that it existed in some parts of Asia and Africa long before +it appeared in Europe and America. Perhaps the earliest record of +dengue is the one dating from Cadiz and Seville, and concerning the +epidemics prevailing in the cities in 1764 and 1768, when it was +believed by the people that the disease had been imported from Africa. +In Zanzibar (Christie), during the epidemic of 1870, the older native +inhabitants {884} remembered that fifty years before the disease had +prevailed in this place. The Arabians living at this island also had +known the disease in their own country, while the inhabitants hailing +from the East Indies had never seen it. From the accounts of other +writers we may presume that dengue has been known in Arabia for many +generations. But, leaving aside its origin, it is authentically known +that wherever dengue has appeared it has almost always been in the +form of an epidemic, spreading from place to place and from family to +family, without respect to race or nationality, to age, occupation or +position, until every one susceptible to the disease was affected. +Slaughter reports from India that even domestic animals, especially +dogs and cats, were not exempt, as they appeared to suffer from +rheumatoid affections of the joints. + +Although toward the end of the last century dengue once prevailed +epidemically in the temperate zone, at Philadelphia, it must +nevertheless be considered as a disease especially at home in the +tropical and semi-tropical regions, where it prefers to haunt low +lands, particularly along the sea-coast, leaving almost untouched more +elevated places. Though nothing definite is known about its special +cause, its history and symptoms evidently show that it is not only +infectious, but also highly contagious, in its nature, and in +consequence must be caused by the entrance of a specific poison into +the system. This view is held by the great majority of physicians +residing in the various localities of the globe where the disease has +prevailed. But, contagious as it may be, it greatly distinguishes +itself from other contagious diseases by almost never proving fatal. +As dengue generally prevails in the summer season and disappears with +the approach of cold and rainy weather, its cause is apparently +subject to the influence of certain meteorological conditions. + +DIAGNOSIS.--When dengue appears epidemically, it is distinguished from +other diseases without difficulty. The only disease with which it +might be confounded when appearing in a sporadic form is acute +articular rheumatism. But even from this affection it may be +distinguished in its earlier stage by the pains not being limited to +the joints, as is generally the case in articular rheumatism, but +being also present in the head, back, and loins. Dengue is, moreover, +characterized by a general physical and mental nervous depression, +while in rheumatism the mind almost always remains clear. In the +latter stage the peculiar eruption and painful swelling of the +superficial lymphatic glands in dengue decides the question. + +It has frequently been stated that dengue resembles yellow fever, and +some physicians have even regarded it as a mild form of this disease. +In examining attentively, however, the temperature of the patient +during the febrile stage, it will be found that while it steadily +rises in yellow fever, it is remittent in dengue. There is, +furthermore, a difference observed in the state of the pulse, which in +yellow fever generally falls on the third day, while the temperature +continues to rise; in dengue, on the contrary, the pulse rises with +the temperature. In the condition of the stomach also dengue +considerably differs from yellow fever, for while in the latter +disease this organ is almost always irritable, and vomiting is very +frequently present, it is but rarely affected in dengue. The urine in +yellow fever very frequently contains albumen as soon as the third +day; in dengue, almost never, so far as the analyses recorded enable +us {885} to judge. Finally, the absence of jaundice and the appearance +of the eruption on the fourth or fifth day remove all doubt about the +nature of the disease. There are a number of other points by which +dengue may be distinguished from yellow fever, which we, however, +forbear to enumerate, for the reason that those already mentioned will +suffice for a correct differential diagnosis. + +PROGNOSIS.--Dengue, as has been stated before, scarcely ever +terminates fatally unless it is complicated by some intercurrent +disease. The prognosis, therefore, is highly favorable. + +TREATMENT.--Nearly all authors recommend a symptomatic treatment in +dengue, beginning with a mild cathartic, mercurial or not, and +followed by a mild diaphoretic. To relieve pain and procure sleep +opium--either uncombined or in the form of Dover's powder--belladonna, +camphor, assafoetida, valerian, etc. have been recommended by +different physicians; liniments containing camphor or chloroform have +also been used with advantage for the same purpose. Foot-baths have +been recommended to relieve the headache. To relieve the stiffness of +the muscles and the articular pains after the subsidence of the fever +iodide of potassium appears to be a favorite remedy in the East. +Colchicum combined with aconite is also recommended for this purpose, +as well as artificial sulphur baths and massage. The nervous +depression during convalescence is to be combated with tonics and with +regulation of the diet. Quinia appears to be generally discarded as a +remedy in dengue. + + + + +{886} + +RABIES AND HYDROPHOBIA. + +BY JAMES LAW, F.R.C.V.S. + + +SYNONYMS.--Canine Madness, Rabidus Canis, Canis Rabiosa. _Greek_, +Lyssa, Lytta, Lyssa Canina, Cynolyssa, Hydrophobia, Pantephobia, +Aerophobia, Phobodipsia, Erethismus Hydrophobia, Clonos Hydrophobia, +Dyscataposis. _French_, Tetanus Rabien, La Rage, Toxicose Rabique. +_German_, Wuth, Hundswuth, Tollwuth, Wuthkrankheit, Hundtollheit. +_Italian_, Rabbia, Arabiata. _Spanish_, Rabia, Rabiosa. _Swedish_, +Hundsjuka. _Roumanian_, Turbarea. + +DEFINITION.--Canine madness is an acute infectious disease, supposed +to arise spontaneously in the genus Canis (dog, wolf, fox, etc.) and +Felis (cat, etc.), but transmissible by inoculation to the other +Mammalia and to birds. It is characterized by a long period of +incubation, by exaggerated reflex excitability, by disorder of the +intellectual, emotional, and other nervous functions, by change of +habits, by extreme irritability of temper, by optical and other +delusions, by spasms of the muscles of the eyeballs and throat, by +paralysis, and by more or less fever. The disease runs a short and +almost without exception fatal course. + +HISTORY.--Plutarch claims that hydrophobia was first recognized by the +Asclepiadae, and Homer's allusions to the malign dog-star and to +Hector's acting like a raging dog have been quoted as implying a +knowledge of rabies. We find no certain reference to the affection, +however, until we come to Democritus and Aristotle, in the fourth +century B.C. The latter clearly describes the disease and uses the +name lytta, but, singularly enough, claims for man an exemption from +the general susceptibility to the infection by inoculation.[1] From +that date to this the successive outbreaks, sufficiently noteworthy to +secure a place in history, are so numerous and widespread as to show a +continuous prevalence of the malady in the Old World, and, since the +early part of the eighteenth century, in the New. + +[Footnote 1: _Historia Animalium_, lib. viii. cap. 22.] + +GEOGRAPHICAL DISTRIBUTION.--Rabies is more prevalent in temperate +regions than in the tropics and Arctic Circle, but this is common to +all animal plagues propagated solely or mainly by contagion, and is +manifestly due chiefly to the density of population, the activity of +commerce, and the free movement of men and animals in the temperate +zone. That a hot or cold climate is incompatible with rabies is +disproved by its prevalence under the tropics in Southern China, +India, Abyssinia, the West Indies, Peru, Chili, and Brazil, and in the +Arctic Circle in Northern Greenland, Lapland, Siberia, and Kamtchatka. +On the other hand, many {887} islands and secluded regions in the +temperate zones maintain a continued immunity or have been invaded +only recently by the introduction of infected dogs. We may instance +the Hebrides, Australia, Tasmania, New Zealand, South Africa, West +Africa, the Azores, St. Helena, and, until the last half century, La +Plata, Malta, and Hong-Kong. The disease is well known throughout +North Africa, Arabia, Syria, Turkey, and Asia generally, in Ceylon and +other of the East Indian islands. It is also notorious that even when +unusually prevalent its progress is often abruptly arrested by a +considerable river, and Schrader and Virchow both notice that though +it ravaged both banks of a river, yet the islands in the river +escaped, as was notorious of the islands in the Elbe during the great +Hamburg epizootic in 1852-53. While, therefore, rabies prevails most +extensively in the more civilized countries and in large cities, yet +we can point to no geographical area in which the contagion has failed +to spread among those bitten by rabid animals, nor to any locality in +which the disease has been shown to arise spontaneously from +unwholesome conditions of climate, soil, or general environment. + +ETIOLOGY.--We know of but one efficient cause of rabies--namely, +infection. Yet as many conditions are believed to favor its extension, +or even to determine its spontaneous eruption, it is necessary to +speak of them shortly. + +As shown above, climate cannot be charged with the generation nor +diffusion of rabies. Many countries formerly thought exempt are now +known to suffer. The following may be named: The East and West Indies, +Syria, Egypt, Cyprus, Siberia, the lands north of the Baltic, and +South America. Others manifestly maintain their exemption only because +the morbid germ has not yet been introduced. + +Certain seasons undeniably show a far wider extension of the disease +than others, but such epizootics are not limited to a particular +season or year, and, unless cut short by human intervention, cover a +succession of years of the most varied climatic character, spare +inaccessible or secluded islands in the very centre of the outbreak, +and the cycles of prevalence will succeed each other, in place of +occurring simultaneously, in closely adjacent countries subject to the +same climatic vicissitudes, but separated by narrow seas. Even a broad +river destitute of bridges usually abruptly arrests an epizootic, and +protects the land beyond lying under precisely the same general +influences. In this connection may be quoted the recent great +epizootic of 1856-72 in England, which succeeded, but did not +accompany, that of 1851-56 in Germany. Prof. Roll reports the +extraordinary prevalence of rabies at Vienna in 1814, 1815, 1830, +1838, 1842, and 1862--years remarkable for diversity rather than +uniformity of climatic characters. + +Popular opinion refers rabies to the extreme heats of summer, and each +year dogs are muzzled or otherwise confined by order of municipal +authorities during the dog days, though left at liberty throughout the +rest of the year. In 1780, Andry observed that the coldest and hottest +months furnished the least number of cases, and later Hurtrel +D'Arboval claimed that in France dogs suffered most in May and +September, and wolves in March and April. Bouley claims that the +majority of dogs suffer in March, April, and May. The following +statistics are interesting in this connection: {888} + + _Cases of Rabies in_ + WINTER. SPRING. SUMMER. AUTUMN. + Dec., Jan., March, April, June, July, Sept., Oct., + Feb. May. Aug. Nov. + Dogs 755 857 788 696 (Bouley). + Men 17 25 42 13 (Boudin). + +The increase of cases of rabies canina in the spring and summer +months, as shown by the above statistics (7-15 per cent.), cannot +reasonably be attributed to the influence of the weather, since even +the strongest advocates for spontaneity would at once decline to claim +any such ratio of spontaneous developments. The increase must +therefore be mainly, if not altogether, due to the increased number of +inoculations; and these latter are provided for in the jealousies and +quarrels in the troops of males that follow each rutting bitch in +spring, the principal period of oestrum in the canine female. The +infection spread in this way in early spring tends to remain more +prevalent throughout the hot summer months. + +With regard to the greatly enhanced mortality in man during the summer +months, as shown in Boudin's statistics for France, in the absence of +any genuine hydrophobia in man apart from inoculation from a rabid +animal, it may be attributed to three principal causes: 1st. The bites +sustained from rabid dogs in spring and early summer, when the disease +is most widely spread among these animals, will give rise to +hydrophobia weeks or months later. 2d. In the warm season the body is +more thinly clad and the hands and other portions are more frequently +left bare, so that the teeth are less likely to be cleansed of the +virulent saliva by passing through the clothes before entering the +skin. 3d. The languor, fever, and nervousness attendant on extreme +heat tend not only to hasten the activity of any disease-germs +actually present in the system, but also strongly favor the increase +of that nervous fear which so often generates a fatal +pseudo-hydrophobia (lyssophobia) in persons that have been bitten by +dogs. + +Hunger, thirst, and spoiled food are invoked as causes of rabies, yet +in the East, where the dogs are the scavengers of the cities and often +suffer severely from hunger and thirst, eat the most offensive +carrion, and drink the foulest water, the disease has a very +restricted prevalence, while in South Africa and Australia the outcast +and sheep-dogs, often the victims of starvation and thirst, entirely +escape. Bourgelat, Dupuytren, Majendie, Breschet, and others have +cruelly destroyed dogs by privation of food and water and by exposure +under a broiling sun, but no rabies, nor anything resembling it, was +produced. Dogs perspire little and suffer severely from heat, but +there is no evidence that this can develop canine madness. It is +claimed that Rossi of Turin developed rabies in cats by withholding +food and drink, but, as he furnishes no inoculation-tests confirmatory +of its virulence, the claim cannot be endorsed. Experiments with an +exclusive diet of salt meat, putrid meat, and water only have failed +to produce rabies. + +The large preponderance of male dogs attacked with rabies has been +constantly remarked by writers. Of 1990 rabid dogs reported by +different authors, 1746 were males and 244 females--a ratio of more +than 7 to 1. This excess of males attacked is much higher than the +ratio of males in the dogs of the districts drawn upon. Thus, Bourrel +found a {889} ratio of 6 rabid males to 1 rabid female, while in his +patients generally the proportion was 4 to 1. Leblanc found that 14 +per cent. of the male dogs went mad, while but 1 per cent. of the +females suffered. That sex is no protection against inoculated virus +is shown by the frequent inoculation of castrated dogs of both sexes. +The excess of male subjects may be attributed mainly to the frequency +with which these bite each other when following a female in heat, and +the respect of all alike for the latter sex. Even in the rabid dog the +sexual instinct rises above the propensity to bite in the early stages +of the malady. + +Toffoli claims that he has caused spontaneous rabies by shutting up +several dogs in a loose box with a bitch in heat and allowing them to +fight for the prize. Weber and Leblanc have noticed similar +occurrences. But Greve and Menecier have repeated the experiments with +a contrary result; so that it remains probable that when successful +the victims had already been inoculated before they were shut up. +Moreover, the seclusion of male canine animals for a lifetime in +menagerie cages, often adjoining those of their corresponding females, +has never been known to induce rabies. + +The bite of the violently enraged dog, and the bites mutually given +when following a rutting bitch, are popularly supposed to cause +rabies; but if this were the case, the disease must have been +universally prevalent. The idea that the bite of a dog will cause +hydrophobia should that dog at any subsequent period go mad is a +similar delusion. Men doubtless occasionally develop lyssophobia under +such an influence, but animals do not contract genuine rabies. + +Dogs are alleged to have gone mad from violent suffering after an +operation, and cats from being scalded or robbed of their kittens, but +all such causes are continually operating without such effect, and +when in a solitary case rabies develops, it can only be looked on as a +coincidence. + +Much popular prejudice exists against certain breeds, and the +Pomeranian has been virtually ostracised on account of its supposed +liability to rabies; but statistics show that the liability to +contract the affection bears a relation to the exposure rather than +the special breed. Eckel, Pillwax, and Hertwig found that dogs kept as +house- or watch-dogs, and most pampered and confined, are the most +liable, while St. Cyr and Peuch found the greatest number of cases +among those running at large and allowed the freest exercise. + +There is a popular belief that the bite of the skunk (_Mephitis +mephitica_) is always rabific. Rev. H. C. Hovey describes a number of +cases of infection from this animal,[2] and John G. Janeway has +reported other instances.[3] Both claim that the disease is +spontaneous in the skunk, and Mr. Hovey holds, on very insufficient +grounds, that the affection is a distinct variety of rabies (rabies +mephitica). The facts seem to warrant only the conclusion that skunks +in certain districts of Michigan and Kansas have had rabies +communicated to them, and follow the rabid impulse to bite other +animals and men. The Mephitinae abound in the Eastern States, but we +never hear of them stealing up and biting men or dogs, nor of the +latter contracting rabies from skunk-bite. Eastern dogs frequently +kill skunks and sustain bites, but do not thereby contract rabies. +Even in Kansas this evil {890} influence of the skunk-bite was unknown +until 1870, showing that it is not inherent in the climate nor soil, +but has been presumably imported. The spontaneity of the affection is +assumed, not proved. + +[Footnote 2: _Amer. Jour. of Science and Art_, May, 1874.] + +[Footnote 3: _New York Medical Record_, March 13, 1875.] + +In the above epitome of alleged causes we find nothing proving the +spontaneous evolution of rabies. The prevalence of the affection in +wolves, foxes, jackals, cats, skunks, etc. proves nothing for +spontaneity, more than its existence in the dog. In all these species +of animals the malady develops the dread propensity to bite, and thus +in all alike provision is made for the perpetuation and propagation of +the malady. Unless a previous attack by a rabid animal has been +observed, owners usually insist that their dogs have contracted the +malady spontaneously, yet a rigid scrutiny will almost always reveal a +strong probability, at least, of inoculation. The rabid dog wanders +far from home, and sometimes accomplishes wonderful feats of leaping +to reach his victim, so that his presence in a district is not even +suspected, and animals thought to be safely secluded inside high walls +suffer from his fangs. He is more inclined to bite and rush on than to +stay and devour, and thus small animals, like the skunk, when bitten +may survive to propagate the disease in places to which a dog could +not possibly find access. Much circumstantial evidence makes strongly +against the theory of spontaneity. Thus, the immunity of the islands +of the Elbe in the very midst of a severe and protracted epizootic, +the continued immunity of the Hebrides and of Malta, each famed for +its indigenous race of dogs, for long centuries, during which the +malady prevailed at frequent intervals on the adjacent mainlands, and +the continued exemption of South Africa and of the Australasian and +other islands, in the face of the counter-fact that the affection +persisted after importation in the West Indies and South America, +speak strongly for the doctrine that the introduction of a +pre-existing germ is an essential condition of the evolution of the +disease. The following statistics of cases which entered the Berlin +Veterinary College furnish further corroborative evidence. There +entered the college, + + In 9 years, 1845-53, inclusive, 278 rabid dogs. + " 1854 4 " " + " 1855 1 " dog. + " 1856 1 " " + " 5 years, 1857-61, inclusive, 0 " " + +The average for each of the first nine years was a fraction less than +31. In the two last of the nine the cases rose to 68 and 82, and this +led early in 1854 to an order for the muzzling of all dogs, which was +rigidly enforced by the police. The disease was promptly suppressed, +the two cases in the two succeeding years being probably due to +infected kennels or to importation from without. The results in Eldena +(Fuertenberg) and Holland (Van Capelle) are equally conclusive. The +inefficiency of some orders for the muzzling of dogs makes nothing +against these facts. A law on the statute-book is not always a law in +force, as I saw in Alfort and Lyons in 1863; the dogs wore their +muzzles only in honor of the periodic visits of the commissionnaire of +police, and rabies prevailed. + +The great majority of competent observers of to-day deny, or at least +strongly doubt, the occurrence of the disease apart from inoculation. +Without assuming to decide the question for all times and places, it +may {891} be safely asserted that there is no sufficient proof of such +an occurrence in any recent time.[4] + +[Footnote 4: Mr. Saze, a former student, informed me that boys in +Japan produce what is believed to be canine rabies by administering to +dogs a fungus (bukeryo) found growing on a coniferous tree. The dogs +do not all seem to die, but are usually killed by way of precaution. +The symptoms are those of delirium, with a propensity to bite, and the +disease is assumed to be communicable, though no facts are given to +show that it is so. This popular fancy has all the air of a popular +fallacy, but as the counterfeit attests the genuine, it shows the +familiarity of the Japanese with true rabies.] + +The contagion of rabies is usually resident in the saliva, but is by +no means confined to that product. Paul Bert found the bronchial mucus +virulent in dogs in which the saliva was non-virulent. The flesh has +conveyed the disease when eaten, though probably only because of sores +or abrasions on the alimentary tract. Smith records the death of +negroes in Peru from eating rabid cows;[5] Schenkius, that of persons +who ate of a rabid pig; and Gohier and Lafosse have infected dogs by +feeding the flesh of rabid dogs and ruminants; Rossi and Hertwig have +separately induced rabies by inoculating sound animals with portions +of nerves from rabid ones. No absolute proof can be adduced that the +disease has been conveyed through consumption of the milk. Cases +quoted to show its virulence are open to the objection that the dam +probably licked the offspring. A similar uncertainty attaches to the +spermatic fluid. Women are alleged to have acquired hydrophobia by +coitus, but no such case can be adduced among animals, though rabid +males have often had connection with healthy females. The alleged +cases in women were therefore probably the result of an excited +imagination or caused by virus introduced through some other channel. +The breath and perspiration seem incapable of becoming media for the +transmission of the disease. The blood was supposed to be non-virulent +by Breschet, Majendie, Dupuytren, Blaine, Youatt, etc., but has been +shown by Eckel and Lafosse to be rabific. Eckel successfully +inoculated the blood of a rabid he-goat on a sheep and that of a rabid +man on a dog. Lafosse accomplished the same in one of three attempts +by inoculation from dog to dog. The blood is probably only virulent in +the advanced stages of the disease, and its virulence implies the +virulence of all vascular tissues. + +[Footnote 5: _Peru as it Is_.] + +The saliva of rabid Herbivora and Omnivora, long held to be harmless, +is now known to be virulent. Berndt has successfully inoculated it +from an ox to four sheep; Eckel from a goat to a sheep; Rey from sheep +to sheep; Lessona from an ox to two horses and a sheep; Tombaro from a +heifer to a sheep, a horse, and two dogs; Youatt from horse and ox +respectively to dogs; Ashburner from an ox to fowls; King from a cow +to fowls; and Majendie, Breschet, Eckel, Hertwig, and Renault from man +to dog; and Earle from man to rabbits. Besides these are a series of +accidental cases, as from horse to man (Youatt), from a sheep to its +shepherd (Tardieu), and from man to man (Aurelianus, Enaux, +Chaussier). + +Experiments by Hertwig and Eckel seem to show that saliva loses its +virulence on the supervention of cadaveric rigidity or putrefaction in +the dead body. Haubner even believed dried saliva to be innocuous. Yet +Count Salm successfully inoculated the dried saliva of a rabid dog, +and Schenkius reports a case of hydrophobia produced by a scratch of a +hunting-knife that had been used to kill a mad dog some years before. +A veterinary student at Copenhagen cut his finger while dissecting +{892} the body of a rabid dog twelve hours after death, and died of +hydrophobia six weeks later. These cases in man may, it is true, have +resulted from fear, but the same cannot be said of the infection of +hound after hound placed in empty infected kennels, as recorded by +Blaine, Youatt, and others. In the face of this it would require very +strong negative testimony, indeed, to prove that the virus of rabies +is devitalized in drying--a process which prolongs the vitality of +other virulent matters. + +Up to the present time the germ of rabies has not been demonstrated. +That it is a particulate living organism may be reasonably deduced +from its power of indefinite increase--a quality possessed by no mere +chemical nor mechanical agent, also from the saliva proving +non-virulent after filtration through plaster, while the solid residue +left on the filter was virulent (Bert). But, although bacteria have +been found in the saliva, those demonstrated up to the present are +manifestly ordinary aerial bacteria, such as in Pasteur's experiments +produced septicaemia rather than rabies. It still remains, therefore, +for some future observer to discover that germ of which we cannot +doubt the existence. + +The point of election of this germ appears to be mainly the nervous +tissue. Pasteur found the brain-matter of rabid animals invariably +infectious, and has preserved the moist brain in an infecting +condition for three weeks at a temperature of 12 degrees C. He found +that by direct inoculation in the brain-substance the period of +incubation was abridged, rabies often showing itself in six, eight, or +ten days. In the face of Rossi's successful inoculation of nerves and +Pasteur's results with brain-matter it is difficult to account for the +unsuccessful inoculation of nerve-tissue in six successive experiments +by Hertwig. It seems to show that though the virus is concentrated in +the brain, and especially in the medulla and pons, yet it does not +equally permeate the entire nervous system. This election of the +poison for the nervous tissue led Dr. Douboue in 1851 to advance the +theory that it is propagated from the seat of inoculation to the brain +through the medium of the nerves--a position now assumed by Pasteur. +This, we fear, is not well founded. The poison, advancing for a month +or more along the lines of the nerves, would probably derange and +abolish their functions, as it does so speedily and effectually that +of the nerve-centres after it has gained a seat in them, whereas, in +reality, the local paralysis only appears in the last stages and after +the symptoms of cerebral disorder are well established. Furthermore, a +common premonitory symptom of rabies is congestion, swelling, and +irritation of the inoculation wound, showing a sudden extraordinary +activity at that point as a herald, if not a condition, of the general +infection, whereas under a slow propagation along the nerves from the +first this irritation would probably have been greatest in the wound +at the outset, and would have thereafter kept pace with the progress +of the virus along the nerves. Again, the blood is not always +infecting. Blaine, Youatt, and others of the older observers had no +fear of the blood. Hertwig obtained rabies in two cases only out of +eleven inoculations with the blood of rabid subjects. The blood in +this, as in some other diseases (variola equina, v. ovina, lung plague +of cattle), proves to a certain extent inimical and destructive to the +poison. Galtier inoculated nine sheep and one goat by intravenous +injection of the saliva of mad dogs, in no case with fatal results nor +indeed with any manifestation of rabies, but with the effect of +fortifying the system so, {893} that subsequent inoculation into the +tissues of the saliva of rabid animals was harmless. Test inoculations +made in the tissues of other animals with the same virus used in his +intravenous injections, and his subsequent inoculations of the animals +so treated, invariably determined rabies. Pasteur repeated these +intravenous injections in dogs with the result of rapidly inducing +rabies in a fair proportion of cases. One of his cases produced in +this way recovered, and thenceforward resisted all further inoculation +with the virus. Others that did not perish from intravenous injection +afterward died of rabies after inoculation in the brain. +Unfortunately, neither Galtier nor Pasteur have reported how much +virulent saliva was injected in any one case, so that we have no data +as to whether the difference was due to the varying quantity of the +virus introduced in the various cases. Lussana, an Italian physician, +had already in 1878 experimented on two dogs by injecting into their +veins the blood of a physician who died of hydrophobia. The blood was +drawn by leeches and cupping-glasses, and five grammes were injected +into each dog. One died on the twenty-fourth day, presenting the +symptoms and post-mortem appearances of rabies. The second at the end +of one hundred and forty days developed symptoms of rabies which +lasted a month, when the animal was sacrificed, and nothing special +found at the autopsy. The data do not warrant a very positive +conclusion, yet they seem to imply that the receptivity on the part of +the dog is greater than that of the small ruminants. They suggest, +further, a greater relative potency in the battle for life of the +blood-globules of the small ruminants with this unknown rabific germ. +This antagonism between the blood of the ruminant and the germ of +rabies finds a parallel in the case of other disease-poisons in their +relations to the nuclei of the tissues. Thus animals may prove +refractory to a small dose of the poison of anthrax, yet Chauveau has +shown that this virus will overcome all native or acquired +insusceptibility when administered in excess. The same is true of the +poison of chicken cholera, which Salmon dilutes until it is non-fatal, +though still affecting the system and conferring an immunity from its +attacks in the future. So with the lymph of variola ovina, which Peuch +diluted to 1/50 and injected with the effect of producing slight fever +and immunity without vesiculation. + +This view would imply that in ordinary cases (inoculation with a +moderate amount of the poison) the virus is for a time localized in +the vicinity of the wound; and this is further supported by the fact +that thorough excision and cauterization of the wound some time after +it has been received is still often protective. It is weakened by the +fact that bites of dogs in the stage of incubation sometimes produce +rabies, but it must be borne in mind that there is still a period +between the passage of the living germ to the salivary glands and +brain and the growth of the germ in the nerve-centres, so as to +produce pathognomonic symptoms, during which both blood and saliva +must be virulent. + +The ratio of successful inoculations to the bites is very varied. +Thus, out of 555 dogs reported to have been bitten by rabid dogs, 188 +contracted rabies; out of 183 experimentally exposed till bitten or +inoculated, 91 became mad; out of 73 cattle bitten, 45 became rabid; +out of 121 sheep bitten, 51 succumbed; and of 890 persons bitten, 428 +took hydrophobia (48 per cent.). Of 440 bitten by rabid wolves, 291, +or 66 per cent., took the disease. Such statistics are, however, far +from satisfactory. Of dogs {894} reported mad, some have only suffered +from epilepsy, convulsions, or colic, while of those bitten by the +really mad dog, some have sustained simple bruises without any real +abrasion; in other cases the teeth have been wiped clean by passing +through thick wool, hair, or clothing, or even the flesh of other +animals just bitten; in other cases the bite has been inflicted at a +time when the virulence of the saliva was at its minimum, or in a +subject which was naturally insusceptible. The protective effect of +clothing was well illustrated in a case which came under my notice in +London. Six animals bitten by a rabid dog all contracted rabies, +whilst a man bitten a few hours before through the coat-sleeve, and +who did not have the wound cauterized for a full hour after the bite, +escaped. Bouley found that in 32 persons bitten in the face, 29 died +of rabies (90 per cent.); of 73 bitten on the hands, 46 died (63 per +cent.); of 28 bitten on the arms, 8 died (28 per cent.); of 24 bitten +on the lower limbs, 7 died (29 per cent.); of 19 bitten on the body +(usually multiple wounds), 12 died (63 per cent.). The high mortality +from the bites of rabid wolves and skunks is mainly due to this habit +of attacking the face and hands. As illustrative of insusceptibility +may be quoted the poodle of Hertwig, which was inoculated nine times +with unquestionably rabic virus without effect; also the pointer of +Rey, which was seventeen times bitten by rabid dogs without harm; also +the acquired immunity of Galtier's sheep and rabbits, above referred +to. + +INCUBATION.--In the dog this varies from 6 days (Pasteur) to 240 days +(Bollinger). In the majority of cases it ends in from 20 to 50 days. +Pasteur, by inoculating into the brain substance direct, reduced the +incubation from 20 days to 6 days. In the horse the limits of reported +cases are from 15 days to 92 days. In the ox incubation varies from 20 +to 30 days; in sheep, from 20 to 74 days; and in swine, from 20 to 49 +days in recorded cases. + +In man incubation is believed to be often much more prolonged. In 6 +per cent. of all cases it is from 3 to 18 days; in 60 per cent., from +18 to 64 days; and in 34 per cent. it exceeds 64 days (Hamilton, +Thamhayn). Quite frequently symptoms of hydrophobia appear from three +to six months after the bite; in a few the period is prolonged to one +or two years, and in rare instances to seven (Schule), and even twelve +years (Chabert). But all such cases of prolonged incubation in man are +at the least extremely doubtful. Man often contracts a +pseudo-hydrophobia as the result of fear, and is curable by moral +suasion alone; and as no such protracted incubations are noticed in +the lower animals, and as no one of these abnormally deferred attacks +in man has been verified by successful inoculation on animals, it is +prudent to reserve a full assent until they are supported by better +testimony. A specimen of such cases is that recorded by Chirac, in +which a cadet bitten at Montpellier afterward spent ten years in +Holland, and then, returning and hearing that his fellow-cadet bitten +by the same dog had died of hydrophobia, he also manifested the +disease and died. Another is the case of a man who, after having been +bitten, spent two years in prison, and then developed hydrophobia and +died. A mind naturally erratic and rendered weaker and more +susceptible by prolonged confinement would prey upon itself and +exaggerate the danger when the subject had been forcibly presented. In +all such cases the attending physician should feel bound in the +interests of humanity to {895} inoculate a dog or other animal and +ascertain whether or not the disease is virulent. The value of such +results in dealing with future cases of the same kind cannot be +overestimated. + +The period of incubation appears to be relatively shorter in the young +(average 45 days) than the old (average 70 days), and is believed to +be shortened by constitutional excitement from violent passion, fever, +the heat of the weather, or electrical disturbances. + +During incubation no sign of the disease can be detected; it is even +said that the wounds heal with unusual rapidity; but it is certain +that toward the end of the latency the cicatrix, alike in man and +animals, tends to become sensitive, itchy, congested, and even the +seat of papular eruptions. The vesicles (lyssi) which, according to +Xanthos, Marochetti, and Magistel, appear near the opening of the +sublingual glands within a few days (6 to 20) after inoculation, have +not been found by any recent observer. + +SYMPTOMATOLOGY.--Three forms of rabies in the dog are recognized--the +furious, the paralytic, and the lethargic. The prodromata are, +however, the same in all, so that these may be conveniently considered +before the different types are noticed. + +The premonitory symptoms are by far the most important, as if these +are recognized the dog may be safely secluded or destroyed before +there is any disposition to bite. Any sudden change in a dog's habits +or instincts is ground for suspicion. Bouley well says that a sick dog +is always to be suspected. In some cases there is unusual dulness and +apathy, in others great restlessness, watchfulness, and nervousness. A +morbid appetite, in house-dogs a tendency to pick up and swallow +straws, thread, paper, pins, and other objects, or to devour their own +dung and urine, is highly characteristic. A desire to lick cold smooth +objects, as a stone, a boot, a piece of metal, or the nose of another +dog, is often seen. Smelling and licking the anus or generative organs +of another dog and the exhibition of sexual desire are frequent +manifestations. An increased fondness for the owner, shown by fawning +and licking, is occasionally seen, though more commonly there is a +change from a formerly amiable temper to a morose, sullen, retiring, +and resentful disposition. If a naturally quiet dog flies into a +violent passion at the sight of another dog or a cat, and attempts to +bite it, he should be carefully watched. If a social dog seeks +seclusion and darkness, or if while crouching and shrinking from a +blow (hyperaesthesia) he yet bears it without howl or whine, he is to +be strongly suspected. Barking without object, constant moving, +searching, and scraping, a disposition to tear wood, clothing, etc. to +pieces, and, above all, an absence from home for a day or two, should +beget grave apprehensions. The rabid bark or howl which is often heard +early in the disease is hoarse, low, and muffled, partaking of the +nature of both bark and howl, the first running into the second, and +consists of one loud howl followed by three or four others +progressively diminished in force and uttered without closing the +mouth. Some rub the chaps with the forepaws as if to dislodge an +offending body from the mouth; others reject bloody matter by +vomiting; and others turn the head and eyes as if following imaginary +objects, and snap at them. Finally, a tendency to bite, rub, or gnaw +the wound is significant, and usually draws attention to the fact that +the wound, long healed, is still red, sensitive, and swollen, {896} or +even papular. The conjunctivae are usually congested, there is an +increased nasal defluxion, and the skin of the forehead and over the +eyes is drawn into wrinkles. This stage lasts from a half to two or +three days. + +Following one or more of the above symptoms, paroxysms of wicked fury +come on, alternating still with periods of quiet, in which prodromata +only are observed. The red congested eyes assume a fixed stare, often +squint or roll as if following an imaginary object, at which the dog +presently snaps. A paroxysm is ushered in by increasing uneasiness, +frequent change of position, and a desire to escape, shown in rushing +at the door, tugging at the chain, or gnawing the post and walls of +the kennel. The tendency to bite and gnaw is further shown by seizing +the straw or tearing to pieces wooden and other articles within reach, +or even by the victim lacerating its own body. + +The rabid howl becomes more frequent, and the rage and disposition to +bite strange animals and persons merge into a mischievous desire to +worry all that come in the way, the respect for former companions and +friends being steadily lost as the paroxysm increases in violence. Yet +for a considerable time the voice of a loved master recalls the +suffering animal to some degree of self-control. If free to escape +during such paroxysms, the dog expends his excitement in wandering, +making long journeys of five, ten, or twenty miles, and flying at +every animal or man he meets, especially if they increase his +excitement by any noise or outcry. If the victim escapes destruction +during one of these wanderings, he returns during a lucid interval +exceedingly dangerous, for, though he may recognize or even fawn upon +his friends, yet the demon of mischief is even more potent within him, +and may be roused to sudden violence by any noise or excitement. The +intervals of quiet are attended by a prostration proportionate to the +violence of the previous paroxysm, and the animal usually seeks +seclusion and darkness, where he may lie dull and torpid, but he may +be roused at any time to a renewed paroxysm by any noise, disturbance, +the presentation of a stick, or, above all, by the approach of another +animal. During the paroxysm the animal is manifestly the subject of +acute delirium, has hallucinations, snatches and bites at unreal +objects, turns on his best friends, even his master, seizes and holds +on to a stick or iron bar until the teeth are detached and the gums +lacerated, bites his own body, even amputating tail, testicles, or +toes with his teeth; a bitch deserts her puppies or worries them, and +all follow the unconquerable impulse to wander and to wound living +beings. The victim will sometimes manifest incredible strength in +breaking his chain and scaling high walls. Twitchings of the muscles +of the face, and even general convulsions, are sometimes seen. Food is +usually rejected, or if swallowed is soon vomited. In the course of +two or three days the furious stage merges into the paralytic one, +first shown by paresis of the hind extremities and a swaying motion in +walking, then by paralysis of the lower jaw, which hangs pendent and +allows the escape of a viscid saliva. The palsy gradually extends over +the whole body--a sure precursor of approaching death, which is rarely +delayed beyond eight days, and never more than ten, from the onset. In +this last stage the animal has become extremely emaciated, with dry +withered hair, hollow flanks, and small weak pulse; he may at first +rise on his fore limbs when {897} disturbed, and even attempt to snap, +but there is now little danger of a bite. Convulsions may alternate +with the paralysis. The result is invariably fatal. + +The peculiarity of dumb or paralytic rabies in dogs is that the last +or paralytic stage supervenes at once on the prodromata, without any +intervening period of acute delirium and fury. The animal is +throughout dull, quiet, and depressed, and shows little tendency to +bite, to wander, or to restless movement. The excitement of the sexual +passion is the same as in the furious forms, and the howl is still +emitted, though much more rarely. Soon the lower jaw drops from +paralysis, allowing the saliva to drivel from the mouth, and the +animal can only succeed in closing it momentarily under the greatest +provocation to bite. Paralysis of the hind limbs and of the whole body +speedily follows, and death ensues in from two to three days. As soon +as the jaw is paralyzed the subject is unable to drink, eat, bite, or +bark, and emaciation advances with extraordinary rapidity. + +The lethargic or tranquil form of rabies in dogs is manifested neither +by furious madness nor by palsy of the jaws, but the nervous +prostration is shown in a profound lethargy and apathy. The patient +curls himself up, and will not be roused by his master's voice, by any +noise, disturbance, or even punishment; he makes no response to the +caresses of his friends, and pays no attention to the food or drink +they bring him, but remains in his place, growing daily more emaciated +and lethargic, until relieved by death toward the tenth or fifteenth +day of the illness. + +Besides the three typical forms there are intermediate varieties, +which are classed with one or other according as the symptoms of that +type seem to predominate. The same virus, inoculated, will produce +different types in separate individuals, the result seeming to depend +more on the susceptibility of the subject than any special quality in +the poison. With many notable exceptions it may be stated that, on the +whole, furious rabies predominates in hounds, bull-dogs, and other +less domesticated or naturally vicious and courageous breeds, while +the paralytic and tranquil types attack especially house and pet dogs. + +POPULAR FALLACIES.--It is a dangerous delusion to suppose that mad +dogs have a dread of water and polished surfaces, that they will not +eat or drink, that they froth abundantly from the mouth, and that they +run with the tail drooping between the hind limbs. There is no +hydrophobia in the dog or other domestic animal. The rabid dog drinks +freely in the early stages of the disease, lapping even his own urine; +later, he still laps, and even plunges his nose in water, though often +unable to swallow; and in his wanderings he swims rivers without the +slightest reluctance. The appetite is not entirely lost, though +greatly impaired and usually depraved, all sorts of unsuitable, +noxious, and disgusting objects being picked up and swallowed with +avidity. Frothing from the mouth is exceptional in rabies, and the +flow of saliva is rarely seen unless when the jaw is paralyzed and +pendent. Carrying the tail between the legs is a symptom of all +diseases attended by abdominal pain, and is by no means constant in +rabies. During the paroxysms the tail is usually carried erect. + +Foxes, jackals, and badgers attacked by rabies lose their natural +{898} shyness, enter villages, follow and bite other animals and men, +and, like rabid dogs, die in an unconscious and paralytic condition. +Wolves are affected like foxes, but are more dangerous because of +their power, the ferocity of their attack, and their habit of flying +at the face and hands. Rabid cats are more retiring than dogs, and +show less disposition to attack, but when they do, use both claws and +teeth, and especially on bare portions of the body. The cry is hoarse +like that emitted during the period of rut. They usually die about the +third or fourth day. + +The rabid horse is the subject of violent excitement, nervousness, and +fear. There are trembling, loss of appetite, rubbing and eversion of +the upper lip, neighing, sexual excitement, and inclination to bite +and kick. Delirium may be suspected, but during the paroxysms the true +nature of the disease is betrayed by the unconquerable desire to bite, +kick, and otherwise injure those about him. He will even gnaw the +manger and kick the stall to pieces, or lacerate his fore limbs and +flanks with his teeth. In the early stages there is the same tendency +to lick and rub the wound, which becomes red and irritable, the same +red glaring or squinting eyes, and the same jerking of the muscles, as +seen in the dog, and the affection winds up in the same way, in +paralysis and death in four or five days. + +Rabid cattle lose appetite, become very restless and excitable, grind +the teeth, lick the cicatrix, evert the upper lip, and otherwise show +sexual excitement, bellow often in a loud, terrified manner, as if +still apprehensive of the attack of the dog, paw and scrape the ground +with the fore feet, butt and kick viciously, have twitching of the +muscles, and finally paralysis and death in from four to seven days. +When paralysis is coming on the hind feet are often drawn forward as +in inflammation of the feet. The pulse and breathing are accelerated +during the paroxysms, but I have not found the temperature raised. + +Rabid sheep and goats present the same general symptoms, bleat +hoarsely, but viciously, have sexual excitement, nibble the cicatrix, +have muscular weakness, emaciation, and paralysis, and die in from +five to eight days. + +Rabid swine show much fear, restlessness, and excitability, hide under +the litter, start violently at noises, grunt hoarsely, champ the jaws, +show a great disposition to bite and to gnaw and tear objects to +pieces, have dark red, glaring eyes, gape and yawn, and become weak +and paralytic. Breathing is often labored, and the mucosae and white +skin assume a dull red or leaden hue. Death ensues as early as the +fourth or fifth day. + +In Herbivora and Omnivora a paroxysm is usually induced by the sight +of a dog--a fact of importance in diagnosis. + +Rabid skunks have naturally received but little study. They tend, +however, to steal up to men and animals and bite some exposed part of +the body, like the finger, ear, or nose, and as stealthily retire. It +is claimed that their odorous secretion is suppressed. + + +Symptoms of Hydrophobia in Man. + +In some cases the prodromata are altogether omitted, the disease +setting in suddenly with spasms of the pharynx and inability to +swallow. More commonly, the premonitory symptoms last from one to +three days. The first symptom is often an itching, prickling, or more +or less violent {899} aching in the seat of the bite, and even of an +aura, a numbness, or shooting pain extending from that point toward +the heart. In such cases the wound is red or bluish, and even swollen. +In other cases there is chilliness, a general feeling of headache, +malaise, and prostration, with lack of appetite or nausea, gloomy +forebodings, taciturnity, nervous excitability, and restlessness. That +restlessness which in patients cognizant of the consequence of the +bite often induces insomnia during incubation, now often shows itself +in an inability to keep quiet or to remain in one position or +place--the exact counterpart of the initial restless stage shown in +the canine patient. The sleep is now even more broken and unrefreshing +and disturbed by fearful dreams. The restlessness soon merges into +intense nervous irritability. Though devoured by thirst, the patient +is afraid of water, and the attempt to drink will cause slight spasms +with a sensation of filling of the throat and difficulty of +deglutition. Even the air blowing upon his surface produces nervous +irritation and apprehension, and a sudden glare of sunshine or other +strong light is still more injurious. The pulse is increased in +frequency, hard, and small; the breathing accelerated, oppressed, with +at times yawning, sighing, or sobbing; there is some redness of the +fauces, vascular injection of face and eyes, with, in some cases, +dilated pupils; nausea or oppression at the epigastrium, sometimes +vomiting; and usually constipation, which cannot, as in dogs, be +referred to the earth, sand, and unsuitable materials swallowed. +Intelligence is unimpaired. + +With or without some or all of the premonitory symptoms above +described the patient is sooner or later seized with constrictive +spasms of the pharynx and respiratory muscles, the immediate occasion +being an attempt to swallow liquid or some sudden fright or +excitement. So great is the agony produced by this attack that, though +consumed by thirst, the patient will rarely afterward attempt to +drink, and the mere sight or offer of water, the noise of liquid +flowing from one vessel to another, or even the sight of the vessel in +which liquid was contained, suffices to bring on a violent paroxysm. +This hydrophobia is peculiar to the human being suffering from this +disease, being rarely seen in rabid animals; and it serves to +enormously enhance the agony and horror of the affection. During a +paroxysm the dyspnoea is usually extreme; there is a gasping or +sighing respiration, and shrill, inarticulate sounds or screams are +emitted which have been likened to the bark of a dog. These are +manifestly due to the threatened suffocation rather than to an attempt +to bark. The sensations have been described as a rising of the stomach +into the throat, while others felt as if the throat had turned into +bone and could not admit nor pass on the liquid. The abdominal +contractions are often well marked, and retching and vomiting ensue. +This reflex irritability of the nerves of deglutition and respiration +is followed or attended by a condition of the most intense +hyperaesthesia and a great exaltation of the special senses. A deaf +and dumb child is said to have heard distinctly at this stage. There +are, besides, during a paroxysm, general muscular trembling and clonic +spasms of the muscles of the trunk and extremities. The facial muscles +are contracted, the nostrils dilated, the face and eyes red and +injected, and the pupils dilated, producing a spectacle of the most +intense agony. Even in the intervals the hyperaesthesia is so extreme +that the slightest touch of an attendant, a {900} current of air, the +approach of a candle, or even the ordinary tones of conversation, +produce extreme agitation and may precipitate a violent convulsive +paroxysm. The duration of the paroxysms and of the intervals varies +much, but in general terms the former increase rapidly in number and +severity, while the latter are correspondingly shortened. Restraint +serves to aggravate the paroxysm, while, according to Hunter, the +earlier and lighter ones may be relieved by running. The intense +excitement sometimes becomes manifest in the persistent talking, and +it is noticeable that the patient is free from mental delusions. As it +is impossible to swallow, the patient spits out the now viscid saliva +on all sides--a feature, like the fear of water, peculiar to man. As +the disease advances the paroxysms are marked by the most perfect +hallucinations and delirium, which impel the victim to acts of insane +violence toward every one and every thing about him. In these fits he +will use every available means of offence, even to the snapping of the +jaws, though on the subsidence of the fit he will often express the +greatest regret and warn his victims to be on their guard when he +finds another paroxysm coming on. In some few instances the delusions +continue even during the remissions, and the patient remains possessed +of a sense of suspicion and horror of all about him, and yet the fear +of being left alone is usually greater still. The convulsions may +become tetanic (as opisthotonos). They are habitually more severe in +men than in women and children. During a convulsion the victim will at +times become black in the face, and may die from suffocation, +apoplexy, or nervous exhaustion. + +Should he survive this danger the final paralytic stage sets in. The +spasms gradually become weaker, reflex irritability is lessened, and a +period of quiet, and even comparative composure, may ensue, during +which the former sights and sounds fail to produce a paroxysm, and +some patients even recover the power of deglutition; but muscular +weakness and prostration become more extreme, the lower jaw may even +drop, and the viscid saliva drivel from the lips; finally, stupor +supervenes, and the patient dies in a state of profound coma or +complete exhaustion. This last stage lasts from one to eighteen hours. + +Cases are met with in the human subject, as in the dog, in which the +paroxysmal stage is omitted in greater part or entirely. The patient +complains only of oppressed breathing, and sighs deeply when he +attempts to swallow, and paroxysms, if they occur at all, are very +mild. Decroix indeed claims that if a person suffering from +hydrophobia is kept in a dark room and perfectly quiet, no paroxysms +appear. The malady is, however, none the less fatal. + +DIAGNOSIS.--The diagnosis of rabies and hydrophobia is not usually +difficult if the disease has progressed to its paroxysmal stage. The +most pathognomonic features are the fact of a bite by a rabid animal +and the evidence of lesions and an extraordinary irritability of the +medulla oblongata, inducing severe reflex spasms of the muscles of +deglutition and respiration under the influence of any peripheral +irritation. The clonic nature of the spasms and the entire absence of +trismus serve to distinguish it from tetanus. From pharyngeal anthrax +and diphtheria attended with spasm it is diagnosed by the extreme +exaltation of the special senses and the absence of any marked febrile +reaction; from acute mania by the difficulty of breathing and +deglutition, the more rapid heart-beats during {901} a paroxysm, and +by the marked hyperaesthesia and exalted reflex susceptibility, as +well as by the perfectly lucid intermissions; and from epilepsy, in +that the latter is not associated with the same hyperaesthesia, that +the paroxysm is not developed by noise, movement, attempts to swallow, +sight of water, etc., that the spasms are more universal, and that +they do not recur often, nor can they be roused by the causes +immediately producing those of hydrophobia. Hysterical cases can +usually be recognized by the imperfection of the symptoms; the +subject, not knowing all the manifestations of hydrophobia, naturally +fails to produce them. + +The most difficult to distinguish from the genuine disease are those +cases in which hydrophobia occurs as a disease of the imagination, the +result of fear--the lyssophobia or hydrophobie non-rabique of the +writers. In these there is always the history of a bite; the cicatrix +even may have become the seat of congestive redness, itching, or +neuralgic pains, and these, acting on a susceptible brain, develop a +disease which is hardly distinguishable from true hydrophobia, and +which is quite as fatal if left to run its course. These cases have +usually less reflex susceptibility than genuine hydrophobia; the +attack mostly occurs shortly after some conversation on the subject, +and especially about the effects of the bites on others; and the +victim is seen to have a nervous organization, and may even be known +to have been subject to hysteria or other nervous disorder. At the +same time, the concentration of the mind on this subject sometimes +produces even structural changes in the medulla, and the reflex +susceptibility in co-ordination with the other symptoms may be almost +perfect. In a case reported a few years ago by Hammond the symptoms +appeared perfectly characteristic, and at the necropsy circumscribed +points of congestion were found near the roots of the vagus; yet the +dog that bit this man was said to be alive and well, and in the +absence of any successful inoculation from biter or bitten the case +must be presumed to have been lyssophobia. + +Many cases with a more favorable issue are recorded. Bellenger had a +patient who had been bitten by his cat, and manifested violent +paroxysms of hydrophobia, but was instantly cured by the sight of the +animal in good health. Bouardel records that a man was bitten by his +dog, which afterward disappeared. He was seized with severe +hydrophobia, which continued for two days, when the lost dog was found +and presented to him, and the symptoms disappeared. Trousseau speaks +of a magistrate whose hand had been licked by his hound, which +immediately after attacked a flock of sheep, so that many of them died +of rabies. The master then manifested hydrophobia, but as death was +deferred beyond the usual time, he concluded it was not genuine and +recovered. Prof. Dick was called to visit a man who had been bitten by +a favorite dog while suffering from distemper, had manifested severe +hydrophobic symptoms, and had been given up by the attending +physicians. He succeeded in convincing the subject that as the dog had +had distemper, and as no two great diseases could coexist in the same +system, it could not have had rabies. In spite of the false premises, +this reasoning had the desired effect and the patient recovered. A few +years ago a boy twelve years old in Ithaca, N.Y., was bitten by a dog +supposed to be rabid, and in due time manifested hydrophobia, which +advanced rapidly until he was having a violent paroxysm every half +hour, and it was pronounced impossible for him to survive another day. +At this time I saw him, observed that he {902} had a nervous +organization, and was somewhat lacking in the hyperaesthesia of +rabies, learned that he had recently been gorging himself with +Christmas delicacies, and was now very costive; and, as there was no +satisfactory history of the dog, I at once suspected lyssophobia. The +friends and strangers who had come to condole with the parents and +feast on the horror were excluded, and the boy's attention fully +engaged in amusing pictures and conversation; the paroxysms were +omitted, and in two hours the patient, overcome by weariness, went to +sleep. Next morning he was still kept secluded and quiet, and two +enthusiastic students took up the role of keeping his attention +constantly engaged on whatever would interest him. The prima viae was +relieved by medicine, and under a course of tonics the boy quickly +recruited, and at the end of a week went back to school. + +In doubtful cases the test by inoculation may be tried. Inoculation +with the saliva of a man suffering from hydrophobia is manifestly +useless, since he must die before we can hope for the development of +the disease. But in the case of a dog having bitten one or more people +the inoculation of the virus on the brain of one or two other dogs +would ensure the development of the affection in the course of one or +two weeks, provided the first was rabid. The non-success of this +operation when practised on two dogs would provide the best possible +medicine for the diseased mind of the person bitten. + +PATHOLOGICAL ANATOMY.--Post-mortem lesions are rather remarkable for +their inconstancy than for their specific characters. Hardly a single +lesion can be specified which may not be absent in particular cases, +yet some are so characteristic that, when taken along with the +symptoms during life, they very materially assist in diagnosing the +disease. Of the pathological appearances common to man, dog, and other +animals the following may be named: The body is greatly emaciated; the +rigor mortis is normal or nearly so; decomposition usually sets in +early; a white skin is livid, cyanotic, or petechial; the cicatrix is +often hardly noticeable even after the animal has been shaved; the +superficial veins, especially those of the neck and head, are filled +with black inspissated blood; the external mucous membranes are of a +dark livid hue, those of the mouth and nose being covered by a +tenacious mucous or muco-purulent secretion (in dogs they are usually +covered with earth or dust); the fauces, pharynx, and tonsils are +usually of a dark livid hue, and sometimes swollen; in other cases the +dark red hue and manifest swelling that obtained during life disappear +after death; similar lesions are found in the larynx, and I have seen +extensive erosions; the bronchial mucous membrane is reddened and +coated with a muco-purulent secretion (and in dogs with earth and +foreign bodies); the lungs are usually congested, often to the extent +of showing death by asphyxia; the heart and large blood-vessels are +filled with a black thick, venous blood, and the muscles, charged with +the same blood, have a dark reddish-brown hue; the stomach is usually +congested, sometimes to a port-wine hue, and is the seat of +blood-extravasations and even erosions; this congestion is often +present, though to a less degree, in the intestines; the mesenteric +glands and those in the vicinity of the pharynx are not unfrequently +enlarged and congested; a very constant feature is the entire absence +of proper food in the stomach and of chyme in the small intestine; the +liver is usually hyperaemic, {903} exuding on pressure the +characteristic dark blood, and it may be the seat of some granular +degeneration, but it usually retains its normal consistency; the +spleen is normal; the kidneys are hyperaemic and leaden or bluish +gray, and slightly cloudy on the surface (in dogs fatty degeneration +of the inner cortical layer is common even in health); the urinary +bladder is usually empty or contains a little turbid, yellowish, +slightly albuminous urine, while the mucous membrane is often covered +with dark reddish-brown petechial spots; the brain is usually +hyperaemic, and, together with its membranes, slightly oedematous, yet +the lesions are not constant either in kind or degree; the medulla +oblongata usually shows a similar condition, and even minute points of +acute congestion, but neither these nor the hyperaemia and oedema of +the spinal cord can be found in every case. + +Some conditions are especially pathognomonic in the dog. In nearly all +cases of furious rabies the stomach is gorged with foreign bodies, +such as hay, straw, wood, coal, leather, portions of textile fabrics, +faeces, earth, sand, stones, pieces of iron, lead, etc., and the same +materials are usually found in the small intestine, while the large +intestines are empty. Portions of these foreign bodies are often found +in the bronchia as well, giving rise to circumscribed lobular +pneumonia. The significance of such matters when found in large amount +in the stomach of a dog which has been given to biting or other +symptom of rabies is very great, and if the stomach contains none of +the natural food of the animal and the duodenum no chyme, it may be +held pathognomonic of rabies. If, however, the materials are small in +quantity and mingled with natural food, and if the duodenum contains +chyme, the dog was probably not rabid. Dogs frequently chew and +swallow fresh leaves of grass, and those in detention gnaw and swallow +pieces of wood, cloth, horn, etc.; but these are used either as an +emetic or a teething-ring, and virtually imply that digestion is not +entirely abolished. Their presence, therefore, along with food does +not indicate rabies. + +PROPHYLAXIS.--In view of the almost or quite constantly fatal issue of +rabies in man and animals, the main attention should be given to the +question of prevention. As the disease is perhaps never in our time +developed except as the result of contagion, we have the most perfect +guarantee that by suitably devised measures it may be absolutely +suppressed and excluded from any country. Even if we allow that a rare +case is at long intervals developed spontaneously, it is none the less +certain that the disease can be practically abolished, as nothing can +be easier than to nip the disease in the bud in the locality where it +first shows itself. Thus in Australia, Tasmania, and New Zealand +rabies has not yet appeared, though prevailing in the same latitude +and climate in both hemispheres. It reached Mauritius in 1813, and has +prevailed uninterruptedly since, while in Bourbon, immediately +adjacent and almost identical in geology, climate, flora, and fauna, +it is still unknown. The same truth is told in the entire extinction +of rabies in Berlin by the universal muzzling of dogs, as recorded +above. The immunity lasted for nine years, during which muzzling was +enforced. A more recent example of the same kind is found in Holland. +In 1875 universal muzzling was made obligatory in all communes where +rabid animals had been and in adjoining communes. From 1877 on the +disease was unknown save on the borders of {904} Belgium and Prussia +and in a very few dogs recently imported. Nearly all cases of +hydrophobia in man and animals being due to bites by rabid members of +the canine fraternity, a fundamental condition of all success in +prevention is the prohibition of its diffusion by dogs. For this +reason the following measures are requisite: 1st. All dogs should be +registered and heavily taxed. The number of useless dogs kept in every +community affords the greatest opportunity for the speedy diffusion of +the rabid germ whenever that has been introduced. Whatever tends to +reduce this number directly tends to the restriction and extinction of +rabies. 2d. Every dog should be made to wear a collar with plate +bearing the name and residence of his owner. All stray dogs without +such badge should be summarily shot by the police. This will secure +the payment of the taxes and the destruction of superfluous and +dangerous dogs. 3d. In all cities and counties where rabies has +existed within a year, and in the counties adjoining them, every dog +should be muzzled except when securely shut up or tied. All dogs found +at large without a muzzle should be promptly shot by the police. The +objection to muzzles is satisfactorily met by the use of the wire +muzzle, which impedes neither breathing nor drinking. 4th. Dogs and +cats suspected or known to have been bitten by rabid animals should be +at once destroyed, or if considered sufficiently valuable may be +confined in a secure cage for six months under veterinary supervision. +5th. Dogs which have bitten and are supposed to be rabid should be +similarly caged and placed under veterinary supervision. If rabid, the +symptoms will be fully developed in a few days, whereas if destroyed +at once the bitten party is liable to develop lyssophobia. 6th. Dogs +imported from countries where hydrophobia is known to exist should be +subjected to a period of quarantine of six months. 7th. Foxes, wolves, +badgers, martens, skunks, must be indiscriminately destroyed in +localities where they have become infected with rabies. 8th. The +disinfection or burning of the kennels where rabid dogs have been is a +natural corollary of the above. + +Other measures less thorough and efficient are often advocated and +resorted to, but should be discarded whenever it is possible to +practise a method of absolute extermination. Among these may be named +the flattening of the teeth, and especially of the canines, with a +file, as advocated by Bourrel, and later by Fleming. While this is a +measure of protection, it does not remove the desire to bite, nor the +power of wounding the skin when that is delicate or tender. Another +method is to hang a block of wood from the neck, so that it may impede +the movements of the forelegs and prevent a rush and sudden attack. +The futility of such a resort need hardly be remarked upon. The +emasculation of dogs is another preventive measure advocated. The +single advantage of this is that it does away with the host of suitors +that follow a rutting bitch, and the mutual worrying and biting that +ensue. But it is not yet proved that the disease is produced by +privation of the generative act, while if it were it is still certain +that cases of spontaneous rabies are extremely rare; that the rabid +dog bites the castrated one as readily as the perfect male; that the +emasculated one contracts rabies as readily as others when bitten, and +that he communicates it no less persistently. Galtier's method of +intravenous injection of the rabic saliva, which seems to have proved +effectual in sheep and rabbits, utterly failed in the hands of Lussana +and {905} Pasteur in dogs. Besides this objection, that it is useless +for the animal which is beyond all comparison the main propagator of +rabies, it has the serious disadvantages that its practice would +necessitate the maintenance of a constant succession of cases of +rabies, that great danger attends this production and handling of the +virus, and the expense and risk of a general application of the +measure must absolutely forbid it. + +More recently Pasteur has found that the virus when transmitted +through several monkeys in succession becomes so weak as to be +harmless to the animal inoculated, and yet protects the animal against +the more virulent poison. This fact he utilizes by inoculating this +mitigated ape-virus on the brain of the animal just bitten, so as to +render that refractory to the disease when the poison from the bitten +wound shall reach it by its ordinary slow channel. At the time of +writing, the method is being attempted on a man bitten by a mad dog. + +Another precautionary measure which is always in place is the +diffusion among dog-owners of correct information as to the +premonitory symptoms of rabies, and the necessity for careful +seclusion when any such symptoms are manifested. + +TREATMENT OF BITES.--The treatment of bites by animals supposed to be +rabid consists mainly in seeking the elimination of the poison or its +destruction by caustic. The first object should be to prevent +absorption of the poison. If the bite has been on a limb, a tourniquet +should be instantly placed above it. A stout cord or handkerchief is +always at hand, and may be tied around the limb and twisted with a +piece of wood until circulation is arrested. Sucking the wound is +usually effective in withdrawing the poison, and can convey no +additional danger to the person bitten. If the patient cannot reach +the wound with his own mouth, another may volunteer to suck it, though +in these days of diseased teeth and gums the act is pregnant of +danger. This may be largely obviated by alternately sucking and +rinsing the mouth with a solution of carbolic acid, or, better, by +applying such a solution to the wound before sucking, or finally by +sucking through a tube. Cupping over the wound is highly commendable, +though less effective than sucking. When cupping can be combined with +wringing of the wound, there is an approximation to sucking. Cupping +is especially valuable in wounds of the trunk, where a tourniquet +cannot be applied. Intermittent squeezing and wringing of the part and +steeping in warm water is an excellent resort when no better measure +can be had. Cutting the wound open to its depth, while it may in +certain cases be necessary to allow of the thorough application of a +caustic, is objectionable as multiplying the points of infection and +absorption. Drinking of liquids to excess temporarily retards +absorption by overfilling the vascular system. Ammoniacal, alcoholic, +and other stimulants are resorted to for the same purpose, being held +to cause plenitude, not only by quantity, but by rarefying the animal +fluids. + +No such measures should, however, be allowed to delay for an instant +the use of caustics. This is the one effectual means of destroying the +poison, and the choice of caustic is of less consequence than its +thorough application. The hot iron in the form of a skewer, nail, +poker, or other available instrument, at a white heat, may be brought +in contact with all parts of the wound to its utmost recesses. + +Of chemical caustics, solid sticks of nitrate of silver, chloride of +zinc, {906} and potassa, or the crystals of cupric or ferric sulphate, +are to be preferred to the liquid forms (mineral acids, butter of +antimony, etc.), because of the greater thoroughness with which they +can be brought into contact with all parts of the wound. Lastly, the +galvano-cautery may be used if within reach. If the liquid caustics +are employed, they may be introduced into the depth of the wound by +means of a pipette, a piece of porous wood, or a pledget of tow. For a +great number of small wounds a bath of corrosive sublimate has been +recommended. + +In some cases the amputation of a badly-lacerated member or one with a +compound fracture offers the only measure of protection. + +But although nothing should be allowed to delay cauterization, yet the +impossibility of an immediate application should not be accepted as a +reason for its neglect at a later date. On the presumption that the +virus is localized in the seat of inoculation until it has increased +largely and is poured into the blood in sufficient quantity to +subjugate the blood-globules to its influence, it is logical to excise +the cicatrix and cauterize the wound, though days or even weeks have +elapsed. + +If it should be shown by further experiment that Galtier's intravenous +injection of virulent saliva is harmless and protective to sheep, +rabbits, and it may be other Herbivora, it would be logical to employ +this in these animals just after they have been bitten, as there will +be ample time to establish the systemic influence of the intravenous +injection before the poison shall have accomplished its recrudescence +in the cicatrix. The constantly fatal result of rabid bites in these +animals would at least warrant such an attempt, the main precaution +being that the liquid shall be most carefully preserved from contact +with any of the tissues, including even the coats of the injected +vein. + +In addition to the local treatment of the sore, certain general +medication has usually been resorted to, though its real value may +well be questioned. Thus, the elimination of the poison has been +sought by profuse perspiration induced by warm, Turkish, and Roman +baths, and by the use of medicinal agents, sudorifics, sialogogues +(mercury), laxatives, and diuretics (cantharides). The neutralization +of the poison has been attempted by ammonia, the sulphites and +hyposulphites, chlorine, etc. Besides these are used nerve-sedatives +and tonics, such as venesection, belladonna, prussic acid, tartar +emetic, sulphates of copper and zinc, arsenic, strychnia, etc. + +What is probably of greater importance is a sound hygiene. Stimulating +food eaten to excess is injurious alike to man and beast, and by +inducing digestive disorder and cerebral congestion will tend at least +to precipitate the attack. Costiveness or biliousness from sedentary +habits and lack of exercise in the outer air and sunshine, exposure to +intense heat or cold and over-exertion, are all to be guarded against. + +Finally, psychical treatment is of the highest importance. Those about +the person who has been bitten should preserve a calm, equable, and +cheerful demeanor and avoid all allusion to the occurrence. The +patient should be protected against all sources of excitement, and +should not be allowed to see that he is an object of solicitude. If +the matter is referred to incidentally, he should be impressed with a +conviction of the efficacy of the treatment adopted. + +THERAPEUTIC TREATMENT.--Almost every agent in the {907} Pharmacopoeia +has been employed as a remedy for hydrophobia, but, up to the present, +it must be acknowledged, with no measure of success. The agents +supposed to be prophylactics are those also resorted to as therapeutic +remedies. To these may be added the potent nerve-sedatives and +anti-spasmodics--chloroform, chloral hydrate, ether, bromides of +potassium, sodium, and ammonium, curare, Calabar bean, and the +sialogogue diaphoretic pilocarpine. + +Chloroform is one of the most appropriate, as it may be taken by +inhalation, though with much excitement to the patient, and it at once +relieves the oppressed breathing and pharyngeal and other spasms, +while it acts as a cerebral sedative and anaesthetic; and if it cannot +be held up as a curative agent, it at least secures euthanasia. +Chloral given as an injection, so as to induce its soporific action, +is equally soothing, though nothing more. Curare injected +hypodermically overcomes the spasms, but does not usually, if ever, +retard death. Three cases of hydrophobia in man treated in this way +recovered, but we have no proof that even these exceptional cases were +rabies. Pilocarpine has been used in a number of cases, but, with the +exceptional case of a young man reported by Denis Dumont, all +terminated fatally. The committee of the Paris Academy of Medicine +reported in 1874 that in three experimental cases "it hastened death +by the fits it brought on." Morphia is often of great value in calming +the excitement and giving rest and sleep during the intervals of the +paroxysms. Daturia and atropia, administered hypodermically, are +somewhat less effectual. Inhalation of oxygen is said to arrest the +convulsions and delirium, but not to retard death. Vaccine virus and +the venom of the viper have each been tried, but with no good effect. + +Of non-medicinal therapeutic measures the following are among the most +promising: Perfect seclusion, quiet, and darkness serve to abate the +hyperaesthesia, the painful acuteness of the senses, and the +convulsive and delirious paroxysms. It can no longer be doubted that a +very few cases of genuine rabies recover, but those that do so have +almost all had special advantages in the way of quiet and seclusion, +and few have had the excitement of medicinal treatment. Eight cases of +the recovery of rabid dogs are reported by Menecier, Decroix, +Laquerriere, Rey, Harold Leiney, and Pasteur. The two first were +attested by successful inoculation on other animals; Decroix's second +case was caused by inoculation with the saliva of a hydrophobous man; +the next three had been bitten by dogs undoubtedly mad; while +Pasteur's was inoculated with the brain-matter of a rabid cow. All in +due time presented the characteristic symptoms of rabies, yet all +recovered, without any record of medicinal treatment. Pasteur's case, +when again inoculated, resisted the disease. A certain number of +recoveries of men from pronounced hydrophobia under medicine and +without it are on record, but in the absence of successful +inoculations it is impossible to tell how many were cases of infecting +rabies. The parallel between rabies and tetanus in the intensity of +the reflex excitability would demand darkness and quiet as a sine qua +non of any rational treatment. Faradization has produced a temporary +relief, but no permanent improvement. Warm baths, steam baths, and +hot-air baths serve to abate excitability and spasm, and have been +lauded as specific in hydrophobia, but have proved useless in the +lower animals. + +{908} Intravenous injection of warm water (two pints) in a +hydrophobous man reduced the pulse from 150 to 86 and restored the +power of deglutition. Life was prolonged for nine days, but in great +agony, from the supervention of suppurative arthritis (Majendie). In +another case the dread of water disappeared, but death ensued in +fifty-four hours. In the hands of Youatt and Mayo it proved equally +unsuccessful in dogs. A cold bath with submersion to unconsciousness +is an old remedy now abandoned. Venesection to fainting, with or +without mercury, mitigated the symptoms, but seemed to hasten +paralysis and death. The excision and cauterization of the cicatrix, +or the cutting of the nerves proceeding from it, has been useful in +delaying, or even absolutely preventing, the paroxysms. When, +therefore, the premonitory symptoms of hydrophobia have set in, and +when an aura or shooting pain is felt proceeding from the seat of the +wound toward the heart, one or other of these measures may serve to +prevent the immediate occurrence of reflex convulsions. When the +poison has actually invaded the brain, this can be looked on as a +palliative measure only, but in the many cases of lyssophobia it may +put an instant stop to the affection. + + + + +{909} + +GLANDERS (EQUINIA GRAVIOR, FARCY). + +BY JAMES LAW, F.R.C.V.S. + + +SYNONYMS.--_Greek_, [Greek: malis]. _Latin_, Malleus, Equinia Nasalis, +E. Apostimatos, Farcinia. _French_, Morve, Farcin. _German_, Rotz, +Lungenrotz, Hautrotz, Wurm, Hautwurm. _Italian_, Morva, Moccis, +Cimurro. _Spanish_, Cimorro, Lamparones. + +DEFINITION.--An infectious, bacteridian disease occurring in the +horse, ass, or mule, and communicated by inoculation to various other +animals, including man. It is usually ushered in by rigors, followed +by articular pains, lameness, and the formation of a specific deposit +in the lymphatic system of some part of the body, with a tendency to +destructive degeneration and ulceration. In the form known as glanders +these deposits and ulcers take place mainly in the nasal mucosa, in +the lungs, and in adjacent glands, while in that known as farcy the +deposits occur in the cutaneous and subcutaneous lymphatic plexuses +and the dependent glands. + +HISTORY AND GEOGRAPHICAL DISTRIBUTION.--Under the name of malis +Aristotle describes a fatal disease of asses, supposed to have been +identical with the malleus humidus of Vegetius Renatus and other +writers of early Christian times, and with the cymoira of other early +Roman writers. This malady was characterized by swelling of the +submaxillary glands and discharge from nose and mouth. From the +fourteenth century onward glanders is reported from different parts of +Europe at frequent intervals; thus in 1320 in England (Rogers); in +1640 in Badajoz, brought by Portugese horses (Villalba); in 1686 at +Treves (Eggerdes); again in 1776 in Southern France (Lafosse); in 1794 +in Bavaria (Plank); in 1796 in Franconia (Laubender); and in 1798 in +Piedmont (Toggia). At the beginning of the present century this +affection was very widely prevalent in Great Britain, the chronic +cases being habitually worked in stage-coaches, but of recent years, +when it has been made criminal to expose or use a glandered horse, the +malady has to a great extent disappeared. To-day glanders is almost +coexistent with the distribution of the domesticated equine family, +yet its prevalence bears a direct relation to the facilities for +infection (horse-traffic, war, preservation of the diseased, +confinement in close stables, ships, etc.), and some countries appear +to be entirely free from the affection. Thus, Krabbe gives the yearly +losses per 100,000 horses for the principal countries of Europe and +Algiers as follows: Norway, 6; Denmark, 8.5; England, 14; Sweden, 57; +Wurtenberg, 77; Prussia, 78; Saxony, 95; Belgium, 138; {910} France +(army), 1130; Algeria (army), 1548. The losses in Prussia more than +doubled after the Franco-German War; thus, in 1869-70 they were 966, +and in 1873-74, 2058. In Bavaria they rose in the same period from 173 +to 390 (Hahn). In Lisbon, Portugal, glanders was unknown for the +thirty years preceding the Peninsular War, whereas after the war it +proved a veritable scourge (Saunier). Charles Percivall, during an +eight years' residence at Meerut and Cawnpore, Hindostan, saw not a +single case of glanders, and so late as 1275, Fleming claims an entire +immunity for India; yet in 1877 complaints were numerous of the very +general prevalence of the disease in Upper India especially, while in +1879 the campaign in Afghanistan was seriously affected by its +ravages. Climate appears to have little influence. The disease is +virtually unknown in the island of Bornholm with 7000 horses, and in +the Faroes and Iceland with 35,000, while it is quite frequent in +Sweden. It is unknown in Australia, but is very prevalent in China, +South Africa, Abyssinia, and Algiers, and but little known in Asia +Minor, Arabia, and Egypt. + +In the United States as in Europe the disease has mainly concentrated +itself in the large cities in times of peace, and spread widely on the +advent of war. It is alleged that it first entered Mexico in 1847 with +the American cavalry, though with the horses kept in the open air it +failed to gain a wide extension. The horses and mules drawn into the +Union armies in 1861 brought infection with them, and soon the disease +was most prevalent and destructive, not only in the ranks, but in +every State in which the armies operated. John R. Page says the first +case he saw in the Confederate army was a captured Federal troop-horse +on the retreat from Manassas, and that the breaking down of the +Confederate cavalry in the last two years of the war was mainly due to +glanders. At the close of the war the sale of army horses distributed +the infection widely through all the States, North as well as South. +Every year in a country district in Western New York I see several +cases of glanders, and occasionally a whole stud is carried off +through an infected purchase. In other States the case is no better. +In Pennsylvania, Ohio, Illinois, and Michigan cases are constantly +seen in the country districts, and in the three last-named States five +human victims have been reported within a short period. In Connecticut +the same is true, and the disease made one human victim in Waterbury +in 1879. In the large cities the case is still worse. Liautard of New +York in 1878, in a single visit to one car-stable, condemned 8 horses, +in another stable 18, and in a third, at two visits, 45, while a +fourth had lost no fewer than 200 horses in the course of one year +from glanders. In the Troy (N.Y.) car-stables the malady prevailed +from 1875-77, most of the subjects suffering from chronic farcy, until +in the latter year, by my advice, these propagators of contagion were +destroyed. In Springfield, Mass., in 1879, the disease assumed such +alarming proportions that it was vigorously suppressed by a city +ordinance enjoining summary slaughter. These are but indications of +what is happening all over the country, entailing losses of many +hundreds of thousands yearly as well as an enormous risk to humanity. + +The following table gives the number of cases occurring in the equine +family in two of the principal countries of Europe in the last few +years: {911} + + Cases of Glanders in-- Great Britain. Germany. + 1878 888 2753 + 1879 1367 + 1880 2048 1941 + 1881 1710 1774 + 1882 1389 1838 + +As both countries systematically suppress this disease through their +veterinary sanitary officials, it cannot be doubted that the figures +for America, if obtainable, would be relatively higher. + +Glanders prevails especially in horses, asses, mules, and other +solipedes, and is communicated by inoculation to all domestic animals +except the genus Bovis. In the sheep and goat the receptivity is +considerable, and the disease may prove fatal in fifteen days +(Gerlach) or it may be delayed for seven weeks (Bollinger). The +Carnivora (dogs, cats, lions, polar bears) contract the affection by +eating diseased flesh, as do some rodents (prairie-dogs, rabbits, +guinea-pigs, mice), and, by administration, solipedes. Swine contract +the disease by inoculation (Gerlach, Spinola), though in these and in +the dog the constitutional symptoms are usually slight and recovery +may follow the local affection. + +The susceptibility of man is doubtless less than that of the +solipedes, judging from the few cases of glanders compared with the +frequent exposures, yet when once established in the system it can +hardly be said to be less malignant or fatal. + +ETIOLOGY.--The one known cause of glanders is contagion, and the +recent experiments of Capitan and Charrin in France and of Schutz and +Lofler in Germany, demonstrating that the bacillus of the glanderous +deposits is the one essential cause of the disease, effectually +dispose of any claim of its spontaneous origin. Glanders can no longer +be considered spontaneous, further than that its germ is now proved +capable, like that of anthrax, of survival and multiplication out of +the animal economy, so that infection may come from other objects than +a sick animal; and it may even yet appear that the bacillus, living at +times as a harmless saprophyte out of the animal body, may acquire +deadly properties under certain conditions of the environment. At the +same time, the most extensive acquaintance with glanders and the +broadest generalizations from known facts do not warrant the +assumption of the extension of the disease by the growth of the +bacillus out of the living body, unless it be on the rarest possible +occasions, while the soundness of extensive countries (Australia, New +Zealand) for a century or more speaks strongly against any frequent +development from a harmless saprophyte. + +To the same effect speak the experiences of the English army. At the +beginning of the century, under the teaching of Coleman, most cases +were attributed to lack of stable care, and extensive experiments were +made in the treatment of the disease, with the result of a very high +mortality from this cause. Now, when contagion is looked on as the +main or sole cause, and all suspected horses in the army are promptly +destroyed, the disease is only seen in recently-purchased animals or +after the inevitable exposures of a campaign.[1] In the French army +the doctrine of the {912} non-contagiousness of chronic glanders led +to a greater prevalence of this disease than in any other country of +Europe. Prior to 1836 it was about 90 per 1000 per annum, whereas now, +under the doctrine of contagion and a corresponding practice, glanders +kills but 2 per 1000 per annum (Rossignol). + +[Footnote 1: Wilkinson, _Jour. of Roy. Agr. Soc._, No. 50.] + +But while the essential cause of glanders is the specific bacillus, an +individual susceptibility is no less requisite to an attack. This may +be innate or acquired. As we have seen, it varies according to the +genus, being greatest in the solipede. But many solipedes show a +strong power of resistance. Of 138 horses similarly exposed by +cohabitation with glandered horses, but 29 (21 per cent.) suffered. Of +28 inoculated with glanders virus, but 9 (32 per cent.) succumbed +(Lamirault, Bagge, Tscherning). The accessory causes which predispose +the system to the reception of glanders may be included under one +general term--low condition and ill health. Three of these causes, +however, deserve especial mention: 1st. Impure and rebreathed air. +Prior to 1836 the yearly losses per 1000 of the French army horses +were from 180 to 197. At the date named the ventilation of the stables +was greatly improved, and the mortality fell to 68 per 1000 per annum, +one-half from glanders. Later improvements have reduced the 34 cases +to 2. During the Italian War, in 1859, 10,000 of these horses were +kept for nine months in open sheds, with but one case of glanders.[2] +In the expedition to Quiberon during the Napoleonic wars, a cavalry +contingent, believed to be healthy, shipped on new transports, +encountered a storm, and had the hatches fastened down, so that +several horses were suffocated. Among the survivors, landed at +Southampton and placed in stables hitherto unchallenged, many soon +developed glanders in its worst form. Similar results followed the +English expeditions to Varna in 1854, and that to Abyssinia in 1867. +In badly-ventilated mines and stables, especially cellar stables, +glanders, once started, is always most virulent. + +[Footnote 2: Larrey, _Hyg. des Hop. Mil._, 1862, p. 63.] + +2d. Cold, damp, draughty stables greatly favor the progress of +glanders. Leblanc reports the case of a stud of 240 horses that had +had no glanders for eight years, but which lost half their number in +three months after removal into a new stable, very lofty, but dark and +damp, and subject to cold draughts. It is worthy of notice that they +had also been subjected to double work, and were consequently +emaciated, but there was not known to be any unusual exposure to +contagion. In a Boston street-car stable, where glanders had long +prevailed, Thayer cut it short by destroying the infected animals and +by improving the ventilation by windows hung at the bottom and opening +inward, so that the air entered in an upward direction, and cold +draughts on the horses were avoided. + +3d. Debility from ill-health, low feeding, or overwork.--The nervous +and nutritive debility consequent on chronic disease, overwork, and +exhaustion lessens the power of resistance to specific poisons, but in +such circumstances there is always the added predisposition of an +excess of waste material in the blood, a specially abundant food for +the disease-germ. So notorious is this that it used to be held that +the specific poison of glanders was generated in connection with the +excess of creatine, creatinine, and lactic acid resulting from +muscular action. Of the effect of {913} low diet we have a striking +example, furnished by Bouley, of a stud of 120 horses, 60 of which +were attacked within a year after they had been placed on a food +insufficient to repair the body-waste, and from which the disease +disappeared after the slaughter of the infected and improvement of the +ration. So long as glandered horses were preserved for work, the then +nearly ubiquitous germ attacked nearly all that were run down by +chronic diseases; hence glanders was looked upon as the natural +winding up of exhausting diseases in the horse, as tuberculosis was +thought to be in the human subject. Modern discovery shows that +without the germ all such debilitating causes are impotent, but it can +never disprove the great potency of these in laying the system open to +attack, nor the value of vigorous health and sound hygiene in +fortifying the system against it. + +The channel of infection manifestly varies in different cases. In +direct inoculations the morbid process develops first at the point of +insertion, and secondly in the nearest lymphatic glands and internal +organs. When contracted in the ordinary way, the lesions are usually +first seen in the posterior nasal passages, the larynx or the lungs, +or in the superficial lymphatics, especially of the hind limbs. This +susceptibility of the deeper portions of the air-passages seems to +imply that the bacillus, borne on the air, is lodged on different +parts of the respiratory mucous membrane, and first sets up the morbid +process in the thinnest or most susceptible portion. That it can be +thus borne on the air is shown by the experiments of Viborg and +Gerlach, who separately collected the particulate elements from the +exhalations of glandered horses and successfully inoculated them. That +the virus is not usually carried far on the air in a virulent form is +attested by the many instances in which horses have stood for months +in the same stable with a glandered animal without becoming infected. +That infection may also take place through the ingestion of infected +matters is undoubted, as glanderous products mixed with food, or even +made into balls and enclosed in paper and administered to horses in +this form, have produced the disease. The virulence is said to be lost +by passing through the digestive canal of man (Decroix), dog, pig, and +fowl (Renault), but even to Carnivora the infection may be conveyed in +the food. + +While the virus is concentrated in the material of the special +glanderous deposits and the discharges from these, yet no part of the +body can be considered as free from the poison. Viborg, Coleman, +Hering, and Chauveau have communicated the disease by transfusion of +blood from a glandered horse to a healthy one; hence every vascular +organ must be liable to infect. The secretions of the diseased body +(tears, saliva, mucus, sweat, urine, and milk) have each been +successfully inoculated, and the conveyance of the disease to the +foetus in utero and to the female by coition imply that even the +generative secretions are virulent. Failures to convey the disease by +inoculation with the blood and secretions have often occurred, +however, and they must be held as less virulent than the products of +the local disease-processes. + +The claims that inoculation with pus, ichor, and other irritants have +produced glanders must be entirely discredited. The deposits and +ulcers in the lungs and elsewhere resulting from such inoculations +have been either septicaemia, mistaken for glanders in the earlier +days of pathological anatomy; or the septic and other inflammations +set up by these {914} inoculations have merely served as fertile spots +for the planting and growth of the glanders bacillus accidentally +present, and which to a healthy system might have proved harmless. + +In 1882, Chauveau had demonstrated the particulate nature of the +glander germ by his unsuccessful inoculations with the liquids +filtered from dilutions of pus taken from a pulmonary glanderous +ulcer. The filtrate and the liquid mixture formed by mixing the pus +with five hundred times its own weight of water retained their +virulence undiminished. In 1868, Christol and Kiener discovered in +glanderous products a bacillus which they figured as made up of a +chain of nearly globular elements apparently enclosed in a common +sheath. In 1881-82, Bouchard, Capitan, and Charrin cultivated these +microphytes in a neutralized extract of meat through five successive +cultures, using in each case a milligramme of the previous culture, or +less than 1/1000 part of the culture-liquid. Counting that the +milligramme of pus would give to each centigramme of the first +culture-liquid 1,000,000,000 bacilli, it follows that the second +culture would, on the principle of dilution, contain 1,000,000, the +third 1000, the fourth 1, while for the fifth it was as 999 to 1 that +it would receive nothing unless the germ were multiplied in the +culture-liquid. Inoculation of a cat with this fifth culture, started +originally from a nasal ulcer of a glandered horse, led to a fatal +result in twenty-five days, with suppurating tumor of the left +testicle and inguinal glands. The products of the first cat were +inoculated on a second, those of the last on a third, those of the +third on a guinea-pig, and those of the guinea-pig on an ass, +producing in every case specific lesions of glanders, including +miliary nodules and abscesses, and death respectively on the following +days: 16, 7, 31, and 10. + +In September, 1882, and the two succeeding months, a similar course of +experiments was conducted by Schutz and Lofler at Berlin. The virulent +matter used for starting the culture was procured from a pulmonary +deposit and spleen of a glandered horse; the cultivation was continued +through eight successive culture-fluids. One horse was successfully +inoculated with the product of the eighth culture, and a second with +both the fifth and eighth. The first died on the fifty-eighth day, and +the second, now very weak, was sacrificed on the fifty-ninth. Both +showed the most extensive lesions of glanders alike in the skin, the +lymphatic glands, the pituitary and laryngeal mucous membrane, and the +lungs. To demonstrate the bacillus they take a thin layer of the +infecting liquid on a cover glass, dry it, stain with methyl violet, +wash with dilute acetic acid, dehydrated by absolute alcohol, and +clear by oil of cedar. Like other pathogenic microphytes this may be +preserved for months or years if thoroughly dried, but in the moist +condition it is easily destroyed by heat (133 degrees F.; Viborg, +Hofacker, Renault), chlorine, and the disinfectant chlorides and +sulphites. + +SYMPTOMS.--Acute nasal glanders in horses has a period of incubation +lasting from three to five days in inoculated cases. Where in infected +subjects the incubation appears to have extended over months or a +year, there have usually (or always) been deposits in internal organs +which passed without recognition until the lesions appeared in the +nose. At the outset there is fever, which appears before any local +lesions are recognizable, even post-mortem (Chauveau), and soon with +languor, {915} and loss of appetite, there is a serous nasal +discharge, often from one side only. By the sixth day this has become +yellowish, the margin of the nostril is often swollen, and upon the +pituitary membrane may be detected elevations of various sizes of a +general yellowish tinge, dotted with minute red points and surrounded +by a bright-red or purple and slightly elevated areola. These may be +simple, pea-like nodules or more or less extensive patches, which in +certain cases extend over nearly the whole pituitary membrane. At the +same time the submaxillary lymphatic glands on the same side become +the seat of a hard nodular painless enlargement, feeling like a +conglomerate mass of peas, and often showing a tendency to become more +closely adherent to some adjacent part (bone, skin, base of tongue); +but they only ulcerate exceptionally. Extensive hot, painful +engorgements also often appear on other parts of the body, and if on +the limbs or joints cause lameness. Soon the swellings on the mucosa +become eroded and are gradually destroyed, forming large unhealthy, +chancrous-looking ulcers, tending to become confluent and to eat +deeply through the mucosa into the subjacent tissues. These are mostly +reddish gray or yellowish gray, with raised ragged red or +yellowish-red margins. They bleed readily, and may be black from +hemorrhage, or greenish or of some other shade from decomposition. The +discharge is always somewhat glutinous and sticky, but it may vary in +color from simple white to yellowish, greenish, brownish, or red, +according to the destruction of tissue, the septic changes, or the +effusion of blood. + +By the sixth to the fifteenth day the acme has been reached. The alae +of the nostrils are glued together by the drying discharge, and this, +with the general swelling of the nasal passages, renders the breathing +snuffling and difficult. The lymphatics on the side of the face are +usually inflamed and corded, and the same is true of the cutaneous +lymphatics of the hind limbs of some other part of the body (farcy). +Death usually ensues from suffocation, preceded by the most painful +dyspnoea. + +Chronic glanders in horses often sets in insidiously, but frequently +also it first shows itself by constitutional disturbance, which +gradually subsides as the local lesions are formed. Among frequent +premonitory symptoms may be mentioned intermittent or continued +lameness, oedema of one or more limbs, infiltration of the testicle, +cough, and bleeding from the nose. The general health may appear good, +and if in good hygienic condition the digestion and nutrition may be +sufficient, the body plump, and the skin shining; but there is usually +some dulness of the eye, dryness of the coat, lack of endurance, and a +tendency to sweat easily and to run down rapidly under hard work or +debilitating conditions. The discharge, at first clear, becomes +turbid, grayish, sticky, and purulent, tending to agglutinate the +hairs and edges of the alae nasi, and is expelled by snorting in +masses. The nasal mucosa, and especially over the septum, is the seat +of the peculiar elevations, ulcers, and firm white, condensed deposits +resembling cicatrices, usually low enough down to be seen or felt. The +submaxillary lymphatic glands are the seat of the nodular enlargement +described in acute glanders, and, as in that affection, there may be +pulmonary or skin deposits shown by cough or oedema, with swelling and +cording of the cutaneous lymphatics with nodules and ulcers. + +These cases often maintain this indolent type for years, spreading the +{916} infection widely, but they tend sooner or later to develop the +acute type, especially under some debilitating conditions. + +When the mucous membrane of the larynx and bronchi is first attacked +the nasal lesions may be delayed for a time, but the cough, the +variously colored tenacious expectoration, the excessive tenderness of +the larynx, and the nodular enlargement of the adjacent lymphatic +glands, with the general ill-condition, suggest that which is later +confirmed by the specific lesions in nose and skin. + +When the affection is confined to the bronchia and pulmonary +parenchyma, there are the usual signs of bronchitis, disturbed +breathing, with hard, soft, mucous, or dry husky cough, and blowing, +mucous or sibilant rale, at points crepitation, and at others some +diminution of murmur and resonance. The breath is mawkish or fetid, +and expectoration more or less sticky and charged with bacilli; but +all these symptoms are at times equivocal, and inoculation alone can +attest the true nature of the disease. This should be practised by +preference on a donkey or an old horse in poor condition but with +general good health. Then the disease shows itself in the acute form +in six days. If solipedes are not available, rabbits or guinea-pigs +may be used for inoculation. + +In acute cutaneous glanders or farcy, premonitory symptoms resemble +those of ordinary acute glanders, which indeed is usually present as +well, and always supervenes before farcy terminates in death. The +local lesions consist in inflammation of the lymphatic vessels, which +become like firm cords, the appearance at intervals along these cords +of rounded glanderous nodules varying in size from a pea to a +hickory-nut, and with a marked tendency to ulceration and the +formation of hot, painful oedematous swellings. The swelling of the +lymphatics appears by preference in the lower part of a hind limb, and +the first nodules may be near the fetlock or tarsus. The ulcers +forming about the sixth day have a yellowish-white appearance with red +points and raised irregular borders, and the discharge is grumous and +viscous, with a yellowish or reddish tinge. The disease extends toward +the body, the upper air-passages become involved, and death speedily +follows. + +Chronic cutaneous glanders, chronic farcy, usually begins by a local +swelling, mostly of the fetlock, in the midst of which a careful +examination detects a small glanderous nodule. This tardily softens, +ulcerates, and discharges the characteristic ichor, the lymphatics +leading up from it become thick and rigid (corded), and new nodules +appear. Though very indolent, these finally tend to ulcerate, and in +time oedematous swellings appear in the vicinity or at distant parts +of the body, with nodules at intervals. This will go on for months, or +even for years, and recoveries occasionally take place, while in other +cases, and especially when the conditions of life are bad, acute +glanders supervene. + +MORBID ANATOMY.--The lesions consist essentially in a cellular growth +in the connective tissue, determined by the presence of the specific +poison, and in destructive changes in the elements of such +growth--softening, fatty degeneration, ulceration, and discharge. In +certain cases of nasal glanders at the earliest stage there is merely +an increased proliferation of the mucous corpuscles, which become more +granular or purulent. Soon, however, the fibro-vascular layer is +involved, the affected part being the seat of dark bluish congestion, +and {917} of the proliferation of small rounded lymphoid cells, +comparable to those of the early stage of tubercle, and enclosed in +more or less dense fibrous areolae. The common nasal nodule or patch +has a soft velvety surface, dirty gray or grayish yellow, and the +lymphoid cells are so circumscribed in nests that when soaked in water +the cells are washed out and the fibrous reticulum is left hollowed +out like a honeycomb. In this fibrous reticulum are many +spindle-shaped and a few rounded cells. Its vascularity is easily +demonstrated by injection. The centre of each nest is the palest part +of the mass, and unless stained by extravasation it contrasts with the +reddish areola. These islets of lymphoid cells, at first isolated and +each the size of a pin's head, may enlarge and become confluent, +forming the larger nodules. With this increase the centre of each +becomes turbid, and the cells are found to have become granular and +fatty, and to have in part broken up into a granular debris. This +characterizes the period of ulceration, and erosions and ulcers follow +in ratio with the extent of the neoplasm and the rapidity of its +growth. If the growth is tardy, the ulcer, with irregular eroded and +everted edges, may remain for some time stationary or even recede, +while if rapid, new tubercles form around the margin of the first, and +by the disintegration of their elements the ulcer is continuously +extended. The lesions are especially common on the septum nasi and +turbinated bones. Similar lesions may be found in the nasal sinuses or +larynx. + +The nodules found in the lungs strongly resemble miliary tubercles, +but are usually less numerous. As in the nose, they have a punctiform, +central, grayish, turbid portion, encircled by a more translucent +ring, surrounded in its turn by a vascular area. They are also +composed of the same granular rounded cells, though they may, +especially in the chronic forms, have undergone caseous, fibrous, or +calcareous degeneration. The acute tubercles are often surrounded by +circumscribed pneumonia with considerable exudation. They are +distinguished from genuine tubercle by their vascularity and by the +absence of giant-cells. + +The cutaneous deposits are composed of the same histological products +imbedded in the dermis or in the subcutaneous connective tissue, and +extending in some cases deeply between the muscles, with no clear line +of demarcation from the sound tissue. Not only the chains of nodules +(farcy-buds), but the connecting lymphatic trunks, are the seat of the +characteristic cellular product, and in chronic cases there is the +enlargement of the adjacent lymphatic glands as well. In these there +is a special tendency to early disintegration and ulceration. + +In the diffuse glanderous swellings (infiltrated glanders, +inflammatory glanders) the affected tissues are the seat of an +inflammatory process with profuse exudation throughout, while in the +interstices of the connective tissue are numerous granular +glander-cells. The same tendency to necrobiosis is shown as in the +other forms of glanderous neoplasms, and such diffuse swellings become +the seats of very extensive, deep, and irregular ulcers, or frequently +of fibroid growth and induration, forming the so-called cicatricial +deposits. These are hard, firm, and resistant, and histologically +consist of a dense fibrous stroma interspersed with the spindle-shaped +cells. They are especially common in chronic cases, and such an +appearance on the nasal mucous membrane is always suspicious, as this +dense fibroid appearance rarely follows a simple traumatic lesion. + +{918} Diffuse glanderous infiltrations in the nose may implicate the +entire mucosa of one or both nasal chambers, and the ulcers are liable +to be greater than from the nodular form of the disease. They are also +especially associated with thrombosis of the veins, which occurs to a +less extent in the nodular form and conduces to the dark-blue tint of +the mucosa. + +Glanderous infiltration of the lungs is inflammatory in its nature +(pneumonia malleosa), attacking an area of two or three inches in +diameter at or near the margin of the lungs, and proceeds to caseous +necrobiosis, suppuration, calcification, or fibroid induration. In the +skin such infiltrations also frequently terminate in induration, while +ulceration and abscess tend to appear when the proliferation of +glander-cells is most abundant (farcy-buds). + +The glander-nodules are not uncommon in muscles, intermuscular +connective tissue, spleen, liver, kidneys, and testicles. Leukaemia is +also a constant feature, the irritation of the lymphatic glands +manifestly stimulating the production of the lymph-cells. + +DIAGNOSIS.--The diagnosis of glanders usually rests on the viscid +nature of the discharge, the painless nodular swelling of the +submaxillary glands and the indisposition to suppurate, the +characteristic appearance of the nodules, elevations, ulcers, and +indurations of the nasal mucosa, and the presence of the specific +bacillus. The diagnosis of farcy rests mainly on the nature of the +nodules and corded lymphatics, of the ulcers and their discharges, on +the extension of the affection toward the trunk, and the tendency to +implicate the respiratory organs. Usually, there are several victims, +the earlier ones chronic cases, the later ones acute, or there is a +history or presumption of exposure. Yet in many cases, and especially +in the more chronic internal forms (laryngeal, pulmonary, etc.), the +diagnosis is difficult, and inoculation of a horse, goat, sheep, or +rabbit may be the only available means of reaching a decision. +Auto-inoculations are unreliable, as parts not yet the seat of active +disease will often resist inoculation. + +PROGNOSIS.--This is always unfavorable. The constancy of internal +deposits and the viability of the germ in such products render it +impossible to eliminate the poison from the system in the great +majority of cases. In external glanders only is there any reasonably +good hope, and even this is confined to the chronic cases. In stating +this much, it is not denied that recoveries even of chronic nasal +glanders do occur, yet these are few, and the majority of those that +do apparently recover usually succumb as soon as they are subjected to +hard work or specially trying conditions of life, so that but little +faith can be placed in most of the alleged recoveries. + +TREATMENT.--Considering the great danger of multiplying and preserving +the germs of a disease so fatal alike to man and beast, the treatment +of glanders is never commendable. The danger is least in the case of +chronic farcy, not only because the processes are less active, but +because the virus is not being thrown out and diffused with the tidal +air of respiration, sneezing, and coughing. The unbroken farcy-buds +and swollen lymphatics may be actively treated by compound iodine +ointment, and the ulcerous nodules freely cauterized with corrosive +sublimate, biniodide of mercury, chloride of zinc, sulphate of copper, +or iodized {919} phenol. Local inflammations may demand fomentations +and astringent antiseptic lotions. Meanwhile, the system must be +supported by a tonic regimen and medication, abundance of pure air, a +liberal and wholesome diet, and the maintenance of the various bodily +functions in a healthy condition. Of medicinal agents the most +pronounced tonics have the best reputation--sulphate of copper and +iron, biniodide of copper, arsenic, and, above all, arsenite of +strychnia. Next to these the sulphites rank, and a combination of the +two last named is perhaps to be preferred. + +PREVENTION.--The glandered horses and all animals attacked with acute +or obstinate farcy should be destroyed and their bodies be burned or +deeply buried. Every State should legally interdict the use of a +glandered horse or his exposure in any public or other place where +infection is likely to reach other animals by contact or through +fodder, litter, stable utensils, or any other objects employed about +animals. No less imperative should be the perfect disinfection of all +stables, harness, and other objects with which glandered animals have +come in contact. The value of such measures is sufficiently attested +by what has been stated above as to the prevalence of this disease in +the French army so long as the doctrines of non-contagion dominated in +its management, and the comparative disappearance of the disease so +soon as a change of theory and method had been inaugurated; the +absence of the disease in the English army, where the doctrine of +contagion and its extinction has long prevailed; and the entire +absence of the disease from Australia, New Zealand, etc., into which +it has never been imported, though prevailing in a corresponding +latitude and climate at the Cape of Good Hope. + + +Glanders in Man. + +Up to 1812 the communication of glanders to man failed to be +recognized. Then Lorin, a French surgeon, published a case of the kind +in which inflammation of the hand was induced by inoculation from a +horse suffering from farcy, and Waldinger and Weith drew attention to +the dangers of infection about the same time. In 1821, Muscroft in +England and Schilling in Germany simultaneously reported cases of +infection from the horse in which the true symptoms of glanders in man +were recognized. Rust, Sedow, and Weiss soon followed with additional +cases; then Forozzi (1822), Seidler (1823), Wolff, Grossheim, Eck, +Brunslow, Lesser, Travers (1826), Kries, Grubb, Brown (1829), Neumann +(1830), Vogeli (1831), Alexander (1832), and Elliotson (1833). Though +the disease was now well recognized, yet its nature has been +elucidated by a series of later writers, including especially Rayer, +Tardieu, Virchow, Leisering, Gerlach, and Koranyi. + +ETIOLOGY.--Man is rarely infected from any other source than the +horse. In a very few instances the contagion has been derived from +infected men. The modes of infection, immediate and mediate, are the +main points to notice in this connection. Those employed about horses +are usually infected by direct contact of the poisonous discharges, +blood, or tissues with abrasions on the skin or mucous membranes. The +inoculation received in giving medicine, examining the nose, +performing operations with effusion of blood, dressing cutaneous +ulcers, slaughtering, {920} skinning, making a necropsy, burying, +etc., is not uncommon. Again, direct infection is sustained through +snorting of the horse, so that particles of the virulent discharge are +lodged on the mucous membrane of the eye or nose. Closely allied to +this is infection by inhaling the exhalations of glandered horses, and +this doubtless accounts for some few cases which have been recorded as +communicated through the unbroken skin. The bite of the glandered +horse is a rare means of infection. From infection by eating glandered +animals man is usually saved by the cooking of his food and by his +inherent power of resistance, yet with instances of this kind on +record, as recorded by Ringheim, and the well-known conveyance of the +disease to animals in this way, it would be folly to ignore the risk +to man from eating the flesh of glandered horses, sheep, goats, and +rabbits. + +Among the mediate forms of contagion may be named drinking from the +same pail or trough after a glandered horse, using a knife that has +been employed to open a glanderous abscess, wiping a wound with an +infected blanket or handkerchief, handling infected harness, +wagon-pole, or manger with wounded hands, sleeping over glandered +horses or in a stall or on litter previously used by such horses. + +Conveyance of glanders from man to man has taken place through using +or handling the same dishes, towels, or handkerchiefs, through +dressing the wounds, or, as in the case of the veterinarian Gerard, +through making an autopsy of a victim of the disease. + +Fortunately, the susceptibility of man is slight, but few out of the +multitudes handling glandered horses becoming infected. It is +essentially an industrial disease, 114 cases being distributed as +follows among the different occupations: hostlers, 42; farmers and +horse-owners, 19; horse-butchers, 13; coachmen and drivers, 11; +veterinary surgeons and students, 10; soldiers, 5; surgeons, 4; +gardeners, 3; horse-dealers, 2; policemen, shepherds, blacksmiths, +employes at veterinary school, and washerwomen, 1 of each. + +A condition of ill-health doubtless predisposes to this as to other +invasions of infectious disease, yet men in apparently the most +vigorous health have succumbed to the poison. + +SYMPTOMS.--The incubation of acute glanders in inoculated cases +usually varies from one to four days. In cases in which the mode of +entrance is not so manifest it may apparently extend over one, two, or +even three weeks. If the disease has occurred by external inoculation, +the seat of the wound shows the first symptoms, consisting of tense +swelling, pain, and a dark or yellowish erysipelatoid redness, while +the edges of the wound are puffy and everted, the matter escaping is +sanious, and the surrounding lymphatics are swollen and red and the +lymphatic glands enlarged and tender. After a few days constitutional +disorder sets in--languor, extreme weakness and prostration, aching in +the limbs (muscles and joints) and in the head, rigors alternating +with fever or a continued fever after the first violent chill, and in +some cases nausea, vomiting, and even diarrhoea. In cases not +resulting from external inoculation the febrile symptoms are the +earliest to be noticed, and the muscular and articular pains may be at +first mistaken for acute rheumatism. In other cases, in which the +gastric and intestinal disorders are the most prominent and the +prostration and weariness extreme, the symptoms at first strongly +{921} suggest typhoid fever. Soon, however, with a sense of +formication a local yellowish or livid erysipelatoid inflammation +appears, by preference on the softer parts of the face, the nose, +eyelids, cheeks, or on one of the principal joints, the shoulder, +elbow, or knee. In the midst of the phlegmonous swelling, or even +antecedent to it, there appear small firm red spots or nodules, +sometimes as small as those of variola, at others like a pea or as +large as a walnut or larger. These gradually blanch in the centre, +soften, and change into pustules or abscesses, and, bursting, +discharge a slimy, thick, sanguineous pus, often emitting a mawkish or +fetid odor. The sores thus formed are ulcerous and unhealthy, with +puffy, ragged, everted borders and a grayish or yellowish red base, +which often extends deeply between the muscles and exposes tendons and +bones. When several deposits of this kind are closely aggregated, they +tend to combine in one slough, which may involve a great extent of +tissue. In all cases there are the swollen, reddened, tender condition +of the connecting lymphatics and the tumefaction of the lymphatic +glands. At times the deposits and abscesses are deeply seated in the +interstices of the muscles, and at other times the joints are enlarged +by exudation. + +In nearly one-half of the cases glanders supervenes on the cutaneous +symptoms. At first a viscid, whitish nasal catarrh appears from one or +both nostrils, mixed with striae of blood; then upon the pituitary +membrane appear ulcers like those already described in the horse; the +same form on the buccal, pharyngeal, and laryngeal mucous membranes, +and by physical examination they may even be found to have invaded the +lungs. The margins of the nostrils become adherent through the drying +of the tenacious mucus; the meati are blocked or narrowed by the +swelling of the mucosa, the detachment of sloughs, and the +accumulation of the discharges; the breathing becomes snuffling and +difficult; the voice altered or lost; the cough weak, with a mucous +and bloody expectoration, and the breath offensively fetid. The +submaxillary lymphatic glands are inflamed and enlarged, and may even +go on to suppuration and ulceration. The conjunctiva is usually +involved, and at times the specific formation and ulceration extend to +the stomach and intestines, and nausea, vomiting, indigestion, +irregularity of the bowels, and fetid diarrhoea ensue. There is +complete anorexia, but thirst is ardent, especially with diarrhoea. +With the advance of the disease dyspnoea supervenes, and nervous +disorder is shown by the extreme weakness, anxiety, sleeplessness, +troubled dreams, nocturnal delirium, dilated pupils, and even coma. +The temperature, though at first unaltered, may later rise to 104 +degrees F., and the pulse to 110 to 120 beats per minute. The +diagnosis is confirmed by detection of the bacillus in the discharges, +and, above all, in the liquids of freshly-opened pustules +(Wassilieff). + +The duration of acute glanders in man may be no more than three days, +though usually it is protracted to fourteen or twenty-one, and +exceptionally to twenty-nine days. The almost constant termination of +this form of the disease is in death. + +Chronic glanders occasionally appears in man, and is in most respects +the counterpart of that of the horse. The morbid process shows itself +in the integumental or other tissues of the body, and only attacks the +nose and air-passages later, when the constitutional symptoms become +more intense. The general malaise, languor, prostration, aching of +{922} limbs and joints, and inappetence are usually present, +complicated by a local swelling in the seat of inoculation (face, +hands, etc.), with small nodules progressing to pustules, congestion +of the lymphatics, and swelling of the lymphatic glands. These lesions +may subside even before suppuration, and the disease is manifested for +a week or two only by a general feeling of weariness and ill-health; +but sooner or later the local symptoms reappear in the same or another +seat, and the neoplasms, though indolent for an indefinite length of +time, finally degenerate, soften, burst, and form ulcers. These ulcers +have the general characters already described--a livid grayish or +yellowish hue, with red, puffy, irregular edges, and a viscid +greenish, yellowish, dirty white, or bloody discharge. They tend to +increase, or they may appear to heal by the peculiar firm cicatricial +formation, but on the swollen margins new deposits, abscesses, and +ulcers tend continually to form. Sometimes these are of considerable +size and seated deeply among the muscles, but when opened they show +the same unhealthy serous or bloody pus, and manifest a tendency to +extension rather than to healing. When the disease extends to the +respiratory organs, often two or three months after the onset, there +is cough and sore throat, blocking of the nose by the tenacious +discharges and swollen mucosa, and in the pharynx, fauces, and nose +the characteristic ulcer may be detected. The attendant constitutional +symptoms are also much more marked--indigestion, nausea, vomiting, +diarrhoea, rigors, profuse perspiration, high temperature, excited +breathing and pulse, a yellowish or earthy hue of the skin, rapid +emaciation, and great prostration. Though great emaciation, debility, +and hectic ensue on the indolent chronic processes, yet the disease +usually assumes all the characters of the acute type before +terminating fatally. + +In cases that recover the fever diminishes, exacerbations cease, +ulcers granulate and cicatrize, vesicles dry up, the nodules and +enlarged glands diminish, the erysipelatoid swellings of skin and nose +subside, and a very tardy and imperfect convalescence is established. + +The duration of chronic glanders, nasal or cutaneous (farcy), is +exceedingly indefinite, varying from three months to ten or eleven +years. One of the most protracted cases is that recorded by Bollinger +of a veterinarian who, after an eleven years' illness, recovered with +cicatricial contraction of the nose and larynx and a decided cachectic +appearance. + +MORBID ANATOMY.--Besides the lesions above mentioned as occurring in +the skin and mucous membranes of the nose, mouth, and pharynx, the +frontal sinuses, the larynx, and less frequently the lungs, are the +seats of the specific glanderous processes. In the lungs there are +then the nodules, hard, caseous, or purulent according to their age, +and varying in size from a millet-seed and pea upward to the involving +of the greater part of a lobe. Beneath the pleurae may be seen +ecchymoses, hard, fibrous nodules, and yellow elevations, which on +being incised furnish grumous pus. The spleen is usually enlarged, +gorged with blood, gray or black, and is the seat of suppuration. The +liver is enlarged, softened, and may be the seat of glanderous +processes, with ulcers in the bile-duct or gall-bladder. The joints, +like other serous cavities, become the seat of specific suppuration. +The bones are often implicated in adjacent deposits, especially in the +face, cranium, and hands, so that the compact tissue may become +reduced to the merest shell, while the medulla and periosteum {923} +abound in the specific products. The cerebral meninges and +brain-tissue are frequently the seat of specific growths and minute +abscesses. It is noticeable that the enlargement of the lymphatic +glands is usually less than it is in the horse, though they are never +entirely free from lesions. Indeed, the tendency in man to the +formation of considerable glanderous neoplasms is much less than in +the solipede. + +The microscopy of the lesions is essentially the same as in the horse. +O. Wyss describes the cutaneous nodules as formed by a great +proliferation of round cells (like pus-cells) in the upper layer of +the corium just beneath the papillary layer. In a more advanced stage +the corium and papillae are filled with pus-cells, and, becoming +disorganized, give rise to the formation of pustules and small +abscesses. Lagrange describes in a chronic ulcer of the palm, a layer +about 2 mm. in thickness of embryonic cells closely packed with an +amorphous intercellular substance. The nuclei appeared larger than in +ordinary ulcers or tubercles. Extending into this layer were capillary +vessels packed with red globules and with blind extremities, or in +some instances minute ruptures and hemorrhages. Beneath this +superficial cellular layer was a stratum of striated muscle, +especially noticeable for the excess of condensed connective tissue +making up the intermuscular septa, and the great multiplication of +nuclei with large, clearly-defined nucleoli, not only inside the +sarcolemma, but also between the fibrillae and separating them widely. +At some points the muscular tissue had undergone a vitreous +degeneration, while at others were many fusiform cells. At one point, +where the ulcer extended to the phalanx, the compact layer of the bone +was attenuated to the thinnest shell and perforated, so that the +medulla was continuous with the ulcer. The medulla contained a great +number of white globules, medulla-cells, and minute embryonic nuclei. +The vessels were remarkable by the extensive fibroid thickening of +their coats. On section of the ulcer many orifices stood widely open +because of the rigidity of their walls. The internal coat was +plicated, as if too large for the lumen. The external fibrous layers +were at points abundantly interspersed with, and even replaced by, +groups of embryonic cells, the active proliferation of which meant the +destruction of the perivascular fibrous layer. These embryonic cells +even invaded the lumen of the vessel and partly blocked it, so that +the remnant of the tube remained as the centre of a disintegrating +mass, or later a caseous or purulent focus. + +DIAGNOSIS.--Acute glanders, when well developed, is unmistakable. The +presence on or near the skin of the characteristic nodules, pustules, +phlyctenae, and ulcers, the oedema or erysipelatoid condition of the +adjacent skin, the redness of the lymphatics, the presence of the +neoplasms and ulcers in the nose, and the sticky, fetid, variously +colored nasal discharge, with the acute fever, prostration, and pains +in the limbs and joints, make a tout ensemble that is pathognomonic. +In the initial stage only it may be confounded with rheumatism, but +the arthritic pains are not usually attended by the same amount of +redness and swelling of the joints, the prostration is far more +profound, and there are in most cases an irritable, unhealthy-looking +wound and a history of exposure to infection from glandered horses. + +In chronic glanders, and especially in the external form (farcy), the +diagnosis is often more difficult. From pyaemia and septicaemia it is +{924} usually to be distinguished by the comparative absence or the +slightness of the chills, by the less healthy character of the pus, +and by the implication of the nasal mucosa, the larynx, and lungs. +When the nose, larynx, or lungs are but slightly affected, there may +be a strong resemblance to syphilis or miliary tuberculosis, but a +close attention to the character of the lesions, the absence of any +concomitant history or symptoms of syphilis, and deductions drawn from +the occupation of the patient and the presumptive exposure, will +greatly assist in reaching a diagnosis. + +The detection of the bacillus is not conclusive, as in tuberculosis +and some forms of septicaemia there are similar organisms, agreeing +with the microbe of glanders even in the matter of size. In cases of +doubt a little delay will usually allow the development of new and +more characteristic symptoms. + +The final resort, however, is to inoculation. Auto-inoculation, as +practised by Poland, is rarely satisfactory, as the system has +acquired a partial tolerance of the disease and local lesions are not +so certainly developed as in the healthy subject (St. Cyr). +Inoculation on a healthy goat, sheep, or rabbit can always be availed +of, and if practised on more than one subject can be relied upon, as +the virus loses nothing of its power in passing through the human +system, but usually determines an acute form of the disease in the +animal inoculated. + +PROGNOSIS.--Acute glanders is almost constantly fatal to man. Of +chronic cases, and especially the external form (farcy), from +one-third to one-half of the subjects recover. When both internal and +external (farcy--glanders), the issue is usually fatal. Kutner claims +that cases caused by external inoculation are more favorable than +those caused by the inhaled poison. This accords with the general +principle, that a poison viable in the comparatively vitiated air of +the lungs or on the surface of the intestinal canal is better fitted +by its habit of life for survival in the blood and plasma, and is +consequently more redoubtable. The greater the duration of the disease +in any particular case, the more favorable is the prognosis. + +TREATMENT.--In the treatment of glanders in man the same principles +must guide as in animals. In external, inoculated cases the wounded +tissues should be early destroyed by potent caustics--fuming nitric +acid, corrosive sublimate, iodized phenol, chlorine, sulphate of +copper, carbolic acid, or the hot iron. The erysipelatoid swellings +may be treated by leeching, followed by solutions of carbolic acid, +iodine, or chlorine-water, by ice, and internally by laxatives and +iodide of potassium. The first two antiseptics may be freely used by +hypodermic injection. Abscesses and tumors should be laid open and +cauterized as above, and then treated by weaker solutions of the same +agents. Nasal ulcers may be treated by insufflation of iodoform and +injections of creasote, carbolic acid, nitrate of silver, or +permanganate of potash solutions. Of the greatest importance is a +general tonic and stimulating regimen. A nutritious diet (including +beef-tea), abundance of pure air, alcoholic stimulants, quinia, +tincture of the chloride of iron, and, above all, arseniate of +strychnia, have been used with advantage. Various anti-ferments, such +as the bisulphites in full doses, carbolic acid, and iodide of +potassium, have apparently proved beneficial, and deserve a further +trial. As in the horse, a great {925} variety of other agents, mostly +of a tonic nature, have been employed, but with very variable results. + +PREVENTION.--The first step toward the prevention of glanders in man +is the systematic restriction and extinction of the affection in +animals. This has been already sufficiently referred to above. Further +measures of prophylaxis embrace the following: the avoidance of +contact with glandered and suspected horses by all persons having any +wounds, abrasions, or ulcers on their skins; the cauterization with +nitrate of silver of all such sores on persons necessarily brought in +contact with glandered or suspected animals or their products; the +general diffusion of information as to the danger from glandered +animals; washing of hands and face in a solution of carbolic acid or +chloride of lime after handling infected or suspected animals or their +carcases or products; the thorough disinfection or destruction +(preferably by fire) of harness, clothing, racks, mangers, +wagon-poles, buckets, troughs, brushes, combs, litter, and fodder that +have been exposed to infection; and, finally, the exclusion from the +markets of all meat derived from suspected or infected animals. It is +generally held that the flesh of the horse alone demands inspection, +but with the known susceptibility of sheep, goats, and rabbits it can +easily be conceived how the infection may reach man through his food, +though horse-flesh is never consumed. That glanders has never been +recognized as arising from the consumption of diseased sheep or +rabbits does not prove that it has never reached man by this channel, +any more than the absence of all recognition of the infection of man +from the horse would prove the non-occurrence of such infection until +the beginning of the present century. The knowledge that the animals +used for food in this country are liable to contract and convey this +disease is an additional reason for the systematic and universal +suppression of the disease among the equine population. + + + + +{926} + +ANTHRAX (MALIGNANT PUSTULE). + +BY JAMES LAW, F.R.C.V.S. + + +SYNONYMS.--_Latin_, Ignis Sacer, Anthrax Epizooticus, Pustula Maligna, +Pustula Pestifera, Erysipelas Carbunculosum, Carbunculo Contagioso, +Glossanthrax, Angina Carbunculosa, Anthrax Haemorrhoidalis, Mycosis +Intestinalis, Apoplexia Splenitis, etc. _English_, Black Erysipelas, +Malignant Vesicle, Anthrax Fever, Splenic Apoplexy, Splenic Fever, +Inflammatory Fever, Carbuncular Fever, Black Quarter, Blood-Striking, +Bloody Murrain, Blain, etc. _French_, Pustule maligne, Charbon, Fievre +putride, Typhohemie, Pelohemie, Mal de Rate, Splenite Gangreneuse, +etc. _German_, Karbunkelkrankheit, Contagiose Karbunkel, Milzbrand, +Milzseuche, Milzbrandfieber, Brandbeulenseuche, Rothlauf, etc. +_Russian_, Jaswa (boil-plague). _Italian_, Antrace. _Spanish_, +Carbunculo, Lobado. _Swedish_, Boskapssjukan. _Mexican_, Calentura del +piojo. + +DEFINITION.--Anthrax is an acute, infectious, bacteridian disease, +occurring mostly in the Herbivora and Omnivora, but communicable to +other mammals (including man), to birds, and even fishes. Its local +manifestations are exceedingly varied in kind, but the malady is +characterized by the presence in the tissues or blood, or both, of +specific spherical and linear bacteria (micrococcus and bacillus +anthracis), leading to arrest of haematosis, to disintegration of the +blood-globules, to sanguineous engorgement of the spleen, to capillary +embolism, and to a spreading gangrenous inflammation. + +HISTORY AND GEOGRAPHICAL DISTRIBUTION.--While ancient history is not +clear as to the specific diseases of animals, yet there is the +strongest presumption that nearly all great plagues that attacked +indiscriminately animals and man were of this nature. Thus, the plague +of murrain, with boils and blains breaking out on man and beast, in +the days of Moses, was probably of this kind (Gen. ix. 3.); also that +which at the siege of Troy extended from animals to man, and many +later epizootics in all parts of the world. No infectious disease of +man and animals, with the single exception of tuberculosis, has been +more widely diffused, and none can be considered as more cosmopolitan. +Heusinger, in his classic work on _Milzbrandkrankheit_, traces the +ravages of the disease from the highest to the lowest latitudes in the +northern and southern hemispheres and in the Old World and the New. He +adduces outbreaks in Siberia, Astrakan, Lapland, and Finland, in +Russia, Prussia, Poland, Silesia, Bavaria, Holland, Belgium, France, +Spain, Portugal, Italy, Switzerland, Austria, Hungary, Greece, Turkey, +Egypt, East and West Indies, {927} North and South America, etc. We +can now add all the great English, French, and other European colonies +not included in the above (South Africa, Australia, New Zealand, +Algeria, etc.), together with China and Japan. We find, moreover, that +the disease is always most prevalent where agriculture is in its most +primitive condition, so that there can be little doubt of the +prevalence of the affection in the less-civilized countries as well. +But while the disease is prevalent in all parts of the world, its +ravages are largely subordinate to the nature of the soil. Wherever +this is close, impervious, marshy, or charged with an excess of +organic matters, the gaseous emanations of which drive out most of the +oxygen, the anthrax-germs, once introduced, tend to be preserved +indefinitely. Thus, in drying up basins with no natural drainage, on +lake and river margins, on deltas, in forests, in mucky, mossy, or +peaty soils, and on those that are habitually over-manured, the germs +of anthrax are especially liable to be perpetuated. It has long been +noticed that herbivorous animals are the most susceptible to anthrax, +while the purely carnivorous, and to a less extent the omnivorous, +have relatively a far higher resisting power. That the immunity is +largely due to the food is manifest from the experiments of Feser on +rats. Those fed on vegetable aliment contracted anthrax readily from +inoculation, while those kept on an exclusive diet of flesh +successfully resisted. The same rats that escaped while on a flesh +diet were afterward placed on a vegetable diet, and then perished +after inoculation.[1] Davaine found the same to be true of foxes kept +on meat and vegetables respectively, and inoculated with the virulent +blood of the allied disease, septicaemia. He found, moreover, that +guinea-pigs were much more susceptible to anthrax than rabbits. +One-thousandth of a drop of virulent anthrax blood invariably killed +the guinea-pig, while it left the rabbit unharmed.[2] Klein has never +found a rabbit insusceptible. It has recently been claimed that pigs +are insusceptible, but I have known of many instances in which the +offal of anthrax cattle, when devoured by pigs, has determined fatal +anthrax in the latter. Chickens too prove much less susceptible to +anthrax than the Herbivora. Inoculations made by Cohn and others +proved invariably unsuccessful, while Pasteur has showed that they can +be infected easily after the body has been cooled by partial immersion +in cold water.[3] Pasteur attributes this immunity to their normally +high temperature, yet rabbits, sheep, pigs, wolves, and foxes, though +maintaining a correspondingly high temperature, are still subject to +anthrax. Even the herbivorous mammal suffering from acute anthrax +fever has its temperature raised to that of the chicken, yet the +disease progresses none the less surely to a fatal result. Again, +anthrax liquids inoculated under the skin of a fox proved harmless, +while if thrown into the warmer peritoneal cavity they proved fatal. +It may well be suspected that the relative insusceptibility of +chickens is in part due to the large amount of animal food consumed by +them, and that the chilling process increases the receptivity by +deranging sanguinification and nutrition. + +[Footnote 1: _Wochenschrift f. Thierheilkunde und Thiersucht_, Nos. 24 +and 25, 1879.] + +[Footnote 2: _Rec. de Med. Vet._, Mar. 15, 1879.] + +[Footnote 3: _Ibid._, Mar. 15, 1880.] + +The insusceptibility to anthrax is often characteristic of certain +individuals or families or of the animals living in a particular +district. Thus, Chauveau found that some French sheep, and nearly all +Algerian ones, {928} resisted inoculation with a moderate amount of +anthrax virus, while the introduction of a maximum amount proved fatal +to these as to others. In the same way, it is often noticed that +animals living in an anthrax region escape the evil effects of the +poison, while strange animals brought in either fall ready victims or +for a time do badly until they have become habituated to the locality. +In view of the subsequent protective effect on the system of a first +and non-fatal attack of anthrax, it is probable that all these +examples of immunity in the Herbivora depend on a previous mild attack +of the same disease or on the extinction of the more susceptible +races. Even in the case of the animals that do badly on first coming +into an anthrax district, and recover better health with immunity +later, we may well infer that a mild form of the anthrax infection has +been passed through. + +ETIOLOGY.--The one essential cause of anthrax is the introduction into +the system of a specific bacteridian germ (bacillus anthracis or its +spores). This is not, as a rule, carried far on the atmosphere, but +demands for its propagation contagion, immediate or mediate. Unless, +therefore, it meets in the soil the conditions necessary to the +preservation and propagation of the germ, it is transmitted with some +uncertainty from animal to animal, and thus the disease does not +spread widely and rapidly, like an ordinary plague, but tends to +become localized in particular districts as an enzootic. + +But its dangers are none the less real nor its existence less to be +dreaded. In predisposed localities, where the disease-germ has gained +a footing, the animal mortality may exceed that caused by the great +plagues, while the risk to human beings is incomparably greater than +from any other acute infectious disease of the lower animals. Thus, in +San Domingo, in 1770, 15,000 people perished in six weeks from eating +the carcases of anthrax animals, and the mortality was only arrested +when the meat was legally interdicted. In the worst anthrax years on +some of the Siberian steppes as many as one-fourth of the whole human +population suffer from the malady. The prevalence and death-rate, +however, vary greatly in different localities and seasons. Sometimes +only one or two solitary cases of the affection are observed; at other +times the disease becomes moderately prevalent, but a lack of +virulence in the poison or a previously acquired insusceptibility of +the individual protects the great majority of the animals exposed, +while at others, still, the poison attacks nearly all exposed to its +contagion. + +The animal products that mainly convey the disease are the blood, the +liquid exudations, portions of the diseased carcase, and the bowel +dejections. The virus is most potent when derived from an animal still +living or only recently dead, yet under certain conditions (with +spore-formation) it may long retain its virulence under the most +extreme changes of climate, temperature, dryness, and humidity. +Russian hides tanned in England or America frequently convey anthrax, +which is known especially as a tanner's malady, and wool and hair sent +from Buenos Ayres have repeatedly produced malignant pustule +(woolsorter's disease) in Britain and the United States. The preserved +scabs of malignant pustule have been often successfully inoculated on +the lower animals, so that, like other forms of poison, this seems to +be preserved indefinitely by desiccation. + +The simple contact of the virus with the slightest abrasion will +suffice {929} to convey the disease. It has often been communicated +where no lesion of the epidermis could be found, yet the presumption +is that even in such cases the cuticle had been in some way wounded. +Eating the flesh of animals killed while suffering from anthrax has +often conveyed the disease. In an outbreak in Swineshead, +Lincolnshire, England, in 1863, I found a dog and a number of swine +suffering from eating the bodies of dead bullocks. In 1864 an East +Lothian (Scotland) farmer fed his pigs with the offal of a slaughtered +anthrax bullock, and lost nearly the whole herd. The carcase of the +bullock had been sent to market. About 1860 cattle, and even horses, +died yearly on a swampy meadow at Brighton, Mass. On one occasion the +owner, John Zoller, fed the offal of a dead bullock to his pigs, which +were speedily attacked with anthrax, and as speedily killed to save +their bacon (Dr. Thayer). Even when cooked the flesh is not always +safe. Of this we have the undoubted case in San Domingo above noticed, +the alleged death of 60,000 people in the vicinity of Naples from the +same cause in 1617 (Kircher), and the thousands that die on the +Russian steppes every anthrax year from eating the sick horses +(Rawitch). But in all these, and in the ever-recurring cases in which +families suffer from eating anthrax meat, there is the possibility, if +not the probability, of the contamination of the meat subsequently to +cooking by the knives, forks, tables, and dishes used. The San Domingo +slaves had few appliances for cleanliness, much less disinfection, and +the Tartars eat their meat from the same board on which it has been +chopped up raw. + +In accurate experiments it has been found that the bacilli are +destroyed by a temperature of 145 degrees F. maintained for five +minutes, but the spores are capable of surviving the boiling +temperature for five or even ten minutes. The varying power of +resistance may be compared to that of the green stalk of the pea and +the dry flinty seed. The first is destroyed by a very moderate heat, +while the second will sprout after having had boiling water poured +over it. The resisting bacillus-spores are never found in the living +animal, but may be developed in the blood and tissues after death, and +may account for the occasional extraordinary viability of the poison +when exposed to a boiling temperature. + +Milk, though often used with impunity, conveyed the disease when +inoculated by Bollinger, and the same was true of the vaginal mucus. +Innocent in the early stages of the disease while the germs are still +localized, they become virulent after the bacilli swarm into the +blood. + +Healthy men and animals often carry the poison, though themselves +insusceptible. The question of its conveyance by insects has been much +debated, but the constant occurrence of malignant pustule on the +uncovered parts of the body goes far to settle the question. Bourgeois +long ago noticed that it was most frequent on the face, hands, neck, +and arms, and rare on the trunk. In sixty cases recorded by A. W. Bell +of Brooklyn, all occurred on the face except two on the hands, one on +the wrist, and one on the forearm. The bite of a fly or mosquito had +in many of these cases proved the starting-point of the malady. +Bollinger has shown the presence of the bacillus in the stomach of +such flies as fed on flesh and blood (horse-flies, bluebottles, etc.), +and, together with Raimbert and Davaine, has produced anthrax by +inoculations with the stomachs, legs, and proboscides of these +insects. + +{930} Surgical instruments occasionally convey anthrax. At +Cockburnspath, East Lothian, Scotland, a yearling heifer contracted +anthrax, and the whole herd was bled, commencing with the sick one. +Next morning seven were found dead, the disease in each case extending +around the fleam-wound. At Brunt, in the same county, a shepherd +skinned an anthrax bullock, and after washing and taking a turn among +his sheep, on the same day castrated several litters of pigs, all of +which perished. In St. Lawrence Co., N.Y., in 1870, a surgeon +inoculated himself while opening a vesicle on the hand of a farmer. + +Harness, stables, stable utensils, vehicles, fodder, and litter are +frequent bearers of contagion. At Geneseo, N.Y., in 1877, three horses +and a cat died in midwinter after licking the blood from a stone-boat +which had conveyed the skin of an anthrax bullock to market. Green +fodder or hay harvested from ground formerly occupied by anthrax +victims or from their graves often convey the poison, but probably +only by the adherent earth and dust containing the anthrax-germ. + +That the anthrax bacillus and its spores may be long preserved in +earth is abundantly proved. At Avon, N.Y., nine months after any cases +of the disease, the liquid leaking out on the river-bank near to the +grave of a victim of the year before was licked by six cattle, and in +two days they all perished. On the same pasture victims were seized +yearly for seven years, but with a rigid seclusion of these, their +products, and their graves the malady has finally disappeared. The +persistent deadly effect of some soils on animal life, apart from the +presence of the carcases, seems to show that in certain soils we find +the normal home of the anthrax bacillus, while the migration into the +animal economy is but an accident of its existence. The soils that are +especially subject to anthrax are the dense clays, the limestones, and +the rich alluvials. Among the essential conditions are the exclusion +of oxygen, excepting a limited amount bearing some relation to what is +found in the animal fluids, and the abundance of some alkaline agent +(lime, potash, soda, ammonia), so that the earth is either neutral or +only very slightly alkaline or acid. An acid vegetable infusion is +inimical to the germ, which soon disappears from such a medium. The +requisite paucity of air is found in all the dense, less pervious +soils (clays, etc.), in soils habitually waterlogged (swamps, deltas, +river-bottoms, low meadows, natural basins, drying lakes and ponds), +and in soils rich in decomposing organic matter (peat, alluvial, +over-manured). The antacid is often found present as lime or potash, +or is constantly being produced in the form of ammonia, etc. by +organic decomposition. Such places are known to farmers as "dead +lots," because no stock will live on them. The bacillus in the buried +carcase does not produce spores (Bollinger), though it may in the soil +at any temperature between 59 degrees and 110 degrees F. In the +graves, therefore, at a lower temperature, the poison can only be +preserved by a continuous generation of the bacillus. + +Pasteur, who successfully inoculated the casts of earth-worms taken +from anthrax graves, attributes to these an important role in bringing +the germs to the surface. A more important agent, however, is probably +the rise and fall of water in the soil. By this means the bacilli and +spores are washed up toward the surface, and when the superficial +layers dry out they are easily carried by the winds. Hence it is that +anthrax is usually prevalent in late summer and when the soil is dried +and heated to its {931} greatest depth. Thus it is, too, that wet +seasons followed by specially dry and hot ones are, above all, +productive of anthrax in herds. Wet seasons fulfil the further purpose +of carrying off the germs into rivers and depositing them on the banks +or on inundated meadows, where after the subsidence of the flood the +disease appears, for the first time perhaps. + +There is, however, good reason to believe that the effect of a warm +season is not confined to its influence on the soil and its germs. The +high temperature deranges the vital functions of the animal economy, +and, inducing a febrile disturbance, lessens the power of resistance +to the anthrax virus, just as the cooling of the warm-blooded bird +lays it open to infection. On this account, and because of the +frequently recurring electric storms, the hot dry season is especially +the season of anthrax. The hottest, driest autumns of Siberia always +coincide with the anthrax years, and in the last fifteen years in the +United States I have noticed the wide extension of anthrax whenever +the season has been unusually hot and dry. In Corsica the herdsmen +confidently pasture their stock in the close still valleys throughout +spring and early summer, but whenever the surface soil is dried out +they make all haste to remove it to the hills, well knowing that delay +means devastation and ruin. + +Plethora is undoubtedly an important predisposing cause of anthrax, +and so is the alternation of cold nights with hot days. The febrile +condition induced in the animal economy is perhaps the main factor at +work in each case. Finally, youth is on the whole more liable than +age, but whether because of the greater receptivity of the growing +system and its tissues, or because it has not yet acquired some +immunity by exposure to the milder effects of the poison, is not +certainly determined. Sex is without influence. + +It is not a little remarkable that the bacillus germ has not yet been +found in the placental liquids nor foetal blood of sheep, goats, or +rabbits, though swarming in that of the mother. Bollinger attributes +this to the action of the placenta as a "physiological filter"--a +conclusion seemingly at variance with the passage of the bacillus +through all the other animal membranes, including those lining the +mammary glands and the vagina. Two other possible explanations remain: +first, that the secretions of the uterine glands are inimical to the +bacillus; and, second, that the foetus, being in some sense a +carnivorous animal, possesses the immunity characteristic of +Carnivora. Bacilli have recently been found in the foetal guinea-pig. + +The bacillus anthracis was first observed by Pollender and Branel in +1849 (Birch-Hirschfeld), but it was only publicly claimed as the cause +of the disease in 1855 by Davaine. Branel discarded Davaine's theory, +because blood in which he had failed to find bacillus produced anthrax +with bacillus in the blood of two foals inoculated. Later observations +by Bollinger and others have shown that cultures of bacillus can +always be made from such infecting blood, and that in most cases the +presence in the infecting blood of spherical bacteria can be +demonstrated by the microscope. That the bacillus is the true +pathogenic element is proved by the following facts: 1st. That the +bacillus is the only ectogenous, particulate, organized structure +constantly found in the anthrax blood and fluids; in cases in which it +is apparently absent cultures show its actual presence. 2d. After +cultivation in pork or beef infusion to the {932} hundredth generation +the virulence is unimpaired, though it must be assumed that all +non-organized poisons derived from the infected animal body must have +been diluted or decomposed to extinction. 3d. That filtration of the +anthrax liquids through a plaster or other efficient filter renders +the filtrate innocuous, while the solids retained in the filter remain +infecting (Chauveau, Bert, Toussaint). 4th. That the clear filtrate +injected to excess killed by virtue of its contained chemical products +in twelve hours, while the solids filtered out and containing the +bacillus or its spores only killed after thirty hours.[4] 5th. Anthrax +blood from the living animal or one just dead, and destitute of +spores, when subjected to compressed oxygen (50 atmospheres), is +non-infecting (Bert). 6th. The same anthrax liquid, destitute of +spores, after boiling is completely innocuous. 7th. The same liquid, +if kept in a closed tube apart from oxygen for eight days, shows the +bacilli broken down by granular degeneration, and proves absolutely +harmless when inoculated in small quantity. 8th. The same sporeless +anthrax fluid when treated with absolute alcohol loses its virulence. +9th. The anthrax liquid which has been cultivated with free access of +air in a temperature varying from 25 degrees C. (77 degrees F.) +(Klein, Loffler) to 41 degrees C. (105.5 degrees F.) forms spores, and +then remains infecting, though it may have been subjected to +compressed oxygen, boiling for several minutes, absolute alcohol, +dilution with water, putrefaction, or the exclusion of oxygen. + +[Footnote 4: Bert, _Compt. Rend. de la Societe Biol._, p. 355, 1879.] + +The bacillus anthracis, as found in the blood and animal fluids, is in +the form of fine rods, straight (rarely bent or angular), motionless, +and 0.007 to 0.012 Mm. in length. Smaller forms are seen to be minute +ovoid or oblong bodies, and the smallest absolutely spherical +(micrococcus); but in all cases, as seen under the highest powers of +the microscope, they have clear-cut, even margins, linear or curved, +which easily distinguish them from the irregular normal granules of +the blood and tissues. Under the highest powers of the microscope the +bacillus is seen to be made up of a series of oblong (Koch) or cubical +(Klein) cells enclosed in one common sheath. This is rendered more +manifest if they are first swollen by the addition of water. The +motionless form of the anthrax bacillus is of especial value in +distinguishing it from the motile bacteria of putrefaction +(saprophytes). + +Within the living animal body the development never goes aside from +these forms. The growth appears limited to micrococcus and bacillus +rods, while spores or bacillus threads are never found. This finds its +counterpart in the micrococcus poisoning caused by the inoculation +with the spores of common moulds (Grawitz); and in septicaemia also +micrococcus and bacillus forms only are found, the filamentous never. + +When grown in organic infusions out of the animal body the +anthrax-germ develops from micrococcus or bacillus into a long, +branching, filamentous product, which in the presence of oxygen +develops into spores. Apart from oxygen or when the proper nourishment +of the bacillus is exhausted the protoplasmic elements within the +filamentous sheath undergo granular degeneration, and finally the +empty envelope disintegrates and disappears. The spores appear at +intervals in the protoplasm of the filament as clear, brightly +refrangent bodies, at first spheroidal, afterward larger and oblong. +Unlike the micrococcus and bacillus, {933} they do not stain. Under +favorable circumstances the primary cell is capable of forming one, or +if extra long, two spores (Koch, Klein). Cossar-Ewart claims to have +seen the formation of motile flagellate organisms aggregating +themselves into zooglaea masses, but as these were not found in the +carefully-conducted cultures of Koch and Klein, they are supposed to +have been aerial microphytes accidentally introduced. + +The great tenacity of life in the spores in heat and cold, dryness and +wet, excluded from air and under several atmospheres of oxygen, in the +midst of putrefaction and in pure watery fluids, well accounts for the +persistence of infection in buildings and localities where the poison +has gained a foothold. In order to their destruction in a natural +manner it seems necessary that they should germinate and develop into +the anthrax micrococcus, bacillus, or mycelium. This germination may +take place in the presence of moisture, oxygen, and suitable +nourishment, whether in the soil, the animal body, or elsewhere, and +then the exhaustion of the aliment, the exclusion of the oxygen by +putrefaction, the submergence in a medium unfavorable to development, +or exposure to a very high temperature, may suddenly destroy the +poison. + +There is reason to believe that a too free exposure to oxygen proves +destructive to the virulence, if not to the life, of the poison, and +thus in all porous, well-drained soils the anthrax poison, even when +introduced from without and concentrated by the death and burial of +many victims, soon disappears. This feature, which is common to many +zymotic diseases the germs of which live and multiply outside the +animal body (typhoid, yellow fever, tuberculosis, swine plague, +chicken cholera, diphtheria, etc.), offers countenance to the claims +of Buchner that he had by prolonged culture, in the presence of air, +metamorphosed the bacillus anthracis into a harmless mycrophyte, and +that, conversely, by continuous cultivation under the surface of a +suitable beef infusion he had changed the harmless bacillus subtilis +of hay into the deadly bacillus anthracis. Koch, Klein, and others +have discredited Buchner's results, on the ground that he had not, in +their opinion, taken due precautions against impure cultures, and that +his alleged transitions took place too abruptly; yet further +observation must determine whether he has been condemned too hastily. +The diminished virulence of Pasteur's attenuated virus, which is +unaffected by the next subsequent culture or by the formation of +spores, shows plainly enough that the bacillus anthracis is capable of +physiological changes under the influence of varying conditions of +growth, and that such changes are not at once undone by a return of +the former conditions. + +How anthrax-germs enter the body is partly known and partly +conjectured. Direct inoculation on a sore by contact, by insects, by +harness, by accidents, etc. is an undoubted method. The sound cuticle +is probably an efficient barrier, since bacteria habitually inhabit, +without hurt, the surface and gland-ducts of the skin; yet the +entrance of these saprophytes through the shell and membranes of the +egg leaves a doubt as to the efficiency of the cuticular obstacle. The +mucous membranes are manifestly frequently penetrated by the parasite. +Hence the local affections in the mouth and throat (glossanthrax, +anthrax angina) and in the lungs (pulmonary anthrax). Cohn claims that +the gastric juice of Carnivora especially is destructive to the +anthrax poison, yet the constant recurrence of intestinal anthrax +(mycosis) seems to imply that the germs often escape destruction {934} +in the stomach. Pasteur supposes that anthrax-infected food is only +injurious when there are inoculable sores in the mouth or pharynx, but +it seems as if in that case the disease would be first shown at these +points and in the nearest lymphatic glands rather than in the bowels, +the rule for the inoculated anthrax being to develop first in the +tissues and thence to reach the blood-vessels through the lymphatics. + +The anthrax poison expends its fatal energy especially on the blood +and blood-vessels. The bacilli in the blood use up the available +oxygen, so that the circulating liquid becomes venous, dark, and +unfitted for the maintenance of the normal functions of life. What is +even worse, the ability of the blood to absorb oxygen is greatly +impaired. In men and dogs suffering from anthrax the consumption of +oxygen was found to be reduced in one instance even by two-thirds, +probably in part by reason of the action of the chemical products of +the bacillus. A third condition constantly found is embolism of the +capillaries by the bacillus and the occurrence of local gangrene. + +SYMPTOMS.--Anthrax shows itself in three principal forms: 1st, the +apoplectiform; 2d, anthrax fever without local external lesions; and +3d, external localized anthrax. The two last forms correspond in the +main to the acute and subacute forms. + +The period of incubation varies according to the dose of the poison +and the receptivity of the animal. In some cases infection is at once +followed by illness. In these it is probably the chemical products +that produce the first effect, while the disease caused by the +propagation of the bacillus appears later should the animal survive. +Such incubation is shortest for the smaller animals (mice, rabbits, +guinea-pigs, cats), in which illness usually sets in in from +twenty-four to forty-eight hours. In sheep and goats incubation may be +extended to three or four days, while in horses and cattle it may last +a day longer. + +The apoplectiform type attacks animals which a few minutes before +seemed in fine health, appetite, and spirits, striking them down as if +by lightning, and the victims struggle convulsively for some minutes, +expel blood perhaps by the nose or anus, and expire. In the less +suddenly fatal cases there may be muscular trembling, unsteady gait, +excited breathing, accelerated pulse, tumultuous heart's action, +bleeding from some natural orifice, and death in from one to several +hours. Occurring as these cases often do in summer, the sudden death +is probably hastened by insolation. + +In anthrax fever or acute internal anthrax there is loss of appetite, +and, in ruminants, of rumination, suppression of milk, dulness, +languor, staring coat, or even a rigor, and thirst. Then follows the +hot stage, in which the temperature may rise to 106 degrees or 107 +degrees F.; there are acceleration of pulse and breathing, petechiae +or a brown or yellowish tinge of the mucous membranes and white parts +of the skin, tenderness of the spine, often jerking or clonic spasms +of the muscles of the extremities, and much prostration and weakness, +the patient hanging back on the halter, leaning against a wall, or +swaying when made to move. The feces are usually more or less mingled +with blood-clots, or may be at once liquid and bloody. Bloody urine +and the discharge of blood from other natural channels are frequent. +Some cases are manifestly delirious, and in others the skin crackles +on being handled. Remissions are not uncommon, {935} during which the +animal remains dull and prostrate. As the disease advances and the +blood is robbed of its oxygen, the temperature descends below the +natural standard, great weakness and stupor set in, the pupils are +widely dilated, and death from asphyxia occurs in one or two days from +the onset. + +In localized external anthrax the local swellings may be first seen. +There are usually some tenderness of the skin, erection of the hair, +and the formation of a little nodule, like a hazel-nut or walnut, +adherent to the deeper parts of the skin, firm and comparatively +painless even when cut. Sometimes the swelling is diffuse, with a +dropsical or erysipelatoid aspect, and crackles like parchment when +handled. Whether the affection attacks the tongue, the throat, or some +part of the head, body, or limbs, the tendency is to gangrene of the +part, and, if the subject survives long enough, to an extensive +sloughing and unhealthy sore. The sloughs and sores have either a +black sanguineous appearance or they are lardaceous and intermixed +with streaks of dark red. If fever is not present at the outset, it +sets in early, and passes through the same stages as in the acute +internal anthrax, the animals being suddenly plunged in prostration +and stupor, with dusky yellow or blood-stained mucous membranes, +dyspnoea, dilated pupils, convulsions, and death. On the mucous +membranes (gloss-anthrax, anthrax angina) the engorgement is usually +complicated with bullae with red or yellow contents, and which on +bursting leave unsightly gangrenous ulcers. In all such cases the +morbid liquids of the swellings teem with bacilli. + +MORBID ANATOMY.--The most characteristic changes are usually met with +in the blood. This is black, thick, tarry, uncoagulable or coagulates +only in loose diffluent clots, which are redissolved before squeezing +out the serum; the fibrin is diminished (often by two-thirds), the red +globules are not adherent in rouleaux, and are crenated and broken +down and the haematin diffused through the liquid, so that it stains +the hands or paper deeply; the white globules are increased, probably +by reason of the early irritation of the lymphatic glands and spleen +by the poison; and it reddens slowly and but slightly on exposure to +the air, and speedily passes into decomposition. The blood can +scarcely be made to flow in a full stream, but often trickles down the +hair and skin by reason of its thick, consistent character. The +microphytes above described are usually found in the blood, and always +in the affected tissues if examined just after death. + +Next to the blood, the spleen presents the most constant lesions, +being enlarged (by one-third, one-half, or to double, triple or +quadruple its normal size) and gorged with blood (sometimes even to +rupture). The lymphatic glands, and especially those adjoining the +local anthrax swellings of the tissues, are always enlarged, marked +with petechiae, friable, easily reduced to a pulp, and swarming with +bacilli and micrococci. Next to the glands of the affected parts the +central ones, the axillary, prepectoral, thoracic, sublumbar, and +abdominal, are the most constantly affected. The lymph is reddish and +opaque. + +Decomposition sets in early, and the resulting gases cause a puffy, +emphysematous condition of the connective tissue. The fat and other +white tissues are dusky brown or yellow, and petechiated; the muscles +are soft, flabby, and dark red or brown, with occasional blood {936} +extravasations; the blood-vessels, especially the veins, and the right +heart are gorged with black, uncoagulable blood, and have their inner +coats blood-stained. The serous membranes present numerous petechiae, +and contain more or less of a reddish serum. The intestines, and +sometimes the stomach, are dark red throughout, marked by petechiae, +and are often the seat of thickening from sanguineous or transparent +colloid infiltration. The lesions are especially extensive on the +small intestines and rectum. The vagina and womb are also the frequent +seats of sanguineous infiltration. The liver and kidneys are enlarged, +congested, softened, and friable, and the ganglia of the sympathetic +are enlarged, congested, and softened. The swellings are of two kinds, +sanguineous and colloid. The former, when cut into, present one or +more loose clots of black blood or a grumous mass of blood-elements, +separating the tissues and often mixed with fetid gases. The colloid +exudations are glairy, semi-solid, jelly-like masses, infiltrating the +tissues. The tissues affected and the skin covering them are the seat +of bacterial embolism and gangrene, and there is no tendency to +suppuration. These products swarm with the specific microphytae. + +DIAGNOSIS.--The differential diagnosis of anthrax from other +affections due to the propagation of microzymes in the system is not +always easy--so much so that a variety of bacteridian and allied +diseases (septicaemia in its various forms, erysipelas, swine plague, +chicken cholera, poisoning by the micrococci of fungi, black quarter +from bacteria, milk sickness, and Texas fever) have been erroneously +confounded with this affection. These all show the same dusky or +cyanosed mucous membranes, disintegrating blood-globules, loose +blood-clots, petechiae, blood-extravasations, sudden and great +prostration, and enlargement and congestion of the lymphatic glands or +spleen. In some of these the duration of incubation (in swine plague +six to fourteen days and in Texas fever one month) serves to +distinguish, while in the majority the microzyme is globular (Texas +fever, micrococcus of fungi-poisoning, chicken cholera); in swine +plague the cocci are arranged in pairs; in black quarter the microbe +is a refrangent ovoid, single or in chains of two or three and a +motile linear body with a refrangent nucleus in one end; and in milk +sickness the germ is a spirillum. The germs are far more likely to be +detected in the local lesions and lymphatic glands than in the blood. +The specific nature of the symptoms and lesions can usually be relied +on, but in cases of doubt the inoculation of a small animal (rabbit, +guinea-pig, sheep) will be a material guide. + +PROGNOSIS.--True anthrax leads to a very high mortality. The +apoplectiform cases are fatal almost without exception; the acute +cases of anthrax fever in many outbreaks perish to the extent of 75 or +80 per cent., and the more tardy ones to the number of 50 per cent. In +a general outbreak the earlier cases are usually the most fatal, while +later, when the less susceptible animals are attacked, the mortality +is often decreased. Again, the mortality is often at once arrested by +the emigration of the herd to a more healthy soil, a large proportion +of those already attacked recovering. + +PROPHYLAXIS.--In prophylaxis the soil demands the first attention. If +this is damp and calcareous or rich in organic matter, the remainder +of the herd should be at once removed to a drier and more porous soil, +where the germ is less likely to be preserved and increased. In an +{937} enzootic in Livingston County, N.Y., in 1875, 40 bullocks out of +200 had perished in ten days, yet after removal to an adjacent dry +pasture and the use of antiseptics with the food and water the attacks +abruptly ceased and 48 out of 50 head already sick recovered. The +drainage of anthrax soils leads to a steady reduction of the poison, +favoring as it does the germination of the spores and the destruction +or modification of the germ. When drainage is impossible, the +mortality may be reduced by driving the stock to drier grounds during +the hot, dry season, by stabling them morning and night when the dews +are on the grass, also in wet times, when they are likely to pull up +the plants by the roots, or, better still, by cutting the fodder and +soiling the stock in stables or yards. Yet in all these cases the +germs will at intervals find access to the animals in the green food +or hay, so that badly infected soils must be secluded from live-stock, +and either be abandoned or devoted to other cultures. A point of the +very first importance is the safe disposal of the products and +carcases of the sick. These should be thoroughly burned, or, failing +this, deeply buried (4 feet) and the graves covered with coal tar and +fenced in from all other stock for from five to ten years. +Contaminated litter and fodder should share the same fate. Stables and +yards where the sick have been, and all vehicles and implements used +for them or their products, should be thoroughly disinfected. In the +epizootic in Livingston County, above referred to, these measures seem +to have eradicated the disease in the course of six years, though the +land was neither drained nor subjected to cultivation, and the +dangerous meadows are now again pastured with impunity. + +In the case of sick animals the greatest care is requisite to keep +them from common drinking- or feeding-troughs; to exclude all other +animals, even the smaller quadrupeds and birds, which may become the +bearers of the poison; to avoid the chance of the drainage of infected +excreta into other yards and pastures, and to carefully disinfect and +guard the human attendants against contamination. The sale of animals +out of an infected herd, and, above all, for the meat-market, and the +use of the milk or other products of such animals, until attested +sound, are highly reprehensible. + +Finally, there are the different methods of protecting the system by +inoculation with modified virus. The first of these is that of +Burdon-Sanderson, Dugnid, and Greenfield, who in 1878 and 1879 +inoculated six cattle with the blood of guinea-pigs dead of anthrax, +all of which survived except an old, emaciated, worn-out, and pregnant +cow, and all the survivors would only afterward contract anthrax in a +mild form. The anthrax blood of the guinea-pig inoculated on the sheep +proved fatal. The second mode is that of Pasteur, who cultivated the +anthrax-germ artificially in flasks of meat-infusion, and after the +nourishment in the latter had been used up left the bacilli to +degenerate until their virulence had been so far decreased that the +liquid could be safely inoculated on animals, so as to produce a mild +anthrax infection and thereafter secure immunity from this poison. For +all the larger domestic animals he found that the eighth day of the +culture sufficed, provided there had been no formation of spores; and +the method has now been applied on many scores of thousands of +domestic animals. Klein, however, has found that cultures in +pork-broth of the same age are invariably fatal to rodents, {938} and +that a guinea-pig which survived inoculation with culture a month old +did not possess immunity against fresh virus. The third method, that +of Toussaint, consists in heating the fresh virus, so as to lessen its +activity, and then inoculating it on the animals to be protected. He +found that a temperature of 55 degrees C. (131 degrees F.) maintained +for one hour rendered the virus non-fatal, without impairing its +prophylactic powers on animals inoculated. In spite of a partial +failure at Alfort from insufficient heating of the virus, the method +has now been firmly established as at once easy and effective. + +The great value of these discoveries can hardly be overestimated, yet +it is to be feared that the eclat of their reception has led to a far +too general adoption of the methods. No one of the methods professes +to destroy the life of the bacillus nor to impair its power of +self-propagation. The bacillus, therefore, is likely to be planted in +the localities where it is being employed, and, if the soil is +favorable, to be perpetuated there. It follows also, from the +susceptibility of the bacillus to change under varying conditions of +life, that the modification impressed on it by the methods of Pasteur +and Toussaint may be reversed under a reverse state of the +environment, and that the harmless virus sown by our inoculators may +in favorable soils produce the more deadly types. The methods secure +the safety of the individual herd inoculated, at the expense of +planting in the pasture a seed most perilous to all future +uninoculated herds that may roam there. The only place for such +protective inoculations is on pastures already charged with the +anthrax bacillus, and from which that cannot be eradicated. On the +dry, healthful soils where the bacillus cannot survive the inoculation +is useless, while on the dense, damp, rich soils favorable to its +preservation, but as yet uninfected or nearly so, this inoculation is +but sowing deadly seed to secure a very temporary and questionable +advantage. + +TREATMENT.--Bloodletting and laxatives have been largely used in the +treatment of anthrax, though both are mostly useless in acute cases, +their possible good effects being anticipated by the early death. When +of service at all, it is probably mainly in reducing that plethora +which serves often to enhance the virulence and severity of the +malady. Apart from these, the agents resorted to are more or less of +an antiseptic nature, and probably exert their action mainly on the +bacilli undergoing development near the surface of the skin or +intestinal mucous membrane. In extensive outbreaks I have had the best +results with the administration thrice daily of carbolic acid, +nitro-muriatic acid, or bichromate of potassium, and hypodermically of +iodide of potassium and sulphate of quinia. Alcoholic stimulants, +chlorate of potassium, and muriate of iron are equally indicated, +especially when the period of prostration has set in. If the local +anthrax can be detected when there is as yet but a hard nodule, there +should be no hesitation in cauterizing it to its depth and treating +the resulting sore and surrounding parts with tincture of iodine or +iodized phenol. After crucial incision the nodule may be treated with +powerful caustics (potassa, nitric acid, chloride of zinc), to be +followed by iodized phenol, with or without poultices or fomentations. + + +{939} Anthrax in Man (Malignant Pustule or Vesicle, Anthrax +Intestinalis, Mycosis Intestinalis). + +Fournier in 1769 first traced the communicated anthrax of man to the +consumption of the flesh of diseased animals and the handling of their +wool. Until quite recently, however, the form which originated as a +local external affection was the only type recognized, while internal +anthrax was confounded with a multitude of other affections. + +ETIOLOGY.--That anthrax in man is almost invariably derived from the +lower animals by infection is now undoubted, while for the direct +infection of man, as of animals, by the germs propagated in the soil, +there is no absolute proof. The latter mode of propagation has only +been recognized in the Herbivora, which are so much more exposed to +contamination from the soil; yet, abstractly, there is no reason to +suppose that man is less susceptible to the earth-grown bacillus than +to that produced in the animal, if only he were as frequently exposed +to its infection. The spontaneous development of anthrax apart from +the pre-existent bacillus in animals or soil is a chimera. The +principal modes of infection may be considered as direct and mediate. +Among the direct are included infection from handling the sick +animals, their carcases, their wool, hair, bristles, hides, fat, and +guts; the inoculation of physicians, surgeons, and nurses from their +patients; and the infection of men by the meat, milk, and cheese +eaten. As attested modes of mediate infection may be cited the +inoculation by insects (mosquitoes, bluebottles, and other +bloodsuckers), and the introduction by water into which anthrax +products have drained or been washed; there are also hypothetical +cases in which anthrax-germs from the earth have entered the system in +the air, drink, or food (raw vegetables). The direct inoculations are +especially common in certain classes (shepherds, farmers, butchers, +knackers, tanners, veterinarians, and workers in hides, hoofs, +glue-factories, fat-rendering works, in hair, wool, bristles, and +catgut, and in felting and paper-making). In such cases the disease +usually begins as a local one, and occurs on uncovered portions of the +body. Three such cases occurred in 1875 on one farm at Avon, N.Y., +where the victims had assisted in burying forty dead cattle, and a +number of other similar instances can be adduced in different parts of +the same State, in one of which a physician was accidentally +inoculated in dressing a farmer's hand. Physicians whose practice +includes large tanneries become very familiar with the disease and +recognize it very readily. + +Infection through food is much less frequent in men than in animals, +the process of cooking combining with the action of the gastric juice +in destroying the poison. Yet it is by no means unknown. The records +above given of infection in St. Domingo, Naples, and the Russian +steppes can be easily supplemented. Dr. Keith of Aberdeen, Scotland, +records the case of a family that suffered, two of them fatally, after +partaking of broth and meat which had been boiled for hours, one +member of the family (a vegetarian) having alone escaped. Infection +through milk, butter, and cheese is less common, the gravity of the +disease in animals leading to an early suppression of the mammary +secretion. In all such cases the infection enters through sores in the +mouth or from the bowels. + +Those cases in which the bacillus enters the system with the inspired +{940} air are probably the least numerous. Yet the germ may reach the +lungs in fine dust, and then find in the delicate respiratory mucous +membrane the most accessible of all channels into the system. + +The proportion of men affected is much greater than that of women and +children, doubtless by reason of their greater exposure to infection, +and, as in the lower animals, the summer months are most productive of +anthrax. The susceptibility of the human race appears to be less than +that of the Herbivora, and doubtless varies, as in these animals, with +the nature of the food. It is at least temporarily exhausted by a +first attack, though in exceptional cases and under a strong dose of +the poison a man may be affected a second time. + +SYMPTOMS.--Symptoms usually set in within twenty-four hours after +inoculation of the poison, though it is alleged that the incubation +may be extended to twelve or fourteen days. Itching draws attention to +a small red spot like a mosquito bite, but with a black central point. +This speedily increases to a small rounded swelling (papule), and in +fifteen hours is surmounted by a minute vesicle with dark-red or +bluish contents. From the size of a millet-seed this increases to that +of a pea, and in thirty hours bursts spontaneously or under friction +and forms a dark-red, indurated, comparatively painless nodule (parent +nucleus, Virchow). The adjacent skin shows a swollen areola livid and +red, on which there appear vesicles similar to the first, which pass +through the same stages, burst, and leave a livid, hard, or doughy +gangrenous surface. By this time the surrounding skin is red, shining, +and puffy, and the disease continues to spread by the same method of +extension. The diseased part now becomes the centre of an oedematous +swelling which may invade the entire arm, face, or neck, and is +attended with more or less constitutional symptoms. The affected part +may be cold or hot, and it may show the red lines of lymphangitis and +the swelling of the adjacent lymphatic glands. + +The pyrexia, at first slight, often reaches a high grade, attended +with occasional chilliness, pains in the back and loins, great +prostration, languor, dulness, and even delirium, with cold sweats, +anxiety, dyspnoea, and at times muscular spasms. As in beasts, there +are the dusky skin and mucous membranes, petechiae, and cyanosis, and +in bad cases there may be sudden collapse and death. The symptoms vary +much, however, according to the extent of the local lesion, to the +amount of poisonous chemical products thrown into the blood, to the +degree of the invasion of the blood by the bacillus, and to the +complication (not infrequent) of the affection with septicaemia. In +the very mildest cases the affection never proceeds beyond a local +slough, the size of a quarter or half dollar, the germs do not enter +the blood in sufficient numbers to survive, the constitutional +symptoms are few or absent, and the sore heals by granulation. + +The disease usually lasts from six to ten days, and for the first +forty-eight hours the symptoms are generally purely local. + +Malignant anthrax oedema (oedeme maligne) was first observed by +Bourgeois as occurring in the eyelid, and has since been recognized in +other parts of the body (arm, forearm, head). It differs mainly from +malignant pustule in the absence of the preliminary vesicle, of the +hard nodule (parent nucleus), and of the early circumscribed gangrene. +It has this further peculiarity, that the local disease often appears +as a {941} sequel rather than a precursor of the constitutional +disturbance. It corresponds in the main to the diffuse erysipelatoid +anthrax of the lower animals, and has been attributed to the anthrax +poison introduced by inhalation. It has been observed to follow eating +of anthrax flesh (Leube, Muller). Inasmuch as the active disease is +often delayed a week or ten days after exposure to infection, it may +reasonably be supposed that the bacillus has been imprisoned on the +mucous membrane, or, entering the blood in small quantity only, has +been held in check by the antagonism of the blood-globules until some +elements, escaping into the connective tissue, have started the local +disease. The symptoms are usually first languor, sleeplessness, +restlessness, with some sense of chill, debility, and headache, and +finally, after a few days, the formation of the specific oedema at one +point or more. This has a pale, semi-translucent, slightly yellowish +or greenish aspect, pits on pressure nearly equally at all points, and +tends to a rapid extension, with concomitant aggravation of the +constitutional symptoms, and in many cases nausea and vomiting. +Gangrene sets in--not progressively, as in malignant pustule, but +simultaneously over a more extensive surface--and is followed by great +prostration, stupor, dyspnoea, cyanosis, collapse, and death. + +Anthrax intestinalis may be looked upon as the counterpart of the +internal anthrax or anthrax fever of animals, described above. As in +animals, the constitutional symptoms may result early in a fatal +issue, with scarcely any local lesion save in the blood and spleen +(Carganico, Leube, Muller, Winkler, Lorinser). As in animals too, the +sanguineous engorgement of the spleen and the intestinal anthrax are +often complicated by external anthrax oedema or malignant pustule +(Heussinger, Virchow, Buhl, Waldeyer, etc.). In this form pyrexia and +other constitutional disturbances are first seen. There is a general +feeling of languor and depression, with some chilliness, fever, pains +in the limbs, back, and head, vertigo, and ringing in the ears. Even +at this early stage there is noticed a dusky hue of the skin and +visible mucous membranes, which goes on increasing to a brown or +yellow tinge, to petechiae, or, with the supervention of dyspnoea, to +cyanosis. Digestive derangement is early shown in abdominal pain, +nausea, vomiting, tenderness, some swelling, and finally diarrhoea, +often bloody and sometimes profuse and exhausting. In acute cases the +symptoms become rapidly worse, and then follow discharge from the +mouth and nose of uncoagulable blood, dyspnoea, cyanosis, small pulse, +dilated pupils, great anxiety or drowsiness, and stupor, or there may +be tonic spasms of the trunk or extremities. Death usually results +from asphyxia or collapse, as in animals. These cases are almost +invariably fatal within a period of thirty-six hours, though some +linger six or seven days. + +Allied to the intestinal anthrax is anthrax angina, a not unknown +occurrence in man. This begins as a bad sore throat, with an +especially dark-red hue of the pharyngeal mucous membrane. As it +advances the shade becomes increasingly darker, the power of +deglutition is lost, serous phlyctenae with gangrene and deep +ulceration set in, but without any tendency to the formation of false +membrane as in diphtheria. There are early superadded the +constitutional symptoms above described, and the patient dies in a +state of collapse or asphyxia. + +MORBID ANATOMY.--The lesions closely agree with those already {942} +described for animals in general. The blood presents the same dark-red +or black, tarry, incoagulable, or only slightly coagulable condition +in the worst cases, yet this is less constant in man, as the bacteria +are less constant or numerous in the blood, in keeping with the more +prolonged localization of the external anthrax in man, and the more +pronounced antagonism between the blood and the bacillus which results +from feeding exclusively or largely on flesh. The red globules do not +tend to adhere together, and the white globules are in excess and very +granular. The spleen is less extensively enlarged than in animals, but +is highly charged with blood, bacilli, and micrococci. The lymphatic +glands too are enlarged, hyperaemic, cloudy, hemorrhagic at points, of +a dark grayish, deep red, or blackish color, and highly charged with +the bacillus. The surface of the skin and mucous membranes (mouth) +presents hemorrhagic spots and patches, with serous vesicles and +eschars. The malignant pustule when cut into presents a central slough +and a surrounding hard indurated mass, both of a dark blood-red, with +similar prolongations downward into the adipose tissue, and around all +the characteristic oedematous infiltration, often streaked with blood. +The bacillus is found in tufts or dense groups at intervals in the +rete mucosum, the dermis, and the subcutaneous connective tissue. The +serous membranes present the same general lesions as in animals. The +walls of the stomach and bowels are the seat of cloudy red +infiltration, with at intervals small hemorrhagic foci, and on the +mucous surface distinct sloughs. Jelly-like exudations are also found +in these membranes in the mesentery and in the retro-peritoneal +tissue. The liver and kidneys are usually congested or are infiltrated +with an oedematous exudate, and in these, as in all the local anthrax +lesions, the characteristic bacilli are found. + +DIAGNOSIS.--Malignant pustule is distinguished by its commencing from +a minute red point with dark centre, and by its progressive extension +from this point by a dark-red, puffy, and vesicular areola, with +steadily advancing induration and gangrene. The bites of insects have +a yellowish central point with red areola. A boil lacks the dark +centre and the rapidly rising elevated red areola. Carbuncles and +plague-boils tend to appear on clothed parts of the body, respectively +on the back of the neck and shoulders and on the trunk and +extremities. In carbuncle several boils rise and burst simultaneously, +though they may finally slough into one sore, while in anthrax the +extension is from one point. The plague-boil is usually multiple and +much more painful than anthrax. The glanderous nodule is usually +multiple, situated at intervals on the course of a lymphatic, the +intervening portion of which is inflamed, hard, and cord-like. It is +also usually associated with the specific glairy discharge from the +nose, the nasal ulcers and nodules, and the enlarged painless, +nodular, and indolent submaxillary lymphatic glands. As a last resort +the detection of the bacillus in the indurated nucleus and the +inoculability of the disease on the lower animals (rabbit, +guinea-pig), may be appealed to. + +Malignant anthrax oedema is less easily recognized, but may be +inferred from the sudden swelling with a dusky yellow or greenish hue +and a tendency to vesiculation and gangrene, the whole preceded and +attended by the constitutional symptoms of anthrax, and, above all, +from the presence of the bacillus in the exudate. + +{943} In both of these forms much may be deduced from the known +liability of the district to anthrax, from the occupation of the +subject as being exposed to infection (worker in hair, wool, bristles, +hides, catgut, etc.), or from his having eaten meat which was open to +suspicion. + +Internal anthrax is less certainly diagnosed because of the absence of +local symptoms until the constitutional disorder is well advanced. Yet +the reasonable suspicion of infection and the sudden and violent +eruption of the disease (headache, nausea, vomiting, bloody diarrhoea, +extreme anxiety, debility, dyspnoea, cyanosis, convulsions, collapse, +with petechiae, and local discharges of diffluent blood) serve to +identify it. The bacillus is not always to be detected in the blood +under the microscope, but its presence can usually be demonstrated by +inoculation. + +PROGNOSIS.--The prognosis of malignant pustule energetically treated +in its early stages is good. The disease is as yet a local one, and +the germs can be extinguished by local treatment. In anthrax +districts, where the disease is feared and early recognized, the +mortality may be from 5 per cent. (Nicolai) to 9 per cent. (Lengyel, +Koranyi). Even this mortality is mainly due to delay in treatment. In +districts, on the other hand, where the malady is infrequent, and +where efficient measures are applied too late, the mortality is often +30, 40, or even 50 per cent. After internal infection, and where local +symptoms only appear after general infection, the case is very +hopeless. + +PROPHYLAXIS AND TREATMENT.--The prophylaxis of anthrax in man is to a +large extent identical with that for animals. All considerations as +regards soil, culture, drainage, sick and dead stock, cremation, +burial, disinfection, etc. have a most important if only a secondary +bearing on the protection of man. Still more important is the free use +of carbolic acid, chloride of lime, or tincture of iodine for the +hands of those dressing unhealthy sores in animals or handling +suspicious cases of sickness or cadavers, and of those working in +hides, wool, hair, horns, hoofs, guts, etc. Similarly, all products of +animals with anthrax should be withheld from general use. + +In external anthrax of man, before the system has been contaminated, +the thorough destruction by caustic of the diseased part with its +contained poison is most effectual. Where there is as yet but the +preliminary papule it may be incised and thoroughly destroyed by a +stick of chloride of zinc, caustic potassa, or nitrate of silver, or, +if more convenient, by fuming nitric acid, muriatic or sulphuric acid, +or, perhaps preferably to all others, iodized phenol. Should the +parent nucleus have already formed, it should be excised with the +knife or deeply incised in a crucial direction, and then thoroughly +cauterized with one of the more potent escharotics (caustic potassa, +strong nitric acid) or with the iodized phenol. The latter agent may +be further applied on the sound skin adjacent, especially if there is +the slightest swelling or redness. Should the peripheral oedema +persist or reappear after the cauterization, the latter should be +repeated until this tendency is overcome. Hypodermic injections of a +solution of iodine and iodide of potassium may be made into the entire +swelling. After the caustic has done its work the eschar may be +softened and its separation favored by a warm poultice containing a +small amount of carbolic acid or iodized phenol. This treatment is +often highly beneficial, even after constitutional symptoms have set +in, by arresting the {944} propagation of the bacillus and checking +its introduction and that of its chemical products into the +circulation. + +Constitutional treatment is not to be forgotten. Carbolic acid may be +profitably given to the extent of fifteen drops daily, iodide of +potassium ten to twenty grains thrice a day, and sulphate of quinia +ten grains at the same intervals. The strength should be sustained by +iron (tincture of the chloride) and wine or other alcoholic beverage, +both being, like the agents already named, calculated to retard if not +to limit the propagation of the bacillus. The diet throughout should +be nutritious and easily digested. + +When a person is known to have eaten anthrax meat an emetic will be +indicated, followed by a smart oleaginous purgative combined with five +drops of carbolic acid, and subsequently by the constitutional +treatment above recommended. In case of extensive anthrax oedema, +incisions may be made into the part as far as the yellow exudate +extends, and a poultice containing carbolic acid may be applied. Or, +preferably, the swelling may be freely injected with a weak solution +of iodized phenol (1:100 water), and then painted with the same agent +or with tincture of iodine. + + + + +{945} + +PYAEMIA AND SEPTICAEMIA. + +BY B. A. WATSON, M.D. + + +HISTORY.--There is little to be learned from existing literature of +the views which were maintained by the ancients, prior to the birth of +Christ, in regard to the morbid conditions now designated pyaemia and +septicaemia; although it is certain they were recognized by the +"Father of Medicine," who reports a well-marked case of puerperal +fever terminating fatally on the twentieth day of the disease, and +also a case in which death was unquestionably caused by septic +poisoning, as is clearly shown in the following:[1] "Criton, in +Thasno, while still on foot and going about, was seized with a violent +pain in the great toe; he took to his bed the same day, had rigors and +nausea, recovered his heat slightly; at night was delirious. On the +second, swelling of the whole foot, and about the ankle, erythema with +distension and small bullae (phlyctaenae); acute fever; he became +furiously deranged; alvine discharges, bilious, unmixed, and rather +frequent. He died on the second day from commencement." Additional +confirmation of the fact that Hippocrates was familiar with the +phenomena of these diseases may be found in his dissertation on +empyema and fevers. Prof. C. Heuter says, under the head of septic +fever,[2] "Hippocrates and Celsus observed the fever in cases of +injuries which proved so dangerous that this danger could not have +originated from the inflammation or from the wound alone." Jacotius, a +commentator of Hippocrates, has even mentioned putrid fevers, the same +as Adrianus Spigelius, who spoke of fevers which arise from +putrefaction; but both authors, as well as their followers, did not +discriminate between septicaemia arising from the putrescence of +wounds and pyaemia. In the mean time both varieties were regarded as +intermittent fever. + +[Footnote 1: _Works of Hippocrates_, trans. by Adams, vol. i. p. 377.] + +[Footnote 2: Pitha und Billroth, _Handbuch der Chirurgie_, 1 Band, 2 +Abth., 1 Heft, 1 Liefg., S. 6.] + +"Aretaeus lived during the middle of the second century of the +Christian era. In his remarks on pneumonia he observes that the +subjects of this disease die mostly on the seventh day. 'In certain +cases,' he says, 'much pus is formed in the lungs, or there is a +metastasis from the side if a greater symptom of convalescence be at +hand. But if, indeed, the matter be translated from the side to the +intestine or bladder, the patients immediately recover from the +peripneumony.' He speaks of a metastasis to the kidneys and bladder +being peculiarly favorable in empyema. He ascribes suppuration of the +liver to intemperance and protracted disease, {946} especially +dysentery and colliquative wasting. The symptoms described by him +resemble those of chronic pyaemia."[3] + +[Footnote 3: Braidwood on _Pyaemia_, p. 2.] + +Galen and some of the other ancient physicians recognized the +existence of septic poisoning, as is shown by the opinions expressed +on the subject of putrid fevers. According to Galen, putrid fevers may +either arise from the conversion of ephemerals, or originally from +putrefaction of the fluids within the vessels. + +Aetius states that they arise from constriction of the skin or +viscidity of the humors, whereby the perspiration is stopped, and the +quantity of vital heat so altered as to give rise to putrefaction, +first of the fluids, and afterward of the fat and solid parts. When +these corrupted fluids are contained within the vessels they occasion +synochous fevers, but when distributed over the body they give rise to +intermittents. Synesius and Constantinus Africanus give a similar +account. Alexander gives an interesting and ingenious disquisition on +the origin and nature of putrid fevers, one of the most common causes +of which he holds to be the conversion of ephemeral fevers, and the +inseparable symptoms being want of concoction in the urine and +quickness of the pulse with systoles. This is the account of them +given by most of the other authorities, both Greek and Arabian, so +that we need not enter into any circumstantial exposition of their +views. We shall merely give the brief account of those furnished by +Palladius. There are, he says, two kinds of synochous fevers, the one +being occasioned by effervescence, and the other by putrefaction of +the blood; of these the latter are the more protracted and dangerous. +In them the pulse is contracted, the heat pungent, and the urine white +and putrid.[4] + +[Footnote 4: Paulus Aegineta, trans. by Adams, vol. i. p. 236 +(Sydenham Soc., 1844).] + +A new era in the literature of this subject dawned during the +sixteenth century. Ambrose Pare and Bartholomew Maggi each published a +work in which they pointed out the old errors and announced new +truths. Pare's _Treatise on Gunshot Wounds_ was published in Paris in +1551, while Maggi's treatise appeared a year later at Bologna. Pare +gained his first experience in the treatment of gunshot wounds in +1536, which is described as follows: "The storming of the small +mountain-fortress Villane, near Susa, probably gave him for the first +time full occupation, and he followed in all things the example of +older colleagues. Like them, although hesitatingly, he poured into the +gunshot wounds boiling oil of elder to destroy the poison, but the oil +fell short, and then he was compelled to dress the other wounded men +with an ointment of oil of roses and turpentine. Fearing that the +latter would soon become victims of the wound-poison, he passed a +sleepless night, got up early to see the ill consequences, but was +greatly surprised to find those that he had half given up free from +pain and without inflammation or swelling, while those who had been +treated with boiling oil lay in a state of fever, with great pain and +much swelling. He therefore determined, as he tells us, never again to +burn the poor subjects of gunshot wounds so cruelly."[5] It will be +seen that Pare's treatise on gunshot wounds was published fifteen +years after this impressive experience at the fortress of Villane. In +this work he sought to correct the prevailing idea that {947} gunshot +wounds were poisonous, and was ably supported in his effort by +Bartholomew Maggi; but it required all the respect which Pare enjoyed +in riper years to gradually obtain consideration for the new view. The +idea that gunshot wounds were poisonous is supposed to have originated +in the fact that in every war there are cases of acute sepsis, +developed after the infliction of these injuries, which agree in all +their essential points with the results of the bites of poisonous +snakes. We are even informed that during the late Franco-Prussian War +there were cases which even excited suspicion among the laymen that +the enemy had used poisoned missiles. + +[Footnote 5: _German Clinical Lectures_, 2d series (New Sydenham Soc., +1877), p. 65 _et seq._] + +The nature of the error which Pare and Maggi endeavored to correct is +shown by the declaration made by Johannes de Vigo at the commencement +of the sixteenth century, who expressed in dogmatic form the views +then firmly held by physicians. "A gunshot wound is a contused wound, +he says, for the bullet is round; it is burnt, for the bullet is +heated; it is poisoned, for the powder is poisonous. The poisoning is +the essential condition; therefore the treatment must be directed +above all to counteract this." + +The next step was that a poisonous substance may develop itself or +settle in the wound, and especially in gunshot wounds--a substance +which has nothing to do with powder or lead. Pare himself adopted this +view. When he took part in the siege of Rouen many wounds sloughed and +had a cadaverous smell, and on opening the bodies of those who died +numerous collections of pus were found in different parts full of +greenish ill-smelling ichor. Besiegers and besieged believed +themselves to be wounded with poisoned bullets. Pare looked for the +cause in a deterioration of the air by the large quantity of +decomposing substances, and he appears to have assumed, as is done at +this day, a direct action of the so-called deteriorated air upon the +wound itself. + +The evil influence of air vitiated by the products of decomposition, +not upon wounds only, but upon the organism generally, has never been +lost sight of by physicians since that time. That rotten straw, +decomposing bodies of men and animals, surfaces saturated with +excrement, and overcrowding of badly-ventilated hospitals give rise to +infectious fevers and unhealthy state of wounds is not a result of +modern observation only. That it was a question of the processes of +fermentation which became communicated to the body by means of the +exciters of fermentation contained in the air was a view frequently +adopted. "To quote one only out of many; John Pringle, in his +_Observations on the Diseases of the Army_, published in 1775, devotes +a chapter especially to 'Diseases resulting from Bad Air,' and his +forty-eight experiments on septic and antiseptic substances contain +numerous hints at attempts resembling those made at the present day to +determine the antiseptic power of certain things. No advance was made, +however, beyond vague surmises concerning the nature of the exciters +of putrefaction, and they were for the most part looked for amongst +the volatile, ill-smelling products of decomposition, and were +believed to be extremely subtle gaseous matters."[6] + +[Footnote 6: _German Clinical Lectures_, Second Series (New Sydenham +Soc., 1877), p. 67 _et seq._] + +Ambrose Pare (1582) first taught that secondary abscesses in surgical +cases, "which he had observed in the spleen, lungs, liver, and other +viscera, were due to a changed condition of the fluids produced by +some {948} unknown alteration in the atmosphere and determining a +purulent diathesis."[7] The following quotations force the conclusion +that in the early history of medicine there was supposed to be some +important relation between wounds of the head and multiple abscesses. +"Nicholas Massa (1553) mentions a case of abscess of the left lung, +following an injury of the head."[8] "Valsalva (1707) was induced by +his own observation to say that the viscera of the thorax were +sometimes affected in wounds of the head." "Desault (1794) considered +abscesses of the liver to be a very frequent sequence of head +injuries."[9] The fact that wounds of the head were frequently +followed by abscesses of the lungs, liver, and other organs probably +led to the opinion expressed by Desault, Barthez, Brodie, W. Phillips, +Copeland, and others, that the disease had its origin in a nervous +agency.[10] "Bertrandi and Audouille (1819) sought for a mechanical +explanation of the occurrence of hepatic abscesses after head injuries +and in cases of apoplexy." Morgagni (1740) somewhat obscurely hinted +at the doctrine of the reabsorption of pus--a doctrine which was +afterward elaborated by Quesnay in 1819. Morgagni, after quoting a +great number of instances of wounds of the head followed by visceral +abscesses, opposes the idea of a mechanical transportation of pus +thither, and states that abscesses are not confined to the liver and +that they may follow wounds and ulcers of other parts besides the +head. He ascribes their formation to particles of pus (not always +deposited in the form of pus) resulting from the softening and +suppuration of small tubercles, which, having been mixed with the +blood and disseminated, are arrested in some of the narrow passages, +perhaps of the lymphatic glands, and by obstructing and irritating +these, as happens in the production of venereal buboes, and by +retaining the humors therein, distend them and give origin to the +generation of a much more copious pus than what is carried thither; +and by this means, he says, we may also conceive how it is that much +more pus is frequently formed in the viscera and cavities of the +bodies than a small wound could have produced.[11] + +[Footnote 7: Braidwood on _Pyaemia_, p. 2 _et seq._] + +[Footnote 8: _Ibid._, p. 2.] + +[Footnote 9: _Ibid._, p. 3.] + +[Footnote 10: _Ibid._, p. 10.] + +[Footnote 11: _Ibid._, p. 3 _et seq._] + +Cheston (1766) believed that the translation of matter from one point +to another was a frequent occurrence after amputations of the larger +limbs. John Hunter (1793), and after him Velpeau, demonstrated the +existence of pus in the blood. Hunter believed that the pus was +derived from the interior of the inflamed veins. He described three +forms of inflammation of these vessels--viz. adhesive, suppurative, +and ulcerative. Pyaemia he considered to be an aggravated form of +phlebitis. Arnott (1829) concluded from his observations--1, That +death does not result from the extension of the inflammation of the +veins to the heart; 2, that the dangerous consequences of phlebitis +have no direct relation to the extent of the vein which is inflamed; +and, 3, that the presence of pus in the veins, though the principal, +is not the sole, cause of the secondary affection. He accordingly +opposes the idea of Abernethy, Carmichael, and others that the +constitutional affection is owing to the extension of the inflammation +to the heart. The publication of Arnott's and Dance's treatises led to +the general opinion being held in England and in France that phlebitis +and purulent infection were identical affections, or, at least, that +the latter was invariably caused by the former.[12] + +[Footnote 12: _Ibid._, p. 14.] + +{949} Cruveilhier (1829), admitting the doctrine of the formation of +secondary abscesses being due to capillary phlebitis, further laid +down an axiom, since proved untenable, that the foreign body +introduced into the veins, whose elimination by the emunctories is +impossible, will produce visceral abscesses similar to those which +occur after wounds and operations, and that these abscesses are the +result of capillary phlebitis of those viscera.[13] + +[Footnote 13: Braidwood on _Pyaemia_, p. 14 _et seq._] + +During the early part of the present century it was generally admitted +by the best authorities that the symptoms and lesions in pyaemia were +entirely due to the presence of pus in the blood, but whether absorbed +from the wound or developed by an inflammation of the veins was at +that time a disputed question. + +Haller made the first experiments on animals with putrefying +substances in the latter part of the eighteenth century, and was +convinced that nothing destroys the animal fluids more powerfully than +putrefaction. Gaspard (1822) published a complete work based upon his +experimental research in regard to the action of putrefying substances +on living organisms. He, having produced septic infection in animals +by injecting into their blood pus or other putrefying substances, thus +prepared the way for other experimenters, by whom he was quickly +followed. Ernst R. Virchow repeated the experiments of Gaspard, and +discriminated with greater precision between the surgical +diseases--septicaemia with its sharply-defined group of symptoms, the +opposite of pyaemia. Furthermore, "he showed that the changes in the +veins which had been regarded as due to phlebitis were caused by the +coagulation of the blood and by subsequent degenerative changes in the +thrombi thus formed; that the infarctions and abscesses seen in the +viscera were due to emboli which had become detached from softened +thrombi; that, as the white blood-globules and pus-globules were +identical in appearance, they could not be distinguished; and that it +was improbable that pus-globules made their way into the blood."[14] + +[Footnote 14: _The International Encyclopaedia of Surgery_, ed. by +Ashhurst, vol. i. p. 204.] + +Panum (1855) conducted a series of important experiments, and +endeavored to separate the infectious substance and determine its real +nature. He concludes that the real poison is not identical with any of +the chemical combinations or any of the single substances which have +until now been isolated by chemical analysis from the products of +nitrogenous decomposition, but adds that it is probably a concealed +ferment belonging to the so-called extractive matters--carbonate of +ammonium, leucin, tyrosin, fatty acids, acetic acid, etc. Furthermore, +that the putrid poison is stable, fixed, and non-volatile; that it is +neither decomposed by boiling nor by evaporation to dryness; that it +is insoluble in absolute alcohol, but soluble in water; that the +albuminous substances found in putrefying liquids become venomous only +because they are impregnated with the septic poison; and that washing +these substances in a large quantity of water renders them innocuous; +and that the energy of these putrid poisons can only be compared to +the venom of serpents, curare, and other vegetable alkaloids. + +The prize offered by the Faculty of Medicine at Munich for the best +essay on the action of putrefying substances in the animal organism +was awarded to Hemmer in 1866. His essay was distinguished for its +{950} accurate delineation of the pertaining literature and for the +number of experiments reported, while his conclusions bear a striking +resemblance to those of Panum. + +Bergmann in 1868 sought to determine the poisonous element contained +in decomposing animal substances, and for this purpose chemically +treated putrid fluids, hoping to find the agent that would excite all +symptoms of septic poisoning. He obtained a body of this nature from +decomposing yeast, which he called sepsin, although we have no proof +that either he or any one else has ever found the same in pus or any +decomposing animal matters; and even if it had been found in these, it +would then become necessary to demonstrate the fact that no other +substance contained in the putrefying liquids could produce septic +poisoning. Many other experiments, similar to those which have just +been mentioned, were made in the mean while by Magendie, Stich, +Billroth and Hufschmidt, O. Weber, Duprey, Learet, Urfrey, Saltzman, +Fischer, Frese, Muller, and others. Bergmann had extracted the sepsin +from yeast, but Schmidt and Petersen (1869) were able to obtain it +from putrefied blood. In 1869, Zuelzer and Sonnenschein claimed, on +the contrary, to have separated a new, unnamed septic alkaloid, which +was not the sepsin, and the action of which resembled that of atropine +and hyoscyamine. Nevertheless, the separation of the sepsin or of the +alkaloid of Zuelzer seemed to demand a talent in the manipulator which +is not possessed by everybody, and rare are the chemists who possess +it--so rare that these substances are not yet either officinally +recognized or classified. The attention of the medical profession had +now become thoroughly fixed on the chemical character and the +physiological action of these newly-discovered substances. It is +therefore only natural that we should find during the next few months +that the medical societies were much occupied with discussions on +these subjects, although no important progress seems to have been +made. + +Political events now gave a new direction to thought, and the +Franco-Prussian War filled the hospitals of both nations with wounded +in which there was opened a grand field for the practical study of +purulent infection in all its various forms. Humanity now demanded the +best efforts of the medical profession. Neither the mechanical nor +chemical theories had ever yielded practically any beneficial results; +consequently, something better was demanded in this emergency. It was +during this important epoch that the germ theory began to assume form +and to attract some general attention in the medical profession, +although Schroeder and Dusch had shown in 1854 that the filtration of +the air through cotton was sufficient to prevent the putrefaction of +albuminous substances which had been previously boiled. Pasteur also +demonstrated the existence of germs in the air in 1863, and likewise +showed their agency in the process of fermentation. + +Lister began the antiseptic treatment of compound fractures in 1865, +although he did not publish his report until 1867. The cotton-wadding +treatment of wounds, which is based on the fact that the air passed +through cotton is freed by it from all germs, was first employed by +Alphonse Guerin, who refers to it in the following language: "In the +latter part of 1870 I had the idea that the cause of purulent +infection existed in the germs or ferments which Pasteur had +discovered in the air. It was at the end of the war; all the cases of +{951} amputation had succumbed to the purulent infection, and not a +single large wound escaped the scourge. The studies which I had made +from the month of September to the end of December in 1870 had +confirmed me in the opinion that purulent infection is neither due to +phlebitis nor to the absorption of pus. I believed more firmly than +ever that the miasms emanating from the pus of the wounds were the +real cause of this frightful malady to which I had been compelled to +see the wounded succumb, whether they were treated with charpie or +cerate, whether with the lotions of alcohol or of carbolic acid +applied several times a day, and which was soaked up by the linen +which remained in contact with the wounds. But this miasmatic theory +remained, nevertheless, useless, since from 1847, when I professed it, +the cases of amputation in my service succumbed to purulent infection +in about the same proportion as those who were cared for by my +partisan colleagues did from the absorption of pus or the inflammation +of the veins. In my despair, seeking constantly a means to prevent +this terrible complication of wounds, I had thought of the miasm of +which I had admitted the existence, because I was not otherwise able +to explain the production of the purulent infection, and which was not +only known to me by its deleterious influence, but which appeared to +consist of living corpuscles of the nature of those that Pasteur had +seen in the air; and then the history of the miasmatic poison +possessed for me a new clearness. So, said I then, the miasms are the +ferments. I am able to protect the wounded against their fatal +influence by filtering the air, as Pasteur had done, while +maintaining, in opposition to Pouchet of Rouen, that there is no +spontaneous generation. I thought then of the cotton-wadding +treatment, and had the satisfaction of seeing my anticipation +realized. It was from this time that dates in reality the theory of +germs or of ferments as a cause of purulent infection."[15] + +[Footnote 15: _Nouveau Dictionnaire de Medicine et de Chirurgie +pratiques_, t. xxx. p. 265.] + +A series of important experiments were made in 1872 by Coze and Feltz, +which consisted in injecting into the jugular vein and the +subcutaneous cellular tissue putrid liquids; and they record, among +other interesting results observed by them, that the blood of the +animal thus destroyed always contained infusoria. These experiments +have been repeated and their results confirmed by several observers, +and in particular by Davine in 1872. + +Another series of experiments were made by Behier and Lionville, which +absolutely confirmed those of Coze and Feltz; they likewise found in +the blood rounded and rod-shaped corpuscles possessed of movements +more or less energetic. Vulpian also confirmed the results obtained by +Davine and Behier. He says: "It will not do to deny to the immovable +or movable vibriones and corpuscles found by Coze, Behier, and Davine +a very important role, because they are not the essential contagion of +the poisonous blood; it is at least necessary that they should be +there in order to produce the alterations which have occurred in this +fluid." Chauveau has experimented extensively, and likewise admits the +action of the septic vibriones of Pasteur. + +Pasteur has made known the result of his investigation in +communications to the Academy of Medicine in 1877, 1878, and 1879. +There exist, according to him, two principal vibriones--the pyogenic, +or the {952} producer of pus, and the septic, the producer of the +properly so-called septicaemia. But the latter is not a unique +disease, and, as we have seen from the outset, there are confounded +under this name different states, light or grave, corresponding with +as many forms of vibriones. + +The questions of greatest practical importance in regard to this whole +group of diseases seem to us to be, as expressed by Dr. Budd, where +and how the specific poisons which cause them breed and multiply; and +all who have closely followed the scientific investigations bearing on +these points which Prof. Tyndall has conducted during the past few +years, and who have repeated even a portion of his experiments, cannot +fail to be powerfully impressed with the value of the views which he +embodied in his work entitled _Floating Matter of the Air_. + +NOMENCLATURE.--The want of a systematic classification of the various +morbid conditions arising from septic infection has long embarrassed +alike authors and students, and even at the present time the vague +manner in which the terms pyaemia and septicaemia are used leads to +much confusion. The Pathological Society of London appointed, in 1869, +a committee to investigate the nature and causes of those infectious +diseases known as pyaemia, septicaemia, and purulent infection. This +committee, having spent ten years in the study of these affections in +connection with nearly all the large hospitals of London, report the +following: "Summary.--It would seem, from a careful study of all the +cases here collected, that it is probable that the diseases commonly +known clinically as pyaemia and septicaemia may be grouped as follows: +1. Septic intoxication.--The effects of poisoning by the chemical +products of putrefaction. A non-infective disease. 2. Septic +infection.--A general infective process arising from the introduction +of some peculiar constituent of putrid matter into the blood-stream. +It is supposed by some to be due to the multiplication of living +organisms in the blood, and by others to the effect of a non-organized +ferment. It terminates fatally without secondary inflammations. 3. +Pyaemia (for want of a better name).--An infective process probably, +similar in nature to septic infection, but differing from it by giving +rise to local inflammation and suppurations, often complicated by +thrombosis and embolism, probably due to the blood condition. 4. +Thrombosis with softening and decomposition of the thrombus and +embolism, causing local abscesses in the viscera wherever the septic +emboli lodge, but without the development of any general infective +process. 5. Various combinations of one or more of the foregoing +conditions in the same subject. 6. Infective periostitis or acute +necrosis. 7. Infective endocarditis or ulcerative endocarditis. 8. +Infective myositis. 9. A group of obscure cases in which it is +impossible to form any idea as to the exact nature, often called +spontaneous septicaemia or pyaemia."[16] + +[Footnote 16: _Trans. Pathological Soc. of London_, vol. xxx. p. 38.] + +It will be observed that the earlier writers on medicine, although +aware of the existence of septic diseases, wholly failed to +discriminate between pyaemia and septicaemia until 1848, and even +since that date these terms have been only partially adopted by +authors, by whom frequently the meaning of the same word has been so +modified as to refer to essentially different conditions. Custom +having fully sanctioned the use of these terms, it is now thought that +a separate consideration of their {953} nomenclature may be +advantageous, and consequently we shall pursue this course. + +NOMENCLATURE OF PYAEMIA.--In Dunglison's _Medical Dictionary_ the +definition given to pyaemia is, "Pyohaemia," and the latter word is +defined as follows: "Pyohaemia, Pyaemia, Pyohemie (F.), from _pyo_, +and [Greek: haema], 'blood;' alteration of the blood by pus, giving +occasion to the diathesis seu infectio purulentia." + +The committee appointed by the Pathological Society of London in 1869 +report on this subject as follows: "The most common definition of +pyaemia is, no doubt, that adopted by the College of Physicians in the +nomenclature of diseases. It is as follows: 'A febrile affection +resulting in the formation of abscesses in the viscera and other +parts.'" + +Birch-Hirschfeld includes under the name pyaemia "all cases in which +any general infective process is set up as a secondary consequence of +a wound."[17] Virchow has proposed the name ichorrhaemia. O. Weber +uses the name embolhaemia for the condition in which emboli are found +in the blood. Hueter in pure cases of purulent infection without +metastasis calls the disease pyohaemia simplex; in cases with +metastasis, pyohaemia multiplex; and when complicated with septicaemia +he designates it as septo-pyohaemia. The term hospitalism has been +applied to this disease by Erichsen and Sir James Y. Simpson, and the +former remarks that "the term pyaemia is used in a very wide and +elastic manner, and by many is made to include various forms of +blood-poisoning."[18] Billroth says: "Pyaemia is a disease which we +believe to arise from the taking up of pus, or of the constituent +parts of pus, into the blood." Koch employs the term pyaemia merely to +denote a general affection accompanied by metastatic inflammation and +suppuration. + +[Footnote 17: _Trans. Pathological Soc. of London_, vol. xxx. p. 22.] + +[Footnote 18: _On Hospitalism_, p. 73.] + +The French definition and nomenclature of pyaemia, according to +Guerin, is as follows: "Purulent infection, or pyohaemia, purulent +fever, surgical typhus." The purulent infection is a poisoning of the +blood, which terminates by the formation of multiple abscesses, which +have been improperly known under the name of metastatic abscesses. + +From 1820 to 1870 surgeons admitted that these abscesses were the +result of a phlebitis having its origin in a wound exposed to the air. +Therefore, this disease was variously designated under the name of +phlebitis, pyohaemia, or purulent infection. Tessier called it +purulent diathesis; "in 1847, I compared it to the typhus, and, as the +poison is absorbed from the surface of the wound in the purulent +infection, I gave it the name of surgical typhus or purulent +fever."[19] + +[Footnote 19: _Nouveau Dict. de Med. et de Chir. pratiques_, t. xxx. +p. 222.] + +Having given enough on this subject to answer our purpose, we will +consider the nomenclature of another septic complication. + +NOMENCLATURE OF SEPTICAEMIA. The term septicaemia was first employed +by Piorry, and was applied for a considerable time to all those +diseases in which the blood was submitted to a septic influence. +Therefore, the term was made applicable to the morbid conditions +existing in anthrax, glanders, typhus and typhoid fevers, variola, and +also all forms of purulent and putrid infections. Guerin now adds: +"Fortunately, for several years the most competent authors seem to +have wished to {954} reserve the name of septicaemia for what surgeons +call putrid infection, and for the morbid state that the experimenters +produce by the injection of putrid material into healthy animal +tissues; it is consequently the experimental septicaemia which we aim +at first and foremost."[20] + +[Footnote 20: _Nouveau Dict. de Med. et de Chir. pratiques_, t. xxx.] + +Dunglison defines septicaemia with a single word, septaemia. The same +authority gives the following derivation and definition to septaemia: +"From [Greek: septos], 'rotten,' and [Greek: haema], 'blood.' A morbid +condition of the blood produced by septic or putrid matters." + +Sanderson says: "What I mean by septicaemia is a constitutional +disorder of limited duration, produced by the entrance into the +blood-stream of a certain quantity of septic material. It must, +therefore, be regarded less as a disease than as a complication, +differing from pyaemia not only in the fact that it has no necessary +connection with any local process, either primary or secondary, but +also in the important particular that it has no development."[21] + +[Footnote 21: _British Medical Journal_, Dec. 22, 1877.] + +Both Davine and Koch designate as septicaemic all cases of general +infection from wounds in which no metastatic changes occur. +"Birch-Hirschfeld limits the term septicaemia much in the same way as +Sanderson. He describes as septicaemia those cases in which the +disease results merely from the absorption of the products of +putrefaction, and regards it merely as a process of poisoning, such as +might arise from the injection of any other noxious chemical substance +into the blood. Pyaemia, on the other hand, he considers a truly +infective process, probably due to the entrance of specific organisms +into the body. He would therefore include many of the cases described +by Koch as septicaemia under pyaemia."[22] + +[Footnote 22: _Trans. Pathological Soc. of London_, vol. xxx. p. 9.] + +Billroth defines septicaemia as an "acute general affection which +arises from the taking up of various kinds of putrid substances into +the blood, and it is believed that these putrid substances so change +the quality of the blood that it can no longer fulfil its +physiological functions."[23] + +[Footnote 23: _Lectures on Surgical Pathology and Therapeutics_ +(trans. from 8th ed.), vol. ii. p. 41.] + +Heuter defines septicaemia as a fever caused by the entrance into the +circulation of the products of putrefaction from local centres of +decomposition. He draws no clear distinction between an infective and +a non-infective form, but the affection he describes as pyaemia +simplex or pyaemia without metastasis seems to include many cases +which Davine, Koch, and others would include under septicaemia.[24] + +[Footnote 24: _Trans. Path. Soc. of London_, vol. xxx. p. 9, 1879.] + +Having before us the views of some of the prominent authors who have +written upon the nomenclature of pyaemia and septicaemia, we observe +that the use of these terms is based either on known or imaginary +morbid conditions of the body, more especially of the blood. It +therefore seems that the first step toward determining the proper +limit within which these terms can be employed consists in learning +their accurate meaning, which is fortunately clearly shown by their +derivation. The next step consists in the application of these terms +to the morbid conditions which are described more or less completely +by these words. It may be here added that there will be frequently +required for a full and definite expression certain modifying words, +and consequently we may {955} properly employ such phrases as +puerperal septicaemia, spontaneous pyaemia, etc. + +Having carefully examined the terms employed by various authors in +connection with the morbid changes which are known to occur in certain +cases of septic contamination, we give our preference to the following +nomenclature: Septicaemia, septo-pyaemia, pyaemia simplex, and pyaemia +multiplex. + +The term septo-pyaemia is applied to a morbid condition possessing +certain peculiarities of both septicaemia and pyaemia, and it is +supposed to arise from the absorption of both poisons; the term +pyaemia simplex is applied to a pyaemic condition in which there is no +metastasis; while the name pyaemia multiplex is given to that form of +disease which is characterized by the existence of metastatic +abscesses. It may be well to add here that this nomenclature is not +intended to cover all cases of septic poisoning, but to be applied to +those cases only in which the morbid changes give to the terms a +certain degree of appropriateness. + +Septic poisoning may be justly regarded as a single chain composed of +many links. Take, for example, a case of amputation of the thigh, +followed within a few hours by traumatic fever, later by septicaemia; +afterward there may be developed secondary fever; formation of +ichorous pus, with absorption and its concomitants; pyaemia, +accompanied by embolism, thrombosis, abscess in the lungs, liver, etc. +To these may also occasionally be added phlebitis and inflammation of +the joints, terminating speedily in suppuration. This chain may in +this case be further lengthened or varied with traumatic erysipelas or +with hospital gangrene. In fact, the variations in these cases are +very numerous, and all these conditions, together with many others, +are due to septic blood-poisoning. + +ETIOLOGY OF PYAEMIA.--Four theories have been advanced at different +times to explain the etiology of pyaemia, and they have been +designated as follows: the mechanical, the nervous, the chemical, and +the germ theories respectively; and their action is based on the +following hypotheses: 1, that pus enters the blood, circulates in it, +and acts as a poison; 2, that an irritation is excited in certain +visceral organs in sympathy with inflammation of the fibrous membranes +of the cranium or the bones of the upper or lower extremity, and there +is thus produced a metastasis to these organs of an ichorous miasm or +of a fluid which is more or less acrid; 3, that a chemical poison is +generated from the pus in the wound, and when it is absorbed produces +pyaemic manifestations; 4, that the putrefaction of pus in wounds is +caused by a microscopic organism which enters the circulation and +produces pyaemia. + +The first hypothesis was somewhat modified, as we have already +mentioned, by John Hunter and others, who advanced the idea that +pyaemia consisted essentially of a phlebitis, and that the pus found +in the circulation had its origin within the veins. However, it has +since been shown conclusively that pyaemia cannot be produced by the +injection of healthy pus into the cellular tissue or veins. This fact +having been generally admitted by the profession, it is thought +unnecessary to adduce here either the experiments or the arguments +which have been accepted as conclusive on this important point. It is +not even necessary to bring forward the disputed question of the +possibility of the entrance of pus into the blood, since laudable pus +does not produce pyaemia. In fact, we have reached a point in the +{956} progress of medicine when the discussion of either the first or +second hypothesis ceases to be interesting to medical men. +Consequently, our chief interest in the study of the etiology of +pyaemia centres in the third and fourth hypotheses; and we believe +that it may be safely asserted that the origin of this disease has +been fully demonstrated by an almost unlimited number of experiments. + +The injection of pus into living animals produces local, remote, and +constitutional symptoms. The character of these symptoms depends +principally on the kind of pus, laudable or ichorous, the quantity +injected, and the site of the injection. It will be readily perceived +that in cases where the pus is thrown directly into a vein the local +symptoms would be unimportant, while the danger of remote +trouble--metastatic abscesses in the lungs, liver, etc.--would be very +great; but should the injection be made into the connective tissue, +then the relations would be reversed. Constitutional symptoms may +exist in both cases, but will differ in character and degree. + +In regard to the character of the pus, and its agency in the +production of this disease, Billroth says: "The old view, that pyaemia +is only induced when decomposed pus (ichor) is reabsorbed, is entirely +erroneous. There are cases where decomposed, putrid pus enters the +blood, and which present a combination of the symptoms of septicaemia +and pyaemia (septo-pyaemia of Hueter)."[25] Dupuytren failed to +produce metastasis by injections of pus into the veins of dogs; these +results were confirmed by Boyer, who only obtained metastasis when he +used ichorous pus in his experiments. The same results are recorded in +the works of Gunther and Sedillot, based on numerous experiments. Beck +made fourteen experiments very carefully, but did not succeed in +producing metastasis in a single case. The same results are recorded +by a commission of the Physiological Society of Edinburgh. O. Weber +has recently shown by extended experiments that carefully filtered pus +will not produce metastatic abscesses in the lungs. Therefore, it may +be considered as proved that fluid pus injected into the veins of an +animal produces no metastatic points of inflammation. + +[Footnote 25: _Surgical Pathology_, p. 344.] + +It should not be supposed, however, that because injection of fresh +(non-ichorous) pus failed to produce metastatic abscesses, it was +therefore without results, as the earlier experimenters thought. +Billroth and O. Weber have shown by their recent experiments that +these injections are uniformly followed by fever, and, if +subcutaneous, by abscess; and further, that injections of fresh pus +produce even a higher temperature than do those of ichorous pus; but +the pus taken from cold abscesses has apparently very slight effect. +The fresh non-ichorous dried pus was found to possess in a similar +degree the power to excite inflammation and suppuration; even the +removal of the albumen did not change its character or power. It will +be observed that these injections caused not only local inflammations, +but severe constitutional symptoms, as high temperature, etc. +Experiments have thus far completely failed to show the agent that +excites the inflammation, although it is generally admitted that it at +least exists in the molecular bodies. + +Virchow and Panum have shown conclusively by their experiments on +living animals that the introduction of foreign bodies into the {957} +veins--as powdered coal, wax balls, and quicksilver--fail in all cases +to produce metastatic abscesses in the visceral organs or symptoms of +pyaemia. These foreign bodies were frequently found blocking up the +terminal branches of the pulmonary artery, in some cases encapsulated, +frequently resembling miliary tubercles, and occasionally surrounded +by evidences of slight local inflammation, but in every instance +without suppuration. The same experimenters, however, observed that +the introduction of ichorous pus and decomposing animal tissue into +the veins was attended with the formation of metastatic abscesses and +other symptoms of pyaemia. They therefore conclude that the +introduction of putrid animal substances into the veins, and the +further transport of the same to the branches of the pulmonary artery, +produce metastatic abscesses, and that the origin of these deposits is +independent of the mere stopping up of the branches of this artery. + +The occlusion of the blood-vessels in this diseased condition is a +subject which has given rise to much discussion. Some of the earlier +writers supposed this phenomenon constituted the disease pyaemia, +while others believed it to be the essential cause. Roser says: "But +the thrombus is, as can be easily proved, not the cause, but only a +symptom, of pyaemia. If a surgical patient--_e.g._ one suffering with +an injury of the head--is attacked by inflammation, and occlusion of a +large vein, as of the common iliac vein, for instance, then there are +three different theories for the inflammation of the occluded +vessel--viz. Hunter's, Rokitansky's, and Virchow's. According to the +old Hunterian phlebitic theory, the coagulation of the blood should be +the result of the inflammation of the vein. On account of the +circumstances under which the coagulation of the blood in the vein has +occurred, one might suppose that the cause must be the oozing of +coagulable exudation from the inflamed wall of the vein, but +pathological dissections, especially Rokitansky's, would not accord +with it. Large veins were found plugged up without the existence of +corresponding indications of inflammation, and perfectly clear +indications were often present that occlusion had preceded the +inflammation. Consequently, the occlusion of the vein was the primary +condition, and this must be explained in some other way than by its +inflammation. Rokitansky in his theory recognized an independent +disease of the blood. Yet it does not appear, on examination of the +morbid conditions, that this theory can account for them. If it is +recognized as correct that a primary disease of the blood is to be +admitted, yet the coagulation of the blood in a large vein has not +been traced back to it. It remained wholly unexplained why a single +vein, especially one so large and strong as the common iliac, should +become the seat of the local coagulation. The necessity of finding a +local basis for the local coagulation could not be denied. For that +reason it was greeted as a highly desirable advance when Virchow +pointed out that the occlusion of such large veins could be dependent +on the coagulation of the blood in the concave spaces behind the +valves of the veins, or through the coagulation in the small +branches--_e.g._ the hypogastric veins, which is gradually carried +forward until it reaches the common iliac, and by continual increase +this vein may also be filled up. At the same time, it was demonstrated +that not infrequently, much oftener than {958} was formerly supposed, +the coagulated masses of blood are broken up and carried farther on in +the circulation, in this manner producing occlusion of the pulmonary +artery or its branches."[26] + +[Footnote 26: _Archiv der Heilkunde_, Erst. Jahrg., Erst. Heft, S. 4.] + +The examination of this subject finally brings Roser to this +conclusion: "Contamination of the blood is essentially the primary +cause of pyaemia; thrombosis is only a result of this morbid +contamination, and cannot, therefore, be regarded as the cause of +pyaemia, but only as an apparent part, as one of the symptoms of the +same."[27] The opinion here expressed by Roser I believe to be the one +generally entertained by the profession at this time. + +[Footnote 27: _Ibid._, S. 43.] + +In cases of pyaemia there are recognized two principal sources of +contamination of the blood--viz. the wound itself, and the vitiated +condition of the atmosphere surrounding the patient--contamination, in +the first place, directly from the wound through the blood-vessels; +and in the second, by the passage of disease-germs or of the poisonous +elements into the blood along the respiratory tract. E. Wagner says: +"The latest examinations in regard to the vegetable parasites have +made it very probable not only that these are the active agents, but +also--what has been clinically quite generally accepted--that +septicaemia and pyaemia owe their origin to different plants (the +first to rod bacteria, the latter to globular bacteria); and, finally, +that both may combine."[28] These germs may be generated in the wound +or be received into it from the surrounding atmosphere. The character +of the wound and the conditions surrounding the patient thus become +important subjects for the consideration of the surgeon. + +[Footnote 28: _Manual of General Pathology_, p. 593.] + +It has been observed, and is now generally admitted, that wounds +complicated with a fracture of the long bones of the extremities, +opening large medullary cavities and accompanied by extensive +laceration of the soft parts, always increase the danger of +blood-poisoning. This fact may be more thoroughly understood by a +brief consideration of the condition of the parts. Frequently in open +fractures large quantities of pus constantly remain in contact with +the surface of the wound, while detached fragments of bone, which +become speedily necrosed, move about with every motion of the injured +limb, lacerating more or less the surrounding tissues, and thus +exciting inflammation and suppuration. The periosteum becomes +inflamed; a widespread suppurative periostitis is the result; necrosis +of the bone from insufficient nutrition follows, while mechanical +pressure on the pus aids in its absorption. The medulla frequently +takes on suppurative inflammation, and here the surgeon fails to +receive prompt warning of danger; slowly the suppuration progresses, +without pain or other symptoms unless the disease has extended to the +other tissues; the medullary cavity at the fractured end of the bone +may be completely or partially occluded by a new osseous formation; +and in such cases the absorption of pus by the comparatively large +venous vessels of this cavity is greatly facilitated. + +The soft parts may also be the seat of dangerous trouble. The same +force that produced the wound and fracture may have also contused the +soft parts, destroying in a greater or less degree their nutrition, +thus giving rise to gangrenous sloughs, or in other cases to the +formation of abscesses, etc. I will also call attention to the fact +that the laudable pus {959} in these cases is most favorably situated +for a rapid change into that commonly called ichorous. The heat of the +parts and the contact of the pus with the atmosphere will not fail to +effect its rapid decomposition. + +ETIOLOGY OF SPONTANEOUS PYAEMIA.--It is unquestionable that cases of +true pyaemia have been observed in which the etiology was not +traceable to a wound; and it is equally certain that this failure to +discover such a source of contamination in the majority of cases is no +proof that it did not exist. When it is remembered that a large +portion of the alimentary canal, the respiratory and the +genito-urinary tracts, are so situated that the existence of a +contaminating wound might be absolutely undiscoverable, we are +compelled to admit the possibility of a local centre of contamination +in all these cases. But the question may be asked here with propriety, +"Is fatal pyaemia, independent of a wound, ever produced by breathing +vitiated air?" The answers to this question must generally be a +negative, although it is certainly true that poisoning of the blood +does take place to a certain degree, as is abundantly shown by the +different symptoms arising in patients thus exposed who are not +suffering with wounds. It is said that dogs exposed in this way are +found to rapidly emaciate and suffer from severe and constant +diarrhoea. The various symptoms arising in patients confined in +overcrowded and pus-infected wards, among which may be mentioned loss +of appetite, with diarrhoea and emaciation, are too well known to +require an enumeration here. Therefore it appears highly probable that +living in and breathing a vitiated atmosphere may act as a strongly +predisposing cause, only requiring a slight scratch or abrasion of the +skin, in which the infection may be said to act as an exciting cause +of pyaemia. + +In reference to such complications the following questions are asked +by Roser: "Is it a specific deleterious material, a miasmatic or +contagious disease-poison, or, as it is generally expressed, a zymotic +agent? Must we regard each particular typhus-like fever, with its +remarkable changes of blood, with its various localizations in all the +organs and membranes, with its chills, furred tongue, petechiae, +delirium, etc., as we regard typhus, scarlatina, variola, etc.? or, as +Virchow teaches us, is this pyaemia, so greatly feared by all +surgeons, only an ontological idea? Is the word pyaemia only a general +name for three different conditions--viz. leucocythaemia, thrombosis, +and embolism, or ichorrhaemia and septicaemia? or are there, as many +have supposed, two ways in which pyaemia may originate? Is there one +primary miasmatic pyaemia analogous to the other epidemic, so-called +zymotic diseases? and again, a secondary pyaemia arising from +suppurative inflammation, wherein the poison is formed in the +patient's own body, which is infected by a single organ?"[29] + +[Footnote 29: _Loc. cit._, S. 39.] + +That this disease is caused by a specific deleterious material in the +large majority of cases is no longer a question for discussion. The +only question to consider is, whether it always arises from the same +cause. Is it possible for pyaemia to originate spontaneously? Are +there any cases of sporadic origin, or are they always due to endemic +or contagious influences? No definite answer can be given to these +questions, although, undeniably, the weight of the argument is +strongly opposed to a sporadic origin. The term miasmatic, as {960} +used by Roser, probably refers to the vitiated condition of the +atmosphere, as seen in the overcrowded surgical and obstetrical wards +of hospitals. In no other sense can the word be appropriately used in +connection with the subject of pyaemia. It is true, pyaemic diseases +are found to prevail at certain seasons and in certain localities much +more extensively than under other circumstances. The same, however, is +true of cholera, typhus fever, scarlatina, variola, and other +contagious diseases. That pyaemia is contagious has been frequently +demonstrated. I therefore conclude that the prevalence and spread of +this disease must be explained by the same rules as are applied to the +existence and propagation of these allied affections. + +This inquiry into the etiology of pyaemia brings before us again the +four hypotheses which have been given in explanation of the same +number of theories. The first and second have been already abandoned +by the medical profession, after it was satisfactorily demonstrated +that they were based on false theories, and consequently there remain +for our consideration only the third and fourth. + +The third hypothesis assumes that a chemical poison is developed in +the wound-secretions, which when absorbed produces pyaemia. An +examination of the subject does not justify us in asserting that this +proposition has been proved, although it is certain that the results +of experimental inquiry demand for it a more extended investigation. +In all the analyses which have thus far been made the investigators +have entirely failed to give us an adequate knowledge of this poison, +and not a word has ever been said in regard to the agency by which it +is produced, although it is universally admitted to have been only +obtained from decomposing animal substances. It is therefore pertinent +to the continuation of this inquiry to ask, By what agency is the +putrefaction of animal substances produced? It has now been fully +shown that there can be but one answer given to this question--viz. +the putrefaction of albuminoid substances can only be effected by +living organisms. We therefore conclude that the fourth hypothesis +brings us at least one step nearer the correct explanation of the +etiology of pyaemia than the third, since we justly assume that if +there is a chemical poison in decomposing albuminoid substances, it is +produced through the agency of living organisms. + +ETIOLOGY OF SEPTICAEMIA.--The first question which arises in the +discussion of the etiology of this morbid condition is entirely +dependent on the scope which we give to the word septicaemia. +Sternberg says: "The view which is entertained by high authorities, +upon clinical and experimental evidence, is that there are two forms +of septicaemia--the one a septic toxaemia due to the effects of a +chemical poison or poisons evolved during the putrefactive +decomposition of certain organic substances, especially of nitrogenous +animal products; the other an infective disease produced by the rapid +multiplication in the body of the infected animal of a parasitic +organism. The best-studied and most widely known form of septicaemia, +due to the presence of a parasitic organism, is the disease known as +anthrax--charbon of the French, milzbrand of the Germans--but several +other varieties are now well established, in which similar symptoms +and pathological results are produced by organisms morphologically +different from the bacillus anthracis. Among these may {961} be +mentioned the form of septicaemia in the mouse, so well studied by +Koch, which is due to a minute bacillus, and the form of septicaemia +in the rabbit, produced by the subcutaneous injections of human +saliva, due to micrococci, which has been studied by Pasteur, Vulpian, +and myself independently."[30] + +[Footnote 30: _Amer. Jour. Med. Sci._, July, 1882, p. 70.] + +The terms septic toxaemia and septic intoxication are applied +indiscriminately to the same disease, and the committee appointed by +the London Pathological Society to investigate the nature and cause of +those infectious diseases known as septicaemia, etc. further report +that "ordinary wound-fever is merely septic intoxication in a very +mild form, and it is only necessary for the dose absorbed to be +sufficient in quantity for fatal consequences to ensue. Septic +intoxication is, therefore, of the commonest possible occurrence as a +complication of severe surgical injuries, but it is in so mild a form +as to bear but little resemblance to that experimentally produced on +animals."[31] The question which now arises is, Shall septic +intoxication be classified with septicaemia? + +[Footnote 31: _Trans. Pathological Soc. of London_, vol. xxx. p. 14.] + +We have been long accustomed to speak of this complication as a +surgical or traumatic fever; and consequently any change in this +classification must necessarily lead to confusion. Furthermore, it is +now generally supposed there is much difference in the etiology of +these morbid conditions. It is claimed that septic intoxication arises +from the absorption of a chemical poison evolved through the agency of +living organisms during the process of putrefaction in a wound, and +that the conditions are unfavorable for their development within the +blood or tissues of a living animal; but in true septicaemia the +organisms are developed in the wound during putrefaction, and then +find their way into the blood and tissues of the body, where they +rapidly multiply. Consequently, the former condition tends to a rapid +recovery--unless the quantity of poison primarily admitted to the +system has been excessive--while the latter tends to a fatal +termination. + +Septic intoxication is regarded as a non-infective disease, and true +septicaemia as an infective malady. The only etiological similarity +between these morbid conditions is found in the fact that they take +their origin in putrefaction, which is effected by the action of +different organisms possessing marked morphological differences and +requiring essentially different surroundings for the maintenance of +life and reproduction. Thus, it is supposed that in cases of septic +intoxication the organism by which putrefaction is caused in the +wound-secretions can only live in the open air, and that its life is +commonly only of a few hours' duration. The brevity of bacterial +action in this instance may be due to a failure of the absorptive +power or to a changed condition in the wound-fluids, rendering them +unfit to support the organism. + +It is now a well-recognized fact that all septic absorption ends so +soon as the wound-surfaces are covered with healthy granulations, but +that septic absorption, which produces septic intoxication, is most +commonly of a much shorter duration, and, consequently, that the wound +complication, which I prefer to designate traumatic fever, is +essentially an acute disease, and can only be lengthened out by +unusually favorable circumstances for the continuance of the +absorption of the poison by which it is produced. {962} The severity +and danger of the disease will necessarily depend on the amount of +poison absorbed and the resisting power of the patient; but since +there is no multiplication of the materies morbi within the body, a +rapid elimination by the natural emunctories may be reasonably +expected under favorable circumstances. + +It should be observed here that the etiology of septicaemia differs +from that of traumatic fever, since the organisms in the former +condition are first formed in the wound-secretions, but quickly enter +the body, where they rapidly multiply; consequently, Chauvel has +defined surgical septicaemia as follows: "The particular intoxication +which results from the penetration and multiplication in the body of a +specific microbe designated by Pasteur under the name of septic +vibrio." The bacterial origin of this disease is now generally +accepted, and the only question in the professional mind seems to be +whether the organisms are the direct or indirect cause of the malady. + +There are also some other interesting questions which have arisen in +connection with the study of this subject, and are thought to be of +sufficient importance to merit mention here. It has long been known +that dissecting wounds are most dangerous when made while examining +the body very soon after the death of the subject. Recent observations +seem to justify the conclusion that the greatest activity of the +septic agent is often, if not always, attained before the odor of +putrefaction has become fairly perceptible; and even before this odor +has reached its maximum degree of offensiveness the danger from septic +poisoning has generally disappeared. In some cases septic intoxication +is promptly followed by a slight inflammation in and about the wound, +which may entirely disappear within a few hours, but only to reappear +after a lapse of eight to fifteen days, with the first vigorous +physical exercise of the patient. Two cases of this kind have recently +come under my observation. In both instances the wounds were located +in the hands, and the exercise which developed the septicaemia +consisted in rowing a boat, and while thus engaged the local symptoms +reappeared with such severity as to cause the patients to quickly +discontinue the labor. The reappearance of the local inflammation in +both these instances was quickly followed by a rigor and the rapid +development of other constitutional symptoms, although prior to the +recurrence there was no pus, nor even marked inflammatory action, in +any part of the hands. + +Professional attention was first called to the above-stated facts by +Panum in 1855, who discovered that the maximum toxic action of putrid +substances is generally developed during the first hours of bodily +activity. In this stage of incubation in cases of surgical +septicaemia, if we admit the bodily action as an etiological factor, +we observe a striking resemblance to one of the leading +characteristics of all the infectious diseases, which unquestionably +depend on some sort of septic poison. Furthermore, this analogy +becomes most striking if we contrast the effects arising from +dissecting wounds with those of the bites of poisonous serpents and +rabid animals. + +Further investigation is required to settle the perplexing questions +of etiological and pathological differences in these allied morbid +conditions, for although much has been accomplished during the last +two decades, still much more remains to be done. It has only recently +been discovered {963} that the septic material in septicaemia is +absorbed by the lymphatics, while in pyaemia the poison enters the +body through the veins. + +ETIOLOGY OF SEPTO-PYAEMIA.--It is now generally admitted that +remittent fever and typhoid may be associated, and this morbid +condition is commonly designated by the term typho-malarial fever. The +etiology is unquestionably dependent upon the action of the two +distinct and entirely dissimilar poisons. Scarlatina is likewise +frequently complicated by diphtheria, and here we have the combined +action of two poisons, each commonly designated as septic and supposed +by many physicians to be similar. + +In a like manner, it is believed that septicaemia and pyaemia may be +associated, and take their origin in dual poisons; but since the +etiology of both these morbid conditions has been already described, +it is not deemed necessary to dwell longer on septo-pyaemia under this +division of our subject. + +PATHOLOGY OF PYAEMIA.--The study of the pathology of pyaemia is +advanced by adopting the following classification, which is based on +recognized post-mortem lesions. The pathological appearances in these +forms of the disease differ widely, although the clinical symptoms are +often similar. In pyaemia simplex the pathological conditions are +essentially more negative. This variety of the disease can only +destroy life by the height and duration of the fever which is +maintained in connection with the continued existence of ichorous pus. +There is found, as an essential basis of this form of disease, +extensive suppuration in the subcutaneous tissues. + +The arguments in favor of the admission of pus-corpuscles into the +blood are as follows: 1. The blood in pyaemia is known to contain more +white granular spherical bodies than are normal. The question has been +raised, Are they pus-cells or white blood-corpuscles? The answer is +difficult, and has not yet been attained. Virchow, in the mean time, +has proved that we cannot differentiate, morphologically, between the +blood- and pus-corpuscles. 2. Cohnheim has demonstrated the existence +of the wandering corpuscles in cases of inflammation. Therefore it +appears probable that in cases of pyaemia the blood may contain the +pus-corpuscles, but further investigation is needed to establish this +fact. However, the establishment of this point would still leave the +more important undetermined. + +There are often important changes observed in the blood of patients +dead of pyaemia, to which I now desire to direct attention. The red +corpuscles of the blood, even in the early stage of the disease, in +many cases show signs of disintegrating into molecules, and are +observed to be accumulated in masses without showing the slightest +tendency to form rouleaux. There is a steady increase in the number of +pus- or white corpuscles in the blood of pyaemic patients during the +whole course of the disease in fatal cases. The condition of the red +corpuscles, already mentioned, becomes more and more marked toward the +fatal termination. + +In all cases of pyaemia multiplex the increased coagulability of the +blood may be observed in the early stages of the disease, and steadily +increases as the disease progresses. + +In pyaemia simplex this condition is less marked, although generally +present, "while we know septicaemia diminishes or destroys the {964} +coagulability of the blood. Hereby the possibility is given, at least +on the cadaver, to differentiate between pyaemia simplex and +septicaemia, although cases occur of the more fatal septic infection +in which the post-mortem condition is a complete or almost complete +negative. Therefore, in these cases the differential diagnosis on the +cadaver must be limited to this, that we are able to demonstrate the +existence of a purulent or ichorous deposit." It will be readily +observed that the difference in diagnosis mentioned above relates to +pyaemia and septicaemia, and not to the different varieties of the +former disease. + +The following facts should be constantly kept in mind by the surgeon +to enable him to differentiate between the two forms of pyaemia: In +pure cases of purulent infection, without metastasis, the disease is +called pyaemia simplex, and in cases with metastasis, pyaemia +multiplex. The various conditions on which the metastasis may depend +are shown by Hueter, who says: "The metastatic abscesses of pyaemia +multiplex met with in the lungs, liver, spleen, and other internal +organs are regarded, with the greatest probability, as a result of the +embolic process. The metastatic inflammation of the serous membranes, +of the cellular tissues, and of the parotid glands, and probably also +a few metastatic inflammations of the internal organs, are at present +supposed to arise from a general inflammatory diathesis."[32] It has +already been shown by numerous experiments on animals that metastatic +abscesses in the lungs, liver, and other visceral organs only arise +after the introduction of ichorous pus, while healthy pus has +uniformly failed to produce these results. + +[Footnote 33: Billroth's _Handbuch der Chirurgie_, S. 88.] + +It now remains to be shown how the introduction of ichorous pus acts +in the production of pyaemia multiplex. The ichorous pus, having found +its way into the venous circulation, gives rise to the formation of +thrombi in the veins; these clots become more or less broken up, and +are carried forward by the blood to the right auricle; from this +auricle to the right ventricle; from this ventricle to the pulmonary +artery, and through its ramifications to every part of the lungs. In +the minute ramifications of this vessel are found wedge-shaped clots +of various sizes in different conditions, some softened and others +still firm. The possibility of these clots ever passing through the +lungs, and afterward being arrested in other visceral organs, has been +demonstrated on animals. It has been shown that fine particles of +foreign matter injected into the veins have passed through the lungs +and subsequently lodged in the liver. This theory enables us to +account, upon a mechanical basis, for the existence of the metastatic +abscesses in the liver which have apparently originated as the result +of primary infection. + +In other cases these abscesses are supposed to arise from secondary +infection. Thus, ichorous pus, having found its way into the venous +circulation, produces primarily venous thrombi, which, as in other +instances, break up, the clots being carried in the same manner into +the terminal branches of the pulmonary artery, where they are +designated as emboli. The first action of the emboli is the mechanical +closure of these vessels, thus depriving the surrounding parts of +nutrition to a greater or less extent. It will be proper now to recall +the fact that the composition of these emboli is such as to favor +rapid suppuration; this commonly commences {965} in the clot and +surrounding tissues, having been preceded by a brief stage of +congestion and inflammation. There is also occasionally found around +these points more or less extravasation. The metastatic abscess thus +formed in the lungs is favorably situated for the production of +secondary infection. From this abscess thrombi arise in the pulmonary +veins, which become disintegrated, and are carried to the auricle, +thence to the left ventricle, and finally through the aorta, and find +lodgment in the terminal branches of the arteries of the various +organs, where they produce the characteristic lesions. + +The organs which most frequently become the seat of this secondary +infection are the liver, spleen, kidneys, brain, and eyes. + +Let us now briefly examine this mechanical theory. Do metastatic +abscesses arise from a single cause or from a combination of causes? I +am inclined to the opinion that the proximal cause of metastatic +abscesses in the visceral organs is the existence of emboli in the +terminal branches. The vitiated atmosphere surrounding the patient, +the existence of a wound, and the formation of ichorous pus are +conditions which should not be lost sight of. These are the elements +acting on the blood, producing in it morbid changes, and may therefore +be regarded as predisposing causes. The morbid conditions of the +blood, the increased number of white blood-corpuscles (possibly pus), +the disintegration and other changes in the red corpuscles, may be +regarded as the exciting causes of metastatic abscesses. It is thus +readily observed that emboli may form in the lungs and liver at the +same time, or the origin of those in the lungs may precede the +formation in other organs. + +Is the formation of emboli in the terminal branches of arteries always +dependent on the disintegration of thrombi? The answer to this +question must, I think, be a negative, although in surgical practice +it rarely happens that the emboli take their origin from any other +cause. In the large majority of cases, unquestionably, the thrombi +primarily exist in the vicinity of the wound in which ichorous pus is +generated; but it not infrequently happens during the process of +disintegration that broken-up clots are carried forward by the current +of blood, receiving accretions on the way, until finally they fill a +large venous trunk. In confirmation of these facts relating to the +primary origin of thrombi, it is said to have been observed in +epidemics of puerperal fever, which were complicated with metastatic +abscesses of the visceral organs, that the thrombi occurred in the +pelvic veins. In case of wounds of the lower extremity the clot is +frequently found in the common iliac vein, although probably it should +always be regarded as a secondary formation. In rare cases the only +thrombi discovered at the autopsy are found situated far away from the +injury. + +Observation fully establishes the fact that, after death from pyaemia, +pathological changes are much more frequently met with in the lungs +than in any of the other organs. This certainly strengthens the +embolic theory. Billroth mentions eighty-three cases of true pyaemia +multiplex, in which the metastatic abscesses occurred as follows: +seventy-five times in the lungs, seventeen times in the spleen, eight +times in the liver, and four times in the kidneys. Sedillot remarks +that in one hundred cases of pyaemia we find the lungs affected in +ninety-nine, the liver and spleen in eight, the muscles in seven, and +the heart and peripheric {966} cellular tissue in five cases. The +brain and kidneys are comparatively seldom involved. + +The theory previously mentioned as the embolic relates to the +aggregation of fibrin into clots; but another theory has been recently +advanced by E. Wagner, who found in many cases the capillaries in the +lungs filled with fat, and was inclined, from the direction it +extended in these vessels, to explain a certain number of the pyaemic +cases by the fat emboli; but it has been shown that the existence of +the fat emboli in pyaemia is purely accidental and possesses no +significance. Pyaemia multiplex very frequently occurs without fat +emboli, and vice versa; either process may complicate the other, and +so the fat emboli may acquire special importance by obstructing the +respiration, and probably also in their way the embolic fat may serve +as a carrier of putrid material. + +MORBID ANATOMY.--The external appearance of the body varies greatly. +The skin, in those cases in which the patient was jaundiced before +death, will be found in every part of the body to be of a dark orange +or dirty icteric tinge, but in other cases it may present a pale or +anaemic appearance. There are also sometimes found circumscribed +ecchymoses or purpuric patches, while the edges of ulcers or open +wounds are generally of a blackish or dirty yellow color. The lips and +finger-nails present a livid appearance; epithelial defects are +observed in the cornea, but these had their origin there before the +death of the patient. + +The eyes in some cases are sunken deeply in their sockets, and where +the disease has been protracted there is often very great emaciation. +Rigor mortis is commonly well marked after a few hours. When death +occurs from puerperal pyaemia there are generally found some +indications of the recent parturition, although the principal +lacerations or injuries may be confined to the womb. All fluids +disappear from external wounds before the death of the patient, and +they remain dry afterward. + +In some cases the cellular tissue is the seat of diffuse suppuration. +The pus formed is thin, fetid, and unhealthy. This suppuration is +limited to certain parts of the body, as an injured extremity, or, as +frequently happens, it may be found on the trunk and limbs at the same +time. The pus in this form of suppuration is exceedingly apt to +burrow, on account of the peculiarities of the tissue in which it +occurs, and also the condition of the surrounding structures, +especially the relaxed and flabby condition of the skin. These +abscesses in some instances are superficial, in others deep-seated. + +There are few changes which occur in the muscles, and these are not +uniform or constant. They are occasionally the seat of abscesses, +which have been observed in the heart, tongue, and other organs. The +muscles may be of a light-brown or greenish color when they have been +covered a considerable time with pus, and are sometimes softened and +pultaceous. Suppuration may also take place beneath the fascia of the +tendons. + +The brain and its membranes are frequently found in a perfectly +healthy state after death from pyaemia, although when the diseased +process has extended during the life of the patient to the lungs and +pleura, giving rise to great dyspnoea, there will generally be +observed some congestion of the membranes, an increased quantity of +fluid in the brain-substance and ventricles, and also an increased +fulness of the meningeal veins and sinuses. Occasionally there have +been observed suppurative {967} meningitis, blood extravasations on +the surface of the brain, lymph-deposits on the membranes, softening +of the cerebral tissues, and circumscribed abscesses in the substance +of the brain, which in some cases have been traceable to embolism of +its vessels. The changes in the spinal cord and its membranes are +probably similar to those found in the brain, but these parts appear +to have been rarely examined. + +Virchow found emboli of the retinal and choroidal vessels. Heiberg +found these vessels occluded with colonies of micrococci. There have +also been observed opacity of the cornea, sloughing of the +conjunctival epithelium, suppurative infiltration into the periphery +of the vitreous body, and deposits of pus in Petit's canal and in the +anterior and posterior chambers. Pyaemic ophthalmia has been observed +somewhat frequently in puerperal cases, especially when preceded by +endocarditis, with deposits on the semilunar or mitral valves. In +surgical cases it is rarely seen. + +Toynbee "relates several cases of purulent infection following +suppuration of the ear. Cases of disease in the mastoid cells +terminate fatally, he says, from two different causes: first, from +purulent infection, arising from the introduction of pus into the +circulation through the lateral sinus; second, from disease of the +cerebellum or its membranes. Cases of purulent infection, he further +remarks, have not been met with where the disease occurs in the +tympanic cavity."[34] + +[Footnote 34: Braidwood on _Pyaemia_, pp. 168, 169.] + +Numerous lesions of the osseous system have been noted in pyaemia, +probably from the fact that this disease results very frequently in +cases of bone-lesions, but these changes have very little diagnostic +importance. The following have been observed: thickening or +infiltration of the periosteum, which may be found to separate readily +from the bone after the death of the patient, or there may be pus +found between the periosteum and the bone. In the bone-structure there +were found caries and necrosis, "while in other cases the whole +thickness of the compact tissue is perforated in a honeycomb-like +manner by minute cavities filled with thickish pus or caseous matter +of a pinkish-white color."[35] "To sum up, the chief morbid +alterations met with in the bones are congestion, dilatation of the +Haversian canals and cancellated tissue, tending to abscess formation, +and the excavation of the cavities by the unhealthy pus."[36] + +[Footnote 35: _Ibid._, p. 192.] + +[Footnote 36: _Ibid._, p. 194.] + +The pathological lesions of the joints commence with marked congestion +of the synovial membranes and increase in the synovial fluids, and +afterward the fluid is mixed with pus; these conditions are followed +by erosion of the cartilage and ligaments, the former thus becoming +separated from the bone. Both the small and large joints are +occasionally the seat of morbid changes. + +The parotid gland is occasionally the seat of a secondary inflammation +during the progress of pyaemia, and this may endanger life by +interfering with respiration and deglutition. The lymphatic glands are +only secondarily affected, and even this takes place very rarely. The +changes in the glandular system, when observed, are similar to those +which happen in other tissues of the body--viz. congestion, +inflammation, and suppuration. + +The arteries are usually found empty after death from this disease, +and the coats are sometimes apparently thickened. The veins, on the +contrary, are commonly found filled, or even distended, with firm +fibrinous clots. They are sometimes also found inflamed or altered, +although more {968} commonly healthy. The distended condition of the +veins gives rise to the cord-like feeling often mentioned by different +observers. In some cases of phlebitis there may be pus deposited +between the coats of these veins. The most important pathological +changes are found in the blood. These changes occur early in the +disease, become more marked toward its fatal termination, and may be +always studied after death. It is generally admitted that pus is +frequently found in the blood of these patients; but it has been shown +by numerous experiments that healthy pus never produces the +pathological changes which characterize this disease. Pyaemia is only +produced by the presence in the blood of ichorous pus or some other +decomposing animal substance, or some material having its origin in +the decomposition of the same, and no decomposition in these +substances is ever effected except through the agency of living +organisms. It therefore follows that the discovery of living organisms +in the blood of those sick and dead of this disease has given a +renewed interest to the study of its pathology. The recent +investigations made by Pasteur, Koch, Birch-Hirschfeld, and the London +Pathological Society show conclusively that in all cases of pyaemia +and septicaemia organisms are present in the blood during the entire +course of the disease, and that in the former there is found the +globular, and in the latter the rod bacteria. It has further been +observed in each morbid condition that the severity of the disease is +always increased in proportion to the increase of the organisms in the +blood, and that the bacteria found within the body are of the same +species as those in the wound from which they have gained admission. +The micrococci found in the blood of pyaemic patients are surrounded +by the decomposed products of the red and white corpuscles, which +appear in the blood-plasma in the form of pale granular bodies. There +is likewise in this disease an increased coagulability of the blood, +and it steadily increases as the disease progresses. In this condition +there may be found in the blood-vessels both thrombi and emboli. The +thrombi are occasionally observed as firm fibrinous clots, but they +may be likewise found in the rapidly fatal cases to have undergone +suppurative changes. These changes begin in the centre of the clots, +which often contain true pus or a greenish or puriform fluid. + +The pericardium may contain a small amount of serum tinged with blood, +but it is seldom covered with recent lymph. Both the lung-tissue and +pleurae are commonly inflamed in this disease. The costal and visceral +layers may be agglutinated by old adhesions, but are more commonly +united together by recently formed lymph. The pleural cavities often +contain some opaque, muddy, sero-purulent fluid, mixed with blood and +having masses of lymph floating in it. + +The lungs are more frequently the seat of metastatic abscesses and +other morbid changes in pyaemia multiplex than any other organs of the +body. There may be found emboli in the branches of the pulmonary +veins, and in the lung-tissue metastatic abscesses surrounded with +capillary congestion and other evidences of inflammation; "The smaller +vessels, trying to overcome this afflux of blood, may produce +ecchymosis or extravasation beneath the lining membrane of the +air-vesicles, but the minute capillary congestions are generally +observed as red points studded over the pulmonary surface, which by +and by exhibit yellowish-white or bluish-white centres. While one +part, generally the lower half of the {969} lung, is thus hepatized, +solid, and of a dark greenish color, the remainder of the lung is +emphysematous and more or less oedematous. A section of the former +presents the same appearance as is observed in the lungs of pneumonic +patients. Whether these incipient abscesses are developed from the +minute points of congestion before mentioned, by the breaking down of +the thrombic clots in their centres, or whether the pus is developed +out of the serum exuded by the walls of the engorged capillaries, +cannot be easily determined, and has as yet not been decided. These +secondary abscesses vary in size from that of a hemp-seed to that of a +hen's egg."[37] These are generally situated on the periphery of the +lungs and in the lower lobe, although in some cases they are found +imbedded deeply in the pulmonary tissue. The contents of these +abscesses are similar to those found in other parts of the body in +this disease. The bronchial mucous membrane is commonly of a bright +pink color, while its secretion is increased in quantity, and may be +clear and frothy. These changes are the result of acute bronchial +catarrh. Lobular pneumonia has been frequently observed as a +complication of pyaemia, and is supposed by some authors to be caused +by the vitiated condition of the blood; but probably it is more +frequently occasioned by infarctions and embolic abscesses, which have +been previously mentioned in this connection. + +[Footnote 37: Braidwood, _op. cit._, p. 173 _et seq._] + +Billroth and Sedillot observed pathological lesions involving a +solution of continuity in the spleen, liver, and kidneys, in the order +in which they are mentioned; other authors, however, assert that the +liver, next to the lungs, is the most frequent seat of purulent +deposits. Enlargement of the spleen is frequently met with in cases of +pyaemia multiplex. The metastatic abscesses found in the spleen and +kidneys are much smaller than those found in the lungs and liver, but +in other respects are of a similar character. The capillary congestion +and the accompanying infarctions require no special attention here. +The liver, like the spleen, is sometimes enlarged, and at other times +is found to have undergone fatty degeneration to a greater or less +degree; in which condition its tissues are generally soft and friable. +Abscesses in the liver are so much like those in the lungs as to need +no separate description. The same may be said of other pathological +changes found in this organ in pyaemia multiplex. The abscesses found +in the kidneys vary from the size of a hemp-seed to that of a bean, +and are surrounded by the usual zone, marking more or less definitely +the extent of the inflammation. The capsule is generally healthy. +There are also, in very rare cases of this disease, abscesses found in +the stomach and intestines, involving the thickness of the mucous +membrane; and it is further supposed that these abscesses may be found +occasionally on any portion of the mucous membrane lining the +alimentary canal. Post-mortem examinations in pyaemia multiplex have +established the fact that there is no organ in the body that may not +become the seat of pathological lesions in this disease; but there is +unquestionably a vast difference in the relative frequency of these +changes in the various organs. In some instances of this disease +peritonitis is developed, with its concomitant changes in this +membrane and the abdominal fluid, which is generally increased in +quantity and sometimes slightly tinged with blood, but more frequently +remains clear. {970} This inflammation is commonly dependent on an +extension of the inflammatory process from a metastatic abscess, which +may be situated near the periphery of some organ covered with +peritoneum, although it is claimed that pleuritis occasionally occurs +in connection with pyaemia independent of metastatic abscesses in the +lungs. + +The careful study of the pathology of pyaemia multiplex renders it +exceedingly probable that the immediate agency in the production of +all these lesions is the presence in the blood of a particular species +of living organism, and that all the morbid changes which occur in the +visceral organs are secondary to those which take place in the blood, +but that the former are only dependent on the latter in a minor +degree. The pathological changes effected by these organisms seem to +be as follows, and to occur in the following order: viz. +disorganization of the blood, especially a destruction of the red and +white blood-corpuscles; the formation of granular bodies around the +organisms out of this debris; the production of an increased +coagulability of the blood; the lodgment in the blood-vessels of these +granular bodies, which are increased in size by a deposit of fibrin; +these obstructions occur most frequently in minute ramifications of +the pulmonary arteries; nutrition is effected locally by these +infarctions, and generally by the vitiated condition of the blood, +which enables the organisms under these favorable circumstances to +penetrate the adjacent tissues and produce the metastatic abscesses +and other accompanying lesions. + +The pathological changes in pyaemia simplex are of the same kind as +those which have just been described as characterizing pyaemia +multiplex, with the exception of the metastatic abscesses, which are +always absent. Furthermore, the disease in both instances is believed +to have its origin from the same causes, and the dissimilarities in +the pathological lesions are equally susceptible of a rational +explanation, as are those of scarlatina simplex and scarlatina +maligna. + +There were reported by the committee of the London Pathological +Society some interesting details pertaining to this form of pyaemia. +Their report shows that among the one hundred and fifty-five cases +classed as pyaemia there were twenty-four cases without visceral +abscesses; and furthermore it shows that in twenty-three of these +cases there was no suppuration, although local inflammations affected +many of the different tissues, since these patients suffered with +arthritis, cellulitis, pleuritis, meningitis, pericarditis, and +carditis. It is also added that "the post-mortem appearances, in +addition to the local secondary inflammation before noted, were in +many cases those changes common to all forms of blood poisoning. Out +of the twenty-four cases, the following are noted: Swollen spleen, +nine times; congestion of the lungs, ten times; swollen liver, six +times; cloudy swelling of the kidney, fourteen times."[38] + +[Footnote 38: _Trans. London Pathological Soc._, vol. xxx. p. 26.] + +In this form of pyaemia it has been supposed by some authors that the +materies morbi occasionally produces death before the metastatic +abscesses have had time to develop, but this is not always the case. +The same committee report on the above-mentioned twenty-four cases, on +this point, as follows: "The duration of the cases before the fatal +termination was very various. It is tolerably accurately recorded in +eighteen cases: of these five died in the first week, five in the +second, {971} four in the third, and the remaining four survived to +the thirtieth, forty-ninth, fifty-second, and sixty-second days."[39] + +[Footnote 39: _Trans. London Pathological Soc._, p. 25 _et seq._] + +The pathology of pyaemia multiplex having been already fully +described, and since the only essential difference in these morbid +conditions consists in the complete absence of the metastatic +abscesses in cases of pyaemia simplex, it is therefore thought +unnecessary to dwell here longer on this subject. + +The morbid anatomy of septicaemia has been carefully studied of late, +and it is now known that the most characteristic lesions are found in +the blood and the alimentary canal. + +As a manifestation of the general poisoning of the blood, it might be +expected that putrefaction would follow rapidly after the death of the +patient. In fact, Davine defines septicaemia as "putrefaction of a +living body." Observation has now thoroughly confirmed that which was +formerly an anticipation. Panum, Hemmer, and Bergmann have each called +attention to the fact that rapid decomposition follows the death of +all animals in which septicaemia has been produced for experimental +purposes. It has also been observed that putrefaction in the human +cadaver begins much sooner, and progresses much more rapidly, under +similar circumstances, when the death has been produced by this +disease than when it has occurred from any other cause. Furthermore, +this rapid decomposition is not limited to the internal organs, but +may be frequently strongly marked on the surface of the body after the +lapse of twelve hours, although it has been kept in a comparatively +dry and cool atmosphere. In those cases where the septicaemia has +originated in an external wound it has been uniformly observed that +putrefaction goes on most rapidly in the vicinity of the wound after +the death of the patient. + +In every case of fatal septicaemia the post-mortem examination will +show that the coagulability of the blood has been diminished or +destroyed. In fact, it has been abundantly shown that in all cases of +true septicaemia the coagulability of the blood is more or less +diminished. The few imperfect clots of blood found after death are of +a deep-black color. The putrefaction of the soft tissues is greatly +hastened by the presence of this blood; and, consequently, this +process goes on most rapidly in the most dependent portions of the +body, especially along the course of the large veins. The septicaemic +blood possesses a peculiar putrefactive odor, and it is occasionally +found to be acid in its reaction, according to Vogel and Scherer, +making it highly probable that it will end in the formation of the +carbonate of ammonium. The chemical examinations of septicaemic blood +which have heretofore been made have completely failed to give +satisfactory results in regard either to the existence or nature of +the materies morbi in this disease, although, without doubt, there has +occasionally been found, principally in the blood of those who have +died of acute septic intoxication, a poisonous substance, which +Bergmann designated sepsin. Microscopic examinations have shown that +in the blood and also in various organs of those who have died of +septicaemia there are always present, under these circumstances, a +large number of the rod bacteria; in fact, they are more numerous than +after death from any other infectious disease. Furthermore, they are +found in the blood, lymph-glands, and cellular tissues during the +whole course of the disease. + +{972} There are no pathological changes in the central nervous system +which arise directly from septicaemia, although in some cases, when +there has been some cardiac complication or very severe dyspnoea from +any cause immediately prior to the death of the patient, there may be +found hyperaemia of the membranes of the cerebro-spinal axis. The +brain and spinal cord remain unchanged. + +The endo- and pericardium occasionally present a somewhat mottled +appearance resembling ecchymosis, which is evidently a deposit from +the blood, and may be washed off with water. The inner surface of the +ventricles presents a similar appearance from the same cause. In +addition to those changes which have been mentioned there are +occasionally found some slight traces of an inflammatory process in +these parts; but it never extends to the formation of pus or +ulceration, which frequently happens in cases of pyaemia. The quantity +of pericardial fluid is sometimes increased in septicaemia, and is +generally somewhat thickened, cloudy, and slightly tinged with blood. +The changes in the pleural surfaces are the same as those which have +been noted in the pericardium, but any increase of the fluid within +the pleural sacs is an exception to the general law, and is very +rarely seen. The lungs are generally found slightly congested, but +there may be some ecchymosis in exceptional cases. Pus is never found +in the lungs or within the pleural cavities in pure unmixed +septicaemia. The pathological changes in the liver resemble those in +the lungs. This organ is commonly found in a state of passive +congestion, while the color of its tissues is slightly darkened. The +congestion of the kidneys and spleen in this disease is much more +marked than that of the lungs and liver. The parenchymatous tissue of +the kidneys is commonly found in an oedematous condition, and the +tubuli uriniferi are more or less affected by a catarrhal +inflammation, which is manifested by the exfoliation of granular +epithelium. The same catarrhal condition, but in a milder form, is +found to affect the mucous membrane of the bladder. In females the +ovaries, uterus, and vagina are in a state of hyperaemia, with more or +less catarrhal inflammation of the latter organ. Septicaemia +invariably causes pregnant females to abort. There is commonly +softening of the spleen. The alimentary canal is almost constantly +affected by acute intestinal catarrh, with enlargement of the +intestinal follicles and mesenteric glands, while there are frequently +hemorrhages from the serous and mucous membranes. The various muscles +of the body and the extremities are found to be of a dark brownish-red +after the death of the patient, instead of possessing their natural +pale-red color. It may now be stated, finally, that the pathological +changes in septicaemia are less marked than those of pyaemia +multiplex. + +The semiology, etiology, and pathology of septo-pyaemia consist in a +blending, in different degrees, of the essential parts of pyaemia and +septicaemia; and since the pathology of both these diseases has been +presented separately, it is deemed unnecessary to enter into a +consideration of this combination. + +SYMPTOMS OF PYAEMIA.--Pyaemia very rarely, if ever, develops except in +connection with an open suppurating wound, and consequently it must +generally be regarded as a wound complication or as a secondary +diseased condition. Those open wounds are unquestionably the most +favorably situated for the development of this disease which involve +the medullary {973} cavities of the long bones, owing to the liability +of unhealthy suppuration, the difficulty of complete drainage, and the +favorable anatomical conditions for absorption. + +Every form of pyaemia is frequently preceded by a distinctly marked +prodromal stage, which varies in duration from four days to two weeks. +In fact, the ordinary precursor of this disease, in all those cases in +which the bones are involved, is an attack of osteo-myelitis; but in +other cases the patient often complains of malaise, giddiness, +headache, pain in the limbs, weakness, and loss of appetite, while the +experienced surgeon will be deeply impressed with the patient's rapid +emaciation and cadaverous face. These symptoms are soon followed by +jaundiced skin, etc. The commencement of an attack of pyaemia is +commonly manifested by a chill. The importance which will naturally be +attached to this phenomenon in connection with an open wound must +depend to a certain degree on the circumstances attending its +occurrence; and therefore the following question will present itself: +Is the chill associated with suppuration? A negative answer to this +question, based on the fact that insufficient time has elapsed since +the occurrence of the injury to render suppuration possible, can never +fail to be a source of satisfaction to the surgeon, whose experience +has taught him to dread pyaemia. + +Billroth has observed in 83 cases of true pyaemia multiplex that 62 +commenced with a chill, and 21 without; in 81 cases of septicaemia and +simple pyaemia 24 commenced with a chill and 57 without. The number of +chills in each individual patient occurred according to the following +table: + + Number of patients 19 21 14 15 9 5 2 3 4 1 1 1 + Number of chills 1 2 3 4 5 6 7 8 9 10 13 14 + +In one patient during three weeks sixteen chills were observed, and +probably the longer the duration of the disease the greater is the +number of chills. Still, there are chronic cases with a single chill, +and acute cases with many. It rarely occurs that a patient has more +than one chill in twenty-four hours. Billroth noticed among his +patients only sixteen who had two chills, and only six who each had +three chills, in one day. The experience that fewer chills occur +during the evening and night than in the morning and afternoon has +been confirmed by statistics. Among 287 chills, 220 occurred from 8 +A.M. to 8 P.M., while during the night, from 8 P.M. to 8 A.M., only 67 +were observed. By this arbitrary division of the twenty-four hours +Billroth desired to take into consideration the daily exacerbation in +connection with the usual daily irritation of the wound, the +bandaging, and other manipulations. He saw, for example, a chill occur +three times from the introduction of a sound, and twenty times after +the opening of an abscess. The time which elapsed from the first +injury to the first chill is shown in the following table: + + First chill began, times 14 19 15 9 4 3 2 4 + Length of time after injury, in weeks 1 2 3 4 5 6 7 8 + +Patients who had fever before the operation were more inclined to +early chills than recently-injured healthy individuals. Billroth's +experience was to have only the first chill before the end of the +first week. It may be further stated that nervous, irritable patients +suffer much more {974} frequently from chills than those of a +phlegmatic temperament. This fact has given rise to the opinion that +the absorption of pus acts especially on the central nervous system. + +The chills in pyaemia are supposed by Billroth to be associated with +inflammation, and he says: "It must be mentioned, as a matter of +observation, that chills occur almost exclusively in the commencement +of an acute inflammation, and are intermittent only in intermittent +fever and reabsorption of pus, while they do not occur in acute +septicaemia."[40] But the fever in pyaemia rarely intermits entirely; +it is generally lower, however, in the morning than in the afternoon. +This symptom is even more important than the rigors in enabling the +surgeon to make a correct diagnosis. Let it, however, be remembered +that the temperature frequently becomes very high within a few hours +after the receipt of an injury or the performance of a surgical +operation; that this high temperature may be due to septic absorption, +and that this diseased condition is what we designate as septicaemia. +Another condition, less marked, with an elevated but somewhat lower +temperature, is usually spoken of as traumatic fever. In this +condition the fever may gradually increase for a few days, and then +disappear. + +[Footnote 40: _Surgical Pathology_, p. 344.] + +One important peculiarity of the temperature in pyaemia are the sudden +and great changes; thus, at one hour the temperature may be slightly +raised above the normal, and at the next the thermometer may mark 105 +degrees F. These sudden changes of temperature are of frequent +occurrence, are not observed to the same extent in any other disease, +and therefore supply a very important diagnostic indication. It is +impossible to know, or even to anticipate with any degree of +certainty, when the highest temperature will exist; consequently, +Billroth and other writers have suggested the desirability of having a +thermometer constantly kept in a position to indicate every change in +the heat of the body, and a careful attendant to note the same; but, +thus far, I am not aware that this has been attempted, probably on +account of the inconvenience to the patient and the additional labor +in nursing it would entail. It has been further observed that during +the existence of a chill the temperature continues to steadily +increase, and the maximum seen during the whole course of the disease +is attained during the hot stage which immediately follows the rigors. +"This condition is followed by profuse cold perspirations. The +perspirations which accompany this disease are most profuse, like +those of advanced phthisis. They never precede the rigors, but may +occur independently of them. They are either continuous in their +duration, or exhibit more or less distinct exacerbations. They are +occasionally accompanied by sudamina, and they do not abate with the +use of any known remedy.... Occasionally perspiration is scanty; but +before death a cold clammy sweat and a tawny discoloration of the skin +occur."[41] + +[Footnote 41: Braidwood, _op. cit._, p. 112.] + +Besides the sudamina there are frequently observed on the skin +vesicles, pustules, and boils, purpuric patches, and various +discolorations. There is frequently observed to arise in the +neighborhood of the wound a reddish erythematous blush, which soon +extends to the whole limb, and commonly begins to disappear in the +early part of the second week. This recently occurred to a patient +under my care, and was speedily followed by an abscess of the +knee-joint. The wound was situated at the hip-joint, {975} and the +first change in the color of the integument took place around its +lips. The redness extended rapidly downward until it covered the foot, +and even the toes; but the extension upward was slight, not much above +the nates, on which there was situated at the time a bed-sore. It +observed the same order in passing off as in coming on--_i.e._ where +it first made its appearance it first disappeared. The superficial +veins leading from the wound were inflamed and cord-like. This +condition of the integument and the abscess of the knee-joint were +followed by diarrhoea, on which medicines had no beneficial effect. It +continued, with occasional vomiting, until the death of the patient. + +The pulse in pyaemia may be nearly normal as regards frequency, while +at other times very rapid. It has been remarked in some cases that the +pulse seldom rose above 90 per minute until near death. The pulse, +although only moderately accelerated at the commencement of the +disease, always becomes more rapid, quick, feeble, and irregular +toward the termination of the unfavorable cases, while in cases of +recovery it returns gradually to the normal standard. + +In all cases in which the blood has been examined during the progress +of pyaemia the examiners have agreed in regard to its extreme +coagulability, the diminution of the number of red corpuscles, and the +increase of the granular spherical bodies. The red corpuscles, even in +the earlier stages of the disease, show evident indications of +disintegrating; and these become more and more marked as the disease +progresses, while there is a steady increase in the number of pus- or +possibly of white blood-corpuscles. Epistaxis occasionally occurs, and +also venous oozing from the wound. + +The condition of the tongue in pyaemia may be regarded as an important +symptom, indicating the state of the alimentary canal--not, however, +during the prodromal stage, but after the disease has progressed a few +days. It is then observed that the tongue has become peculiarly +smooth, dry, and often excessively red. This smoothness is caused by +the collapse of the papillae, and the dryness by a diminished +secretion. The organ now frequently appears as if covered with a thin +layer of collodion which had been caused to dry on the surface, so as +to present a glazed look. Again, the tongue may be covered with brown +crusts and the teeth with sordes. These brown crusts and sordes are +usually seen in advanced cases, following the first condition +described. Much importance is attached to these brown crusts by many +experienced surgeons, and although there may be very marked +improvement in all other symptoms, still they insist on a very guarded +prognosis until the tongue has assumed a healthy appearance. Aphthae +on various parts of the mouth and pharynx are frequently present in +the more chronic cases, but are usually absent in acute cases. Herpes +of the lips sometimes occurs in the commencement of the disease. + +Vomiting is comparatively rare, but there is, even in the early +stages, a complete failure of the appetite, with great thirst. +Singultus is rarely present in genuine pyaemia, but frequently so in +septicaemia, and occasionally in septo-pyaemia. Diarrhoea is not so +frequent or the stools so copious in pyaemia as in septicaemia. +Billroth observed in one hundred and eighty cases of pyaemia +thirty-two cases of diarrhoea. It is impossible to determine whether +those cases in which the diarrhoea {976} occurred were pure or mixed +pyaemia. The stools are often of a pappy consistence, and passed +involuntarily in bed. There are, however, severe cases of pyaemia with +high fever, and accompanied by obstinate constipation. + +Examination of the heart may, in rare cases, show the existence of +pericarditis, although usually the only indications of disease are the +too feeble sounds. Auscultation and percussion of the lungs may yield +unsatisfactory results when the metastatic abscesses are small and +scattered, for the same reason as in miliary tuberculosis. The large +deposits in the lungs are by these means readily determined. There may +be a sensation of suffocation, the pneumonic sputa, the friction sound +of pleurisy, or the signs of pleuritic effusion; and the existence of +these symptoms or signs would naturally aid in the diagnosis of +metastatic abscesses. + +Enlargement of the liver and spleen may be determined before death, +and in connection with other symptoms would aid in diagnosing deposits +in these organs. + +The urine in the first stage of this disease is scanty, high-colored, +contains a large amount of salts, and is of a high specific gravity. +Epithelial, fibrinous, and blood casts, and also albumen, are +occasionally found in it during the course of the disease. Billroth +mentions a case in which there was complete suppression, with uraemia. + +In many cases of pyaemia suppuration of the joints, one after another, +takes place with great rapidity and with comparatively little pain, +but occasionally some swelling, redness, etc. are present. In most +cases these suppurations are easily diagnosed. Instead of suppuration +taking place in the joints, there are cases in which it occurs in the +cellular tissue; and I have recently seen a case where abscess after +abscess formed with such rapidity that within a single week the +patient was literally covered with abscesses from the crown of his +head to the soles of his feet. + +Delirium generally exists during some stage of the disease, more +frequently the last, and is then mild in its character, although +active delirium has been observed in the first stage. Patients are +low-spirited and very apprehensive of death. The face at the beginning +of the attack may be flushed or pallid, but toward the end it always +becomes careworn and haggard. The breath occasionally has a sweetish +or purulent odor. + +The changes in the wound are in some cases very marked, even in the +first stage of the disease. The suppuration, which has been previously +free and healthy, may be suddenly checked, the wound becoming dry. The +discharge, if it continues, becomes scanty, thin, ichorous, or +greenish. The granulations, if previously healthy, may soon slough. +These changes may not always appear in the first stage, but should +they not then take place they may be expected later in the disease. + +SYMPTOMS OF SEPTICAEMIA.--These are commonly developed within +twenty-four hours after the receipt of an injury or the performance of +a surgical operation, and they may be sketched as follows: Frequent +pulse; tongue, lips, and throat dry; skin hot and the temperature of +the body high. The patient replies accurately to questions, but with +some hesitation. He is much inclined to sleep, has entirely failed to +take nourishment, drinks frequently when aroused from his lethargic +condition, and has vomited everything taken into his stomach since the +receipt of the injury or the performance of the operation. If {977} +the dressings are now removed from the wound, the foul odor of +putrefaction greets the attendants. In cases of amputation-wounds +considerable discoloration of the flaps may be observed, the edges +being blackened. Above these blackened edges the integument is +reddened and slightly oedematous. The wound having been closed with +sutures, which are now removed, there escapes a few drachms--possibly +ounces--of highly offensive fluid, the decomposed remains of blood, +etc. A further examination of the flaps on their inner surfaces show +that their capillary circulation has ceased. The tissues, instead of +presenting a life-like appearance, are now of a very dark color and +occasionally mottled with dull grayish spots, although the movements +of the ligature at the point where it embraces the femoral artery, for +example, show that the blood still rushes against the artificial +boundary. + +Let us now leave our patient, without further comment, for the next +forty-eight hours, when we will resume the examination. We now find +the same dryness of the mouth that was previously noticed; the pulse +is more frequent, and has become very feeble; he complains of much +thirst, has vomited frequently, and has taken very little nourishment, +and that only at the earnest solicitations of the attendants. The +temperature is higher than at the former examination, and has been +steadily increasing; in the morning it is lower, however, than in the +evening of the same day. The patient is lethargic, and is suffering +with a profuse diarrhoea. The odor of the stools is highly offensive; +they are properly described as rice-water evacuations. The abdomen is +tympanitic; the body bathed in perspiration; the respirations rapid; +the urine scanty, high-colored, and contains albumen. The examination +of the stump shows that gangrene has extended rapidly, involving not +only the flap, but a portion of the adjacent tissues. The stench +arising from the wound is almost stifling. The decomposing fluids are +continually forming. That portion of the thigh not already gangrenous +is now very oedematous, and the integument covering it is much +discolored, being of a dark, icteric, or reddened hue. + +We now allow twenty-four hours to elapse, and then make our final +examination. The patient's tongue is more moist; the body still bathed +in perspiration; the eyes dull; the conjunctivae icteric, and the same +hue extends to the body, though in a less marked degree; the pulse has +become very frequent, feeble, and not easily counted; the temperature +is below normal. Singultus is now present, and has been so during the +last twenty-four hours. Bronchial symptoms, combined with marked +oedema of the right lung, have appeared; the diarrhoea continues the +same; the gangrene is still extending. + +It must be admitted that the report here offered shows only the +symptoms that are found in a single class of cases. The symptoms vary +greatly in different cases, but they are especially marked in the +acute sepsis mentioned by Massanneuve under the head of _gangrene +foudroyante_. In these cases there appears, immediately after the +receipt of an injury, enormous oedema about the wound, which extends +rapidly in every possible direction, followed by the death of the +patient within a few hours unless prompt measures are adopted. The +puncture of the cellular tissue or of the blood-vessels involved in +the oedema prior to the death of the patient gives rise to the escape +of a highly offensive gas. Roser mentions a case of this disease in +which he promptly amputated {978} the limb of the patient through the +healthy parts, without even waiting for the administration of an +anaesthetic, and his patient recovered. + +The symptoms of septicaemia must necessarily depend greatly on the +condition of the patient and the amount of septic material introduced, +but it is not deemed necessary to dwell longer on this subject. + +DIAGNOSIS.--It is thought that a brief presentation of the +etiological, pathological, and semiological differences may be +advantageous to busy physicians who desire to obtain, with the least +expenditure of time, an accurate knowledge of the chief points of +distinction between these morbid conditions. This effort at +differentiation is merely intended to place the most important +characteristics in marked contrast; and consequently it should be +remembered that it is not our intention to give here the complete +etiology, pathology, or semiology of either of these morbid states, +but only their essential differences. Furthermore, it is thought that +the following arrangement will facilitate the object which we desire +to accomplish: + + ETIOLOGY. + PYAEMIA. | SEPTICAEMIA. + 1. Pyaemia generally commences | 1. Septicaemia generally + with the putrefaction in an | commences with the + open wound of the secondary | putrefaction in an open wound + wound-fluids--pus, etc.--in | of the primary + which there are developed | wound-fluids--blood, serum, + globular bacteria, which enter| etc.--in which there are + the blood and certain tissues | developed rod bacteria, which + of the body, where they | enter the blood and certain + multiply and produce | tissues of the body, where + constitutional disturbances. | they multiply and produce + | constitutional disturbances. + 2. Pyaemia is commonly preceded | 2. Septicaemia is commonly a + by some local inflammatory | primary wound-complication, + wound-complication, such as | which is generally developed + suppurative periostitis, | within forty-eight hours after + osteo-myelitis, etc., and is | the receipt of the injury. + rarely developed before the | + end of the second week after | + the receipt of the injury. | + + PATHOLOGY. + 1. Increased coagulability of the| 1. Diminished coagulability of + blood. | the blood. + 2. There are metastatic abscesses| 2. Complete absence of purulent + in various parts of the body, | or ichorous deposits in all + especially in the lungs, | cases of unmixed septicaemia. + liver, and kidneys: serous | Post-mortem appearances may be + cavities frequently contain | completely negative, with the + sero-purulent deposits; | exception of the condition of + similar deposits are often | the blood, although there is + found in the joints; abscesses| often some oedema of the + in the cellular tissue; and | lungs. + also abundant evidence of the | + existence during the life of | + the patient of pyaemic endo- | + and pericarditis. | + + SEMIOLOGY. + 1. Pyaemia commonly commences | 1. Septicaemia commonly commences + with a chill. | without a chill. + 2. Fever variable, but rarely | 2. Fever steadily increases, but + entirely intermits. | is lower in the morning. + 3. Sudden and great changes in | 3. The temperature is high at the + temperature, followed by | beginning of the disease, + profuse perspiration. | increases until near the fatal + | termination, when it falls + | below the normal. The skin is + | moist, but without profuse + | sweatings. {979} + 4. Pulse variable; toward the | 4. Pulse rapid, and gradually + fatal end rapid, feeble, and | increases in frequency toward + irregular. | the fatal end. + 5. Facies at the beginning | 5. Facies expressive of a dull, + flushed or pallid, toward the | listless condition throughout + end careworn. | the whole course of the + | disease. + 6. Tongue smooth, dry, and | 6. Tongue, lips, and throat dry + excessively red, later | at the commencement, toward + brown-coated, and even the | the end moist. Thirst is + teeth coated with sordes. | marked. + 7. Diarrhoea with stools of a | 7. Rice-water evacuations, very + pappy consistence. | offensive; obstinate vomiting. + 8. Epistaxis. | 8. Epistaxis rarely occurs. + 9. Mild delirium toward the fatal| 9. A lethargic condition from the + end. | beginning, increasing toward + | the fatal end. + 10. Aphthae in the mouth and |10. Icteric hue of conjunctivae; + throat, sudamina, vesicles, | singultus often present. + pustules, and purpuric | + patches. | + +The differences in the local manifestations occurring in and around +the wound, during the progress of these diseases, may be summed up as +follows: + + At the commencement of this | The odor of putrefaction is + disease the suppuration is | commonly very marked within + commonly checked, the wound | twenty-four hours after the + becoming dry, and if a discharge | receipt of the injury, the + continues, it becomes scanty, | integument slightly reddened + thin, ichorous, greenish, etc. | about the wound, and the + The granulations, when previously| surrounding parts somewhat + healthy, soon slough, and venous | oedematous. The wound-tissues + oozing sometimes takes place. | soon assume a dark-brown color, + There occasionally appears in the| and are occasionally mottled + later stages of this disease | with dull grayish spots, while + around the wound a reddish | the edges of the wound are at + erythematous blush, which soon | the same time blackened, + extends over the whole limb. | although the movements of the + | ligature, when arteries have + | been tied, show us that the + | blood still rushes against its + | artificial boundary. + +TREATMENT.--It must be admitted that the management of either pyaemia +or septicaemia, when fully developed, is always unsatisfactory, and +generally unsuccessful; consequently, the success which has attended +the use of the prophylactic measures employed in connection with the +treatment of wounds during the last ten years has given much +satisfaction to the medical profession. The committee of the London +Pathological Society reports as follows on this subject: "The +accumulation of septic matter in the uterus after labor, in contact +with the raw surface left by the separation of the placenta, would +also present the conditions favorable to acute septic intoxication. In +the present day, when the necessity of thorough drainage of wounds is +so thoroughly understood, and the means at the surgeon's command for +carrying it out are so efficient, it can only be under peculiar +circumstances that a sufficient quantity of putrid serum or pus to +yield the fatal dose of the septic poison is allowed to accumulate in +the wound. Moreover, the antiseptic treatment of wounds, now so +largely adopted, by preventing decomposition of course renders septic +intoxication impossible. Ovariotomy would seem to furnish conditions +most favorable to septic intoxication, and a large proportion of the +deaths occurring in the first forty-eight hours {980} have always been +attributed to it. The proportion of fatal cases from this cause has, +however, of late been greatly diminished by drainage, and more +especially by the employment of the antiseptic treatment."[42] + +[Footnote 42: _Trans. Path. Soc. of London_, vol. xxx. p. 15.] + +We cannot repeat too frequently or too emphatically the fact that the +treatment of pyaemia and septicaemia, when fully developed, is almost +invariably unsuccessful, and that consequently he who desires to save +the greatest number of lives must make every exertion and use all +available means to prevent their development--a task which fortunately +has now been brought within the scope of possibility in the large +majority of cases. Every surgeon will readily admit that, were it +possible to secure union by first intention in all cases of wounds, +then it would be impossible for either septicaemia or pyaemia to occur +in surgical practice. Therefore, it follows that the character of the +wound, the method of operation, the surroundings of the patient, the +character of the treatment, become proper points to consider in this +division of the subject. The character of the wound and its relations +to pyaemia and septicaemia have already been briefly referred to under +the etiology of these diseases. The various methods of operating, with +their respective advantages and disadvantages, are of course not +suitable topics for discussion in this work. + +The surroundings of the patient form a subject of vast importance in a +prophylactic view, and should never be lost sight of in the +construction of hospitals. I desire here to express my firm conviction +that surgical pyaemia is essentially and almost wholly a hospital +disease. The question of surroundings for the patient presents to my +mind the following demands as a sine qua non for obtaining the best +possible results in surgery: (1) Absolute cleanliness. This demand +should be strictly enforced in regard to the wound, the patient's +body, the bedding, and everything else, including nurses and +instruments. (2) Absolute purity of the atmosphere. (3) Moderate and +equable temperature, containing a proper amount of moisture. (4) +Proper quantity of nutritious and easily digestible food, with +suitable drinks, etc. (5) Cheerful and pleasant surroundings, +especially in companions, nurses, and other attendants. It may be +objected to these conditions that they can never be obtained. I must +confess that perfection in every detail cannot always be attained, but +I am thoroughly convinced that he who makes a determined effort in +this direction will succeed far better than that person who is +constantly looking about for some excuse for negligence. + +The question of treatment brings up the entire subject of antiseptics. +The favorite remedies of this class are carbolic and salicylic acids, +permanganate of potassium, chloride of zinc, bichloride of mercury, +and liquor sodae chlorinatae. There is no doubt that good results may +be obtained with any of these remedies. The surgeon should never +forget that he uses medicines merely as agents to enable him to +accomplish certain objects; and, keeping this in mind, he need very +seldom fail with his antiseptic when the object is to prevent +putrefaction in an open wound. Therefore it appears certain that each +method of treatment may possess special advantages in particular +cases, and probably the same may be said of the antiseptic itself. The +importance of this subject may be more fully appreciated when it is +remembered that it is generally admitted by the best surgical +authorities {981} that more lives are lost from septic infection than +from all other causes combined during a war. The further consideration +of this subject may be arranged for convenience under the heads of +local and general treatment. + +The local treatment of the wound should, if possible, be of such a +character as to prevent the absorption of either putrid substances or +pus. It therefore becomes highly important, in cases of amputation and +other operations, that all tissues injured to such a degree as to be +likely to excite either putrefaction, irritation, or inflammation +should be removed. The same care is necessary in removing all foreign +bodies from the wound in cases where no operation is to be performed. +The amputation of the injured limb may be necessary to prevent the +development of these diseases, or it may be resorted to in certain +rare cases after the origin of pyaemic symptoms; however, in the +latter instance great care should be taken to remove all the tissues +already infiltrated with serum, otherwise nothing will be gained. The +use of the surgeon's knife at the proper time may be the best +prophylactic against both pyaemia and septicaemia, but it should be +directed by an intelligent mind and the instrument guided by a +practiced hand. Again, it is found that opening a large medullary +cavity may be attended with danger to the patient. This fact teaches +us an obvious lesson. + +The wound existing or the operation having been performed, the surgeon +now turns his attention to the prevention of putrefaction and +inflammation. The first source of danger requiring attention from the +surgeon is the fluid escaping from the wounded surface. Do not allow +it to undergo putrefaction in contact with the wound. It should not be +forgotten that pyaemia is an infectious disease, having its origin in +a local nidus, an open wound, in which putrefaction of pus or other +wound-fluid is taking place. The question of amputation, or of the +extirpation of the parts for the relief of this disease, should only +be entertained when the surgeon is confident that he can remove the +whole of the infiltrated tissues. In other words, the performance of +these operations after the disease has become constitutional can never +be advantageous to the patient. Even in those cases where infiltration +is limited to the lymphatics, unless all these glands so affected are +removed the operation will be unsuccessful. It has been further +recommended in the treatment of this disease, in order to prevent the +formation of metastatic abscesses, to ligate the veins in which +thrombi have formed or may be reasonably expected to form, at some +convenient point between the heart and these obstructed points. The +value of this proceeding has never been fully determined, and may be +reasonably questioned. The formation of metastatic abscesses in +various parts of the body within the reach of the surgeon's scalpel +demands his attention; and we have been taught by experience that they +should be speedily opened, which generally lowers the temperature and +diminishes the danger from septic absorption. In the performance of +this operation Lister's antiseptic system of wound-treatment should be +strictly adhered to, since it unquestionably gives the best results +which can be obtained under the circumstances. When the metastatic +inflammation which occasionally appears in the thyroid and parotid +glands during the course of this disease terminates in the formation +of pus, this should be speedily evacuated. This prompt action is often +required, particularly for the relief of the grave symptoms which are +apt {982} to arise in connection with respiration and deglutition. The +accumulation of pus within the joints in pyaemic cases should, it is +now thought, be treated in the same manner as abscesses in the +cellular tissues--_i.e._ the articulations should be opened and +thoroughly disinfected, and afterward kept in a perfectly aseptic +condition, and also rendered absolutely immovable during the +treatment. + +Having directed attention to the more important local measures, we may +now briefly enter on the consideration of some of the constitutional +remedies. In the general treatment of pyaemia there have been +recommended at various times a great variety of drugs, but the general +want of success attending their use leaves comparatively few to be +mentioned here. The mineral acids are still employed, and are found to +be at least agreeable drinks, and as such can be still recommended. +The sulphites of magnesium, sodium, potassium, and lime were +recommended by Giovanni Polli for the treatment of typhus fever, +scarlet fever, small-pox, septicaemia, and pyaemia. He further +suggested that the medicine should be given until the whole quantity +taken bore to the weight of the patient's body the proportion of 1 to +1000. The experiments made on animals with these salts seem to confirm +their value in the treatment of septic diseases. It is certainly true +that animals treated with these salts are not so easily affected by +septic poison as those which have not received this treatment. +Further, it has been shown that putrid substances when mixed with +either permanganate of potassium or the sulphite of sodium, and then +injected, are harmless, although the same quantity of putrid matter +injected without either of these salts destroys life. + +Brandy and other alcoholic stimulants have been strongly recommended +on account of their well-known antiseptic properties. The sulphate of +quinia is certainly, in most cases of pyaemia, a valuable agent. In +large doses it enables the surgeon to reduce the temperature of the +patient, and in smaller doses it frequently serves a valuable purpose +as a tonic. It has also considerable value as an antiseptic. + +Lattin has recommended the use of large doses of ergotine in +infectious fevers, but this substance, when employed in the treatment +of pyaemia, should be given in the formative stage of the disease. The +use of drastic cathartics should be avoided, as should that of +sudorifics, on account of their prostrating effects. In some cases +hypnotics may be required to secure sleep. + +Tonics are always more or less useful. The free use of stimulants and +nutritious food is also indicated. Brandy, wine, and whiskey may be +advantageously used as stimulants. Musk, ammonia, and camphor are +occasionally required. However, it should not be forgotten that in +cases where the disease has become fully developed the usual +termination is death, few recoveries being recorded. In the early +stages of this affection, by the removal of the patient from an +overcrowded hospital ward to some place where pure air and proper +hygienic arrangements can be obtained, recovery may take place, but +under other circumstances the prognosis is exceedingly grave. + +The treatment of septicaemia in most particulars is the same as that +of pyaemia. The first effort should be to prevent the development of +the disease, and the second to care for the patient in cases where the +affection has already developed. It is not, of course, in our power to +limit or in any way {983} regulate the primary injury, for we are +obliged to take the patient as he is. The amount of injury to living +tissue may be great or small. The question of an operation, the +character of the same, and the subsequent management must be +determined in accordance with the circumstances of each particular +case. + +The primary death of the parts is generally due chiefly to the injury +itself; the secondary, frequently to bad surgical management. Let us +now take a case in which the primary injury has been severe, greatly +diminishing, but not destroying, the circulation in the injured parts. +Here the immediate application of ice would be injurious, but a warm +application might assist nature. It is humiliating to the profession +that we are obliged even at this date to admit that the treatment of +septicaemia is largely symptomatic. The profuse choleraic diarrhoea +which generally accompanies this disease may be regarded as an effort +of nature to eliminate the septic poison; but, nevertheless, it is so +prostrating in its effects that it requires to be controlled with +properly selected astringents, and these remedies may be still further +aided by the use of stimulants and tonics. + +The treatment of septicaemia may be summarized as follows: (1) A +strict adherence to the five rules given under the head of the +prophylactic treatment of pyaemia. (2) The avoidance of all +putrefaction in contact with the wound, especially prior to the +development of sufficient granulations to completely cover its +surface. This object is to be accomplished by the removal of all +necrotic tissues, the avoidance of putrescent fluids by cleanliness, +and the proper use of antiseptic agents. (3) Free use of the alkaline +sulphites and hyposulphites. These drugs should be used in all cases +where there is reason to anticipate the development of septic +diseases, as soon after the receipt of the injury as practicable, but +should not be neglected even after the disease has become fully +developed. (4) Sulphate of quinia should be used in all cases where +the temperature is above 100 degrees F., and its persistent use in +large doses may be necessary to prevent the fever from rising still +higher. It will be remembered in this connection that experience has +taught us that "a temperature of 108.5 degrees F. is the limit beyond +which life can no longer exist,"[43] and even a much lower temperature +is not without dangers. "The essential danger of fever in acute +diseases consists, then, in the deleterious influence of a high +temperature on the tissues."[44] + +[Footnote 43: Liebermeister, _New Sydenham Soc. Trans._, vol. lxvi. p. +278.] + +[Footnote 44: _Ibid._, p. 280.] + +The treatment of puerperal septicaemia, although requiring the +application of the same principles as any other form of this disease, +may be briefly described as follows: The womb should be maintained in +a firmly-contracted state by the proper use of ergot, even as a +prophylactic measure, and also during the whole course of the disease; +the uterus and vagina should be kept in an aseptic condition by the +efficient use of antiseptics; sulphate of quinia should be given in +large doses, and repeated as often as may be necessary in order to +lower the temperature; and morphia or some form of opium should be +employed for the relief of the pain. + + + + +{984} + +PUERPERAL FEVER. + +BY WILLIAM T. LUSK, M.D. + + +DEFINITION.--Puerperal fever is an infectious disease, due, as a rule, +to the septic inoculation of the wounds which result from the +separation of the decidua and the passage of the child through the +genital canal in the act of parturition. + +To maintain this definition it is, however, necessary to group by +themselves cases of childbed fever dependent upon causes which are +operative in the non-puerperal condition, though the latter imparts to +these causes oftentimes an exceptional activity and virulence. In this +category are to be placed especially scarlatina, typhus, typhoid, and +malarial fevers. It is to be borne in mind that the zymotic fevers may +provoke in the puerperal woman the same inflammatory lesions commonly +associated with puerperal fever.[1] This is in accordance with the +well-known surgical experience that a febrile paroxysm from any cause +exerts an unfavorable influence upon a wounded surface. + +[Footnote 1: Hervieux, _Traite clinique et pratique des maladies +puerperales_, pp. 1073 _et seq._] + +Like all brief statements, the writer is well aware that the foregoing +definition is necessarily imperfect, and stands in need of further +limitations to meet the requirements of exactness. Exceptions, +however, either apparent or real, will be noted hereafter in their +proper connections. + +FREQUENCY.--In a careful search through the records preserved by the +Health Department of New York City, I found that from 1868 to 1875 +inclusive the total number of deaths for nine years was 248,533. Of +these, 3342 were from diseases complicating pregnancy, from the +accidents of child-bearing, or from diseases of the puerperal state; +or, in other words, 1:75 of all the deaths occurring during that +period was the result of the performance of what we are in the habit +of regarding as a physiological function. + +The deaths from miscarriage, from shock, from prolonged labor, from +instrumental delivery, from convulsions, from hemorrhage, from rupture +of the uterus, and from extra-uterine pregnancy, and deaths from +eruptive fevers, from phthisis, and from inflammatory non-puerperal +affections complicating childbirth, made a total of 1395, or about 42 +per cent. of the entire number. The remaining 1947 cases, variously +reported as puerperal fever, puerperal peritonitis, metro-peritonitis, +phlebitis, phlegmasia dolens, pyaemia, and septicaemia, represent the +very serious sacrifice of life resulting from inflammatory processes +which have their starting-point in the generative apparatus. If we +apply the general term, puerperal fever, to this class of cases, it +will be seen that the malady is the cause of nearly one {985} +one-hundred-and-twenty-seventh of all the deaths occurring in the +city. The actual number of births for the nine years in question was +roughly estimated at 284,000[2]--an estimate erring upon the side of +liberality. The total number of deaths to the entire number of +confinements was, then, at least in the proportion of 1:85, or, from +puerperal fever alone, in the proportion of 1:146. Garrigues[3] +examined the records of the various city institutions during the +period in question, and from them estimated the number of births which +took place in hospitals at 10,572. The recorded deaths were 420. +Deducting these from the totals given above, the general death-rate in +civil practice from puerperal causes in New York City was in the +proportion of 1:94. Max Boehr[4] in his now-famous statistics reckons +that one-thirtieth of all married women in Prussia die in childbed. +The Puerperal Fever Commission[5] appointed by the Berlin Society of +Obstetrics and Gynaecology arrived at the conclusion that from 10-15 +per cent. of the deaths occurring in women during the period of sexual +activity were due to childbed fever, and that this disease destroyed +nearly as many lives as small-pox or cholera. But puerperal fever +differs from either small-pox or cholera in that the latter presses +largely upon the aged and the very young, while the former gathers its +victims exclusively from a selected class--viz. from women in adult +life, the mothers of families, whose loss, as a rule, is a public as +well as a private calamity. + +[Footnote 2: This estimate was based upon the assumption that the +natural birth-rate is 33 to the 1000--a proportion believed by the +statisticians of the Board of Health to be approximatively correct, +though probably somewhat in excess of the reality. P. Osterloh has +recently stated that my statistics were computed in so arbitrary a +manner as to render deductions from them valueless. In this, however, +he is mistaken. The most conscientious care was taken in their +preparation; wherever the possibility of error existed the fact was +distinctly indicated, and all calculations were made in such a way +that whatever corrections might be required would strengthen the +conclusions.] + +[Footnote 3: "On Lying-in Institutions," _Trans. Am. Gyn. Soc._, vol. +ii., 1878.] + +[Footnote 4: "Untersuchungen uber die Haufigkeit des Todes im +Wochenbett in Preussen," _Zeitschr. f. Geburtsk. und Gynaek._, vol. +iii. p. 82.] + +[Footnote 5: _Zeitschr. f. Geburtsk. und Gynaek._, vol. iii. p. 1.] + +For those who regard statistics with habitual distrust it may perhaps +be well to state that the foregoing frightful picture is no +exaggeration, but is less sombre than the actual truth. + +Before proceeding to consider the nature of puerperal fever it is +desirable to first recall the anatomical lesions with which it is +associated. These, it will be found, are for the most part +inflammatory processes having their starting-point in injuries of the +genital passage produced by parturition, complicated in many cases by +septic changes in the blood, by secondary degeneration of +parenchymatous organs, and at times by phlegmonous and erysipelatous +affections in remote as well as in the adjacent serous and cutaneous +tissues. + +MORBID ANATOMY.--The primary lesions connected with puerperal fever +are so various that the student will find it convenient to classify +them according as they are situated in the mucous membrane of the +utero-vaginal canal, the parenchyma of the uterus, the pelvic cellular +tissue, the peritoneum, the lymphatics, or the veins. Not, indeed, +that such an arrangement is strictly in accordance with clinical +experience--as a rule, the inflammatory processes are rarely limited +to a single tissue--but because the prognosis and treatment {986} are +determined in great measure by the tissue-system which is +predominantly affected. The significance of puerperal inflammations, +wherever seated, likewise depends upon whether they are local and +circumscribed or whether they present a spreading character. + +Personally, I have found the following classification of +Spiegelberg[6] of great utility as a means of keeping in mind the +principal points to which inquiry should be directed in estimating the +significance of the febrile conditions of childbed: + +1. Inflammation of the Genital Mucous Membrane.--Endocolpitis and +endometritis. + +_a_. Superficial. + +_b_. Ulcerative (diphtheritic). + +2. Inflammation of the Uterine Parenchyma, and of the Subserous and +Pelvic Cellular Tissue. + +_a_. Exudation circumscribed. + +_b_. Phlegmonous, diffused; with lymphangitis and pyaemia (lymphatic +form of peritonitis). + +3. Inflammation of the Peritoneum covering the Uterus and its +Appendages.--Pelvic peritonitis and diffused peritonitis. + +4. Phlebitis Uterina and Para-uterina, with formation of thrombi, +embolism, and pyaemia. + +5. Pure Septicaemia.--Putrid absorption. + +[Footnote 6: "Ueber das Wesen des Puerperalfiebers," _Volkmann's +Samml. klin. Vortr._, No. 3.] + +ENDOCOLPITIS AND ENDOMETRITIS.--In the superficial, catarrhal form of +inflammation the mucous membrane of the vagina is swollen and +hyperaemic, the papillae are enlarged, and the discharge is profuse; +in the vaginal portion of the cervix the labia uterina are oedematous +and covered with granulations which bleed at the slightest touch; in +the cavity of the body there are increased transudation of serum and +abundant pus-formation. The deep structures of the uterus are usually +not affected. Sometimes the inflammation extends to the +tubes--_salpingitis_--or, passing outward through the fimbriated +extremities, it may spread over the adjacent peritoneum. + +The small wounds at the vaginal orifice are at times converted into +ulcers with tumefied borders. These so-called puerperal ulcers are +covered with a greenish-yellow layer. They are associated usually with +oedematous swelling of the labia. Under favorable sanitary conditions +the deposit, which consists in the main of pus-cells, clears away and +the surface heals by granulation. The ulcerative form of inflammation +is very rare outside of crowded hospitals. + +Diphtheritic ulcers are situated with greatest frequency in the +neighborhood of the posterior commissure or around the vaginal +orifice. In rarer instances they are found upon the anterior wall and +in the fornix of the vagina, in the cervix, and upon the site of the +placenta. The borders are red and jagged; the base is covered with a +yellowish-gray, shreddy membrane; the secretion is purulent, alkaline, +and fetid; and the adjacent tissues are oedematous. From the vulva +they may extend to the perineum or pursue a serpiginous course down +the thighs. In the uterus and about the cervix they vary as regards +size, and are either of a rounded shape or form narrow bands. The +intervening portions of tissue which have not undergone destructive +changes swell and stand out in strong {987} relief. Where the entire +inner surface has become necrosed, it is often covered with a smeary, +chocolate-brown mass which, when washed away with a stream of water, +leaves exposed either the deepest layer of the mucous membrane or the +underlying muscular structures. + +The difference between the superficial ulcerations of the genital +canal and the diphtheritic form involving destruction of the deeper +tissues is due to the presence in the latter of minute organisms +termed micrococci, the relations of which to puerperal infection will +be considered in a subsequent division. + +METRITIS AND PARAMETRITIS.--In ulcerative endometritis, and even in +the extreme catarrhal form, the parenchyma of the uterus likewise +becomes involved. The changes which are designated under the term +metritis consist in the first place of oedematous infiltration of the +tissues. As a consequence, the organ contracts imperfectly and becomes +soft and flabby, so that sometimes, upon post-mortem examination, it +bears the imprint of the intestines. + +In diphtheritic endometritis the gangrenous process may attack the +muscular tissue, and give rise to losses of muscular substance--a +condition known as necrotic endometritis or putrescence of the uterus. + +Inflammatory changes are rarely lacking in the intermuscular +connective tissue, which exhibits in places serous or gelatinous +infiltration, with afterward pus formation, and with here and there +small abscesses. The sero-purulent infiltration of the connective +tissue is specially marked beneath the peritoneal covering of the +uterus either behind or along the sides at the attachment of the broad +ligaments. In the same situations the lymphatics, which normally are +barely perceptible to the naked eye, are sometimes enlarged to the +size of a quill, and are characterized by varicose dilatations +occurring singly or presenting a beaded arrangement. In the substance +of the uterus the dilated vessels are liable to be mistaken for small +abscesses. The pus-like substance contained in the lymphatics is +composed of pus-cells and of micrococci. From the cellular tissue +surrounding the vagina, or that beneath the peritoneal covering of the +uterus, the inflammation may spread by contiguity of tissue between +the folds of the broad ligament, and thence pass upward to the iliac +fossae. Usually the process is unilateral. After the inflammation has +crossed the linea terminalis it may take a forward direction above the +sheath of the ilio-psoas muscle to Poupart's ligament, or it may creep +upward, following the course, according to the side affected, of the +ascending or descending colon, to the region of the kidney. It is rare +for inflammation of the cellular tissue to travel around the bladder +to the front. In such cases it pursues its course between the walls of +the bladder and the uterus, and along the round ligament to the +inguinal canal. In a few cases the cellulitis mounts above Poupart's +ligament, between the peritoneum and the abdominal wall. + +The course of the inflammation is not simply fortuitous, but follows +prearranged pathways in the connective tissue. Konig[7] and +Schlesinger[8] have shown that when air, water, or liquefied glue is +forced into the cellular tissue between the broad ligaments the +injected mass has a tendency to invade the iliac fossae. In +Schlesinger's experiments, if the canula of the syringe was inserted +into the anterior layer of the broad ligament, {988} the glue spread +between the folds to the abdominal end of the Fallopian tube; thence, +following the track of the vessels, it passed to the linea terminalis; +and finally mounted upward along the colon or swept forward to +Poupart's ligament until the advance was stopped at the outer border +of the round ligament. If the injection was made to the side of the +cervix through the posterior layer at the junction of the cervix and +the body, the posterior layer gradually bulged out, the peritoneum was +lifted from the side wall of the pelvis, and the glue passed beyond +the vessels to reach the iliac fossa. If the injection was made to the +side of the cervix through the anterior layer, the glue passed between +the bladder and the uterus, and forward along the round ligament to +the inguinal canal, while another portion of the fluid passed between +the layers of the broad ligament, and reached the peritoneal covering +of the side walls behind the round ligament. If the injection was made +in the median line in a peritoneal fold of Douglas's cul-de-sac, the +fluid travelled forward upon one side along the round ligament and +thence to the posterior wall of the bladder. + +[Footnote 7: _Arch. der Heilkunde_, 3 Jahrg., 1862.] + +[Footnote 8: _Gynaekologische Studien_, No. 1.] + +The term parametritis, introduced into use by Virchow, is, properly +speaking, limited to inflammation of the connective tissue immediately +adjacent to the uterus, the older one of pelvic cellulitis furnishing +a more comprehensive designation for cases where, as a consequence of +a progressive advance from the point of departure in the genital +canal, the remoter regions have likewise been invaded. +Connective-tissue inflammation presents, as the first essential +characteristic, an acute oedema, the fluid which fills the gaps and +interspaces consisting of transuded serum rendered opaque by the +presence of pus-cells or possessing a gelatinous character. In the +mild, uncomplicated cases the oedema disappears rapidly. Where the +cell-collections are of moderate extent the entire process may vanish +without leaving a trace of its existence. If the cell-elements, on the +other hand, are present in great abundance, they, as a rule, first +undergo fatty degeneration, and, after the absorption of the fluid +portion, form a hard tumor composed of a fine granular detritus, which +under favorable circumstances likewise after a few weeks becomes +absorbed. In rare cases abscess-formation in the tumor results. + +In the cellulitis resulting from septic infection, especially in cases +complicated by diphtheritis, the tissues seem as if soaked with dirty +serum, and contain scattered yellowish deposits, which soon present, +even to the naked eye, the appearance of pus-collections. This +sero-purulent oedema is always associated with lymphangitis, the +lymphatic vessels possessing varicose dilatations and beaded +arrangements similar to those already described in the uterine tissue. +The foregoing changes are most distinct in the firm connective tissue +adjacent to the uterus and at the hilum of the ovary, while they are +less clearly traced in the looser structure of the broad ligament +(Spiegelberg). + +In favorable cases the inflammation is circumscribed, or at least is +limited, by the nearest lymphatic glands. In cases of intense +infection it spreads rapidly, and justifies the title bestowed upon it +by Virchow of parametritic malignant erysipelas. + +PELVIC AND DIFFUSED PERITONITIS.--Inflammation of the pelvic +peritoneum may result from severe attacks of catarrhal endometritis, +the inflammatory process either traversing the uterine tissue or +passing {989} through the Fallopian tubes to the adjacent serous +membrane; or it may proceed, secondarily, from the stretching and +irritation occasioned by an associated parametritis. + +As a rule, pelvic peritonitis is not attended with much exudation. The +latter is situated upon the folds of the peritoneum limiting the +cul-de-sac of Douglas, upon the ovaries, and upon the broad ligaments. +In favorable cases it consists of fibrinous flakes and fluid pus. If +the latter is abundant, it may become encysted by the formation of +adhesions between the pelvic organs. + +General peritonitis may result from the extension of a pelvic +peritonitis, or from the transport of poison through the lymphatics +into the peritoneal sac. In the first case the entire peritoneum is +injected, and the contents of the abdominal cavity are loosely bound +together by pseudo-membranes, composed of pus and coagulated fibrine. +The intestines are at the same time distended and the diaphragm is +pushed upward. In the so-called peritonitis lymphatica the +inflammatory symptoms are at the outset lacking. The abdominal cavity +is found filled with a thin, stinking, greenish or brownish fluid +composed of serum and micrococci. The intestines are lax and +oedematous, and the muscular structures are paralyzed, with resulting +tympanitic distension. The peritoneal covering of the intestines is +devoid of lustre, and covered with injected patches, or is stained of +a dark-brown color. Death often ensues before the occurrence of +exudation. + +Septic forms of pelvic inflammation are often associated with +oophoritis, the dilated lymphatics either extending to the substance +of the ovaries, where they may lead to the production of small +abscesses, or, as a result of blood-dissolution, the organs become +soft, pulpy, and infiltrated with discolored serum, and present +hemorrhagic spots distributed over the surface. + +PHLEBITIS AND PHLEBO-THROMBOSIS.--The formation of thrombi in the +uterine and pelvic veins is sufficiently common during the puerperal +period. The coagulation may result from compression or from +enfeeblement of the circulation. A predisposition to its occurrence is +created by relaxation of the uterine tissue. A normal thrombus is in +itself harmless. In time it becomes organized, and the occluded vessel +is converted into a connective-tissue cord, or a channel may form +through it which permits the passage of the blood-stream. When, +however, pus or septic matters obtain access to a thrombus, it +undergoes rapid disintegration, and the particles get swept away into +the circulation until arrested in the ramifications of the pulmonary +artery. Wherever these poisoned emboli happen to lodge inflammation is +set up in the adjacent tissues, and abscesses result (pyaemia +multiplex). Sometimes countless collections of pus may form in the +lungs. Less commonly abscesses are found in the liver or spleen, +originating either from emboli which have already made the pulmonary +circuit or from thrombi in the pulmonary veins. + +Inflammation of the veins (phlebitis) sometimes occurs when the +vessels have to traverse tissues in or near the uterus infiltrated +with purulent or septic materials. The endothelium then undergoes +proliferation, and thrombosis is produced. Phlebitic thrombi do not +necessarily break down, and may in that case act as a barrier to the +progression of septic germs into the circulation (Spiegelberg). As a +rule, however, {990} under the influence of inflammation and +infection, they become converted into puriform masses. + +The thrombi grow by accretion in the direction of the heart. They may +extend from the uterus through the internal spermatic, or through the +hypogastric and common iliac veins, to the vena cava. Sometimes the +thrombus may be traced back to the placental site. + +SEPTICAEMIA.--From these local conditions, sooner or later, secondary +affections develop in distant organs. The general affection is, in +great part at least, likewise of local origin. Sometimes, however, +where the poison, which enters the system through the lymphatics and +veins, is very active and abundant, death may follow from acute +septicaemia before the changes in the sexual organs have had time to +develop. The fatal result in these cases is probably due to paralysis +of the heart. After death post-mortem decomposition rapidly sets in, +the blood is sticky, and swelling is found in the various +parenchymatous organs. + +The secondary affections consist in the metastatic abscesses already +noticed as produced by infected emboli, in circumscribed purulent +collections due to the conveyance of septic materials into the +blood-current through the lymphatics, in ulcerative endocarditis, in +inflammations of the pleura, the pericardium, and the meninges, and in +purulent inflammation of the joints. + +A study of the nature of puerperal fever will best show how intimately +these seemingly distinct processes are linked together. + +EARLIER VIEWS CONCERNING THE NATURE OF PUERPERAL FEVER.[9]--According +to the teachings of Hippocrates, Galen, and Avicenna, of Ambrose Pare, +of Sydenham, and of Smellie, the fevers of puerperal women were +attributable to the suppression of the lochia. For twenty centuries +this doctrine was accepted almost without dispute, the best clinical +observers confounding a symptom which is often lacking with the cause +of the disease itself. + +[Footnote 9: For data given, and for a great variety of historical +information, vide Hervieux, _Traite clinique et pratique des maladies +puerperales_.] + +In 1686, Puzos[10] taught that milk, circulating in the blood, is +attracted to the uterus during pregnancy and to the breasts after +confinement, but that milk metastases may form in other parts, and +produce the symptoms of malignant or intermittent fever. In 1746, A. +de Jussieu, Col de Villars, and Fontaine advanced in support of this +theory the fact that they had found, on opening the abdomen in women +who had died from an epidemic which raged that year in Paris, a free +lactescent fluid in the lower portion of the abdominal cavity and +clotted milk adherent to the intestines. This doctrine, which seemed +to be based upon, and to accord with, observation, found many +adherents in France. It lost ground, however, when, in 1801, Bichat +pointed out the true nature of the abdominal effusions of women who +had died in childbed, and demonstrated that they were to be found +likewise in peritoneal inflammations occurring in men and in +non-puerperal women. + +[Footnote 10: _Premier Memoire sur les Depots lacteux_.] + +While, during the second half of the eighteenth century, the doctrine +of milk metastasis held full sway in France, in England and Germany +the dominant leaders in medicine referred the causes of puerperal +fevers to inflammations of the womb and of the peritoneum. With the +advances made in pathological anatomy in the beginning of the present +{991} century, France taking the lead, stress was likewise laid upon +inflammations of the veins and of the lymphatics. The vitality of the +doctrine of local inflammations is well shown by the records kept by +the Health Board of this city, where a large proportion of the deaths +returned from childbed fever are entered under the head of metritis, +of peritonitis, of metro-peritonitis, and of puerperal phlebitis. + +In opposition to the doctrines of the so-called localists, the theory +that puerperal fever is an essential fever, and as much a distinct +disease as typhus fever, typhoid fever, or relapsing fever, has been +strenuously advocated by some of the most distinguished clinical +teachers who have devoted their attention to obstetrical science. + +Fordyce Barker, the most recent exponent of the essentiality of +puerperal fever, in his classical work upon the _Puerperal Diseases_, +states the arguments against the local origin of the diseases as +follows: 1st, that puerperal fever has no characteristic lesions; 2d, +that the lesions which do exist are often not sufficient to influence +the progress of the disease or to explain the cause of death; 3d, that +there may be inflammation, even to an intense degree, of any of the +organs in which the principal lesions of puerperal fever are found, +and yet the disease will lack some of the essential characteristics of +puerperal fever; 4th, that the lesions are essentially different from +spontaneous or idiopathic inflammations of the tissues where these +lesions are found; 5th, that puerperal fever is often communicable +from one patient to another through the medium of a third party, and +that this is not the fact in regard to simple inflammations in +puerperal women. + +However, neither Barker, nor those who entertain views similar to his, +question the local origin of many febrile affections in childbed, but +claim that purely local inflammations have each their characteristic +symptoms, which differ from those of true puerperal fever, that +puerperal fever is a zymotic disease of unknown origin, and that local +lesions, where they coexist, are not the primary source of trouble, +but are secondary to changes in the blood. + +In 1850, James Y. Simpson[11] published a short paper "On the Analogy +between Puerperal and Surgical Fever." This article may well be +regarded as the foundation of the modern doctrine concerning puerperal +fever, and is well worthy of perusal at the present day; for, though +in the then existing state of pathology many of the links were wanting +which have since raised the argument to nearly a mathematical +demonstration, the paper furnishes a brilliant example of the +scientific foresight which is able to discern the truth even where the +evidence lacks completeness. + +[Footnote 11: _Edinburgh Medical Journal_.] + +In 1847, Semmelweis, who was at that time clinical assistant to the +Lying-in Hospital at Vienna, made the startling assertion that +"puerperal patients were chiefly attacked with puerperal fever when +they had been examined by the physicians who were fresh from contact +with the poisons engendered by cadaveric decay; that fever ensued in +the practice of those who after post-mortem examination washed their +hands in the usual manner, whereas no fever or but few cases of +disease followed when the examiner had previously washed his hands in +a solution of chloride of lime." In the face of insult, ridicule, and +abuse Semmelweis {992} maintained this position for years, almost +unaided, with fanatical persistency. It was easy for his opponents, +for the most part managers of the great lying-in asylums, to show from +clinical experiences the weakness of so one-sided a theory. But the +employment of the equivocal demonstration _falsus in uno, falsus in +omnibus_, served only as a temporary defence against the laxity which +prevailed in hospital management only a quarter of a century ago. +Though Semmelweis died with no other reward than the scorn of his +contemporaries, it is impossible at the present day to so much as +contemplate the abuses he attacked without a shudder. + +In 1860, Semmelweis published the result of his ripened experience in +a treatise entitled _Die Aetiologie der Begriff und die Prophylaxis +des Kindbett fiebers_, in which, abandoning his earlier exclusive +position, he maintained that puerperal fever arises from the +absorption of putrid animal substances, which produce first +alterations in the blood, and secondly exudations. He distinguished +between cases in which the infection was introduced from some external +source, and which he believed to be the most frequent variety, and +those where the poison was generated in the system. The sources from +which the infection is derived he believed to be--1st, from the dead +body, regardless of age, sex, or disease, no matter whether the latter +is of puerperal or non-puerperal origin, the virulence depending upon +the stage of decomposition; 2d, diseased persons, whose malady is +associated with decomposition of animal tissue, no matter whether the +affected person suffers from childbed fever or not, the decomposing +matter alone furnishing the product from which infection is derived; +3d, physiological animal substances in the process of decomposition. +As carriers of infection he regarded the fingers and hands of the +physician, midwife, or nurse, sponges, instruments, soiled clothing, +the atmosphere, and, in brief, anything which, after being defiled +with decomposing animal matter, was brought into contact with the +genitals of a woman during or subsequent to parturition. Absorption +takes place from the inner surface of the uterus or from traumata in +the genital canal. Infection seldom occurs in pregnancy, because of +the closure of the os internum, the absence of wounded surfaces, and +because of the rarity with which examinations are made; during +dilatation infection is common, but exceptional during the period of +expulsion, because the inner uterine surface is at that time rendered +inaccessible by the advance of the child; in the placental and +puerperal period infection occurs from utensils and instruments, but +chiefly through the access of atmospheric air when the latter is +loaded with decomposing organic matter. In rare instances +auto-infection may result from spontaneous decomposition of the +lochia, of bits of decidua, of coagula of blood, of necrosed tissue, +or in consequence of severe instrumental labors. In a word, puerperal +fever was according to Semmelweis no new specific disease, but a +variety of pyaemia. + +I have been thus particular in giving prominence to the labors of +Semmelweis partly from justice to a man who was hated and despised in +his lifetime, and partly because I believe that few outside of Germany +are really cognizant of the immense service he rendered to humanity, +or that to him is really due a large part of what is now current +doctrine concerning the nature and prophylaxis of puerperal fever. + +THE NATURE OF PUERPERAL FEVER AS REGARDED FROM THE {993} STANDPOINT OF +MODERN INVESTIGATION.--The older beliefs in the suppression of the +lochia and the metastases of milk have long since been relegated to +the domain of old nurses' lore, and do not call for serious +discussion. The localist theory, that puerperal fever is a metritis, a +peritonitis, a phlebitis, or an inflammation of the lymphatics, is, as +mortuary records show, still adhered to by many practitioners, and, as +we have seen, is justified by the fact that puerperal fever is, with +rare exceptions, associated at some period of its progress with +certain inflammatory processes which have their starting-point in the +generative apparatus. But the localist theory leaves out of view the +existence of blood-poisoning, and yet the coexistence of a +blood-poison with the local lesions is an essential feature of +puerperal fever. It was this defect which gave to the advocates of the +specificity of puerperal fever their real importance. The outcome of +modern investigation tends, however, to prove that the puerperal +poison is of a septic nature, and that the usual points of +introduction of the poison are the lesions of the parturient canal. +This does not, indeed, exclude other points of entry, for clinical +experience renders it probable that, under certain conditions, the +poison may be primarily introduced into the blood through the +respiratory and digestive organs. Puerperal fever is really a surgical +fever, modified, however, by the peculiar physiological conditions +which belong to the puerperal state. The argument against its septic +origin is based chiefly upon mistaken ideas concerning the nature of +septicaemia. So long as the symptoms of the latter were derived for +the most part from the effects observed as a consequence of injecting +putrid materials into the veins of dogs, a confusion arose from the +fact that the results obtained were commonly those of putrid +intoxication, and not those of true septicaemia. Under such +circumstances it was not difficult to formulate definitions of +septicaemia which could be shown to be at variance with the phenomena +which ordinarily exist in puerperal fever. + +The argument that the infectious diseases of childbed are of a septic +nature can best be understood by presenting the proofs in their +orderly sequence. + +1st. _It is demonstrable that septic poisons are capable of producing +the lesions ordinarily associated with puerperal fever._ Thus, it is a +matter of ordinary experience that the retention of a small bit of the +membranes within the uterus will produce fetid lochia, and, as the +result of infection, a febrile condition, which, as a rule, subsides +with the expulsion of the offending body and the use of disinfectant +washes. A virulent form of fever is not unfrequently occasioned by +retained coagula or placental debris which have undergone +decomposition. I was once sent for to see a puerperal patient +suffering from fever on the fourth day following her confinement. On +entering the room I found the stench intolerable; turning down the +sheets, I discovered that the patient was lying in a decomposing mass, +and learned that her doctor had forbidden, after the birth of her +child, the removal of the soiled linen and blankets. The patient died +in the third week from pyaemia multiplex. + +Haussmann[12] reported a case of auto-infection in the rabbit which +terminated fatally. A portion of the membrane, retained in the left +cornu, {994} led to diphtheritic losses of substance in the lower +portion of the vagina, to hemorrhagic enteritis, and to peritonitis. +The same author produced death from septicaemia by injecting into the +gravid uterus of one rabbit serum from the abdomen of another which +had died from infection. The post-mortem examination showed the +muscles filled with granules and the peritoneum injected, but no +fibrino-purulent exudation. Injections into the uterus of pus from the +abdomen of a woman who had died from infectious puerperal disease +produced no effect upon rabbits two weeks gravid, while in the second +half of pregnancy premature delivery and death occurred, in one case +in one and a half, in another in two and a half, days. In the animal +which died in thirty-six hours there was commencing perimetritis and +peritonitis, while in the one that died after the lapse of sixty hours +the abdomen was found to contain fibrine and pus.[13] D'Espine +injected into the uterus of a rabbit which had just produced her young +pus from the abdomen of a woman who had died from puerperal disease +two days before. This was subsequently followed by other injections of +fetid fluids during the four days following. On the twelfth day the +animal died. The autopsy revealed peritonitis, most marked in the +pelvic cavity, inflammatory alterations in the vagina, uterus, and +tubes, small abscesses in the body of the uterus, softened clots in +the veins of the broad ligaments, and infarctions of the liver.[14] +Schuller found that subcutaneous injections of septic material in +female animals during pregnancy produced a diphtheritic ulcerative +process on the uterine surface, which determined the separation of the +placenta; diphtheritic patches, likewise, were found in the cornua of +the uterus.[15] + +[Footnote 12: "Entstehung der ubertragbaren Krankheiten des +Wochenbettes," _Beitr. zur Geburtsk. und Gynaek._, Bd. iii. Heft 3, p. +345.] + +[Footnote 13: _Contribution a l'etude de la septicemie puerperale_, +Paris, 1873, p. 28.] + +[Footnote 14: _Ibid._, p. 394.] + +[Footnote 15: "Experimentelle Beitrage zum Studium der septischen +Infection," _Deutsch. Zeitschr. fur Chir._, Bd. vi. p. 141.] + +Thus we find that in the human subject and in experiments made upon +animals septic poisons introduced into the system following or near +delivery produce lesions similar to those found in puerperal fever. As +a further coincidence, we notice that, as in puerperal fever, the +lesions from direct septic poisoning have nothing characteristic about +them, producing in one case pyaemia, in another partial peritonitis, +in another general peritonitis, in another diphtheritis, while in +others the lesions are comparatively trivial, these differences being +due to variable facta, such as the qualities of the septic poisons, +the points of entry into the organism, and the resistance offered by +the invaded tissues. + +2d. _Septicaemia is a disease characterized by the invariable presence +in the organism infected of minute bodies generally termed +bacteria._[16] + +[Footnote 16: In 1865, Mayrhofer (_Mon. Schr. f. Geburtsk._, vol. +xxv., p. 112, 1865), at that time clinical assistant to the Lying-in +Service of Braun in Vienna, stimulated by the researches of Pasteur, +maintained that septic endometritis was the result of putrid +fermentation within the uterine cavity, and drew attention to the +vibrios--a term which he applied to the round as well as to the +rod-like bacteria--as the source, and not the product, of +putrefaction. He claimed that while in puerperal processes vibrios are +always present, in healthy women they never occur before the second, +third, or fourth day, and not always even then. The chief progress +that has been made as regards our knowledge of puerperal fever in the +last ten years has been in the direction of strengthening Mayrhofer's +argument by careful experiment, and by defining the action of +microscopic fungi in the production of septic morbid processes.] + +Until very recently the whole subject of septicaemia has been in a +state of wellnigh hopeless confusion. From Gaspard and Panum, through +a long list of experimenters, hardly any two arrived at precisely +similar {995} results. Something like an approach to order has, +however, been produced since it has begun to be understood that the +effects produced by septic fluids vary with the quality of the poison +and the method of experimentation, and that to obtain identity in the +result there must be identity in all the conditions. Thus, Samuel has +shown that the same organic substance produces different effects at +different stages of decomposition; again, that the enteritis which is +commonly quoted as characteristic of septic poisoning occurs, as a +rule, in animals when the septic fluid is injected directly into the +blood, and is rare when it finds its way into the circulation through +the lymphatics, as is the case usually in clinical experiences.[17] +There is one experimental point of extreme practical importance too in +connection with puerperal septicaemia--viz. that if the injection of a +septic fluid be made directly into a vessel, toxic effects speedily +follow, but are transitory, unless the amount of the fluid be large, +or its virulence exceptional, or the animal very young;[18] whereas +very small amounts injected subcutaneously, by developing +rapidly-spreading phlegmonous inflammation, resembling malignant +erysipelas in man, are capable, after a period of incubation, of +producing fatal results; or they may, if injected into a shut cavity +or underneath a fascia, lead to the development of an inflammation of +an ichorous character. In other words, the eliminating organs suffice, +under ordinary conditions, to remove from the blood the same amount of +septic fluid which would prove fatal if injected into the tissues.[19] +To produce similar results the injections into the blood need to be +repeated at intervals. This experience leads us to the conclusion that +in the tissues septic poison possesses the capacity of +self-multiplication, and that in the local inflammation set up a +reservoir is formed from which poison is continuously poured into the +circulation. + +[Footnote 17: _Loc. cit._, p. 349.] + +[Footnote 18: "Traube und Gescheidlen, Versuche uber Faulniss und den +Widerstand des lebender Organismus," _Schles. Ges. f. vaterlandische +Cultur_, Feb. 13, 1874.] + +[Footnote 19: In some instances in which absorption from the tissues +is very rapid the effects of subcutaneous injections may be similar to +those produced by injections made directly into the circulation, and +the local lesion be insignificant.] + +This capacity of self-multiplication which septic fluids possess has +recently been found to be coincident with the presence of certain +parasitic bodies, generically termed bacteria. All carefully-made +experiments serve to show that if a septic fluid be deprived of these +organic bodies by boiling or filtration while it continues capable of +producing inflammation, the inflammation is usually of diminished +intensity and remains local in its character;[20] whereas the bacteria +retained upon the filter possess all the virulent properties of the +original fluid.[21] This does not alone necessarily prove that the +virus resides in the bacteria, for it does not exclude the possibility +that both the virus and the bacteria remain upon the filter. + +[Footnote 20: In filtration through porous earthenware cylinders the +filtrate possesses no phlogogenic properties.] + +[Footnote 21: Tiegel, _Correspondenzblatt fur Schweizer Aertze_, 1871, +S. 1275; Klebs, _Archiv fur exp. Pathol. und Pharmakol._, Bd. i. Heft. +1, S. 35.] + +So far, attempts at isolating the microspores of septicaemia and +cultivating them separately in vehicles composed of water holding in +solution inorganic constituents, or sterilized fluids containing +organic matters, or of the semi-solid gelatinous substances +recommended by Koch, have been only partially successful in proving +them to be the sole source of {996} infection. Some earlier +experiments of Tiegel and Klebs[22] were attended with positive +results, and more recently confirmatory evidence has been furnished by +Pasteur and Doleris.[23] Hiller, rarely quoted now, arrived at +different conclusions. He found that bacteria washed in pure water +were innocuous.[24] But pure water had long before been proven by +observers to be inimical to the well-being of the organisms in +question. Schuller says that Hiller's experiments prove apparently +that while a putrid fluid may be in the highest degree poisonous, its +component parts--viz. either the fluid or the bacteria singly--are +neither deadly nor poisonous.[25] The fact is, that isolation +experiments are subject to what has hitherto been in most experiments +an unavoidable source of error. As Davaine noted early in his +observations, the physiological action of bacteria is very dependent +on the constitution of the medium in which they are developed, which +is in entire harmony with what is known of organisms much higher in +the scale. "Many plants," says Burdon-Sanderson,[26] "containing +active principles, become inert when transplanted from an appropriate +soil." Bucholtz, in a series of experiments designed to test the +influence of antiseptics upon the vitality of bacteria, found not only +a difference between those taken directly from the infusion and those +cultivated in artificial fluids, but between bacteria derived from the +same source and cultivated in modifications of the nutrient +medium.[27] Then, too, it is not always safe to transfer to the human +species the results of experiments made upon the lower animals. +Indeed, among animals, not only in different species, but in varieties +of the same species, differences in the susceptibility to septicaemic +poisons are found ranging from gradations as to the intensity of the +effect produced to absolute immunity. In anthrax, a disease analogous +to the one in question, the bacterial origin has been established +beyond dispute by the inoculation of isolated bacilli, which multiply +in the blood and permeate in enormous numbers the lungs, liver, +kidneys, spleen, and glandular structures. If the same unequivocal +testimony has as yet not been obtained from isolation experiments as +regards septicaemia, it is reasonable to suppose that this is due to +the defects in the technique, for which it is presumable the ingenuity +of investigators will in future find the remedy. + +[Footnote 22: _Archiv fur exp. Pathologie und Pharmakologie_, +"Beitrage zur Kenntniss der Pathogenen Schistomyceten," Band iv. Heft +3, S. 241 und ff.; Tiegel, _loc. cit._] + +[Footnote 23: In this connection may be mentioned some very +interesting experiments by Dr. George Gaffky (_Experimentellen +Erzengte Septicaemie, Mittheilungen aus den Kaiserlich, Gesundh. +Amte_), in which micrococci from the blood of septicaemic mice were +successfully cultivated in a gelatine preparation, and produced, when +inoculated in small quantities, the symptoms identical with those +obtained by inoculating the blood itself.] + +[Footnote 24: "Exp. Beitrage zur Lehre von der organisirte Natur der +Contagion und von der Faulniss," _Archiv fur klinische Chirurgie_, Bd. +xvii. Heft 4, S. 669 u. ff.] + +[Footnote 25: "Exp. Beitrage zum Studium der septischen Infection," +_Deutsche Zeitschrift fur Chirurgie_, Bd. vi. S. 162.] + +[Footnote 26: "Lectures on the Relations of Bacteria to Disease," +_British Med. Journal_, March 27, 1875. See also Klebs, "Beitrage zur +Kenntniss der Pathogenen Schistomyceten," _Arch. fur Pathol. und +Pharmakol._, Bd. iii. S. 321.] + +[Footnote 27: "Antiseptica und Bacterien," _Arch. f. exp. Pathol. und +Pharmakol._, Bd. iv., Heft 1 und 2.] + +It is, however, from the constant presence of the bacteria in infected +wounds, and their distribution through the tissues, that the argument +in favor of connecting septic symptoms with the bacteria has been +mainly deduced. Here the ground is sufficiently solid, and, judged by +ordinary laws of scientific evidence, the pathological importance of +the microspores {997} may be regarded as established. To be sure, we +find them in tongue-scrapings of healthy individuals, but +tongue-scrapings are poisonous if injected into the tissues. That they +do not ordinarily prove so in the mouth is no more singular than that +woorari can be swallowed with impunity. Tiegel[28] has endeavored to +show that round bacteria are found normally in the internal organs of +the body; but Koch[29] states that he has on many occasions examined +normal blood and normal tissues by means which prevented the +possibility of overlooking bacteria, or of confounding them with +granular masses of equal size, and that he has never in a single +instance found organisms. + +[Footnote 28: _Arch. f. Path. Anat. u. Physiol. u. f. klin. Med._, +vol. lx. p. 453.] + +[Footnote 29: On _Traumatic Infective Diseases_, New Sydenham Soc. +publication p. 15.] + +It is stated that bacteria are sometimes absent from the blood +withdrawn during life in septic diseases. As, however, their constant +presence has been confirmed in the vessels and glomeruli of the +kidneys, it is fair to assume that those organs, acting as filters, +must have received the colonies observed in them from the general +circulation. + +The difficulty of obtaining bacteria from the blood in many cases +during life in septic diseases does not, however, as was once +supposed, invalidate the theory of their pathogenic importance. +Septicaemia is at present employed as a collective term for a number +of processes which may occur singly or in combination with one +another. When a relatively large quantity of a putrid fluid is +injected into the veins of an animal, death follows from the action of +a chemical poison (sepsin). The blood during life rarely displays the +presence of bacteria, the latter disappearing in the circulation. In +animals thus poisoned blood does not possess infectious properties. +This form is termed putrid intoxication. That the poison in these +cases is, however, produced by the bacteria is shown by experiments of +Gutmann,[30] who demonstrated that bacteria from a drop of putrid +blood cultivated in Cohn's solution developed in the fluid a poison +which, when injected into the veins of dogs, occasioned death with all +the symptoms of putrid intoxication. Still more conclusive were the +experiments of Koch. This observer injected four drops of putrid blood +beneath the skin of mice. The latter died in from four to eight hours. +There were no bacteria in the blood, and the blood was not infectious. +When, however, a single drop was injected, the mice often remained +unaffected, but in a third of the cases they became ill after +twenty-four hours, death occurring in from forty to sixty hours. The +blood during life communicated the same disease to other mice, and +bacilli were always present in large numbers. In these cases the +dissolved poison in the fluid injected was too small in amount to +destroy life, and death resulted only after a period of incubation as +a consequence of the multiplication of bacilli in the blood and in the +tissues. + +[Footnote 30: Vide Semmer, "Putride Intoxication," etc., _Virchow's +Arch._, vol. lxxxi. p. 109.] + +In another class of cases Koch experimented, not with putrid blood, +but with a fluid produced by macerating a piece of mouse-skin in +distilled water. Of this he injected a syringeful into the back of a +rabbit. The result was peritonitis, swelling of the spleen, gray +wedge-shaped patches in the liver, and in the lungs were found +dark-red patches the size of a pea, devoid of air--all appearances in +harmony with what is designated as pyaemia. Oval micrococci were found +in great numbers {998} everywhere throughout the body. But the point +of special interest in the present connection is the fact that +wherever these micrococci come in contact with the red +blood-corpuscles the latter stick together and become arrested in the +minute capillary network. The thrombi thus formed are further enlarged +by the deposition of micrococci, which multiply, block up individual +capillary loops, and invade contiguous tissues. In the blood-current +itself, however, the micrococci do not increase in numbers, and cannot +always be found in the circulation upon a single examination, but +Doleris[31] assures us that in puerperal fever by repeated trials, +especially after a chill, he has never failed to demonstrate their +presence. + +[Footnote 31: _La Fievre Puerperale, etc._, p. 120.] + +As to the exact manner in which these minute bodies exercise their +pernicious influence, whether they operate mechanically, or whether +they produce a virus in the process of nutritive activity, or whether, +as is probable, both suppositions are correct, must be decided by +future investigations. It is enough for us to note that the connection +between sepsis and bacteria is intimate and vital. + +3d. _Pathogenic bacteria are invariably associated with puerperal +fever, and to them the infectious qualities of the disease are due._ I +have been explicit regarding the evidence concerning bacteria in +septic diseases, because it places the question of the infectious +group of puerperal fever cases in the following position: Experiences +occurring clinically, as well as those produced upon animals, teach us +that certain lesions and symptoms, similar to those we are accustomed +to regard as characteristic of puerperal fever, results from septic +poisoning. In a large class of cases, however, the connection between +childbed fever and sepsis has been deduced rather from analogy than +direct proof. For those who chose to regard such as due to a specific +poison peculiar to the puerperal state there was really no objection. +If, however, bacteria are characteristic of septic poisoning, the +question presents itself in a different light, and we have to inquire +whether, in the less obvious cases, bacteria are present in puerperal +fever in the proportions and groupings that we find them in other +diseases due to putrid infection. Now, it is precisely proof of this +nature that has recently been abundantly rendered. + +Waldeyer,[32] Orth,[33] Heiberg,[34] and Von Recklinghausen[35] found +the tissues and lymphatics of the parametria filled with pus-like +masses, which consisted, in addition to pus-cells, chiefly of +bacteria. Bacteria swarmed in the fluid of the peritoneal cavity. In +one case examined by Waldeyer six hours after death, while the body +was still warm, the peritoneal exudation was like an emulsion, and +furnished an abundant deposit which consisted almost entirely of +bacteria. Orth injected ten minims of peritoneal fluid from a woman +dead of puerperal fever into the abdomen of a rabbit. As the animal +was dying he broke up the medulla oblongata, and found in the +peritoneal fluid enormous quantities of these {999} organisms. In +puerperal fever round bacteria have been likewise found, though in +less quantities, in the lymphatics of the diaphragm and in the fluids +of the pleura, the pericardium, and the ventricles of the brain. In +post-mortem examinations of fresh subjects the serous fluids, +withdrawn under proper precautions, do not contain round bacteria +except in cases of septic infection.[36] Orth found in the purulent +contents of the vessels of the funis, in children who died of sepsis, +precisely the same formations as existed in the exudations of the +mother. + +[Footnote 32: "Ueber das Verkommen von Bacterien bei der +diphtheritischen Form des puerperal Fiebers," _Archiv fur +Gynaekologie_, vol. iii. p. 293.] + +[Footnote 33: "Untersuchungen uber puerperal Fieber," _Virchow's +Archiv_, vol. lviii. p. 437.] + +[Footnote 34: _Die puerperalen und pyaemischen Processe_, Leipzig, +1873.] + +[Footnote 35: For the views of Von Recklinghausen I am indebted to his +pupil Steurer. Vide the writer's paper on "The Nature, Origin, and +Prevention of Puerperal Fever," _Trans. of the International Med. +Congress_, Phila., 1876.] + +[Footnote 36: Klebs, "Beitrage zur Kenntniss der Pathogenen +Schistomyceten," _Archiv fur exp. Pathol. und Pharmakol._, vol. iv. p. +441 _et seq._] + +Doleris, in a remarkable essay already referred to, published in +1880,[37] furnishes not only conclusive evidence of the presence of +bacteria in the various tissues and serous cavities of women dying of +puerperal fever, but has added the evidence of their pathogenic +character by cultivating them apart in sterilized fluids, and by +reproducing in animals, by means of subcutaneous injections of the +isolated bacteria, the infarctions, the blood-changes, and the +suppurative processes of the original disease. + +[Footnote 37: _La Fievre Puerperale et les Organismes Inferieurs._] + +So far, the generic term bacteria has been employed to indicate the +disease-germs which are the active agents of infection in puerperal +fever. It is not, however, intended to assume that the germs of septic +processes are all identical, or that they all produce precisely the +same pathological conditions. Koch, indeed, maintains that a distinct +specific bacterial form is found in such closely-allied affections as +pyaemia, septicaemia, gangrene, and erysipelas, the different forms +possessing, however, this link in common--viz. that they are alike +generated in putrefying media. Singularly enough, the bacterium termo +and the bacterium commune--to which the fetidity of matters undergoing +putrefaction is due--are in themselves harmless. They are rapidly +destroyed in the circulation, and are not inoculable. Fetid discharges +from wounds are not therefore necessarily dangerous. The putrid odor +serves a useful purpose, as it gives warning of the existence of +conditions which favor the development of life-destroying organisms; +but the latter may develop without the concurrence of the forms which +give rise to putrefaction--a fact of considerable importance in view +of the common belief that septic infection is excluded by the absence +of fetid odors. + +In puerperal fever Doleris found the prevailing pathogenic organisms +consisted of bacilli or rods, and micrococci or round bacteria in the +varieties of micrococci, simple points; diplococci, double points; and +chains or wreaths. The bacilli he regarded as the source of acute, +rapid septicaemia, while pus-production was associated with the +multiplication of the round bacteria, and especially of the +diplococci. + +4th. _The presence of germs in puerperal fever serves not only to fix +cases hitherto doubtful in the category of septic diseases, but +affords the most satisfactory explanation of the protean phenomena of +puerperal fever itself._ + +We have seen, from both Koch's and Gutmann's experiments upon animals, +that death may occur independently of bacteria by the rapid absorption +of a chemical poison developed in a putrefying fluid. Clinical +experiences, such as the speedy death sometimes observed when retained +coagula or portions of placenta undergo decomposition within the +uterine cavity, renders it probable that similar cases of putrid +intoxication are {1000} not unknown in puerperal women, though, so +far, the anatomical demonstration of the fact has not been furnished. + +In cases, however, where puerperal fever has a distinct period of +incubation, and progresses step by step to the fatal ending, bacteria +are always found invading the tissues of the genital canal. In rare +cases they pass by the Fallopian tube to the peritoneal cavity and +excite salpingitis and peritonitis. More commonly from local lesions +they enter the canalicular spaces of the connective tissue forming the +framework of the genital canal, which is continuous with the +subperitoneal connective tissue of the pelvis. From the canalicular +space they enter the lymphatics. Cellulitis is excited by their +presence, and the lymphatic glands become inflamed and enlarged. In +pernicious forms they produce a sero-purulent oedema, which spreads +rapidly with a wave-like progress after the manner of erysipelas; or +in milder cases the progress of the disease-germs is arrested by the +lymphatic glands or the resistance offered by the tissues themselves, +and the ordinary circumscribed phlegmon is produced. By the lymphatics +which accompany the vessels of the Fallopian tubes they reach the +ovaries (puerperal ovaritis), and by the broad ligaments they pass to +subperitoneal tissues of the iliac and lumbar regions. Through the +same system they are conveyed to the great serous cavities of the +body. In the peritoneum they give rise, unless death occurs too +speedily, to pyaemic peritonitis, which, unlike the traumatic form, is +attended with but little pain, and for which the claim has been set up +that it is peculiar to puerperal fever. The wide stomata upon the +abdominal surface of the diaphragm allows the facile entrance of the +organisms into its lymphatics. Waldeyer found in diaphragmitis the +lymphatics of the diaphragm filled with bacteria. And thus, following +the lymphatic system, if we only admit that bacteria are the active +agents of sepsis, the frequency, in severe types of puerperal fever, +of inflammation of the serous membranes of the peritoneum, the +pleurae, the pericardium, the meninges, and the joints finds an easy +explanation. Nor is it altogether accident which determines in +different cases the precise serous membranes which are affected. The +widespread ramifications of the lymphatic system would naturally give +rise to eccentric inflammations in place of those following the +apparent continuity of tissues. + +The ductus thoracicus is the principal channel through which the +bacteria enter the blood. It is possible that they may further obtain +access into the circulation through the radicles which furnish the +communications between the capillaries and the lymphatics. We have +seen that bacteria are found with difficulty in the blood during life. +A few hours after death they swarm in that fluid. That they do, +however, enter the general circulation during life is incontestable. +Steurer writes: "As the kidneys are the great filters of the human +system, I never neglected to examine them, and almost invariably found +micrococci filling the arterioles and glomeruli." This is in +correspondence with what occurs in other septic diseases, and accounts +for the albuminuria and interstitial nephritis which often supervene +in the advanced stages. + +The action of the bacilli upon the blood differs materially from that +of the round bacteria. So soon as the latter come in contact with the +red corpuscles, the corpuscles stick together and form larger or +smaller clots in the blood. They then are no longer able to pass +through the minute {1001} capillary networks, but are arrested in the +larger or smaller vessels (Koch). The micrococci in the resulting +infarctions multiply, and migrate into the vessels and cellular tissue +of the neighborhood. Thus fresh foci of infection are formed. Or by +their destructive action they may, when situated near the serous +surfaces, penetrate into the serous cavities, and in this way +indirectly occasion peritonitis, pleurisy, meningitis, and purulent +inflammations of the joints. When the micrococci enter directly into +the circulation, they sometimes, in passing through the heart, adhere +to the endocardium and the valves, where they cause exudation and +ulceration, and give rise to the so-called endocarditis ulcerosa +puerperalis.[38] The red globules of the blood undergo changes of +shape, assume a stellate aspect, and rapidly disappear. The white +globules are greatly increased in numbers, and the blood itself +becomes nearly colorless. A certain amount of light is thrown upon +these blood-changes by Doleris, who added micrococci to the fresh +blood of a frog and watched the ensuing changes under the microscope. +The micrococci could be seen in the act of penetrating the red +globules, which thereupon lost their color and became shrunken, and, +following the discharge of the organisms, which meantime had +multiplied in an astonishing manner, little or nothing of the original +globules remained. + +[Footnote 38: Heiberg, _Die puerperalen und pyaemischen Processe_, +Leipzig, 1873, pp. 22 and 34, with references to cases reported by +Wiege and Eberth.] + +In the bacillar form of septicaemia the blood is dark and has a +semi-gelatinous appearance, compared by French writers to +partially-cooked gooseberry jelly. The red globules, though they +exhibit the various stages of deformation, are not diminished in +number. The disease is further characterized by ecchymoses and minute +apoplectic effusions, and by the absence of pus-formation. In the +artificial septicaemia produced by Koch in mice by means of bacilli +the rod-like organisms were found to enter the white corpuscles and to +compass their destruction. They did not cause the red globules to +adhere together, and there was no clogging of the capillary +circulation. All the principal structures of the animals subjected to +experiment were infiltrated with bacilli. The distribution of the +latter was apparently accomplished by the blood-vessels, and not by +the lymphatics, the bacilli probably effecting their entrance into the +vessels by virtue of their penetrative power, in place of traversing +preformed pathways. Possibly it is this action of the bacilli which +causes the weakening of the vessel-walls, as evidenced by the large +number of red corpuscles which pass out from them. + +In puerperal fever it is rare to find either round bacteria or bacilli +acting singly as the agent of infection. As a rule, both forms exist +together in varying proportions, the predominant form, however, +determining in general the character of the symptoms. + +Thrombosis of the veins may be a physiological phenomenon, or may be +due to an alteration of the blood, to weakness of the heart, or to +local influences. So long as the clot remains firm its influence is +limited to disturbances of the circulation. The pyaemic symptoms--viz. +suppuration of the coagulum, the separation of emboli, and the +formation of metastatic abscesses--are always dependent upon the +presence of round bacteria. In phlebitis the latter are found in the +endothelium and in the sheaths of the veins. The inflammation of the +veins is followed by {1002} thrombosis. According to Doleris, +micrococci derived from the blood are deposited upon the central +extremities of the clots; beyond these depots a fresh inflammation is +set up, followed by fibrinous coagulation. Thus the micrococci become +imprisoned between two plugs. The same process may be repeated until a +series of abscesses are formed. For a time no mischief may ensue. +Finally, however, the resistance of the outworks is overcome, an +embolus becomes detached, and an infectious abscess is opened into the +blood--an event which is announced by an intense chill and the +familiar systemic derangement. + +In septic diseases death takes place from apnoea, partly from the +inability of the blood-corpuscles to carry oxygen to the tissues, and +partly from paralysis of the nerve-centres.[39] + +[Footnote 39: Schuller, "Exp. Beitrage zur Studium der Septischen +Infection," _Deutsche Zeitschr. f. Chir._, vol. vi. p. 149 _et seq._] + +In hospital epidemics of puerperal fever diphtheritic patches situated +upon the lesions of the vulva and in the course of the utero-vaginal +canal are sometimes observed. Steurer found these patches were always +associated with loss of substance, and were composed of disintegrated +fibrin, white and red blood-globules, and colonies of round bacteria +in great abundance. Morphologically, these so-called diphtheritic +patches are identical with those which appear in the throat. +Pallen[40] has reported an instance of the simultaneous occurrence of +puerperal diphtheritis in the mother and throat diphtheritis in the +two-weeks' old child. In lying-in hospitals it is the genital organs, +as the locus resistentiae minoris, and not the throat, which are the +usual points of attack. + +[Footnote 40: _Trans. N.Y. Obst. Soc._, 1876-78, p. 78.] + +The question as to the extent to which erysipelas and puerperal fever +are cognate diseases is in a fair way to be solved by recent +investigation. Orth took the contents of a vesicle from an +erysipelatous patient which contained bacteria in great abundance, and +employed the same for injections under the skin of rabbits. In this +way he succeeded in producing in these animals a species of erysipelas +malignum. In the subcutaneous oedema and affected portions of the skin +he found enormous masses of bacteria, so far exceeding in quantity the +amount introduced as to prove an abundant new production.[41] Samuel +produced similar results by the injection of ordinary putrid fluids +containing round bacteria. An affection resembling simple erysipelas +he obtained most frequently by the application of fluid to a wound +torn open after the second or third day.[42] Lukomski found that +erysipelas could be produced by fluid containing micrococci even when +putrefaction did not exist. The contents of erysipelatous vesicles +containing no micrococci excited no morbid manifestations. Where the +erysipelatous process was fresh and progressing micrococci were found +in great abundance in the lymphatics and canalicular spaces. Where the +process was retrogressive, there were no micrococci to be found, even +in cases in which inflammation existed to an intense degree.[43] +Doleris submitted to the culture-process of Pasteur fluid obtained +from vesicles which developed in the course of facial erysipelas in a +man of forty years. Micrococci in chains were found in the liquids +employed identical with those he had discovered in puerperal fever. In +many cases I have seen an erysipelatous inflammation start from a +puerperal diphtheritic ulcer {1003} upon the introitus vaginae, and +extend outward over the buttocks, the thighs, and the lower portion of +the abdomen. + +[Footnote 41: "Untersuchungen uber Erysipel.," _Arch. fur exp. Pathol. +und Pharmakol._, Bd. i. S. 81.] + +[Footnote 42: _Arch. fur exp. Path. und Pharmak._, Bd. i. S. 335, u. +ff.] + +[Footnote 43: "Untersuchungen uber Erysipel.," _Virchow's Archiv_, Bd. +lx. S. 430.] + +Virchow[44] has so far given in his adhesion to the new school as to +say: "Especially in this connection are to be mentioned the +diphtheritic process and the erysipelatous, especially erysipelas +malignum. The granular deposit in diphtheritically affected tissues, +of which I formerly spoke, has more and more proven to be of a +parasitic character. What we formerly regarded as simple, organic +granules, as infiltration or exudation, has since proven to be a dense +aggregation of micro-organisms which penetrate into the tissues and +cells to compass their destruction." + +[Footnote 44: _Die Fortschritte der Krieg's Heilkunde_, Berlin, 1874.] + +Thus we find in surgical fever, in puerperal fever, in diphtheria, and +in erysipelas the presence of a common element which links them +together, and which establishes the relationship which has long been +recognized as existing between these various processes. + +4th. _The differences between surgical and puerperal septicaemia are +due to differences partly structural and partly physiological in the +wounded surfaces exposed to septic contamination._ + +A certain amount of misapprehension has arisen from the circumstance +that along with many coincidences in the symptoms of puerperal and +surgical fever there are observable differences which, from a purely +clinical point of view, would justify a separate classification of the +two affections. It will not do, however, to ignore the fact that the +conditions which prevail in the parturient canal subsequent to labor +have no strict analogue in the lesions which the surgeon is called +upon to treat, and that therefore a complete identity as to all the +clinical features of puerperal and surgical fever would hardly be +within the range of possibility. + +In the puerperal state it is necessary to take into account the +blood-changes induced by pregnancy, the effects of shock and +exhaustion in protracted labors, the frequency of hemorrhage, the deep +situation of puerperal wounds, the presence of clots, decidua, and +dead tissue in a state of disintegration or decomposition, the ease +with which deleterious matters are absorbed by the wide lymphatic +interspaces, the serous infiltration of the pelvic tissues, the +exaggerated size of the lymphatics and veins, and the proximity of the +peritoneal cavity. + +Samuel,[45] in speaking of the immunities and dispositions to septic +poisoning, says: "The statistical frequency of septic puerperal +disease is due to the length of the parturient canal, to the fact that +through this long passage there must pass all the pathological and +physiological excretions, and to the soiling of these parts with +fingers, instruments, and secretions which have become the bearers of +sepsis." He found, on the other hand, that it was extremely difficult +to produce a progressive ichorous condition by daily painting an open +stump with a septic fluid,[46] though the same was readily obtained +when an infinitesimal quantity of septic fluid was injected underneath +a fascia. + +[Footnote 45: "Ueber die Wirkung des Faulniss Process auf den lebenden +Organismus," _Arch. f. exp. Pathologie_, vol. i. p. 343.] + +[Footnote 46: _Loc. cit._, p. 339.] + +5th. _In the present state of our scientific knowledge it is necessary +to admit that there is a limited number of febrile and inflammatory +disturbances occurring in puerperal women, the bacterial origin of +which may be fairly questioned._ As illustrations of this class may be +{1004} mentioned: 1. Cases of catarrhal endometritis due to errors of +diet and exposure. Indeed, I have frequently, in hospital practice, +been able to trace severe cases of cellulitis, pelvic peritonitis, and +general peritonitis occurring in the winter season to the patient +getting out of bed dripping with perspiration, and clad only in a +night-dress, and going thus barefooted over a cold, uncarpeted floor +to the water-closet. 2. Cases of puerperal disorders proceeding from +emotional causes, the nervous system furnishing the first impulse to +the disturbed action. 3. Cases of excessive vulnerability in +non-pregnant women; individuals are sometimes found so susceptible +that a parametritis follows a simple application of the tincture of +iodine to the cervix. 4. Cases of pelvic peritonitis starting from old +intra-peritoneal adhesions. 5. Cases of peritonitis and +retro-peritoneal inflammations secondary to ulcerative processes in +the caecum or the descending colon. This condition is apt to be masked +during pregnancy, but starts into activity during childbed as a +consequence of fecal accumulation or of excessive purgation. + +It is by no means easy to decide as to the precise nature of local +inflammations following lacerations of the cervix and the bruising or +crushing of the soft parts in long or instrumental labors. The +marvellous absence of heat, pain, redness, and swelling in wounds +treated in strict accordance with the principles of Lister, the very +slight reaction when the atmosphere is pure, and the severity of these +symptoms in overcrowded hospitals, tend indeed to strengthen the +belief that even the simplest inflammations proceeding from wounds owe +their origin in great part to septic germs. But, on the other hand, in +hospital practice it is not uncommon to observe puerperal +inflammations and febrile conditions which possess this distinctive +peculiarity--that they in no wise visibly affect the health of +puerperal patients in their vicinity. The symptoms of blood-poisoning +too are either absent or present to a subordinate extent. Probably the +difficulty is best solved by assuming with Genzmer and Volkmann[47] +that there is such a thing as an aseptic surgical fever due to the +absorption of the products of physiological tissue-changes at the seat +of injury. In surgical cases, even where the precautions of Listerism +have been faultlessly observed, febrile movements of considerable +intensity, but of no prognostic signification, are of frequent +occurrence. While in puerperal women we can never exclude the +possibility of the septic infection of puerperal wounds, it is in +accordance with clinical experience to assume that a high fever +belonging to the aseptic class may coincide with a septic process of +insignificant proportions. + +[Footnote 47: Genzmer and Volkmann, "Ueber septisches und aseptisches +Wundfieber," _Samml. klin. Vortrage_, No. 121.] + +GENERAL SYMPTOMS.--As in other infectious diseases, there is, from the +time of the entry of the poison into the system up to the outbreak of +fever, a distinct period of incubation. The first febrile symptoms +usually occur within three days of the birth of the child. An attack +coming on a few hours after childbirth is indicative of infection +during or previous to labor. The third day is the one upon which +ordinarily the beginning of the fever is to be anticipated. After the +fifth day an attack is rare, and at the end of a week patients may be +regarded as having reached the point of safety. Apparent exceptions to +this rule are probably referable to cases of mild parametritis, in +which the initial {1005} fever and the pain were insufficient to +attract attention to the existence of local inflammation. + +The symptoms of puerperal fever vary with the character of the local +affections and with the extent to which the general system +participates in the disturbed action. The different groups of +puerperal processes possess the following pathognomonic symptoms--viz. +increased temperature, enlargement of the spleen, disturbed +involution, and sensitiveness of the uterus upon pressure (Braun). + +In most cases the fever is ushered in by chilly sensations or by a +well-defined chill. This symptom, however, does not possess much +prognostic importance. A chill is significant of a sudden change +between the temperature of the skin and that of the surrounding +medium. It may, therefore, be absent in pernicious forms of fever, +provided only that the temperature changes are inaugurated slowly, +whereas it may follow a trifling increase of the body-heat if, as +sometimes happens in sleep, the moist skin is exposed to cool currents +of air. Repeated chills indicate phlebitis and pyaemia. + +In order to grasp the many symptoms of puerperal fever, it is +necessary to keep separately in mind the clinical features of each of +the local processes, although in fact the latter rarely occur singly, +but to a greater or less extent in combination with others. + +The symptoms of ENDOMETRITIS AND ENDOCOLPITIS.--The uncomplicated +catarrhal inflammation of the uterus and vagina is the most frequent +and the mildest of the diseases of childbed. In endometritis the +uterus is large, flabby, and sensitive upon pressure; the after-pains +are often unusually severe, involution is retarded, and the lochia +become fetid, remain sanguinolent for a longer period than usual, and +at the outset may be temporarily suspended. Sometimes the large +intestine is distended with flatus. In endocolpitis the vaginal +discharge is thin and purulent, the patient experiences pain and +burning in the acts of defecation and urination, and, where the wounds +of the vulva and vagina assume an ulcerative character, there is often +found at the same time inflammatory oedema of the labia. + +The fever in these cases is ushered in frequently, but not always, by +chilly feelings, and the temperature reaches its height usually upon +the evening of the third or fourth day, is remittent, almost +intermittent in character, and rarely exceeds 102 degrees to 103 +degrees F. In mild forms the occurrence of the fever is often +overlooked or is referred to disturbance produced by the secretion of +the milk. In severer attacks the febrile symptoms may continue from +three to seven days. At the end of a week the swelling of the labia +subsides, the discharge becomes thick, and ulcers, if present, begin +to assume a healthy granulating appearance. + +In diphtheritic ulcerations, and in endometritis due to decomposing +remains of the ovum, the load condition is often complicated by the +invasion of the neighboring tissues. + +The symptoms of PARAMETRITIS and PERIMETRITIS (Pelvic +peritonitis[48]).--The symptoms of these two affections, as would be +naturally {1006} expected from the proximity of the peritoneum to the +pelvic connective tissue, for the most part overlap. It must be very +rare for one form to occur entirely independent of the other. For this +reason it will be found convenient to consider first the symptoms +common to both morbid processes, and subsequently to direct attention +to what are believed to be points of distinction between them. + +[Footnote 48: The following clinical history, together with the +statistical details, is borrowed in great part from the description of +Olshausen ("Ueber puerperale Parametritis und Perimetritis," +_Volkmann's Samml. klin. Vortr._, No. 28), the exactitude of which I +have had abundant opportunity to verify.] + +During the period of incubation there are usually no prodromic +symptoms. Elevations of temperature in the course of the first twelve +hours following labor are equally frequent under perfectly normal +conditions. Suspicious symptoms are disturbed sleep, excessively +painful after-pains, and a pulse of 80 to 90. + +The beginning of the fever occurs in 90 per cent. within the first +four days of childbed; most frequently upon the second or third day, +and taking place upon the fourth day in scarcely 12 to 15 per cent. of +the cases. If five days have elapsed without fever, the period of +danger, with very rare exceptions, may be regarded as having passed. + +At the outset the fever, especially in perimetritis, is ushered in by +chilly sensations or by an intense chill. The temperature rises +rapidly, though the highest point is usually not reached before the +second, and in rare cases not before the third, day. In most cases the +heat in the axilla exceeds 103 degrees, and may even mount up to 105 +degrees. The decline occurs gradually, the fever ending in 70 per +cent. in the course of a week, in 20 per cent. in two weeks, and only +in 10 per cent. extending beyond that period. Protracted cases +indicate abscess formation. + +The fever does not, however, always pursue a regular course. In place +of progressively declining until the termination is reached, the high +temperature of the second day may be attained upon one or more +occasions. The morning remissions are at first slight, but become +marked as the disease approaches its close. In cases of long duration +the morning hours are often free from fever, a circumstance calculated +to mislead a physician who sees his patient but once a day. A pulse of +80 to 90 beats, a disturbed sleep, lack of appetite, and sensitiveness +to pressure upon the sides of the uterus are, however, symptoms which +should serve as a warning of some disturbing cause, and should lead +the physician to renew his visit in the latter part of the day. + +If, from a mistaken notion that the morbid process has come to an end, +the patient is allowed prematurely to resume her household duties, the +pains across the abdomen and along the hip and thigh return, and an +examination reveals the existence of exudation in the pelvic cavity or +upon an iliac fossa. + +Errors of this kind are most frequent in cases of parametritis +associated with slight peritoneal inflammation, as the local pain is +then insignificant, and the initial chill, happening on the third or +fourth day, is apt to be ascribed to engorgement of the breasts. + +Relapses after the complete disappearance of febrile disturbance occur +in 15 to 20 per cent. They are usually shorter, but sometimes more +obstinate, than the original attack. As a rare exception may be +mentioned cases with evening remissions and morning exacerbations. + +In circumscribed pelvic inflammations the pulse rarely exceeds 120 +beats to the minute. A pulse of 140, of more than half a day's +duration, betokens severe septic complications, and is therefore of +evil omen. In {1007} some cases the slow pulse observed after labor +makes its influence felt in the first day or two of the fever, so that +the curious phenomenon may be witnessed of a temperature of 104 +degrees coinciding for a time with a pulse ranging between 50 and 70 +beats to the minute. + +As regards other symptoms, headache and sleeplessness are rarely +absent. Profuse sweating follows the first febrile attack, and +frequently recurs during the course of the disease. + +Pain is present at the onset in the majority of cases, and is then +usually most violent. The spontaneous pain, which is due to the +affection of the peritoneum, subsides in great part in the course of +one or two days, but the sides of the uterus remain sensitive to +pressure. In the rare cases of pure parametritis, however, this +symptom may be absent altogether. The pain, like that from the +inflammation of serous membranes, is of a lancinating character. +Sometimes it is associated only with the contractions of the uterus. +After-pains occurring under unusual circumstances, as in primiparae or +after the third day, are to be regarded with suspicion. + +Vomiting occurs occasionally, but is comparatively rare unless the +peritonitis becomes diffused and spreads to the region of the stomach. +The appetite is lost, and only returns, as a rule, with the departure +of the fever. The tongue is coated and moist, and constipation is +common. In other cases there is diarrhoea with rumbling in the bowels, +but without pain or tenesmus. The urinary secretion is rarely +interfered with, and when this is the case it indicates the extension +of the inflammation to the peritoneum covering the bladder. + +Most cases of perimetritis and parametritis terminate in five or ten +days, the fever and other symptoms gradually subsiding. When, as may +happen in exceptional instances, the temperature falls suddenly from a +high degree to one below the normal level, the body grows icy cold, +the pulse becomes small and irregular, and symptoms of collapse +develop. But in twelve to twenty-four hours the symptoms of collapse +subside, and the disease reaches its end with a disappearance of the +alarming manifestations. + +If the fever subsides within a week exudation is somewhat rare. Its +continuance beyond that date should lead to a careful exploration of +the pelvic organs. The exudation is usually demonstrable in the course +of the second week or at the beginning of the third week. It is +recognized, according to its location, by external or by internal +examination, or, where the deposit is considerable, by both methods. +In most cases the deposit is extra-peritoneal, and is situated between +the folds of the broad ligament, above and to the sides of the vaginal +cul-de-sac. It has generally a rounded form, though with less +convexity than fibrous and ovarian tumors. Sometimes, however, the +tumor is flat below, like a board. It seldom exceeds in size that of a +large apple. In fresh exudations the sensation produced is often that +of a hard tumor surrounded by a softer layer, due to continued +succulence of the soft parts. In a few weeks they may reach or exceed +the hardness of a fibroid tumor. The older the tumor, unless +suppuration sets in, the less sensitive it becomes. Often the +exudation extends to the pelvic walls. The uterus, as a rule, is +fixed, and in cases of large tumors becomes pushed toward the opposite +side, while as a consequence of later shrinkage the fundus may be +drawn permanently toward the affected side. + +{1008} The cul-de-sac of the vagina is rendered broader and flatter by +the pressure of the deposit, or, when the tumor is deep enough, the +vaginal surface may be rendered convex. Behind the uterus the +exudation is as it were flattened antero-posteriorly, and in some +cases it may be felt in the form of rigid bands between the posterior +ligaments which enclose the cul-de-sac of Douglas. The ante-uterine +tumors have a spherical shape and depress the vagina anteriorly. + +Tumors situated in the iliac fossa have a more or less convex form, +and may be of such considerable size that the swelling may be +recognized by the eye through the abdominal walls. As the exudation +between the broad ligaments may in these cases have been slight from +the beginning, or may have subsequently disappeared by absorption, the +iliac tumors have often apparently a spontaneous origin. + +Sometimes the uterus is surrounded by exudation, and the entire pelvis +appears as though it were a mould filled with a solid mass. The fornix +is then often pressed downward, and irregular rounded masses are to be +felt through the vaginal walls. + +The recognition of parametritic tumors through the abdominal coverings +is possible when they are situated above Poupart's ligament, in the +upper portion of the broad ligaments, and in the iliac fossae. + +The pain and the functional disturbances in the pelvic organs depend +upon the size and situation of these inflammatory deposits. Of the +functional troubles may be mentioned frequent and painful micturition, +obstinate constipation and difficult defecation, contractures of the +ilio-psoas muscles when the exudation is seated beneath the sheath or +between the muscle and the pelvic bones, disturbances of motility in +the abductor muscles, paresis of the lower extremities, and radiating +pains in the upper portion of the thigh and in the renal and lumbar +regions, produced by pressure upon the obturator, the crural, the +cutaneous, and the sciatic nerves. + +So long as fever is present the exudation rarely diminishes. If +absorption takes place in one point, growth almost certainly follows +in some other direction. When, however, the apyretic period is +reached, the exudation, as a rule, disappears rapidly, so that often +in the course of six weeks no trace of its existence remains. In a +smaller number the solid mass may persist for months or even years. + +After the fever has departed the patient usually feels well. The sleep +and appetite return, the night-sweats disappear, the pulse often falls +to 50 or 60 beats, and the temperature is in many cases for a time +subnormal in character. + +Where the fever persists for from five to six weeks there is always a +suspicion of abscess formation. With the exception of afternoon fever +and night-sweats the patient may feel very comfortable. Then the +exudation becomes sensitive, the spontaneous pains recur, sleep is +lost, and locomotion, defecation, and urination occasion acute +suffering. The fever becomes violent, chills announce the presence of +pus, and finally, about the seventieth or eightieth day, perforation +of the abscess takes place. The usual seat at which the pus is +discharged is just above Poupart's ligament; next in frequency +perforation takes place into the colon, and in rare instances into the +bladder, the uterus, and vagina. Fortunately, of very rare occurrence +is the discharge of pus into the peritoneal cavity, which is {1009} +naturally followed by acute peritonitis. Another likewise unfrequent +but most dangerous accident is the septic infection of the abscess--an +occurrence referred to by Olshausen to the diffusion of intestinal +gases through the walls of the tumor. + +In suppuration of parametritic exudations the pus commonly forms in +small scattered collections, and rarely gives rise to large abscesses. + +Although parametritis and perimetritis are usually found associated +together, there are always cases in which the one form of inflammation +so far predominates over the other as to justify an attempt to +establish a clinical distinction between them. + +In the beginning of the attack, sharp pain, high fever, and tympanitic +distension of the lower abdomen are symptomatic of inflammation in the +pelvic peritoneum. Whether the cellular tissue is simultaneously +implicated can only be determined by a digital examination after the +abdominal sensitiveness has subsided. The absence of the objective +signs of cellulitis would then contribute to prove that the case had +been one in which the peritoneum had been in the main affected. On the +other hand, moderate fever, pain elicited only on pressure, and +tympanitic distension confined to the colon, coinciding with exudation +between the folds of the broad ligament, would be indicative of a +nearly pure cellulitis. + +A palpable exudation is by no means the necessary product of +peritoneal inflammation. Indeed, in many cases, the distinctive +symptoms of the latter may be present for from four to eight days, and +may then subside without leaving a trace of its existence at the +pelvic brim. + +The demonstration of a fluid effusion by noting the change of level +upon shifting the position of the patient is rarely possible, either +because the quantity is too small or because it quickly becomes +confined by pseudo-membranous adhesions between the intestines. + +Bandl[49] mentions as a sign of local peritonitis, sometimes +noticeable, a number of resistant points or tumors near the pelvic +brim or above one of the iliac fossae, due to a matting together of +the intestines or to their adhesion to the uterine appendages. They +are distinguished from solid tumors by their emitting a tympanitic +sound upon percussion and by their changing position in consequence of +an accumulation of urine in the bladder or of feces or gases in the +bowels. Again, all tumors may be reckoned as intra-peritoneal which +very rapidly form behind or to the side of the uterus from enclosed +exudation-products, and which at the same time rise far above the +level of the pelvic brim. If, however, they start from the cul-de-sac +of Douglas, and do not much exceed the linea terminalis, or if they +occupy an iliac fossa, it becomes very difficult to decide whether +they are of intra- or extra-peritoneal origin. The peritoneal +exudation, however, long remains soft and fluctuating. It arises, as a +rule, behind the uterus, and does not exhibit a tendency to spread to +the sides or to the anterior or posterior pelvic walls. + +[Footnote 49: _Handbuch der Frauenkrankheiten_, red. Von Billroth, 5te +Abschnitt, p. --.] + +Still more difficult is it to decide as to the seat of exudations met +with beneath the abdominal walls. When diffused and continuous with a +pelvic deposit the diagnosis is uncertain. It is only safe to assume +the peritoneal origin of extravasations of a rounded form, of a +fluctuating consistence, and when they are situated high up and are +disconnected from exudation at the pelvic brim. An opening of the +abscess through the {1010} navel would indicate a peritoneal source, +while the discharge through the abdominal parietes would point to a +seat in the connective tissue. + +After the perforation of an abscess the fever and pain subside; the +wound, if external, either closes in the course of one or two weeks, +or fistulas form which become the source of protracted suppuration. + +In psoas abscesses the exudation extends beneath the sheath of the +muscle or between the iliacus and the bone. In puerperal patients they +proceed from an inflammation originating in the broad ligament. They +are situated too deep to be easily palpated. The pains they occasion +are referred rather to the hip or knee than to the abdomen. The +contracture of the psoas muscle furnishes a diagnostic sign which +distinguishes this form from the superficial abscesses of the iliac +fossae. The pus eventually is discharged beneath Poupart's ligament, +in the lower portion of the inguinal fossa, at some point upon the +crest of the ilium, or exceptionally along the thigh. Often the +discharge is maintained for months. + +The symptoms of GENERAL PERITONITIS.--This form generally begins with +the usual symptoms of pelvic inflammation, but the tenderness, which +at first was limited to the side of the uterus, gradually spreads over +the entire abdomen. The abdominal pain is of a tearing, lancinating, +sometimes colicky character. It is increased by the slightest bodily +movement, by jarring of the bed, or even by the weight of the +bed-clothes. + +As a consequence of the peritoneal inflammation and of the +accompanying exudation, the muscular walls of the bowels become +paralyzed, and tympanitic distension results from the accumulation of +gases. In the dependent portions of the peritoneal cavity it is often +possible to demonstrate by percussion the presence of fluid exudation, +though distinct fluctuation is rarely to be made out. The size of the +abdomen is due much more to the tympanites than to the amount of +effusion. Sometimes the liver, with the diaphragm, is pushed by the +swollen bowels to the level of the fourth or third rib, and exercises +such a degree of compression upon the posterior portion of the lungs +as to place the patient in danger of suffocation. The respirations are +jerky and attended with a moaning sound. + +The loss of muscular power in the intestines permits the contents of +the middle portion to pass unchecked toward the duodenum, and thence, +upon accidental contractions of the abdomen, they may pass to the +stomach and be ejected by vomiting. The first vomited matter has a +dark-green color, and that ejected afterward presents the color of +intestinal matter. Constipation at the outset may be subsequently +followed by colliquative diarrhoea. + +The fever begins, as a rule, though not always, with an intense chill, +the temperature rises to 104 degrees, and the pulse becomes small, +hard, and resistant. Its frequency rapidly increases, varying from 120 +to 160 beats to the minute. The skin is sometimes dry, sometimes +dripping with perspiration. In fatal cases, as the end approaches, the +temperature frequently falls, while the pulse becomes more rapid, the +face assumes a pinched, anxious expression, sweat gathers upon the +forehead, the extremities grow icy cold, and the patient dies in +collapse. The duration of peritonitis averages not more than from four +to six days. + +In cases of recovery the pulse improves, the vomiting ceases, and the +tympanites disappears. The diffuse exudation then becomes converted +{1011} into circumscribed tumors, which on palpation are felt on the +side of the pelvis and extending upward to the level of the umbilicus. +Upon internal examination the uterus is often found depressed by the +weight of the fluid, which likewise may bulge the cul-de-sac of +Douglas into the pelvic cavity. Sometimes the exudation may become +encysted above the pelvis and leave the contents of the latter free. +In still other cases the uterus may become attached high up to the +abdominal walls, so that the vaginal portion disappears and the os is +reached with difficulty. + +The peritoneal exudation may, as in pelvic inflammations, become +absorbed and disappear. When, however, it is surrounded by loops of +intestines it is apt to undergo purulent and septic changes, and the +abscesses may then become discolored and filled with stinking gases. +The patient, whose previous improvement has been watched with delight, +now loses appetite, the pulse becomes frequent, the strength fails, +and death may follow from septic fever or from rupture of abscess into +the abdominal cavity. + +In the pyaemic form--a still more deadly variety of peritonitis--the +symptoms differ materially from those which have been recounted. As, +however, it constitutes only a single one of the pathological changes +connected with the poisoning of the blood through the lymphatic +system, its consideration belongs properly to the study of the septic +infection. + +The symptoms of SEPTICAEMIA LYMPHATICA.--The symptoms of +blood-poisoning in the infectious diseases of childbed vary to a +considerable extent according to the channel through which the septic +germs enter the general circulation. In the murderous epidemics which +prevail in lying-in hospitals the lymphatics are, as a rule, the +vessels primarily invaded. It is to this form that the cases already +described belong, where, with diphtheritic patches upon the +utero-vaginal canal and sero-purulent oedema of the parametrium, there +are associated pyaemic peritonitis and deformation of the +blood-corpuscles; or where, following the migrations of the round +bacteria, the serous cavities become successively involved, septic +vegetations gather upon the heart, and the glomeruli of the kidneys +become choked with micrococci. The lymphatic form of septicaemia +develops soon after labor, and is always ushered in by a chill. The +temperature rises to 104 degrees or even higher, and the pulse is thin +and frequent. The abdomen swells rapidly, without being especially +painful. Indeed, painless distension of the intestines is one of the +characteristics of an acute invasion of the lymphatics. Peritoneal +effusion is absent in cases which run a rapid course, and is +distinctly recognizable only in a peritonitis of long continuance. The +effusion is not so much due to exudation as to a transudation of serum +with which micrococci are commingled. At the same time the tongue is +moist, but slightly coated, and at times quite clean. Sometimes there +is diarrhoea due to catarrh or to a diphtheritic affection of the +colon. When the bowels have been constipated the administration of a +purgative may provoke discharges which it may be found difficult to +arrest. The skin is bathed in perspiration. At the beginning and +during the course of the disease bleeding at the nose is of not +infrequent occurrence. + +Toward the end the pulse runs up to 140 to 160 beats, while in many +cases the temperature falls. Immediately after death the heat of the +body may for a short time exceed the highest point reached during +life. The {1012} respirations are superficial and jerky. In many +instances the face, the neck, and the fingers are blue from defective +oxygenation of the blood. At the same time the skin becomes clammy and +the extremities cold. + +The sensorium, in cases which run a rapid course, is usually affected +at an early period. The patients appear somnolent, are restless in +bed, have light delirium, and respond only when spoken to loudly. As a +rule, they make but little complaint, and, were it not for the +dyspnoea, would have nothing to disturb their sense of comfort. Very +few, even as death approaches, have any idea of the danger that +threatens them. Now and then, in place of stupor, great restlessness, +and even a maniacal condition, is developed. Albumen is usually found +in the urine. + +Pleurisy, so frequently associated with lymphatic septicaemia, is +frequently double, more rarely single, and begins, as a rule, with +sharp pain in the side and an aggravation of the previous dyspnoea. +Pericarditis is less frequent, and occurs usually without symptoms +toward the close of life. The joint affections are characterized by +redness and swelling, and by pain, which is sometimes so great that +touching the inflamed part suffices to arouse the patient from sopor. +Sometimes fluctuation is felt, but death occurs before perforation and +discharge of the pus. + +The most frequent ending is death, which follows in from two to +twenty-one days, and, as a rule, between four and seven days. Recovery +is, however, possible. + +The symptoms of SEPTICAEMIA VENOSA (phlebitis uterina, pyaemia +metastatica).--The putrid infection of a thrombus at the placental +site may take place within twenty-four to forty-eight hours after +labor. Usually, however, the approach is insidious, and the disease +develops from an apparently insignificant endometritis or +parametritis; or the patient, with the exception perhaps of a tired +feeling, of slight chilly sensations, and of profuse perspiration, may +not have been conscious of any indisposition for days preceding the +attack, or even until the first getting up from childbed. The initial +chill in typical cases is characterized by its violence and duration. +In some cases it may last for hours. It is accompanied and followed by +high temperature, the febrile attack ending with profuse perspiration +as in intermittent fever, with which it is apt to be confounded. The +fall in temperature often assumes the form of a prolonged remission. + +In many cases the pulse rises and falls with the variations in the +body heat, while in others it remains permanently above the average. A +frequent pulse is always a suspicious symptom in childbed, even where +the other symptoms are apparently normal. + +Erratic chills announce the lodgment of emboli in distant organs. With +the formation of metastatic abscesses in the lungs and other +parenchymatous organs the typical character of the disease changes. In +place of chills occurring at irregular intervals, followed by +remissions and periods of apparent improvement, the fever is +continuous, the pulse becomes small and rapid, while sopor, slight +delirium, a dry skin, a dry, brown, cracked tongue, and a moderately +tympanitic abdomen, give the case the appearance of one of typhus +fever. + +Peritonitis is present in hardly one-third of the cases. The abdomen +is therefore flat and soft, and often is not sensitive upon pressure. +Icterus, due to disintegration of the blood-corpuscles, is an ominous +symptom. + +Death usually occurs in the second or third week. In the {1013} +typhus-like cases, however, it may follow the first attack speedily. +Recovery is possible where the organs secondarily affected are not of +too great importance. + +A combination of the lymphatic and venous forms of septicaemia is not +uncommon in cases running a protracted course. + +The symptoms of PURE SEPTICAEMIA.--Under the title of pure septicaemia +should be placed cases in which the absorption of putrid materials +into the blood gives rise to symptoms of intense blood-poisoning +without the development of local lesions. A common example of this +form is met with in the fever which results from the presence in the +uterus of decomposing coagula or portions of retained ovum, the fever +subsiding with the removal of the disturbing cause. In like manner we +sometimes meet with cases of intense septic poisoning followed by +speedy death, in which the post-mortem examination reveals only +changes in the blood and softening of the parenchymatous organs. The +symptoms are often similar to those produced by the injection of +putrid materials containing rod-like bacteria into the vessels of +animals. As the long bacteria do not possess the capacity of +self-reproduction in the blood, to produce fatal results the quantity +of putrid fluid injected must be large or be frequently repeated. This +form is said not to be inoculable. + +CAUSES.--The effects of a poisoned state of the atmosphere as a cause +of puerperal fever is best observed in the so-called nosocomial +malaria of hospitals. In days gone by, before I had learned by +experience that the safe conduct of a lying-in service depends upon +the fastidious exclusion of every source of contamination, I had +frequent occasion to witness febrile outbreaks among puerperal women +in the Bellevue Hospital, which were instantly arrested by the simple +transfer of the inmates of the affected ward to a wholesome locality, +though no changes were simultaneously made in either the personnel or +the utensils of the service. In these instances it seems fair to +assume that the previous unhealthy condition was not due to the direct +transfer of an inoculable matter from patient to patient by the +attendants, but by something residing in the air of the vacated +apartment. In the inquiry as to the production of this condition it +can be assumed that it is not caused by aggregation alone. The medical +wards of Bellevue, always crowded, have often furnished in times of +need safe receptacles for puerperal patients. It is certainly not due +to the presence of the ordinary constituents of the atmosphere. We +must therefore look for some additional element capable of unfavorably +affecting the economy. What this element really is, is demonstrated by +a familiar clinical experience. When the disturbance produced by +nosocomial malaria is not at an early stage arrested by change of +locality, the secretions of patients affected become inoculable. Then +the epidemic spreads rapidly, and assumes continuously a more and more +severe type. If during an epidemic the external genitals be carefully +watched, now and then diphtheritic patches will be noticed to form +upon them. At first these patches may disappear or yield readily to +treatment. When an epidemic has assumed a pestilential form the +patches, which may in isolated cases make their appearance at any time +in a hospital, are rarely absent in fatal cases. The composition of +the patches tells the tale of what it is in the atmosphere which +accomplishes the charnel-house work. Favoring conditions have led to +the multiplication of disease-germs {1014} in the air, and have fitted +them to become the active producers of disease. + +In a patient dying in the early stages of an epidemic there may be no +diphtheritic manifestations, though the tissues and secretions are +filled with bacteria. As, however, the epidemic gains headway, the +lesions of the generative apparatus, and especially of the external +organs, which are most exposed to air, become covered with patches +which swarm with micrococci. Under the conditions named it is +certainly more in accord with ordinary scientific reasoning to +conclude that the micrococci play an important part in the production +of puerperal fever than that the puerperal fever produces the +micrococci. + +To be sure, bacteria or their spores are always present in the air, +and it may be fairly asked how patients are ever spared from their +perverse industry. The answer is, that the effect produced by the +atmosphere of a hospital is dependent partly upon the quantity, and +partly upon the quality, of the suspended germs. Floating spores, when +sparsely distributed, rarely possess the power of invading a healthy +organism. In the inauguration of an epidemic the first patient +severely attacked is usually one whose powers of resistance are broken +down by prolonged labor, by hemorrhage, by poverty, or some other +condition leading to impaired vitality. + +Puerperal-fever epidemics due to contamination of the atmosphere, and +not to direct contagion, do not at once reach the maximum of +intensity. At first the temperature tables indicate the prevalence of +milk fever; next follow cases closely resembling those of mild paludal +poisoning; and, finally, if these warnings are unheeded and reliance +is placed upon antiperiodic remedies rather than upon prompt closure +of the threatened ward, the pestilence develops. In the conduct of +lying-in hospitals it should never be forgotten that with the +multiplication of the septic germs the danger increases. + +At the same time, the quality of the agents which pervade the air +where hospital patients are confined is an important element in the +genesis of febrile outbreaks. The bacterium termo, which causes +putrefaction, is not in itself, as we have already mentioned, a source +of danger. A stinking odor is not necessarily incompatible with a low +mortality-rate. The importance of the common forms of bacteria, +according to Pasteur, results from the fact that by their power to +consume oxygen they pave the way for the active development of the +pernicious germs, nearly all of which thrive only in media in which +that element has been materially diminished. Again, there is reason to +believe that the same germs are not[50] always equally active for +evil. Gravitz claims that the ordinary varieties of aspergillus and +penicillium found everywhere on the surface of the ground, on +moistened walls, on food of every variety, on decaying leaves and +fruit, and whose spores are universally present in the purest air, can +by a succession of cultures be gradually brought to flourish in a warm +alkaline fluid, and that they then acquire the capacity to penetrate +living tissues, to proliferate in them, to excite local necroses, and +to cause death in the course of three days. The resistance of +micrococci to carbolic and salicylic acids is found experimentally to +depend in a measure upon the {1015} nature of the vehicle in which +they are cultivated (Buchholz). The action of septic fluids varies too +with the age of the infusions, with the materials employed, and with +the conditions under which the poison-germs are generated. + +[Footnote 50: Gravitz, "Ueber Schimmel vegetationen im thierischen +organismus," _Virch. Arch._, vol. lxxxi, p. 355.] + +Micrococci multiply in hospitals when organic materials favorable to +their growth are present in sufficient quantities. Perrin, Quenquand +and others have shown that the hospital wards in Paris, especially +those upon the surgical and maternity divisions, contain an infinite +number of vibrios, bacteria, and all the coccus forms (Charpentier). +Robin[51] has demonstrated the existence of albuminoid matters in +water condensed upon vessels containing freezing mixtures and placed +in overcrowded wards of hospitals. When the results of crowding become +manifest, these albuminoid matters not only impart a fetid odor and +putrefy with great rapidity, but rapidly impart putrefaction to +healthy muscle and normal blood with which they are brought into +contact. Pasteur was able by the microscopic examination of the lochia +from patients in the services of Hervieux and Lucas-Champonniere to +predict, from the character of the contained organisms, an impending +attack of fever in advance of the slightest symptom betokening danger. + +[Footnote 51: _Lecons sur les Humeurs_, Paris, 1867, p. 195.] + +It is unquestionably the lochial discharge which makes it such a +difficult task to keep a maternity ward in a healthful condition. +Putrid blood has been found to be the most favorable material for +septic experiments. It was noticeable in Bellevue Hospital that +febrile outbreaks always arose in, and were usually confined to, the +ward in the hospital which, by a bad arrangement, was assigned to +patients for the first four or five days following confinement--_i.e._ +during the period of the lochia cruenta. As puerperal fever is rare +after the fifth day, this at first sight would seem natural. But if a +patient was transferred directly after confinement, during one of +these unhealthy periods, to the ward containing the patients who had +passed the first five days, but had not completed the ten days, she +would escape the fever. It was always the same ward that required to +be disinfected. In a communicating apartment all the confinements took +place, and at all times, therefore, the conditions were present for +loading the atmosphere with the products of decomposing blood. In the +summer months, so long as the windows were open and the air was +diluted by the continuous passage of fresh currents, the patients +enjoyed immunity from nosocomial malaria. In the autumn, so soon as it +became necessary to close the windows partially on account of the cool +nights, it was not uncommon for the more trivial disturbances, such as +so-called milk fever, the hospital pulse, and catarrhal affections of +the genitalia, to manifest themselves. Through the months of February, +March, and April the mortality was usually greatest. During the winter +months there was, as a rule, crowding of patients, insufficient +ventilation, stagnation of the air, and the rapid accumulation of +disease-germs. That the later winter months should prove the most +perilous is in accordance not only with the theory of continuous +accumulation, but with the experimental fact that weeks sometimes +elapse before a decomposing substance acquires the highest degree of +virulence. + +Apart from the nosocomial malaria of hospitals, there is reason to +believe in the influence at times of certain general widespread +atmospheric {1016} states which affect the entire community. In the +year 1871 the mortality from childbed in New York was 399; in 1872, +503; in 1873, 431; in 1874, 439; and in 1875, 420. Now, the excess in +the deaths for 1872 was due wholly to an increase in the cases of +metria, those from ordinary accidents remaining nearly the same as in +the preceding years. The disease certainly did not extend into the +city from the hospitals serving as foci, for the mortality at Bellevue +Hospital was hardly more than half the usual average. There was no +especial mortality that year from either diphtheria, erysipelas, or +scarlatina, but the aggregate mortality was the largest known in the +history of the city. There are no positive data connecting the civil +deaths from puerperal fever in 1872 with parasiticism, but the +prevalence of epizootics, of epidemic catarrhal affections, of +peculiarly fatal forms of pneumonia and other diseases which are now +attributed to the presence of minute organisms in the atmosphere, +renders such a source highly probable. + +It is proper to say here that, though the argument is very strong in +favor of regarding the genitalia of puerperal women as the exclusive +point of entry of infectious materials into the system, it seems +impossible at the present time to make all the facts coincide with +such a theory. I have the records of a number of cases occurring +during an epidemic of puerperal fever in which patients were either +attacked with fever previous to parturition, or in whose cases the +unusual length of labor, the frequency of post-partum hemorrhage, and +the imperfect contraction of the uterus immediately after confinement +were signs of some abnormal influence exercised upon the economy at an +early period of labor previous to the existence of traumatism. That +deleterious materials may find other channels for entering the system +than a wounded surface is evidenced by the cachectic condition not +unfrequently produced in physicians by too assiduous attendance in +dissecting-rooms and places in which _post-mortem_ examinations are +conducted. One severe and rapidly fatal case of puerperal fever which +occurred in Bellevue Hospital I find it impossible to attribute to any +other cause than that the woman for five months previous to her +confinement served as a helper in a lying-in ward. The post-mortem +examination disclosed no special local lesions, but her symptoms were +those of intense septicaemia. French writers report instances of +toxaemic conditions developing in young midwives during +puerperal-fever epidemics. While we are not prepared to go as far as +Tarnier, who says, "It is probable that the lungs, by their extent and +activity, offer conditions most favorable to absorption, and that +often, if not always, it is by them that poisoning occurs," it does +not yet seem time to give up the idea that under exceptional +circumstances the respiratory and the digestive tracts may allow the +passage of materials of a septic character. + +Another and frequent source of puerperal fever is by direct +inoculation. Any material of a septic character, introduced into the +genital passages of a woman during or after confinement, may produce a +general infection of the system. But the point upon which I wish +especially to dwell is that it is possible to trace epidemics of +puerperal fever directly to the carrying of puerperal poison from +patient to patient through the medium of attendants. In such cases +changes in wards and the most rigid sanitary precautions avail but +little, so long as the affected personnel is continued {1017} in +charge. Unless this fact is fully recognized, all the cleverest +devices in hospital construction will fail to prevent the occurrence +of disasters. In theory, the doctrine of the contagiousness of +puerperal fever has ceased to be the subject of dispute; and yet no +longer than thirty years ago it was combated as a pernicious heresy by +both Meigs and Hodge of Philadelphia, at that time regarded as the +best authorities upon obstetrical questions in this country. Hodge, +addressing his students, said: "The result of the whole discussion +will, I trust, serve not only to exalt your views of the value and +dignity of our profession, but to divest your minds of the +overpowering dread that you can ever become, especially in women under +the extremely interesting circumstances of gestation and parturition, +the ministers of evil--that you can ever convey, in any possible +manner, a horrible virus so destructive in its effects and so +mysterious in its operations as that attributed to puerperal fever;" +and Meigs, in his letters to students, writes: "I prefer to attribute +them to accident or to Providence, of which I can form a conception, +rather than to a contagion of which I cannot form any clear idea, at +least as to this particular malady." Contrasted with these rhetorical +utterances, in an essay published in 1843 by Prof. Oliver Wendell +Holmes, entitled _Puerperal Fever as a Private Pestilence_, the +opposing testimony in favor of contagion was presented with equal +literary and scientific skill. The evidence was complete and +conclusive, and has exercised a most beneficial influence upon the +practice of midwifery in America. With his many claims to our +admiration and esteem there is probably no title which Prof. Holmes +wears with greater pride than that of pioneer in a movement that has +done so much to prevent the slaughter of innocent women and the +wrecking of happy homes. + +Thanks to changed theoretical views, physicians seem now rarely to be +the carriers of contagion. At least, in studying the records of New +York City for nine years, I find that the occurrence of two deaths +from puerperal disease, following one another so closely as to lead to +the suspicion of inoculation, occurred to thirty physicians; a +sequence of three cases occurred in the practice of three physicians: +one physician lost three cases, and afterward two, in succession; one +physician had once two deaths, once three deaths, and twice four +deaths, following one another; finally, a physician reported once a +loss of two cases near together, then of six patients in six months +and then of six patients in six weeks. Thus in the practice of more +than twelve hundred physicians in nine years I find, excluding cases +occurring in hospitals, that the experience of thirty-six only lends +color to the idea that puerperal fever is due to criminal neglect on +the part of the medical profession. Undoubtedly in many of these +cases, too, the responsibility is only apparent, as when a +practitioner has, for example, had the misfortune to lose in one week +a woman from puerperal convulsions, and another in the following week +from placental hemorrhage. Singularly enough, not one of the sequences +mentioned occurred in the practice of a physician connected with a +lying-in hospital. In face of the charge that the physicians holding +obstetrical appointments in public institutions are active +disseminators of puerperal fever through populous communities, I find +that the total loss from all puerperal causes, occurring in the +private practice of ten physicians intimately associated with such +institutions, numbered during the nine years but twenty-one cases. Of +these, thirteen were the result of ordinary {1018} accidents, and only +eight cases of metria proper, of which one was developed before the +physician was called in attendance; whereas a single physician, +holding no hospital appointment, lost during the same time +twenty-seven cases, of which twenty-one were cases of metria. + +There is, however, a survival of the older ideas, chiefly to be seen +among the laity, in propositions to secure absolute immunity from +puerperal fever in hospital patients by confining them in wooden +structures or by conducting births under carbolic acid spray. + +I have been interested in endeavoring to ascertain how far experience +corresponds with Semmelweis's original theory that puerperal fever +owes its origin to poisonous materials obtained from dissecting-rooms +and introduced into the genital canal by the hands of physicians +attending cases of labor. With this view I have made personal +application to a number of gentlemen who have engaged in midwifery +practice while performing the functions of demonstrators of anatomy in +our medical schools. H. B. Sands, of the College of Physicians and +Surgeons, reports that in the five years during which he held the +office of demonstrator he attended about sixty cases of labor. All did +well. He lost his first patient, from childbed, a short time after he +had resigned his position in the dissecting-room. J. W. Wright, the +present professor of surgery in the Medical Department of the New York +University, who held for one year the position of demonstrator in the +Woman's College, writes me that "during the year I attended one +hundred and four cases, including twenty-two forceps cases, two of +craniotomy, two of podalic version, and four of breech presentation. +Of this number I lost two cases, one from phlegmasia dolens +complicating uraemia, from both of which troubles the patient had +suffered during her previous labor, and one from double pneumonia, the +result of unusual exposure following confinement. Out of these one +hundred and four cases I can recall but three or four cases of +metritis, and those of a mild character; I have never thought they had +any special connection with my duties in the dissecting-room. I may +add that for ten years I have attended a pretty large number of +confinements each year, and that during the whole of this time I have +been in the habit of making autopsies as occasion has offered, and of +handling and examining pathological specimens both in and out of the +dissecting-room, notwithstanding which my death-record among this +class of cases has been unusually low." Samuel B. Ward, formerly +demonstrator at the Woman's College, at present professor of surgery +in the Medical School at Albany, writes: "While I was daily in the +dissecting-room during the winter sessions of the school from 1868 to +1872, I attended thirty-two confinements, of which I have notes. All +of the patients recovered, nor did any of them suffer from any +complication that could be traced to infection." It is familiarly +known that after Semmelweis had introduced the practice, among the +physicians attending patients at the large lying-in hospital in +Vienna, of washing the hands in a solution of chloride of lime, there +was a great diminution in the mortality which prevailed, +notwithstanding which G. Braun reports, however, that in 1857, in the +month of July, in two hundred and forty-five deliveries there were +seventeen deaths. The following month Klein gave orders to suspend the +use of disinfectants. By chance, in August there were only six deaths +out of two {1019} hundred and fifty confinements, and in September, of +two hundred and seventy-five patients, none died. From 1857 to 1860 +the mortality was slight, though disinfectants were not used, while +during the three following years, in spite of the systematic and +persistent employment of these agents, the death-rate once more +assumed formidable proportions.[52] + +[Footnote 52: Braun, _Ruckblicke auf die Gesundheits Verhaltnisse +unter den Wochnerinnen_, u. s. w., S. 32, 33.] + +Of course I do not wish to underrate the importance of Semmelweis's +labors. There is no question but that it is a perilous experiment to +pass from the dissecting-room to a patient in labor without employing +rigorous measures to disinfect the hands and all parts of the person +brought into contact with the dead body. But it is well to call +attention to the fact that puerperal fever is not due to any single, +simple cause, nor can be effectually guarded against by a single +precaution; and, again, that an infectious poison does not of +necessity exist in every cadaver examined. Hausmann found that +injections into the vagina of gravid rabbits, in the latter half of +pregnancy, of serum from the corpse of a person who had not died of +septicaemia produced no fatal results, while rapid death resulted from +injections, under the same conditions, of pus from the abdomen of a +woman who had died from puerperal infectious disease.[53] + +[Footnote 53: "Untersuchungen und Versuche uber die Entstehung der +ubertragbaren Krankheiten des Wochenbettes," _Beitr. zur Geb. und +Gynaek._, Bd. iii, Heft 3, S. 374.] + +Barnes and other English writers lay considerable stress upon cases of +puerperal fever due neither to contagion nor to atmospheric +conditions, but to the poisoning of the patient by her own secretions. +There is justification for this view in the fact that even normal +lochia contain bacteria, and when inoculated into animals produce in +them affections of an ichorrhaemic and septicaemic nature. When death +takes place the tissues of animals thus treated are found to be filled +with round bacteria. Furthermore, the disease artificially produced is +in itself infectious, and can be continuously propagated in other +animals. But it may be asked, "Does not this admission cut both ways? +How is it possible, if even normal lochia possess virulent qualities, +that childbed is ever unattended by accessions of fever?" To this we +can only answer that the reasons for immunity in ordinary cases are +only known in part. Karewski[54] and other experimental investigators +have shown that the virulence of the lochia increases proportionately +to the number of days that have transpired since the birth of the +child, and that during the first three days the lochia are +comparatively harmless. Meantime, the retraction of the uterus, the +closure of the sinuses, and the formation upon the wounded surfaces of +protecting granulations, all act as natural barriers to the +penetration of poison-germs. But, aside from these reasons, there is +undoubtedly an unknown quantity calling for further investigation, +which, in the absence of positive knowledge, we are content to term +the predisposition of the individual patient. The vagina after +childbirth possesses all the conditions most favorable for the +production of putrefaction--viz. the access of air, fostering warmth, +and stagnating fluids charged with dead tissue. It is probable that +the first of these needful conditions is, in normal labors, happily +wanting in the uterine cavity. In these days of intra-uterine +medication it is well to {1020} bear in mind the relatively greater +frequency of infection through vaginal and cervical wounds, as +compared with that which takes place through the denuded intra-uterine +surface. The term auto-infection may, with propriety, be employed as a +distinctive appellation to designate those attacks of fever which, in +the absence of any demonstrable cause, occur in the early days of +childbed, and which there, quoad vitam, pursue a favorable course, and +to cases of so-called late infection--_i.e._ where, after the fifth +day, the accidental opening of a healing wound permits the tardy +absorption of poisonous secretions; but with the reserve that the +primary cause is, in point of fact, atmospheric, and the predisposing +condition the susceptibility of the individual. Cases of +auto-infection are in this country extremely rare, if not unknown +altogether, in salubrious or rural districts. + +[Footnote 54: "Experimentelle Untersuchungen ueber die Einwirkungen +puerperaler secrete auf den thierischen organismus," _Zeitschr. f. +Geb. und Gynaek._, Bd. vii, 2te Th., S. 331.] + +On another occasion I have shown that in New York City the death-rate +from puerperal fever is nearly twice as great during the six months +from December to May, inclusive, as from June to November. The +greatest mortality occurred in February and March, comprising rather +more than one-fourth the entire amount. The smallest number of deaths +occurred in September and October, in which months but one-thirteenth +of the entire number took place. + +That puerperal fever, in its harvest of death, does not spare the +wealthy and well-to-do classes is too familiar a truth to be worthy of +discussion. That, however, the wealthy do enjoy special immunities as +compared with the less-favored members of society, I have shown by +comparisons made between sections of the city which, though lying side +by side, exhibit in a marked degree the two extremes of wealth and +poverty. Thus, the mortality among the representatives of the lower +social strata, in proportion to population, was from three to six +times as great as that among the more fortunate classes. + +RELATIONS TO ZYMOTIC DISEASES.--In investigating, some years ago, the +nature, causes, and prevention of puerperal fever,[55] I prepared, +from the statistics of the Health Board of New York City, tables +extending over a period of nine years to answer the inquiry as to +whether there was any relation between the frequency of deaths from +scarlatina, diphtheria, and erysipelas and those from metria. Previous +to their publication I was anticipated in my deductions by a paper +upon the same subject by Matthews Duncan.[56] Neither Duncan nor +myself found any such relation existing between the statistical +frequency of puerperal fever and the zymotic diseases mentioned. There +was, however, nothing in our investigations to invalidate any direct +testimony which tends to show that, in individual cases, a real +connection between puerperal fever and the zymotic diseases may exist. +Indeed, it seems to me to be fairly established that a poison may be +conveyed from patients suffering from either of the foregoing morbid +processes which may be absorbed by the puerperal woman, and may in her +give rise to an infectious fever possessing an intense degree of +virulence. My friend Prof. Barker has recently drawn attention to the +important relations of intermittent fever to the puerperal state. I +have not, however, thought it advisable to complicate {1021} the +present discussion with any extended notice of his very valuable +observations. So far as malarial fever occurs unequivocally as such in +puerperal women, there is no more reason for establishing a special +category for puerperal malaria than for puerperal typhoid or puerperal +small-pox. In the class of cases characterized by sharp chills, +intense fever, irregular remissions, and profuse perspiration, which +pursue a pernicious course unaffected by antiperiodic remedies, the +nature is extremely dubious. The same symptoms are likewise +characteristic of certain forms of pyaemia, and I cannot learn that +such cases are familiar in the practice of those of our physicians who +practise outside of cities in districts where malarial affections are +most prevalent. + +[Footnote 55: _Trans. of the International Med. Congress_, +Philadelphia, 1876.] + +[Footnote 56: "On the Alleged Occasional Epidemic Prevalence of +Puerperal Pyaemia, or Puerperal Fever and Erysipelas," _Edinburgh Med. +Journal_, March, 1876, p. 774.] + +PREVENTION.--Of the 3342 deaths from puerperal causes in New York City +from 1868 to 1875, inclusive, 420 occurred in hospital, or one-eighth +of the entire number. Of the 1947 cases of metria, about 300, or not +quite one-sixth, were contributed by the hospitals. After such a +showing the first impulse would be to cry out loudly for the +suppression of the maternities. But a wiser policy suggests an inquiry +as to whether the large mortality mentioned is an evil necessity. The +following reports will show how much may be done in the present state +of our scientific knowledge to so control the conditions which favor +the generation of puerperal diseases in large hospitals as to make +them safe asylums for the needy. + +Goodell[57] has stated that at the Preston Retreat in 756 cases of +labor there have been but 2 deaths from septic disease. Winckel[58] of +the Lying-in Institution in Dresden reported, in 1873, 18 deaths from +metria, or 1.8 per cent., but from the 10th of January to the 7th of +July in 570 births there was but 1 case of septic disease; in the year +1872 the death-rate exceeded 5 per cent. The reduction in mortality +was no fortuitous circumstance, but was due to rigid measures for the +prevention of disease. Stadfeldt[59] reduced the mortality from +puerperal fever in the Maternity Hospital of Copenhagen from 1 to 37, +the proportion between the years 1865 and 1869, to 1 in 87 between the +years 1870-74. Johnston[60] reports, in the Rotunda Hospital of +Dublin, during the seven years of his mastership, 7860 births with 169 +deaths, of which 85, or 1 in 91, were from metria. Braun von +Fernwald[61] in sixteen years reports 61,949 confinements in the vast +Maternity Hospital of Vienna, with 825 deaths from puerperal fever, or +1.3 per cent. In a visit made by me to the Vienna Maternity in 1883, I +was informed that the recent mortality, including difficult +operations, had been reduced to one-half of 1 per cent. +Spiegelberg[62] lost, in 901 confinements at Breslau, only 5 cases of +puerperal fever. Beurmann[63] reports that in the Hopital +Lariboisiere, under the administration of M. Siredey, the death-rate +in 1877 was 1 in 145, and in 1878, 1 in 199, confinements; in the +Hopital Cochin, under the charge of M. Polaillon, the total mortality +from 1873 to 1877 was 1 to 108.7. In 1877 there was but 1 death from +puerperal causes in 807 confinements. Upon Prof. Streng's division of +the magnificent {1022} maternity in Prague, I was told that, in +1882-83, in over 1100 confinements there had been no death from septic +causes. + +[Footnote 57: _On the Means employed at the Preston Retreat for the +Prevention and Treatment of Puerperal Diseases_, p. 13.] + +[Footnote 58: _Berichte und Studien_, Leipsic, 1874, S. 183.] + +[Footnote 59: _Les maternites, leur organsation et administration_, +Copenhagen, 1876.] + +[Footnote 60: _Clinical Reports_, from 1870 to 1876, inclusive.] + +[Footnote 61: _Lehrbuch der gesammten Gynaekologie_, S. 885.] + +[Footnote 62: _Ibid._, S. 748.] + +[Footnote 63: _Recherches sur la mortalite des femmes en couches dans +les hopitaux_, Paris, 1879.] + +When the maternity service was transferred in 1872 from Bellevue +Hospital to Blackwell's Island, it became necessary to make some +provision for so-called street-cases--_i.e._ women taken suddenly in +labor without homes, and representing the extremes of penury and want. +At first they were received, in part, by the various private +institutions of charity in New York City, but these in 1877 decided to +exclude them thenceforth, on the ground that their condition at the +time of their reception was such as to endanger the lives of the +inmates for whom the charities were specially provided. An old +engine-house was then put in readiness by the city, and under the name +of the Emergency Hospital was placed under the charge of Henry F. +Walker[64] and myself. The number of confinements in the Emergency has +averaged 220 annually. The death-rate from all causes has been 2 per +cent., which, though large, is not an unfavorable showing when we +remember that the patients all belong to the homeless class, that all +were taken in labor before their entrance, and that many of them were +in a deplorable condition at the time of their admission. The +hospital, too, receives a considerable number of patients annually who +are sent there only after protracted, and often severe, operative +measures have been fruitlessly attempted outside its walls.[65] The +building possesses, for maternity purposes, two fairly ventilated +rooms. Excellent nurses are furnished by the New York Training School +for Nurses. Mr. Osborn, a liberal private citizen, has had constructed +in the rear, but detached from the main house, a small pavilion, +modelled after that of Tarnier, for the reception of infectious cases. +The Commissioners of Charities have promptly responded to every call +made upon them to extend the facilities for the care of patients. + +[Footnote 64: Dr. Walker has since resigned, and my present colleague +is Prof. Wm. M. Polk.] + +[Footnote 65: From Oct., 1883, to Aug., 1884, there have been confined +168 women in the hospital. Twenty were brought in from the street just +after the birth of the child. Of these 188, not one suffered from any +puerperal affection. There were 2 deaths--1 from intestinal +ulcerations, possibly the result of the corrosive sublimate +irrigations, and 1 from exhaustion. This latter patient had been +thirty-six hours in labor before she was brought to the hospital, and +died four hours after admission. Under the admirable management of +Miss Hart, the matron, in addition to the slight mortality, there has +likewise been almost complete absence of even trivial temperature +elevations.] + +Surely these results do not support the idea that it is better for a +woman to be confined in a street-gutter than to enter the portals of a +lying-in asylum. Goodell's experience shows that a hospital for +respectable married women may be so conducted that its inmates may +enjoy absolutely a greater degree of safety than do women in their +homes surrounded by all the aids that wealth can command. Equally good +results are not to be obtained in hospitals which are open to +unfortunates of every class. But there is much misapprehension and +confusion of ideas respecting the fate of these women when no +charitable provision is made for them. In Copenhagen the Maternity +Hospital is closed for from six to eight weeks in the summer-time. +During this period unmarried parturient women receive pecuniary +assistance from the hospital to enable them to obtain a place in which +to be confined. Now, Stadfeldt reports a larger mortality among this +class than among those delivered in the hospital. Yet they are +confined at a favorable season of the year, without any communication +with the furniture, the sage-femmes, or the {1023} physicians of the +hospital. As they fortunately receive nothing but money, that can +hardly be suspected of communicating contagion. What their fate would +be in New York City perhaps may be judged from the following facts: +Excluding cases confined in hospitals, nearly one-thirtieth of all the +deaths and one-twenty-fourth of the cases of metria between 1867 and +1875 are reported by four practitioners. Ten practitioners out of +twelve hundred signed the death-certificates of one-fifteenth of the +women dying from puerperal causes, and one-tenth of the cases of +metria. But it is not to be supposed that these deaths were all the +result of malpractice and incompetence. The true history of most of +them probably was that the doctor was engaged to attend the case of +confinement for a small fee, with the understanding that he should +make no calls subsequently, unless specially summoned by the friends +of the patient. The latter, left to ignorant care or perhaps without +any assistance whatever, and exposed to all the pernicious influences +bred by poverty, when illness supervened probably did not call the +physician to her aid until the time for help had passed, so that in +the end his professional functions were confined to procuring the +requisite permit for burial. + +Humanity demands that charity should furnish places of refuge in which +poor outcasts can receive assistance during the perils of +child-bearing. If we must, then, have maternities, we should make them +safe, and this can be in great measure accomplished by remembering the +twofold source of danger arising from a poisoned atmosphere and direct +inoculation. A hospital must be clean, spacious, and well-ventilated, +or its atmosphere will become charged with the spores of septic fungi +and produce nosocomial malaria. The most rigid sanitary precautions +observed by the attendants will not prevent a badly-ventilated ward +from becoming unwholesome, unless unoccupied wards are kept to which +patients can be transferred upon the first admonition of danger. +Goodell states that at the Preston Retreat the wards are used +invariably in rotation. In connection with the Maternity at Copenhagen +there are a number of small supplementary hospitals scattered through +the city, which serve as safety-valves for the central institution. +Artificial methods of ventilation render the task of keeping the wards +wholesome comparatively easy. They do not need, however, to be +complicated and expensive. The good repute of the Rotunda Hospital, it +seems to me, is in large measure due to the natural ventilation +afforded by open fireplaces. + +In the Vienna Clinic, according to C. Braun, the mortality between +1834 and 1862 averaged 6 per cent., and in 1842 the enormous total of +521 deaths to 3067 confinements was reached. With the introduction in +1862 of what is known as Bohm's heating and ventilation system an +immediate improvement was experienced. In the sixteen years from 1863 +to 1878, inclusive, the total mortality has been 1.6 per cent., though +in that time 5464 practitioners have received an obstetrical training +in its wards. In commenting upon this change, Braun says: "I have now +from practical experience arrived at the knowledge of the fact that +the rapid and thorough prevention of putridity by adequate ventilation +is to be regarded as a good preventive measure against puerperal +fever; that it is not the number of patients in a lying-in hospital, +nor yet the number of patients in a single room, but the deficient +circulation of air--a fault {1024} which may inhere to separate +compartments in the smallest maternities--which is the important +feature in the spread of puerperal fever; that puerperal women are to +be protected from childbed diseases not by isolated buildings and +gardens, nor by walls, but by the permanent introduction of great +quantities of pure, warm air." He then adds, what is in thorough +accord with my own experience, "Before new institutions are built +greater attention than heretofore should be paid to the ventilation of +the old structures, and, where this is found defective, a system +should be substituted corresponding to the scientific requirements." + +In the year 1872 puerperal fever destroyed 28 women of 156 who were +confined in the Bellevue Hospital. The service was then broken up, and +a great outcry arose against "tainted hospitals." Wooden pavilions +were accordingly erected on Blackwell's Island for the reception of +lying-in women. These buildings were constructed upon what is known as +the cottage plan. They were favorably situated in an airy location +remote from the general hospital. They were, however, heated by large +iron stoves, and no means of ventilating the wards was provided, +except by lowering the windows. In less than three months from their +occupancy an epidemic of puerperal fever made it necessary to remove +the service for a time to the Charity Hospital. The same result +followed every subsequent attempt to utilize them for maternity +purposes, until, after three years' trial, it was found necessary to +abandon them altogether. + +In private practice it is likewise important that the lying-in room +should be provided with plenty of light and air. The physician should +insist upon the value of ventilation as a means of contributing to the +speedy recovery of childbed women. By hermetically sealing the +windows, through false fears of his patient's taking cold, he exposes +her to the risk of becoming poisoned with her own exhalations. + +But the early experiences of the Hopital Cochin and the Hopital +Lariboisiere, costly, palace-like structures, with every appliance of +art, prove that fresh air alone does not protect patients from the +consequences of inoculation. + +The great improvement in the condition of maternity patients in recent +years has been due to the application of Lister's principles to +obstetric practice. Complete antisepsis in the surgical sense is, of +course, impracticable. Adequate antisepsis has, however, been proved +to result from the observance of a variety of precautions which have +been the slow outcome of experience. These, in brief, in hospitals, +consist in protecting the patient from every known form of +contamination, and in the prompt removal and isolation of every +puerperal woman who manifests febrile symptoms. + +In citing the examples of the Hopital Cochin and the Hopital +Lariboisiere, I was led to the selection because these hospitals most +strikingly illustrate the extent of the triumph of the new doctrines. +Whereas at the Lariboisiere the mortality in 1854, the year of its +opening, exceeded 10 per cent., as a result of the prophylactic +measures adopted by M. Siredey the mortality was 1 to 145 in 1877, and +1 to 199 in 1878. And at the Hopital Cochin, in 1878, +Lucas-Champonniere, with 770 confinements, was able to report but 2 +deaths from puerperal causes. + +{1025} As regards details, the bedsteads should be of iron and should +be frequently scrubbed with a carbolic solution; after each +confinement the palliasse upon which the woman lay should be washed in +boiling water and the straw should be burned; in place of the usual +rubber covering to the bed, Tarnier recommends tarred paper, which is +antiseptic, and costs so little that it need be used in but a single +case; all soiled linen should be instantly removed from the ward, +either to be burned or disinfected by prolonged boiling; sponges +should be banished, as, when they have once been soaked with blood, +not even carbolic acid can make them safe; nurses employed in the +puerperal wards ought not to have access to cases of labor, as +D'Espine and Karewski[66] have shown that the lochia of even a healthy +person on the third day will poison a rabbit; a patient attacked with +fever should be immediately removed, and the nurse in attendance +should go with her. At the Emergency Hospital, with the first +appearance of catarrhal affection of the genital organs or of +so-called milk fever, the wards are immediately emptied and fumigated +with sulphurous acid. In spite of recent scepticism regarding the +value of the fumes of sulphurous acid as a germicide and disinfectant, +I do not hesitate to express, after long experience, my firm +conviction as to their efficacy. + +[Footnote 66: D'Espine, _"Contributions a l'etude de la septicemie +puerperale,"_ p. 18; Karewski, _loc. cit._] + +Doleris[67] formulates the indications for effective prophylaxis as +follows: 1, prevent the introduction of germs (antisepsis before +confinement); 2, paralyze their action (antisepsis after confinement); +3, shut up the doors--veins, lymphatics, and Fallopian tubes +(employment of means which promote uterine contraction). + +[Footnote 67: _La fievre puerperale_, 1880, p. 303.] + +The first duty of the physician is to refrain from attending a case of +labor when fresh from the presence of contagious diseases or from +contact with septic materials, whether derived from the +dissecting-room or the clinic. Scepticism regarding these sources of +danger is sure in the long run to be severely punished. In a doubtful +case the least concession should consist in a full bath and a complete +change of clothing. A special coat for confinement purposes, stained +with blood and amniotic fluid, is liable to convey infection. In every +case of labor, whether in hospital or private practice, the hands and +forearms should be freely bathed in a carbolic solution before making +a vaginal examination. A nail-brush should form a part of the ordinary +obstetric equipment. Frequent examinations during labor should be +avoided. All instruments employed during or subsequent to confinement +should be carefully disinfected. In prolonged labors, after operation, +in cases of dystocia, or where the membranes have ruptured prematurely +and the foetus is dead, it is a useful precaution after delivery to +wash both uterus and vagina with warm carbolized water or solution of +corrosive sublimate (1:2000). In Vienna both Spaeth and Braun after +difficult labors introduce a suppository of iodoform, 2 to 2-1/2 +inches in length, into the uterine cavity. The formula recommended +consists of-- + + Rx. Iodoformi, 20 grammes; + Gummi Arabici, + Glycerinae, + Amyli puri, _aa._ 2 grammes; + Ft. Bacilli, No. iij. + +{1026} In their introduction the half-hand (left) should be passed to +the cervix; the iodoform bacillus should be seized by a pair of +polypus forceps and pushed into the cervical canal. The hand in the +vagina should then be used to shove the suppository upward past the +internal os. No symptoms of poisoning from the iodoform have been +observed. The disinfection is complete and prolonged. In hospitals the +woman should be bathed before entering the lying-in ward, and the +vagina should in all cases be disinfected with carbolic acid or +corrosive sublimate both before and immediately after labor. The +conduct of labor under carbolic acid spray is commended by Fancourt +Barnes. Doleris advises the application of a compress soaked in +carbolic fluid to the external genitals during the progress of labor. +Tarnier advises dressing the vulva, so soon as the head begins to +emerge, with a pledget soaked in carbolized oil (1:10). With the +recession of the head during the interval between pains a portion of +the oil is carried upward into the vagina. + +In the puerperal period the warm carbolized douche stimulates uterine +retraction and promotes the rapid healing of wounds in the vaginal +canal; in hospital practice it possesses the additional advantage of +preventing the accumulation of putrid albuminoid matters in the air. +In private practice the patient should employ a new syringe; in +hospitals every woman should be supplied with a glass tube to be +attached to the irrigator. When not in use these tubes should be +immersed in carbolic acid. The stream injected into the vagina should +be continuous, like that furnished by the fountain syringe. With my +hospital patients, in place of cloths to the vulva I have been in the +habit of using oakum. By soaking the latter in a solution of carbolic +acid the vulva is surrounded by an antiseptic atmosphere.[68] + +[Footnote 68: I know that of late there has been a strong reaction +against the use of vaginal injections in normal childbed, but +personally I have experienced none of the disagreeable effects +ascribed to them. Indeed, both my hospital and private patients alike +speak of them as soothing and grateful. I therefore have had no ground +to discontinue them. That they are indispensable I do not claim. They +are no longer used in Vienna, in Prague, nor in the New York +Maternity, and yet, none the less, their results have since been in +the highest degree satisfactory. At these institutions, however, +vaginal disinfection is vigorously resorted to during and immediately +subsequent to labor, and during childbed some form of antiseptic pad +over the vulva is employed.] + +Pedantic as these directions may seem, they are justified by +experience, and the carrying out of the details given easily becomes a +matter of habit. That by such precautions puerperal fever is destined +to be erased from the list of dangerous diseases attacking the woman +in childbed is saying more than is warranted. Nevertheless, it is true +that a physician ought never to lose the sense of personal +responsibility for its occurrence. Indeed, puerperal fever ought to be +regarded as a preventable disease, and an attack as the evidence that +some source of danger has been overlooked, though, owing to the +imperfection of our knowledge, it may easily happen that even with the +keenest scrutiny the precise cause in an individual case may escape +detection.[69] + +[Footnote 69: Since the above was written Dr. Garrigues has furnished +a most extraordinary example of the efficacy of the antiseptic +treatment at the New York Maternity Hospital. From the years 1875 to +1882, inclusive, the number of confinements was 2827; the deaths 116, +or a little over 4 per cent. The highest percentage was reached in +1877--viz. 6.67; the lowest in 1881, when it fell to 2.36. In 1883, of +345 women confined, 30 died. In September of that year there were 9 +deaths, and of 5 puerperae who were seriously ill, 1 died later. At +this time he introduced a series of reforms of which the following, +omitting details, gives the essentials: Wards fumigated with +sulphurous acid fumes, and the floors and furniture washed with a +solution of corrosive sublimate (1:1000). Every patient, on entering +the lying-in ward after the bath, had her abdomen, buttocks, genitals, +and thighs washed with sublimate solution (1:2000). During labor +vagina irrigated with latter solution. In prolonged labors irrigation +repeated every three hours. Great care of hands on part of doctor and +nurses. Glycerine and corrosive sublimate (1:1000) used for +lubricating fingers before making internal examinations. Antiseptic +pad applied to the head during its egress, and to the vulva until the +secondines had been expelled. Absorbent cotton covered with netting +soaked in corrosive sublimate solution applied to external genitals +during childbed period. This latter applied and removed with the same +care as in dressing a wound after a capital operation. Irrigation, +first of the vagina and afterward of the uterus, immediately after +labor in cases where the hand or instruments had been passed into the +uterine cavity. + +When the details of this treatment were first published by Garrigues, +many took a humorous view of it, but mark the result: In the following +162 confinements there were no deaths, and from October to July, +inclusive, of the present year, of 409 patients confined, though many +operations were performed, 5 died; but of these, 3 only were from +septic causes, and they, Garrigues believes, were the result of the +neglect of certain of the prescribed details.] + +{1027} Before terminating this section upon the prophylaxis of +puerperal fever, I take great satisfaction in furnishing from +Tarnier's recent treatise the following description, by Pinard, of the +ingenious pavilion designed by Tarnier to make it possible to secure +for hospital patients, at the minimum expense, the benefits of +isolation, and to provide for each room in the pavilion all the +conditions favorable to rapid and complete disinfection. + +The pavilions are two-storied and of a rectangular shape, twenty-four +feet in width by forty-six feet in length. The front and rear face to +the north and south, the ends to the east and west. Two main +partitions divide the interior into three divisions. Each end division +is subdivided by a central partition into two chambers, so that each +story has five compartments--a central one for the attendants, and +four at the four corners destined for the reception of patients. On +the ground floor the central compartment consists of a vestibule +facing to the north, and an office facing to the south. On the former +are placed the staircase, the water-closet, and a reception-closet. In +addition to the main entrance there are three interior doors--one +leading to the water-closet, one to the closet, and one to the office. +The latter, for the occupation of the person on duty, contains a +heater, a portable bath, a table, chairs, and wardrobe. Two windows +face the south. The office has two doors, one opening into the +vestibule, and the other, in the opposite side, opens directly +outward. The four corner rooms for patients have each a door and a +window, the latter looking from the end of the partition and reaching +to the floor, and the former opening out from the facade. These four +rooms are therefore not only independent of one another, but have no +communication with the vestibule or the central office. On the second +floor the arrangement is similar, except that the rooms open upon a +balcony, by means of which communication from the outside is rendered +possible. Upon each facade a glazed screen furnishes shelter in rainy +weather. The screen extends to the roof, but is not in direct contact +with the walls, a space being left for a current of air. The eight +rooms for patients, four on each story, are severally fourteen feet +long, eleven and a half feet wide, and ten feet high. Below, the +floors are of asphaltum; above, of flags or slates. The walls and +ceilings are stuccoed and covered with oil paint. The corners are +rounded to prevent the accumulation of dust. To facilitate {1028} +washing, the floors slant toward a gutter communicating by means of a +pipe with the sewer. In each room panes of glass enable patients and +the office attendant to see one another, so that surveillance is +secured without sacrificing the principle of isolation. The furniture +of the rooms consists of an iron bedstead with metallic springs. The +pillow, bolster, and palliasse are stuffed with straw. In addition, +each room is provided with a night table, a round table, a chair, a +stool, and a crib--all of iron. A bell-rope at the bedside, the wire +of which passes to the office by the outside of the building, enables +the patient to summon assistance. Each room likewise contains a +washstand, with faucets for hot and cold water, the latter supplied +from a cistern on the roof, the former from the office heater. The +patients remain in the rooms where they are confined until they are +discharged. When this takes place the chamber is aired, the furniture +is removed and washed with care, the straw is burned, and the walls +are washed with an abundant supply of water. If a patient is taken +ill, she is carefully isolated, and has assigned to her her own +especial attendant and physician, who do not come into contact with +other puerperal patients. + +That the plans of construction in the Tarnier pavilions would require +some modification to adapt them to the rigor of our winters seems +probable, but the principles which they illustrate are sufficiently +vindicated by the results so far reported--viz. 6 deaths in 1062 +confinements, whereas in the old Maternity the death-rate, formerly +amounting to 5 per cent., still aggregates 2 to the 100. + +TREATMENT.--When the septic germs characteristic of putrid infection +have once entered the blood, they are beyond the reach of the +physician. Except, however, in cases of acute septicaemia, where the +quantity of poison introduced at the outset is excessive, the patient +rallies from the immediate shock, and, provided no fresh pyrogenic +material finds its way into the system, recovery is to be anticipated. +The indications for treatment are, therefore, to neutralize the +puerperal poison at the point of production, in order to prevent its +causing further mischief, and to adopt measures calculated to enable +the patient to tolerate its presence, when once absorbed, until it is +either eliminated or loses its harmful properties. + +Toward the fulfilment of the first indication it is to be recommended +that in every case of fever of puerperal origin the vagina be cleansed +with a 2 to 3 per cent. solution of carbolic acid or corrosive +sublimate (1:3000) every four to six hours. The douche in itself is +absolutely harmless. In most cases the infection starts from the +wounds of the vagina and of the cervix. Then, too, the tendency of the +secretions to stagnate in the vaginal cul-de-sac, bathing as they do +the cervical portion, is a prolific source of septic trouble. In all +but the mildest cases the vaginal orifice should be examined with +reference to the existence of puerperal ulcers. All necrotic patches +should be touched with hydrochloric acid, with a 10 per cent. solution +of carbolic acid, with iodoform, or, what I personally prefer, a +mixture composed of equal parts of the solution of the persulphate of +iron and the compound tincture of iodine. The latter acts as a +powerful antiseptic, while the former, by corrugating the tissues, +closes the lymphatics and shuts up the portals through which the +septic germs penetrate into the system. + +{1029} Intra-uterine injections should be resorted to with extreme +circumspection. They are not indicated by a simple rise of +temperature. A very large proportion of the febrile attacks which +occur in childbed run an absolutely favorable course. Unless the +infection--and this is not the rule, but the exception--proceeds from +the uterine cavity, they are unnecessary. In circumscribed +inflammations, where the morbific poison loses its virulence at a +short distance from the puerperal lesion, they are often injurious. It +is difficult, if not impossible, to so conduct them as to avoid +opening up afresh recent granulating wounds. Yet the practice of local +disinfection is warmly advocated by Fritsch, Schuller, Langenbuch, and +Schroeder as a prophylactic against puerperal affections. On the other +hand, Braun von Fernwald, with his vast opportunities for judging +obstetrical questions, writes with reference to this: "We must protest +against injections made by physicians into the uterine cavity. Such +meddlesomeness is more likely to do harm than good." This corresponds +with my own experience. In theory, the proposition to treat the uterus +as one would any other pus-secreting cavity seems rational, but I have +found that every attempt to carry the theory to its logical conclusion +in hospital practice has been followed by a rise in the puerperal +death-rate. Runge reports an epidemic of puerperal fever in +Gusserrow's clinic brought about by the employment of intra-uterine +irrigations, during which the mortality rose to 3.8 per cent. With the +abolition of the irrigations the mortality sank to .39 per cent. In +1880, Fischel[70] introduced the so-called permanent irrigations into +the Prague maternity. Of 880 patients, 9 died of sepsis. The +irrigations were then prohibited. The following year, of 933 patients, +only 2 died from the same cause, and in 1882, of 521 patients, there +were no deaths from sepsis. Fehling, who limited the use of +intra-uterine injections to special momentary indications, reported, +in 1880, 415 confinements without a single death. + +[Footnote 70: "Zur Therapie der Puerperalen Sepsis," _Arch. f. +Gynaek._, vol. xx. p. 41.] + +Among the accidents which have been referred to the use of injections +are convulsions, shock, and carbolic-acid or corrosive-sublimate +poisoning; but the chief danger lies in the possibility of conveying +the infectious materials from the vagina to the previously normal +uterus. There seems to be no question as to the superior effectiveness +of corrosive sublimate as a germicide. It not only acts more rapidly +than carbolic acid, but its action is more permanent. In the usual +proportion of 1:2000 it is apt, when repeated frequently as a vaginal +douche, to corrugate the vagina and cervix. When used for +intra-uterine irrigation great pains should be taken that no portion +of the fluid remain behind in the uterine cavity. Since its +introduction into the Emergency Hospital there has been one death from +ulceration in the colon, which possibly was attributable to its use. +It is to be hoped the claim that corrosive sublimate is an efficient +antiseptic in the proportion of 1:10,000 may prove well founded. + +In pressing the necessity of caution and discrimination, I have not, +however, intended to discourage the employment of intra-uterine +antisepsis in cases where it is strictly indicated. Thus, it would be +folly, in a fever due to the decomposition of placental debris, of +shreds of decidua, of strips of membrane, or of retained coagula, or +in diphtheritis of the mucous membrane, to treat the general symptoms +and neglect {1030} the local cause of difficulty. In a specific case +it may prove difficult to decide as to the correct course to pursue. +In general it may be stated that it is proper to wash out the entire +length of the genital canal when fever follows prolonged operations +conducted within the uterine cavity or the birth of a dead foetus, and +in cases of fever associated with a fetid discharge which persists in +spite of the vaginal douche, with the presence of recognizable +portions of the ovum or its dependencies in the lochia, with the +repeated discharge of decomposed coagula, or with a large, flabby +uterus. It will, however, be seen that with proper disinfection during +and immediately after labor, the occasions for late intra-uterine +injections are extremely rare. + +The operation of cleansing the uterus should be conducted with the +most scrupulous care. The syringe employed should produce a continuous +and not an interrupted stream, and all air should be expelled from the +pipe. The tube to be passed through the cervix should be of glass, of +the size of the little finger, and bent somewhat to conform to the +pelvic curve. The vagina should first be subjected to a thorough +disinfection, by way of precaution against conveying septic materials +into the uterus. The introduction of the tube should be made with the +guidance of two fingers passed through the external os. But slight +force is requisite to reach the internal os. It is neither necessary +nor desirable to push the tube to the fundus. The fluid injected +should be tepid, and, if carbolic acid is used, of the strength of two +or three drachms to the pint; if corrosive sublimate is employed, the +strength should not exceed 1:3000. It should be introduced very +slowly, and pains should be taken to ensure its unimpeded escape, +which can usually be accomplished by pressing the anterior wall of the +cervix forward by means of the glass tube. Langenbuch recommends +securing permanent drainage by leaving a bit of rubber tubing in the +cervical canal--a plan concerning the merits of which I am not able to +speak from experience. The tube is said to be well tolerated, and to +possess the advantage of enabling subsequent injections to be +performed without disturbing the patient. + +In many cases the results of intra-uterine treatment are very +striking. Often the temperature falls notably within an hour or two of +the operation. This result is, however, rarely permanent. Usually the +fever recurs, and the operation has to be repeated. The patient should +be carefully watched, and with the first sign of returning danger the +injection should be repeated. Two or three injections may thus be +called for in twenty-four hours, and they may require to be continued +for a week. Still, by the means indicated a certain pretty large +proportion of women seemingly destined to destruction in the end make +favorable recoveries.[71] + +[Footnote 71: The admirable monograph of Dr. T. G. Thomas, entitled +_The Prevention and Treatment of Puerperal Fever_, has already done +much good in calling the attention of the profession at large to the +practice of local disinfection. His experience, however, based upon a +very large consulting practice, has perhaps been of a kind to furnish +him with an undue proportion of puerperal cases calling for +intra-uterine treatment. With increasing care in the management of +labor and of the birth of the child there seems reason to hope that +the necessity for the treatment he so eloquently advocates may, in the +near future, disappear entirely.] + +Ehrendorfer[72] relates a case of septic endometritis and erysipelas +{1031} starting from the genital organs, in Spaeth's Clinic, where, +after seven days of ineffective uterine irrigations, two bacilli, +containing together ten grains of iodoform, were introduced into the +uterus. The washings with carbolic acid were then stopped. On the next +day the discharge was diminished and the odor was less marked. On the +fourth day two new iodoform bacilli were introduced. The patient, in +spite of the fact that the erysipelas spread over nearly the entire +body, eventually recovered. + +[Footnote 72: "Ueber die Verwendung der Jodoform staebchen bei der +intrauterinen nach behandlung im Wochenbette," _Arch. f. Gynaek._, +vol. xxii. S. 88.] + +Of the symptoms, the first in order which calls for treatment is +usually the peritoneal pain. It is, as we have seen, commonly of a +lancinating character, and is associated with hurried breathing and +extreme frequency of the pulse. So soon as the pain is once fairly +under control the violence of the onset begins to abate. It should be +met, therefore, by the hypodermic injection of from one-sixth to +one-third grain of morphia in solution. The anodyne action should be +maintained by doses administered by the mouth in quantities and at +intervals suited to the severity of the case. The most important +object to be secured is freedom from spontaneous pain. It is, +moreover, good practice to push the opiate until pain elicited by +pressure is likewise controlled, provided it can be accomplished +without producing narcosis. In susceptible patients and in localized +inflammations the quantity required may not be very great, while in +acute general peritonitis the tolerance of the drug exhibited by +puerperal women is sometimes extraordinary. Thus, a patient of Alonzo +Clark took the equivalent of 934 grains of opium in four days; a +patient of Fordyce Barker 13,969 drops of Magendie's solution in +eleven days; and one of my own, at the Maternity, the equivalent of +over 1700 grains of opium in seven days.[73] In this latter instance +the patient was to all appearance moribund when the treatment was +begun. Thus, the features were pinched, the face was drawn, the pupils +were dilated, the finger-tips were blue and cold, the respirations +were rapid, and the pulse was scarcely perceptible. In this condition +the large doses of opium did not produce narcosis, but were followed +by restoration of the circulation, by normal breathing, and by the +disappearance of the symptoms of shock. Any attempt to relax the +treatment was at once succeeded by a recurrence of the alarming +symptoms. At the expiration of the disease the opium was discontinued +abruptly without detriment to the patient. + +[Footnote 73: The details of this case have been reported in the _Am. +Jour. of Obst._, Oct., 1880, p. 864, by Dr. F. M. Welles, who +conducted the administration of the opium.] + +In contrast to cases of acute peritonitis an extreme susceptibility to +opium is often observed in the pyaemic variety. Here opiates seem to +me rarely to do good. They do not hinder the migrations of the round +bacteria, there is rarely pain to relieve, and I have sometimes +thought that their administration was simply the addition of a second +poison to the one which already was overwhelming the nervous system. + +In pelvic peritonitis, in the course of forty-eight hours plastic +exudation is thrown out and the pain to a great extent subsides. From +this time very moderate doses of opium, as a rule, are needed to make +the patient comfortable. + +In France leeches applied to the abdomen are much used as a means of +relieving peritoneal sensitiveness. That they do this is beyond +question. {1032} Their disuse in this country is due probably more to +popular prejudice than to their inefficacy. + +In the beginning of an attack a turpentine stupe to the abdomen is a +source of comfort to many women, while the sharp counter-irritation +exercises possibly a favorable influence upon the course of the +disease. At a later period I commonly employ flannels wrung out in +water and covered with oil-silk to prevent speedy evaporation. It is +an old experience that in the beginning of a puerperal fever the +provocation of loose stools by purgatives is frequently followed by a +fall in the temperature and a great improvement in the patient's +condition. The result, however, is far from uniform, as in other cases +these artificial diarrhoeas have a tendency to aggravate the +peritoneal symptoms. Owing to this uncertainty in their action, +purgative remedies should be administered with caution, not from any +theory as to their eliminative powers, but because of the ascertained +existence of fecal accumulation. In pelvic inflammations castor oil in +two- or three-tablespoonful doses, or five to ten grains of calomel +rubbed up with twenty grains of bicarbonate of sodium, as recommended +by Barker, may be given when thus indicated. After the bowels have +once been freed, however, the purgative should not be repeated. In +cases of intense local inflammation and in general peritonitis enemata +should alone be employed for the removal of constipation. + +Every increase of body-heat is associated with rapid tissue-waste, +with enfeebled heart-action and with exhaustion of the nerve-centres. +Since the modern recognition of the deleterious effects of high +temperatures per se, antipyretic remedies in place of the old-time +cardiac sedatives have come to play the leading role in the treatment +of fevers. + +Of internal antipyretic agents quinia enjoys a deservedly high repute. +In the remitting forms of fever it may be administered in five-grain +doses at intervals of four to six hours. Given thus in medium doses, +it moderates the fever, diminishes the sweating, and in most patients +lessens gastric and intestinal disturbances. In continued fevers it +should, on the contrary, be given in a single dose large enough to +procure a distinct remission. By making a break in the febrile +symptoms, if only of a few hours' duration, a retardation of the +destructive processes is accomplished. At the first administration +twenty to thirty grains may be given. In favorable cases the +temperature falls in the course of a few hours below 101 degrees. When +the high temperature is only temporarily held in check, at the end of +twenty-four hours, if all symptoms of cinchonism have disappeared, the +same dose should be repeated. If the doses mentioned, given in the +manner prescribed, produce no perceptible effect upon the fever, their +continuance may be regarded as unnecessary. + +C. Braun and Richter speak favorably of the action of salicylate of +sodium.[74] It possesses antipyretic properties, though in a less +degree than quinia. It is, however, rapidly absorbed, circulates +through all the parenchymatous organs, and finally is discharged +unchanged in the urine. It is said by Binz, in small doses, to hinder +the action of the disease-producing ferments, while it leaves +untouched the normal ferments of the organism. It is of special +service where quinia is not well tolerated, or when given fifteen to +twenty grains at a time every four to six hours as {1033} an adjuvant +to large single doses of quinia. The remedy should be continued until +all traces of febrile disturbance have disappeared. + +[Footnote 74: Richter, "Ueber intrauterine Injectionen," etc., +_Zeitschr. fur Geburtsk. und Gynaek._, Bd. ii. Heft 1, p. 146.] + +A more powerful remedy than salicylic acid, where quinia has failed, +is the Warburg's tincture. Some patients find, however, that it is +somewhat difficult to retain upon the stomach. + +Not many years ago, owing to the encomiums of Fordyce Barker,[75] the +tincture of veratrum viride was in great favor in puerperal fever as a +means of reducing the excited pulse of inflammation. The plan +recommended was to administer five drops hourly, in conjunction +usually with morphia, until the pulse was brought down to 70 or 80 +beats to the minute. If the pulse had once been reduced, then three, +two, or one drop hourly would be found sufficient to control it. +Vomiting and collapse from its use were no cause for alarm, as they +were temporary symptoms, and were followed by a fall of the pulse to +30 or 40 a minute, which was rather of favorable prognostic +significance. In the rapid pulse of exhaustion, however, veratrum +should not be given. Since the introduction of the thermometer into +practice the reduction of the pulse by veratrum has been found to be +associated with a fall in the temperature of the body. Of late, +however, veratrum has gone rather out of vogue, not because it is not +a very effective agent, but because its administration is an art to be +acquired, and cannot safely be entrusted to an unskilled assistant. +Then, too, in the last ten years there has grown up a better +acquaintance with less dangerous remedies. + +[Footnote 75: _The Puerperal Diseases_, p. 347.] + +Braun recommends in severe cases, where quinia alone is without +effect, to give in addition from twelve to twenty-four grains of +digitalis in infusion per diem until its specific action is produced. +Unlike veratrum, digitalis effects a permanent slowing of the heart. +By prolonging the cardiac diastole and contracting the arterioles it +allows the left ventricle to fill, restores the arterial tension, +diminishes correspondingly the intravenous pressure, and promotes +absorption. Its tendency to produce gastric disturbances and the +distrust felt as to its safety have prevented its becoming popular in +practice. + +Alcohol as an adjuvant to treatment is indicated in all cases, whether +quinia or salicylic acid or veratrum be simultaneously employed. It +stimulates and sustains the heart, it retards tissue-waste, and is in +itself an antipyretic of no mean value. Usually I give it in +conjunction with quinia, one or two teaspoonfuls hourly of either +whiskey, rum, or brandy, in accordance with the recommendation of +Breisky.[76] But many years before I had learned from my friend Prof. +Barker that the specific influence of veratrum was in many cases not +obtained until the use of alcohol was combined with it. + +[Footnote 76: _Ueber Alcohol und Chinin-behandlung_, Bern, 1875.] + +The antipyretic action of drugs is probably due for the most part to +some direct influence they exert upon the oxygenation of the tissues. +Of course the less the fire the less the heat. It is well, however, to +support their internal administration by the external employment of +cold. Cold owes its effect in fevers partly to the abstraction of heat +from the body-surface, and in a still more important degree to the +impression which it produces upon the nervous system. In healthy +persons the action of cold is to increase the consumption of oxygen +and the production of carbonic {1034} acid. The additional heat thus +generated renders it possible to sustain the vicissitudes of climate. +In fevers the primary effect of cold is similar in character. Its main +therapeutical action is derived from its secondary influence upon the +nerve-centre which regulates the body-heat. If the cold employed be +sufficiently intense or sufficiently prolonged, there follows, not +always immediately, but in the course of an hour or two, a marked +lowering of the temperature, which can only be accounted for by +assuming an indirect influence exerted through the sympathetic nerve +and the medulla oblongata. This peculiarity renders the external +application of cold a most valuable addition to the therapeutical +resources available in fevers. + +In cases of moderate severity frequently sponging the patient with +cold water will be found to be a grateful practice. An ice-cap to the +head, where the blood lies near the surface, will often affect the +entire temperature of the body. From immemorial times it has been +employed to control delirium and promote sleep. An ice-bag placed over +the inguinal region is locally beneficial to deep-seated pelvic +inflammations, and, according to Braun, is capable of effecting a +rapid fall of temperature. Ice-cold drinks should be freely allowed. + +Schroeder recommends a permanent stream of cold water in the uterine +cavity by means of a large irrigator and a drainage-tube; others +advise cold rectal injections maintained for long periods by the aid +of a tube with a double current. + +In fevers of great violence the systematic application of cold by +means of baths or the wet pack is capable in some cases of rendering +important service. The temperature of the bath should range from 70 +degrees to 80 degrees. Its duration should not exceed ten minutes. The +patient should, when removed to the bed, be wrapped in a sheet without +drying, and should be comfortably covered. In employing the wet pack +two beds should be placed side by side. The body and thighs of the +patient should be wrapped in a sheet wrung out in cold water, and be +allowed to remain in the pack from ten to twenty minutes. As the sheet +becomes heated the patient should be placed in a fresh one upon the +second bed, and the transfers should be continued until the desired +fall of temperature is effected. Braun claims that four packs are +equivalent in action to one full bath. + +Both these methods are, however, open to the objection that they +cannot be carried out without considerable disturbance of the +patient--a point of no small importance in cases of peritonitis. G. B. +Kibbie has invented a fever-cot which obviates the ordinary +difficulties of this mode of treatment. The cot is covered with "a +strong, elastic cotton netting, manufactured for the purpose, through +which water readily passes to the bottom below, which is of rubber +cloth so adjusted as to convey it to a vessel at the foot." T. G. +Thomas,[77] who has employed this apparatus extensively to reduce high +temperatures after ovariotomies, explains as follows the modus +operandi: "Upon this cot a folded blanket is laid, so as to protect +the patient's body from cutting by the cords of the netting, and at +one end is placed a pillow covered with india-rubber cloth, and a +folded sheet is laid across the middle of the cot about two-thirds of +its extent. Upon this the patient is now laid; her {1035} clothing is +lifted up to the armpits, and the body enveloped by the folded sheet, +which extends from the axillae to a little below the trochanters. The +legs are covered by flannel drawers and the feet by warm woollen +stockings, and against the soles of the latter bottles of warm water +are placed. Two blankets are then placed over her, and the application +of water is made. Turning the blankets down below the pelvis, the +physician now takes a large pitcher of water, at from 75 degrees to 80 +degrees, and pours it gently over the sheet. This it saturates, and +then, percolating the network, it is caught by the india-rubber apron +beneath, and, running down the gutter formed by this, is received in a +tub placed at its extremity for that purpose. Water at higher or lower +degrees of heat than this may be used. As a rule, it is better to +begin with a high temperature, 85 degrees, or even 90 degrees, and +gradually diminish it. The patient now lies in a thoroughly soaked +sheet, with warm bottles to her feet, and is covered up carefully with +dry blankets. Neither the portion of the thorax above the shoulders +nor the inferior extremities are wet at all. The water is applied only +to the trunk. The first effect of the affusion is often to elevate the +temperature--a fact noticed by Currie himself--but the next affusion, +practised at the end of an hour, pretty surely brings it down. It is +better to pour water at a moderate degree of coldness over the surface +for ten or fifteen minutes than to pour a colder fluid for a shorter +time. The water slowly poured robs the body of heat more surely than +when used in the other way. The water collected in the tub at the foot +of the bed, having passed over the body, is usually 8 degrees or 10 +degrees warmer than it was when poured from the pitcher. On one +occasion Dr. Van Vorst, my assistant, tells me that it had gained 12 +degrees. At the end of every hour the result of the affusion is tested +by the thermometer, and if the temperature has not fallen another +affusion is practised, and this is kept up until the temperature comes +down to 100 degrees, or even less. It must be appreciated that the +patient lies constantly in a cold wet sheet, but this never becomes a +fomentation, for the reason that as soon as it abstracts from the body +sufficient heat to do so it is again wet with cold water and goes on +still with its work of heat-abstraction. I have kept patients upon +this cot enveloped in the wet sheet for two and three weeks, without +discomfort to them and with the most marked control over the degree of +animal heat. Ordinarily, after the temperature has come down to 99 +degrees or 100 degrees, four or five hours will pass before affusion +again becomes necessary." + +[Footnote 77: "The Most Effectual Method of Controlling the High +Temperature occurring after Ovariotomy," _N.Y. Med. Jour._, August, +1878.] + +Since reading this account, I have made a good many trials of the +method upon puerperal women, and have not found that it agrees with +all in an equal degree. In some instances the affusions have been +followed, in spite of hot bottles to the feet and the administration +of stimulants, by such a degree of depression and impairment of +cardiac force, as shown by the persistent coldness of the extremities, +that it has been necessary to discontinue them. On the other hand, I +can look back upon cases, apparently so desperate that the condition +of the patients was looked upon as hopeless, where they proved the +means of saving life as by a miracle. Of course, the difference +depends upon whether the high temperature is the sole cause of the +alarming symptoms, or whether the latter are in part due to +blood-dissolution and secondary changes in the parenchymatous organs. + +{1036} The use of the coil in fever, whether of rubber or of metal +tubing, I can highly recommend. Either the night-dress or a towel +should be placed between the coil and the skin. A current of cold +water passing through the tube rapidly abstracts the surface heat, and +is usually grateful to the patient. The lowering of the temperature by +this means is much slower than by cold affusions. Disturbance of the +patient is, however, avoided, and the method, so far as I have tried +it, has been free from the objections incident to the direct +application of water to the skin. + +It is hardly necessary to state that in puerperal, as in other fevers, +the patient's strength requires to be sustained and the waste of +tissue to be repaired, as far as possible, by the regulated +administration of liquid food, as milk and beef-tea, in such +quantities as can be borne by the stomach, and at one to two hours' +intervals. + +In the treatment of encysted peritoneal effusions, and in inflammatory +exudations into the pelvic and adjacent cellular tissue, after the +acute symptoms have subsided the attention should be directed to the +afternoon fever and to promoting the assimilation of food. So soon as +the sweating and fever are checked the absorption of the plastic +materials begins. The most important agents for accomplishing this +object are quinia, in moderate doses, combined with some form of +alcohol and with tepid sponging. Deep-seated pain in the iliac region +is best relieved by a large blister upon the side over the point where +the tenderness is felt. Prolonged rest in bed should be enjoined. Even +after convalescence is well advanced, so long as the exudation remains +unabsorbed the resumption of household duties is pretty certain to be +followed by a relapse or by the development of a chronic condition of +a most intractable description. The sooner the patient's stomach can +be got to digest and absorb beefsteak and iron the more speedy will be +her recovery. + +In pelvic exudations the hot vaginal douche, warm baths, and the +application of flannels wrung out in water to the abdomen aid in +diminishing the local pain, and, perhaps, in causing a disappearance +of the tumor. The action of mercurials or of iodide of potassium in +melting away plastic inflammatory materials is sometimes very +striking, but more frequently they either do no good or else do harm +by disturbing the digestion. + +If fever, chills, and sweating announce the presence of pus, the most +careful exploration should be made to determine, if possible, the seat +of suppuration. It is of great advantage to treat pelvic abscesses as +abscesses are treated elsewhere in the body. If the redness of the +skin above Poupart's ligament indicates a tendency to point in that +direction, an aspirator-needle should be introduced to make sure of +the diagnosis. If the sac is near the surface, a free incision should +be made and the pus should be allowed to escape. In many cases I make +these incisions three to four inches in length. The redness of the +external skin makes it certain that the abscess has become adherent to +the abdominal wall, and that the incision consequently will not +communicate with the peritoneum. After the abscess has been opened it +should be cleansed twice daily, and the cavity should be filled with +oakum. If, after a time, the granulations become flabby, Peruvian +balsam or iodoform should be introduced into the sac at each change of +the dressing. I can recommend this plan as essentially a mild +procedure. With a large opening for the discharge of {1037} pus the +fever and sweating disappear, the appetite returns, and the abscess +fills rapidly by granulation. With a small incision hectic is apt to +persist, and the abscess to end in the formation of interminable +fistulae. + +If softening and bagginess or distinct fluctuation indicate that the +pus can be reached through the vaginal cul-de-sac, the +aspirator-needle should be inserted deeply at the suspected point, and +if a large amount of pus is detected, an incision should be made with +a long-handled bistoury, using the needle as a director, and making +the opening large enough to permit the introduction of a +drainage-tube. I prefer for this purpose a self-retaining Nelaton +catheter, which is easily passed by means of a uterine sound inserted +into the eye at the extremity. Through the tube--without disturbing +the patient--the pus-cavity can be washed as frequently as required, +and with drainage and cleanliness cases of the longest standing may be +expected to recover. + +P. F. Munde[78] has reported a number of cases of chronic character +where the aspiration of pus has been followed by rapid absorption of +the intra-pelvic exudation. The presence of pus was suspected because +of a boggy, doughy feeling in the exudation tumor. + +[Footnote 78: "Diagnosis and Treatment of Obscure Pelvic Abscess," +etc., _Arch. of Med._, December, 1880.] + + + + +{1038} + +BERIBERI. + +BY DUANE B. SIMMONS, M.D. + + +DEFINITION.--Beriberi is a disease of inanition, most common in +tropical countries, though found in high latitudes (41 degrees N.), +especially in low-lying seaboard towns, during the summer months, and +is both endemic and epidemic. It is usually chronic in form, but is +subject to exacerbations of varying degrees, and has for its +characteristic symptoms anaesthesia of the skin, hyperaesthesia and +paralysis of the muscles, anasarca, palpitation, cardiac and arterial +murmurs (in the wet form), praecordial oppression, and abdominal +pulsation. + +HISTORY AND GEOGRAPHICAL DISTRIBUTION.--It was for a long time +confounded with a great variety of other diseases. The Anglo-Indian +physicians of Ceylon and the Malabar coast were no doubt the first to +recognize the specific nature of the disease, though it is claimed +that Chinese medical works of the thirteenth century contain a fairly +accurate description of it. + +The literature of beriberi, at the first glance, appears to be very +meagre, as some of the most popular medical works make no mention of +the disease at all, while others only give it a passing notice. Its +bibliography, however, is very considerable, as may be seen in the +exhaustive list in Billings' _Index Catalogue_, but for want of space +we refer only to the most recent contributions to the subject. These +are--an article by A. LeRoy de Mericourt;[1] an essay by Tarissan, +entitled _Beriberi in Brazil_; an article by Anderson,[2] and an essay +by myself.[3] + +[Footnote 1: _Dictionnaire Encyclopedique des Sciences Medicales_, +Paris, 1876.] + +[Footnote 2: _Guy's Hospital Reports_.] + +[Footnote 3: _Chinese Maritime Customs Medical Report_ (1880).] + +For a long time beriberi was supposed to have a peculiar territorial +limitation. It is now known to be more or less prevalent on all the +islands and shores of Eastern Asia and Africa from Japan to the Cape +of Good Hope, and in Brazil. + +ETIOLOGY.--I know of no disease in regard to which a greater diversity +of opinion exists as to its cause. Indeed, as one has observed, +"autant d'auteurs, autant d'opinions diverses." Ten years' study and +observation of the malady under a great variety of circumstances and +conditions have led me to the definite conclusion that its exciting +cause is a specific poison or germ, having many striking resemblances +in its mode of production to paludal or marsh miasm, though entirely +distinct and separate from it. A great variety of predisposing causes, +however, exert a powerful influence in rendering individuals or +classes susceptible to the {1039} disease, such as age, sex,[4] +occupation, race, mode of life, diet, and climate. + +[Footnote 4: Women suffer from the disease much less frequently than +men.] + +CLINICAL HISTORY AND SYMPTOMS.--There are three forms of the disease: +1st. Beriberi hydrops (wet beriberi), in which there is a hydraemic +condition of the blood, distension of the general areolar tissue, with +serum, and effusion into the serous cavities. 2d. Beriberi atrophia +(dry or atrophic beriberi), in which there is a notable deficiency of +fluids in the vessels and areolar tissue, and atrophy of the muscles. +3d. Mixed beriberi, in which the above forms lose the sharp lines of +distinction and merge into each other. Cases complicated with +dysentery, diarrhoea, and especially with continued fevers of the +typhoid type, are not uncommon.[5] These last, besides being of grave +prognosis, are frequently very embarrassing and difficult of +diagnosis. + +[Footnote 5: Some authors have designated fatty or convulsive forms of +the disease, which I think unnecessary.] + +In general terms, wet beriberi may be divided into two stages--the +prodromic stage and the stage of attack; and into several types--the +acute or pernicious, and the chronic. From the very insidious nature +of the approach of the disease, sometimes extending over a period of +several weeks, it is often very difficult, or even impossible, to +determine the exact time of its invasion. It is generally admitted +that a residence of some weeks in an infected locality is necessary +before any decided symptoms make their appearance. As in many other +diseases of slow development, the symptoms of the prodromic stage are +certain not easily defined feelings of indisposition, such as an +occasional sense of chilliness, inaptitude for mental exertion, and +especially a tired feeling in the lower extremities. A period of +uncertain length now intervenes, during which the characteristic +symptoms appear and constitute the stage of attack. The first of these +symptoms is, generally, anaesthesia of the skin over the anterior +tibial muscles, in the tips of the fingers, and around the mouth, in +the order given. Paralysis in varying degrees next declares itself in +certain groups of muscles, usually those immediately underlying the +regions of anaesthesia. One of the consequences of this is a drooping +of the toes, causing the patient while walking to lift the feet high +so as to clear the ground, thus occasioning the peculiar gait noticed +by many observers as characteristic of the disease. A sense of +constriction in the muscles of the calves is experienced at the same +time, arising from a veritable contraction, which causes their +apparent enlargement and hardening, with tension of the tendo +achillis. A feeling of tightness in the chest usually accompanies this +condition, due, no doubt, to partial paralysis of the muscles of +respiration. If firm pressure be now made upon the muscles in various +parts of the body, a greater or less degree of tenderness will be +found to exist in many of them, and especially those occupying the +posterior part of the leg, back of the forearm, inside of the arm, and +upper part of the chest. Tenderness of the periosteum of the long +bones and a peculiar roughness of their surfaces often exist also. +Palpitation of the heart, especially on making any considerable +exertion, is a frequent and often troublesome symptom, even at this +stage of the disease. + +Up to this point the above symptoms are common to both the wet and +{1040} dry forms of the malady, and to them the characteristic +features either of beriberi hydrops or atrophia are now added. The +first manifestation of anasarca, the pathognomonic symptom of wet +beriberi, is in an oedematous condition of the areolar tissue of the +anterior part of the legs. This, in reality, is more or less general +even at an early stage of the disease, as is evident from the plump +appearance of the patient and a certain sallow-white color of the +skin, especially of that of the face. In uncomplicated cases the +temperature is normal, or it may be at times a little below the normal +point. There is also little or no increase in the frequency of the +pulse. Its quality, however, is changed, and somewhat characteristic +for both forms of the disease. Thus in the wet form it is full, large, +and easily compressible, indicating a great diminution of arterial +tone, while in the dry form there is nearly an opposite condition. If +the heart be now examined, a decided systolic murmur will be heard, +most distinctly over the pulmonary valves; and in most cases of wet +beriberi it exists in all the large arterial trunks. The heart +furnishes the usual signs of dilatation and want of tone. In the dry +form the cardiac murmurs are either slight or wanting altogether, and +the area of cardiac dulness is variable, and frequently diminishes as +the disease advances. + +In both wet and dry beriberi the appetite is little impaired in the +earlier stages, but if in the former the stomach is over-distended, +there is increased praecordial oppression, and sometimes sudden death. +The bowels in the wet form are sluggish, and urine scanty; in the +other there is but little deviation from the normal in these respects. + +The cases of the subacute type are by far the most numerous. From this +it is evident that the acute or pernicious type of the malady is, in +most cases, only an exaggeration of the subacute, as observed in some +other diseases, notably rheumatism and those of marsh malarial origin. +The term pernicious is, strictly speaking, applicable to the wet form +of the disease only, as the dry form is rarely, if ever, rapidly +fatal. A marked case of wet beriberi is always to be regarded as +dangerous, from the suddenness with which pernicious symptoms often +declare themselves. In these the anasarca (which, as has been stated, +constitutes the leading clinical difference between the two forms of +the malady) plays an important role. It often happens that in the +course of a few hours the local oedema in the extremities and the +slight puffiness of the face become general and extreme, and the neck +is enormously swollen by the distension of the veins, both deep and +superficial. The pleural and pericardial sacs are more or less +distended with serum, thus mechanically embarrassing the action of the +organs they contain. The action of the heart now becomes laborious, +the lungs oedematous and filled with coarse rales, and a terrible +sense of suffocation comes over the patient, causing him to seek +relief by constant change of position. The stomach is irritable, a +greenish-yellow fluid is vomited, and death closes the scene. The +acute stage of dry beriberi, on the contrary, is characterized by a +rapid diminution of the fluids of the body and muscular atrophy. + +The annual appearance in the same individual of either wet or dry +beriberi, and its long continuance, constitute the chronic type of the +disease. + +MORBID ANATOMY.--The morbid anatomical changes in beriberi vary +considerably with its form. Few, if any, observers claim seriously to +{1041} have found in either the wet or dry form of the disease +evidences of acute inflammatory action in any of the tissues or +organs. The blood undoubtedly undergoes important morbid changes, +whereby its nutritive and oxygenating power is impaired, indicating +that this is a disease of inanition. This shows itself most markedly +in necrobiotic and degenerative changes, especially in the muscular +tissues, which are the seat of the leading morbid phenomena in all +stages of both forms of this disease. The respiratory, digestive, and +glandular systems rarely undergo morbid changes other than those of a +secondary or passive kind, such as engorgement with serum and venous +blood. + +The condition of the organs contained in the cranial and spinal +cavities is variable and inconstant. According to some observers, the +substance of the brain and spinal cord is hardened. The greater number +by far, however, have found it more or less softened.[6] The heart in +wet beriberi is habitually large and flabby, its muscular tissue +softened and of a pale-yellow and macerated appearance. Its cavities +are engorged with dark blood, sometimes fluid, but more often clotted. +These clots are often voluminous in the right heart, semi-fibrinous, +and extend into the pulmonary artery and great venous trunks, which +are enormously enlarged. The cardiac muscular tissue I always found to +have undergone metamorphic changes, varying from granular clouding to +advanced fatty degeneration.[7] The tissue of the paralyzed voluntary +muscles undergoes degenerative changes in both forms of the disease. +In the extreme atrophy of dry beriberi I have not unfrequently found +many of the sarcolemma sheaths completely emptied of their contents. +The power of regeneration in these cases is often wonderfully +displayed by an almost complete restoration of the lost elements, and, +in a corresponding degree, of the function of the part. + +[Footnote 6: The former condition was undoubtedly observed in +autopsies made of the dry or atrophic form of the disease, though this +fact is not mentioned. The latter, or softened, condition of the +cerebro-spinal contents belongs to the wet form of the disease (my own +cases being of this kind). I regard this softening as not ante-mortem, +but as consecutive to serous imbibition (as observed by Eismann and +Sanders in chlorosis), and as taking place during the last moments of +life or after death, when the vital forces no longer oppose themselves +to the mechanical disintegrating power of the fluid with which the +nervous as well as all the other tissues of the body are engorged.] + +[Footnote 7: I believe this to be the condition of the heart-muscle in +all cases of death from the wet form of beriberi. In this opinion I am +supported by Oudenhoven and many of the Dutch observers.] + +It would appear that in wet beriberi the heart is first weakened by +paresis of the cardiac ganglia, with consequent incomplete emptying of +its cavities. This, in connection with rapid degenerative changes in +its muscular tissue, causes the walls to yield to the blood-pressure, +producing dilatation and tricuspid insufficiency, with regurgitation +and consequent capillary stasis and dropsy. Vaso-motor +nerve-paralysis, acting at the same time on the pulmonary artery and +arterioles, and on other large arterial trunks, probably gives rise to +the murmurs heard in them. In the dry form of the disease the +vaso-motor nerve-paralysis is less pronounced, and the degenerative +changes in the muscular tissue of the heart slower, while the marked +decrease in the fluids of the system and the great failure of +nutrition tend toward atrophic changes. From this it follows that we +usually have, instead of a large dilated heart, a small weak one, with +a narrow tricuspid orifice instead of a dilated one; little or no +{1042} intercostal pulsation, and hence less cardiac dulness; no +venous distension or capillary stasis, and hence no dropsy. + +PROGNOSIS.--In temperate climates the prognosis of uncomplicated +beriberi is favorable in a majority of cases. In seasons of its +epidemic prevalence, however, all cases of the wet form of the disease +must be carefully watched, as it not unfrequently happens that grave +symptoms suddenly appear at a time when no danger has been +anticipated. An unfavorable prognosis may be ventured when, in a case +of wet beriberi, relief is not obtained by free purging or when +vomiting sets in. In dry beriberi the termination in death is +exceedingly rare as a direct result of the action of the poison +producing the disease, so that when death does occur it is chiefly +from exhaustion. The time of recovery depends on the amount of +muscular degeneration, and also upon the season of the year when the +attack occurred, as all cases of both forms of beriberi usually get +well without treatment during the winter months. + +TREATMENT.--The well-established fact of the influence of certain +localities in the production of beriberi makes the removal of the +patient from them a hygienic measure of great importance, and this is +frequently the only treatment necessary if it can be done early. The +effect of the change is often almost magical, especially if it be made +to an elevated locality and among the mountains. + +Diet is an important element in the treatment of beriberi. At the head +of the list of foods to be avoided is rice. Coarsely prepared grains, +such as wheat, barley, certain kinds of beans,[8] apparently because +of more or less laxative properties, are preferable as articles of +food. + +[Footnote 8: A small red bean called adzuke, possessing both laxative +and diuretic properties, is a favorite remedy with the Japanese for +beriberi. It is used alone or mixed with rice, and is not unfrequently +the only means resorted to for the successful cure of mild cases.] + +No drug has been discovered possessing specific properties in this +disease. In the wet form, medication consists in the administration of +drugs calculated to draw off the excess of serum in the areolar +tissues and in the serous sacs. First in point of efficacy for this +purpose are the hydragogue cathartics. In my own practice the sulphate +of magnesia, in large and repeated doses, has given the best results; +elaterium, a powder of jalap, squill, and digitalis, and, in fact, any +medicine which will give frequent and copious stools, are sure to +afford marked relief to the more urgent symptoms, and in many cases +will alone effect a cure. Care must be taken, however, not to exhaust +the patient, though I have never seen the judicious use of this method +of treatment do harm. + +Copious bleeding is recommended by Anderson, especially in the stage +of greatest danger, but I have never been able to convince myself of +its safety. + +The almost specific virtue claimed by the old Indian physicians for +treeak farook is no doubt due to its cathartic properties. + +Diuretics are indicated for the same reason as cathartics, and any of +the more active are productive of good results. They are too slow in +their action, however, to be relied on otherwise than as adjuvants to +cathartics. I have found juniper gin to answer an excellent purpose, +both as a stimulant and diuretic, where there was danger of exhaustion +from the free use of cathartics. + +The medical treatment of dry beriberi differs materially from that of +{1043} the wet disease. Cathartics and diuretics are alike useless, +and the former injurious. The ordinary means, such as electricity, +strychnia, frictions, etc., employed in cases of muscular atrophy and +paralysis from other causes, are indicated when the active stage has +passed, but they are useless, and even injurious, before this time. +The muscular hyperaesthesia common to both forms of the disease may be +generally greatly relieved by anodyne liniments containing aconite. +The internal use of the latter is highly recommended by some. +Hypodermic injections of morphia afford relief to the painful sense of +constriction in the calves of the legs so often complained of. + + + + +{1045} + +INDEX TO VOLUME I. + + +A. + +Abdomen, state of, in cholera, 741 + in general peritonitis of puerperal fever, 1010 + in relapsing fever, 390 + in septicaemia, 977 + in septicaemia lymphatica, 1011 + in septicaemia venosa, 1012 + +Abdominal cavity, lesions of, in general peritonitis of puerperal + fever, 989 + glands, lesions of, in typhoid fever, 264 + organs, alterations of, in scarlet fever, 531 + +Abortion from septicaemia, 972 + +Abortive form of the plague, 777 + of relapsing fever, 395 + of typhoid fever, 298 + of typhus fever, 354 + +Abortive treatment of erysipelas, value, 638 + +Abscess in symptomatic parotitis, date of pointing, 627 + metastatic, of lungs, complicating relapsing fever, 404 + +Abscesses complicating cholera, 735 + variola, 445 + following the plague, 781 + frequency of, in pyaemia, 976 + in erysipelas, treatment, 638 + in para- and perimetritis, 1008 + in puerperal fever, 989 + metastatic, of pyaemia, modes of production, 963 + of pyaemia, treatment, 981 + pelvic, of puerperal fever, treatment, 1036 + pulmonary, in puerperal fever, 989 + +Acids, mineral, use of, in cholera, 768 + +Aconite, use of, in rubeola, 580 + in scarlet fever, 543 + in yellow fever, 651 + +Acute diseases, relation of, to rubeola, 561 + form of glanders in man, 920 + in horse, 914 + +Adenitis complicating scarlet fever, 511 + vaccination, 468 + +Adenopathy complicating erysipelas, 634 + +Adhesions from infiltration, 55 + +Adulteration of food, 197 + +Adynamic form of typhus fever, 354 + +Age, influence of, on causation of anthrax in man, 940 + of cerebro-spinal meningitis, 802 + of diphtheria, 680 + of erysipelas, 630 + of influenza, 860 + of idiopathic parotitis, 620 + of the plague, 775 + of pertussis, 839 + of relapsing fever, 371 + of rotheln, 583 + of rubeola, 561 + of typhoid fever, 242 + of typhus fever, 342 + proper for vaccination, 477 + +Aged, typhoid fever in the, 301 + +Agminated glands, lesions of, in cholera, 745 + +Air, amount supplied in ventilation, 179 + carbonic acid as a cause of impurity, 177 + -currents, direction of, test, 178 + distribution of, in ventilation, 180 + estimation of carbonic acid, 178 + fresh, value of, in convalescence, 206 + humidity of, as a cause of disease, 133 + impure, as a cause of disease, 177 + influence of, on causation of glanders, 912 + impurities of, due to offensive effluvia, 181 + sources of impurity, 177 + standards of impurity, 178 + transmission of the plague by, 776 + velocity of, in ventilation, 180 + vitiated, as a cause of pyaemia, 959 + supply, method of calculating amount of, in ventilation, 179 + +Albuminoid infiltration, 72 + +Albuminuria complicating diphtheria, 674 + relapsing fever, 407 + scarlet fever, 525 + typhus fever, 355 + following rubeola, 574 + in typhoid fever, treatment, 334 + +Alcohol, use of, in algid form of pernicious malarial fever, 608 + in anthrax, 938, 944 + in cerebro-spinal meningitis, 831 + in cholera, 767 + in influenza, 876 + in puerperal fever, 1033 + in pyaemia, 982 + in scarlet fever, 544 + in typhoid fever, 324 + in typhus fever, 366 + +Algid form of pernicious malarial fever, 606 + causes of death, 607 + frequency, 607 + mortality-rate, 607 + symptoms, 606 + treatment, 607 + +Alum, use of, in pertussis, 845 + +Ammonium bromide, use of, in pertussis, 846 + carbonate, use of, in scarlet fever, 544 + chloride, use of, in diphtheria, 704, 705 + +Amyloid bodies, 86 + degeneration, 84 + +Anaesthesia of skin in beriberi, 1039 + significance of, in general diagnosis, 165 + +Anaesthetic form of leprosy, 790 + +Analysis of urine, importance of, in general diagnosis, 165 + +Anasarca, 69 + complicating scarlet fever, 529 + date of appearance in scarlet fever, 529 + in beriberi, 1040 + +Anginose form of anthrax, 941 + of scarlet fever, 510 + +Animals, cerebro-spinal meningitis in, 804 + diphtheria in, 683 + transmission of diphtheria from, 683 + +Animal vaccine, advantages, 475 + +Anodyne liniments, use of, in beriberi, 1043 + +Anorexia in relapsing fever, 389 + in typhoid fever, 285 + in typhus fever, 350 + significance of, in general diagnosis, 162 + +ANTHRAX, OR MALIGNANT PUSTULE, 926 + Synonyms, 926 + Definition, 926 + History, 926 + Geographical distribution, 926 + Etiology--specific origin, 928 + Modes of transmission, 928 + Transmission from eating flesh of anthrax animals, 928 + by milk, 929 + by insects, 929 + by alkaline soils, 929 + Season, relation of, to causation, 931 + Plethora, relation of, to causation, 931 + Sex, relation of, to causation, 931 + Age, relation of, to causation, 931 + Bacillus, 931 + relation to causation, 931 + physical characters, 932 + effect of heat and cold on activity, 933 + effect of oxygen on activity, 933 + mode of entering body, 933 + effect on blood-vessels, 934 + Forms, 934 + Symptoms--Incubation period, 934 + duration of, 934 + Apoplectiform form, 934 + Anthrax fever, 934 + Localized external anthrax, 935 + Character and seat of lesions, 935 + Morbid anatomy--changes in blood, 935 + Spleen, 935 + Lymphatic glands, 935 + Connective tissue and muscles, 935 + Gastro-intestinal tract, 936 + Vagina and uterus, 936 + Liver and kidneys, 936 + Diagnosis--from other bacteridian diseases, 936 + Swine plague, 936 + Prognosis, 936 + Mortality, 936 + Treatment, 937 + Preventive, 936 + Drainage of anthrax soil, 937 + Disinfection of stables, etc., 937 + Disposal of carcases of sick animals, 937 + Isolation, 937 + By inoculation, 937 + Methods of, 937 + Pasteur's method, 937 + Dangers in, 938 + General, alcohol, 938 + Use of carbolic acid, 938 + nitro-muriatic acid, 938 + potassium iodide, hypodermically, 938 + quinia sulphate, hypodermically, 938 + Local, 938 + Cauterization, 938 + Incision of nodule, 938 + +_Anthrax or Malignant Pustule in Man_, 939 + Synonyms, 939 + History, 939 + Etiology, 939 + Origin from lower animals, 939 + Modes of infection, 939 + direct, 939 + by handling sick animals, 939 + by insect-bites, etc., 939 + by food, 939 + by blood, 939 + by air, 939 + Occupation, relation of, to causation, 939 + Age and sex, relation of, to causation, 940 + Relative susceptibility of man and animals, 940 + Forms, 940 + Symptoms--of incubation period, 940 + Local lesions, 940 + Temperature, 940 + Relation of, to local lesions, 940 + Malignant anthrax, 940 + Symptoms, 940 + local, 940, 941 + general, 941 + Anthrax intestinalis, 941 + Symptoms, 941 + general, 941 + eruptions, 941 + gastro-intestinal tract, 941 + nervous system, 941 + Duration, 941 + Anthrax angina, 941 + Symptoms, 941 + general, 941 + local, 941 + Duration, 941 + Morbid anatomy, 941 + Changes in blood, 942 + Spleen, 942 + Lymphatic glands, 942 + Liver and kidneys, 942 + Skin and mucous membranes, 942 + Appearance of pustule, 942 + Position of bacillus, 942 + Diagnosis--signs, pathognomonic of, 942 + From bites of insects, 942 + Boils and carbuncles, 942 + Plague-boil, 942 + Glanderous nodule, 942 + Importance of detection of bacillus, 942 + Of malignant anthrax oedema, 942 + Internal anthrax, 943 + Prognosis, 943 + Mortality, 943 + Treatment--Preventive, 943 + Disinfection, 943 + Local, 943 + Cauterization of preliminary papule in external form, 943 + Method of cauterization, 943 + Excision of parent nucleus, 943 + Caustics used in, 943 + Hypodermic injections into swelling, 943 + Constitutional, 944 + Carbolic acid, use of, 944 + Alcohol, use of, 944 + Diet, 944 + Of anthrax oedema, 944 + +Antipyretics, use of, in relapsing fever, 428 + in cerebro-spinal meningitis, 833 + +Antisepsis in septicaemia, 983 + value of, in prevention of puerperal fever, 1024 + +Antiseptic treatment of scarlet fever, 545 + +Antiseptics, use of, in cholera, 770 + in glanders in man, 924 + in pyaemia, 980 + +Aphasia in cerebro-spinal meningitis, 810 + +Apoplectic form of anthrax in animals, 934 + +Appetite in cerebro-spinal meningitis, 814 + as a guide to necessary amount of food, 195 + loss of, significance, in general diagnosis, 162 + +Arcus senilis, significance, in general diagnosis, 151 + +Argyria, 93 + +Arsenic, use of, in relapsing fever, 427 + +Arsenical poison as cause of obscure diseases, 193 + +Arterial emboli, 63 + murmur in beriberi, 1040 + thrombosis following typhoid fever, 293 + +Arteritis from thrombosis, 61 + in pyaemia, 967 + +Articular enlargement, significance of, in general diagnosis, 160 + +Artificial alimentation in diphtheria, 713 + +Asthenic form of simple continued fever, 233 + of inflammation, 46 + +Ataxic form of typhus fever, 354 + +Ataxo-adynamic form of typhus fever, 354 + +Atmosphere, impure, influence of, on causation of puerperal fever, + 1013, 1014 + necessity of, for prevention of pyaemia and septicaemia, 980 + +Atmospheric variations as a cause of diphtheria, 682 + +Atrophy following diphtheritic paralysis, 676 + +Atropia, use of, in relapsing fever, 429 + +Auditory nerve, lesion of, in cerebro-spinal meningitis, 824 + + +B. + +Bacillus of anthrax, characters of, 931, 932 + mode of entering body, 933 + of glanders, 914 + of pearly distemper, innocuousness of, from cooking, 105 + species of, 142 + tuberculosis, 99 _et seq._ + description, 100 + duration of effects, 104 + cultivation, 100 + local and general effects of invasion, 103 + methods of detection, 102 + milk as a means of dissemination, 105 + mode of entrance into intestinal canal, 104 + into respiratory organs, 104 + typhosus, 258 + +Bacteria in healthy bodies, 144 + influence of, on causation of pyaemia, 958 + liability to error, from minuteness, 143 + of cholera, 748 + of leprosy, 791 + of puerperal fever, 995 + +Bacterium termo as a cause of putrefaction, 142 + +Barometric variations, influence of, on course and causation of + disease, 134 + +Bartholini's glands, suppuration of, complicating typhoid fever, 296 + +Baths, cold, use of, in puerperal fever, 1034 + in relapsing fever, 428 + warm, use of, in hydrophobia, 907 + in variola, 453 + +Bed-linen, as a means of disseminating typhoid fever, 253 + +Bed-sores, complicating relapsing fever, 400 + typhoid fever, 297 + typhus fever, 355 + in typhoid fever, treatment of, 335 + +Belladonna as a prophylactic in scarlet fever, 536 + use of, in cerebro-spinal meningitis, 833 + in pertussis, 846 + +Benignant tumors, 114 + +Benzoic acid as a prophylactic in scarlet fever, 537 + +BERIBERI, 1038 + Definition, 1038 + Geographical distribution, 1038 + History, 1038 + Etiology--Specific poison, 1038 + resemblance of, to marsh-miasm, 1038 + Predisposing causes, 1039 + Varieties, 1039 + Symptoms--Anaesthesia of skin, 1039 + Muscular paralysis, 1039 + Peculiarity of gait, 1039 + Cramps, 1039 + Muscular tenderness, 1039 + Periosteal tenderness, 1039 + Palpitation of heart, 1039 + Symptoms, special--Of wet form, 1040 + Anasarca, 1040 + Quality of pulse, 1040 + Cardiac murmur, 1040 + Arterial murmur, 1040 + Of dry form, 1040 + Quality of pulse, 1040 + Condition of heart, 1040 + Morbid anatomy, 1040 + Alterations in blood, 1041 + Heart, 1041 + Muscles, 1041 + Prognosis, 1042 + Treatment--By change of residence, 1042 + By diet, 1042 + Of wet form by hydragogue cathartics, 1042 + Sulphate of magnesium, 1042 + Elaterium, 1042 + Treeak farook, 1042 + Diuretics, 1042 + Juniper gin, 1042 + Of the dry form by electricity, 1043 + Strychnia, 1043 + Frictions, 1043 + Use of anodyne liniments, 1043 + Use of hypodermics of morphia, 1043 + +Bites of rabid dogs, treatment, 905 + +Bladder, diphtheria of, general sepsis from, 674 + lesions of, in rabies, 903 + in relapsing fever, 414 + symptoms of diphtheria of, 674 + +Blindness in cerebro-spinal meningitis, 811 + +Blisters, use of, in cerebro-spinal meningitis, 830 + +Blood, alterations of, in anthrax, 935-942 + in beriberi, 1041 + in cerebro-spinal meningitis, 824 + in cholera, 747 + in pyaemia, 968 + in relapsing fever, 411 + in scarlet fever, 530 + in septicaemia, 971 + in typhoid fever, 268 + in typhus fever, 356 + altered, as a cause of symptomatic parotitis, 626 + condition of, in pyaemia, 963 + contamination of, sources, in pyaemia, 958 + degeneration of, complicating diphtheria, 675 + +Blood-vessels, calcification of, 88, 90 + changes in inflammation, 43 + lesions of, in typhoid fever, 267 + new formation of, 55 + +Body, portion of, most suitable for vaccinating, 477 + +Bones, chronic diseases of, following rubeola, 574 + cranial, lesions of, in symptomatic parotitis, 626 + in glanders, 922 + in pyaemia, 967 + +Bone-marrow, lesions of, in relapsing fever, 417 + +Boric acid, use of, in diphtheria, 709 + +Bovine vaccine, 473 + +Bowels, state of, in relapsing fever, 390 + in remittent fever, 602 + condition of, in typhus fever, 350 + +Brain, lesions of, in cerebro-spinal meningitis, 823 + in cholera, 746 + in glanders, 923 + in relapsing fever, 413 + in typhoid fever, 266 + in typhus fever, 358 + and membranes, lesions of, in cerebro-spinal meningitis, 822 + in pyaemia, 966 + and spinal cord, lesions of, in rabies and hydrophobia, 903 + softening of, following cerebro-spinal meningitis, 820 + +Breath, odor of, in typhus fever, 353 + +Bright's disease, aggravation of, by influenza, 870 + +Bromine, use of, in diphtheria, 708 + +Bromide of potassium, use of, in relapsing fever, 430 + +Bronchi, lesions of, in rabies and hydrophobia, 902 + symptoms of formation of diphtheritic membrane, 671 + +Bronchial glands, lesions of, in influenza, 872 + +Bronchitis, complicating influenza, 868 + rubeola, 571 + typhoid fever, 294 + typhus fever, 355 + frequency of, in typhoid fever, 277 + in rubeola, treatment, 581 + in septicaemia, 977 + in typhus fever, 353, 354 + +Broncho-pneumonia, complicating diphtheria, 672 + +Bryce's test of vaccinal infection, 461 + +Buboes, characters of, in grave form of the plague, 778 + date of appearance of, in grave form of the plague, 778 + of the plague, treatment, 784 + pathology of, in the plague, 781 + seat of, in grave form of the plague, 778 + + +C. + +Cadaveric rigidity after cholera, 741 + +Caecum and colon, lesions of, in typhoid fever, 263 + +Calcification, 87 + causes, 87 + of blood-vessels, 88, 90 + of thrombi, 60, 89 + +Calabar bean, use of, in cerebro-spinal meningitis, 834 + +Calm stage of yellow fever, 645 + +Calomel as a specific in typhoid fever, 336 + use of, in cholera, 766 + in hemorrhagic form of pernicious malarial fever, 613 + +Camphor, use of, in cholera, 768 + +Cancer, 117, 123 + hereditary nature, 129 + relation of, to epithelial tumors, 118 + +Capillary bronchitis, complicating influenza, 868 + +Capillaries, intestinal, lesions of, in cholera, 745 + +Carbolic acid, use of, in anthrax, 938 + in diphtheria, 707 + in glanders, 924 + in scarlet fever, 545 + +Carbonic acid, as a cause of impure air, 177 + amount of, in pure and impure air, 178 + +Carbuncles, character of, in grave form of the plague, 778 + seat of, in grave form of plague, 778 + +Cardiac degeneration, complicating diphtheria, 675 + following typhoid fever, 293 + complicating typhus fever, 355 + dilatation, complicating scarlet fever, 523 + inflammation, complicating scarlet fever, 522 + murmur in beriberi, 1040 + sounds in typhoid fever, 276 + thrombi in diphtheria, 687 + +Caseation, 79 + +Cataract, hereditary, nature, 129 + +Catarrh, absence of, in rubeola, 568 + of influenza, treatment, 874 + +Catarrhal affections as predisposing causes of pertussis, 839 + inflammation, 52 + pneumonia, complicating influenza, 869 + pock in vaccinia, 463 + symptoms in influenza, 866 + in prodromal stage of rubeola, 564 + +Causes of otitis in scarlet fever, 520 + +Caustics, use of, in hydrophobia, 905 + +Cauterization, use of, in external anthrax, 938, 943 + +Cathartics, use of, in wet beriberi, 1042 + in scarlet fever, 554 + +Cellular tissue, lesions of, in pyaemia, 966 + +Cellulitis, pelvic, in puerperal fever, 988 + +Cerebral softening from embolism, 65 + symptoms in yellow fever, 644 + +Cerebro-spinal meningitis, 795 + +Certificates of death, duty of a physician in regard to, 210 + +Cesspools beneath dwellings, dangers of, 192 + contamination of water by, 192 + evils of, 126 + +Change of residence as cause of typhoid fever, 244 + +Cheesy degeneration, 79 + metamorphosis, 79 + +Chicken-pox, 481 + +Child-bed fever, relation to erysipelas, 630 + +Childhood, influence of, on occurrence of pertussis, 839 + +Children, causes of frequency of diphtheria in, 682 + typhoid fever in, 301 + +Chills in pyaemia, 973 + +Chinolin, use of, in diphtheria, 703 + +Chloral hydrate, use of, in cerebro-spinal meningitis, 834 + in hydrophobia, 907 + in pertussis, 846 + in relapsing fever, 430 + +Chloride test for detecting pollution of water-supply, 192 + +Chloroform, use of, in cholera, 768 + in hydrophobia, 907 + in relapsing fever, 431 + +CHOLERA, 715 + Definition, 715 + Synonyms, 715 + History, 715 _et seq._ + Etiology--predisposing causes, 720 + Influence of high temperature in origin and spread, 720 + Season, influence of, on causation, 720 + Over-crowding and filth as causes, 720 + Intemperance as a cause, 721 + Contagiousness, 721 + Modes of transmission, 721 + Channels of entrance into system, 721 + Propagation of, by fomites, 721 + by drinking-water, 723 + Cases illustrating spread of, by drinking-water, 724 + Influence of height of subsoil-water on prevalence, 722 + Humidity of soil as a cause, 722 + Special fomites of, 723 + Cases illustrating spread of, by fomites, 727 + Cases illustrating contagiousness, 728 + Objections to contagious nature, 729 + Individual immunity, 730 + Different grades of, from intensity of poison, 731 + Specific origin, 747 + Nature of poison, 748 + Influence of bacteria in production, 748 + Koch's investigations in regard to bacilli, 745, 749 + Symptoms, 731 + Mild forms, 732 + "Cholerine" stage, 732 + Number of stools in mild forms, 732 + Character of stools in mild forms, 732 + Grave forms, 733 + Physiognomy in grave forms, 733 + Stools in grave forms, 733 + Typhoid state, 734 + Stage of collapse, 734 + Reaction, 734 + Convalescence, 735 + Temperature, 736 + Difference between axillary, vaginal, and rectal temperature, 736 + Special symptoms--Low temperature of mouth, 736 + Condition of skin, 736 + Color of skin, 737 + Condition of heart and pulse, 737 + Veins, 737 + Vomiting, 738 + Character of vomit, 738 + Diarrhoea, 738 + Results of diarrhoea, 738 + Characters of stools, 739 + Condition of urine, 739 + Cramps, 740 + Causes of cramps, 740 + State of abdomen, 741 + of nervous system, 741 + Complications and sequelae, 735 + Complicated by diphtheritic exudations, 735 + Inflammation of parotid and submaxillary glands, 735 + Abscesses and ulcers, 735 + Cutaneous eruptions, 735 + Morbid anatomy--general appearance after death, 741 + Cadaveric rigidity, 741 + Muscular contractions after death, 741 + Appearance, post-mortem, of abdominal cavity, 743 + Changes in stomach, 743 + Intestinal canal, 743 + Intestinal mucous membrane, 743 + Nature of exfoliation from intestinal canal, 744 + Changes in isolated and agminated glands, 745 + Capillaries and veins of intestinal canal, 745 + Liver, 745 + Gall-bladder, 746 + Spleen, 746 + Heart, 746 + Pericardium, 747 + Lungs, 746 + Brain and spinal marrow, 746 + Kidneys, 746 + Blood, 747 + Diagnosis--from cholera morbus, 750 + from irritant poisoning, 752 + Order of symptoms as a ground for, 753 + Prognosis, 753 + Symptoms indicating favorable and unfavorable, 754 + Mortality--in different epidemics, 754 + Influence of age, 754 + Sex, 754 + Social condition, 754 + Treatment, 759 + Preventive, 755 + Disinfection, 758 + Modes of applying disinfectants, 758 + Importance of maintaining high degree of health during + epidemics, 758 + Quarantine and sanitary cordons for prevention, 755 _et seq._ + Mode of carrying out quarantine, 757 + Cases illustrating value of quarantine, 757 + Use of drinking-water during epidemics, 759 + General management, 760 + Importance of early recognition, 732 + Necessity of rest, 760 + of prompt, 760 + Diarrhoea, 760 + Vomiting, 761 + Hiccough, 762 + Injection of sodium chloride into veins, 762 + Stage of collapse, 763 + Diet of stage of reaction, 763 + For restoration of circulation in stage of collapse, 763 + Stage of reaction, 763 + Undue reaction, 764 + Urinary suppression in stage of reaction, 764 + Convalescence, 764 + Use of venesection in, 764 + Emetics, 765 + Calomel, 766 + Alcohol, 767 + Opiates, 767 + Mineral acids, 768 + Camphor, 768 + Chloroform, 768 + Intravenous injections, 768 + Hot applications, 769 + Cold affusions, 769 + Of cramps, 769 + Necessity of cold water to allay thirst, 770 + Use of antiseptic remedies, 770 + +Cholerine, 732 + +Chorea, following typhoid fever, 293 + +Chronic diseases, relation of, to rubeola, 561 + forms of erysipelas, 634 + of glanders, 915, 923 + +Cicatrix, condition during incubation of hydrophobia, 895 + in hydrophobia, excision, 906-908 + in vaccinia, description, 460 + +Classification of puerperal inflammations, 986 + +Cleanliness, importance of, in prevention of pyaemia, 980 + in variola, 454 + +Climate, as a cause of disease, 185 + definition of term, 185 + influence of, on causation of influenza, 860 + on causation of rabies and hydrophobia, 887 + of rubeola, 560 + +Clinical history of influenza, 864 + +Clothing as a cause of disease, 198 + +Cloudy swelling, 72 + +Coagulation of exudations, 43 + +Cohnheim's theory of production of morbid growths, 106 + +Colchicum, use of, in dengue, 885 + +Cold as a cause of disease, 133 + and damp, influence of, on causation of glanders, 912 + bath, use of, in diphtheria, 702 + in puerperal fever, 1034 + in typhoid fever, 327 + Contra-indications to use of, in diphtheria, 703 + Use of, in algid form of pernicious malarial fever, 608 + in cerebro-spinal meningitis, 830 + in cholera, 769 + in diphtheria, 702 + in puerperal fever, 1033 + in the hyperpyrexia of scarlet fever, 541 + in scarlet fever, 542 + in yellow fever, 651 + water, intra-uterine injections of, in puerperal fever, 1034 + mode of applying, in scarlet fever, 542 + +Cold stage of intermittent fever, 592 + of intermittent fever, theory of cause, 593 + treatment, 594 + of yellow fever, treatment, 653 + +Cold water, use of, in typhus fever, 364 + +Collapse in cerebro-spinal meningitis, treatment, 831 + in cholera, 734 + treatment, 763 + of lungs, complicating influenza, 869 + +Collections of water, influence on health of a community, 187 + +Colloid degeneration, 83 + metamorphosis, 83 + +Color of skin, significance of, in general diagnosis, 159 + +Coma, in cerebro-spinal meningitis, 812 + significance of, in general diagnosis, 166 + +Comatose form of pernicious malarial fever, 608 + Diagnosis, 609 + Symptoms, 609 + Treatment, 609 + +Coma-vigil in typhus fever, 349 + +Compresses, hot water, use of, in variola, 453 + +Complications of cholera, 735 + of erysipelas, 633 + of idiopathic parotitis, 623 + of influenza, 868 + of pertussis, 843 + of plague, 780 + of relapsing fever, 396-410 + of rotheln, 587 + of rubeola, 570 + causes, 570 + of scarlet fever, 510 + of typhoid fever, 292 + treatment, 335 + of vaccination, 468 + of vaccinia, 464 + of varicella, 483 + of variola, 445 + +Confluent small-pox, 440 + +Conjunctiva, condition of, in human glanders, 921 + symptoms of diphtheria of, 670 + +Conjunctival diphtheria, local treatment, 712 + +Conjunctivitis, diphtheritic, symptoms, 670 + +Consanguineous marriages, effects, 131 + +Constipation in cerebro-spinal meningitis, 814 + in grave form of the plague, 779 + in rubeola, treatment, 581 + in typhoid fever, treatment, 333 + in typhus fever, treatment, 367 + significance of, in general diagnosis, 163 + +Constitutional infection, absence of, in vaccinia, 460 + of syphilis, hereditary nature, 127 + taints, conveyance of, by vaccination, 471 + treatment of anthrax, 944 + of pyaemia, 982 + +Contagion as a cause of disease, 135, 200 + definition of, 200 + of dengue, 884 + of erysipelas, manner of propagation, 630 + nature, 630 + of influenza, 862 + of relapsing fever, transmission, 373 + of rabies and hydrophobia, 891 + dissemination, 891 + of rotheln, nature, 583 + of rubeola, modes of dissemination, 558 + mode of entering the body, 558 + nature, 557 + in typhus fever, nature, 343 + modes of transmission, 344 + +Contagium of variola, duration of activity, 435 + mode of entering body, 435 + nature, 435 + period of greatest activity, 435 + +Contagious diseases, characteristics, 137 + +Contagious nature of cholera, objections to, 729 + +Contagiousness of anthrax, 928 + of cerebro-spinal meningitis, 803 + of cholera, 721 + of dengue, 884 + of diphtheria, 678 + of erysipelas, 630 + of glanders, 911 + of influenza, 862, 863 + of leprosy, 788 + of the plague, 776 + of puerperal fever, 1017 + of pyaemia, 960 + of rabies and hydrophobia, 891 + of scarlet fever, 494 + of typhoid fever, 248 + of typhus fever, 343 + period of greatest, 345 + of varicella, 481 + of variola, 435 + +Convalescence, choice of diet, 206 + in cerebro-spinal meningitis, 819 + management, 835 + in cholera, 735 + management, 764 + in chronic glanders in man, 922 + in dengue, 882 + in grave form of the plague, 779 + in erysipelas, management, 639 + in influenza, treatment, 875 + in relapsing fever, 393 + in scarlet fever, management, 544 + in typhoid fever, management, 335 + in typhus fever, management, 368 + +Convulsions during hot stage of intermittent fever, treatment, 597 + in cerebro-spinal meningitis, 810 + in relapsing fever, 384 + complicating rubeola, 572 + in prodromal stage of rubeola, 565 + in rubeola, treatment, 581 + in yellow fever, treatment, 653 + +Cooking, necessity of a physician's knowledge of, 196 + +Corpuscles, pus-, 43 + +Corrosive sublimate, use of, as antiseptic in puerperal fever, 1025, + 1029 + +Coryza, chronic, following rubeola, 574 + complicating scarlet fever, 520 + of scarlet fever, treatment, 546 + +Cough, in rubeola, treatment, 581 + significance of, in general diagnosis, 158 + +Counterirritants, use of, in pertussis, 848 + +Course of vaccinia, 458 + irregularities, 460 + +Cow-pox, 456 + spontaneous, 456 + +Cramps in beriberi, 1039 + in cholera, 740 + treatment, 769 + causes, 740 + +Cretinism and goitre, hereditary nature, 128 + +Croup, respiration, 157 + +Croupous inflammation distinguished from croup, 49 + of fauces, complicating scarlet fever, 516 + membrane, 685 + characters, 685 + mode of formation, 685 + metamorphosis, 80 + +Crust in vaccinia, composition, 464 + +Crusts, objections to use of, in vaccination, 476 + +Cubebs, use of, in diphtheria, 709 + +Cultivation of bacillus tuberculosis, 100 + +Curare, use of, in treatment of hydrophobia, 907 + +Cutaneous deposits in glanders, microscopic characters, 917 + diphtheria, treatment, 713 + lesions of glanders in man, 922 + symptoms of glanders in man, 921 + +Cysts, definition, 115, 121 + + +D. + +Deaf-mutism following cerebro-spinal meningitis, 819 + +Deafness in cerebro-spinal meningitis, 811 + +Death, causes of, in cerebro-spinal meningitis, 818 + in glanders, 915 + +Debility in cerebro-spinal meningitis, 813 + in influenza, treatment, 876 + influence of, in causation of glanders, 912 + in relapsing fever, 386 + +Decline, stage of, in pertussis, 841 + +Decubitus, significance of, in general diagnosis, 150 + +Definition of anthrax, 926 + of beriberi, 1038 + of cerebro-spinal meningitis, 795 + of cholera, 715 + of contagion, 200 + of cysts, 115, 121 + of dengue, 880 + of diphtheria, 656 + of erysipelas, 629 + of glanders, 909 + of idiopathic parotitis, 620 + of influenza, 851 + of leprosy, 785 + of pernicious malarial fever, 605 + of pertussis, 836 + of the plague, 771 + of puerperal fever, 984 + of pyaemia, 953 + of rabies and hydrophobia, 886 + of relapsing fever, 369 + of remittent fever, 598 + of rotheln, 582 + of rubeola, 557 + of septicaemia, 953 + of simple continued fever, 231 + of symptomatic parotitis, 625 + of term "climate," 185 + of typhoid fever, 237 + of typho-malarial fever, 614 + of vaccinia, 455 + of varicella, 481 + of variola, 434 + of yellow fever, 640 + +Degeneration, 72 + amyloid, 84 + cheesy, 79 + colloid, 83 + fibrinous, 80 + fatty, 74 + granular, 72 + hyaline, 80 + lardaceous, 84 + mucous, 82 + of tubercle, 96 + parenchymatous, 73 + waxy, 84 + +Deglutition, difficult, in idiopathic parotitis, treatment, 624 + +Delirium in cerebro-spinal meningitis, 812 + in erysipelas, treatment, 637 + in idiopathic parotitis, treatment, 624 + in pyaemia, 971 + in relapsing fever, 384 + in typhoid fever, 278 + treatment, 334 + in typhus fever, 348 + treatment, 366 + in yellow fever, treatment, 653 + significance of, in general diagnosis, 166 + +Demonstration of bacillus of glanders, 914 + +DENGUE, 879 + Synonyms, 879 + History, 879 + Definition, 880 + Etiology, 883 + Specific origin, 884 + Contagiousness, 884 + Symptoms--prodromal stage, 880 + Mode of onset, 880 + Temperature, 881 + Pulse, 881 + Delirium, 881 + Facies, 881 + State of gastro-intestinal tract, 881 + State of tongue, 881 + Stomach and bowels, 881 + State of urine, 881 + Eruptions, 881 + Hemorrhages, 882 + Prostration, 882 + Convalescence, 882 + Duration of, 882 + Morbid anatomy, 882 + Specific nature of, 882 + Relation to acute articular rheumatism, 883 + Changes in abdominal organs, 883 + Diagnosis, 884 + From acute articular rheumatism, 884 + From yellow fever, 884 + Prognosis, 885 + Treatment, 885 + Use of colchicum, 885 + quinia, 885 + opium, 885 + +Depletion, local, use of, in cerebro-spinal meningitis, 830 + +Depressing emotions, as a cause of typhoid fever, 245 + +Dermatitis, complicating vaccination, 468 + vaccination, treatment, 469 + +Desquamation, date of, in mild scarlet fever, 506 + in erysipelas, 633 + in relapsing fever, 377 + +Desiccation in varicella, 482 + in variola, 440 + +Diagnosis, general, 148 + divisions of, 148 + main direction of inquiries, 148 + proper method of procedure, 150 + significance of alteration of voice in, 158 + of anthrax in animals, 936 + in man, 942 + of cerebro-spinal meningitis, 826 + of cholera, 750 + of comatose form of pernicious malarial fever, 609 + of dengue, 884 + of diphtheria, 689 + of erysipelas, 635 + of idiopathic parotitis, 624 + of glanders in horse, 918 + of glanders in man, 923 + of influenza, 872 + of intermittent fever, 594 + of leprosy, 792 + of the plague, 782 + of pyaemia from septicaemia, 978, 979 + of remittent fever, 600 + of rabies and hydrophobia, 900 + of relapsing fever, 418-422 + of rotheln, 587 + of rubeola, 575 + of scarlet fever, 532 + of simple continued fever, 234 + of symptomatic parotitis, 627 + of typhoid fever, 311-314 + of typho-malarial fever, 616 + of typhus fever, 358, 359 + of vaccinia, 464 + of varicella, 483 + of variola, 447 + of varioloid, 444 + of yellow fever, 648 + +Diaphoretics, use of, in yellow fever, 649 + +Diarrhoea in cerebro-spinal meningitis, 814 + in cholera, 738 + results, 738 + treatment, 760 + in mild scarlet fever, 503 + in pyaemia, 975 + in relapsing fever, 405 + in rubeola, treatment, 581 + in septicaemia, 977 + treatment, 983 + in typhoid fever, 287 + treatment, 331 + +Diarrhoeal diseases from impure water, 182 + +Diathesis, 127 + hereditary, transmission, 130 + +Diet in anthrax, 944 + in beriberi, 1042 + in cerebro-spinal meningitis, 834 + in cholera, 763 + in convalescence, 206 + in erysipelas, 639 + in glanders, 924 + in influenza, 874 + in relapsing fever, 430 + in pertussis, 848 + in puerperal fever, 1036 + in pyaemia, 982 + in rubeola, 579 + in typhoid fever, 323 + in typho-malarial fever, 619 + in typhus fever, 362 + in yellow fever, 654 + of convalescence, 206 + +Digestion, condition of, in cerebro-spinal meningitis, 814 + +Digestive tract, condition of, in glanders, 921 + in idiopathic parotitis, 623 + +Digitalis, use of, in puerperal fever, 1033 + in relapsing fever, 428 + in scarlet fever, 543 + in typhoid fever, 330 + in yellow fever, 651 + +DIPHTHERIA, 656 + Synonyms, 656 + Definition, 656 + History, 656 _et seq._ + Panum's view regarding relation of bacteria to, 667 + Etiology--Age, influence of, on causation, 680 + Sex, influence of, on causation, 680 + Causes of frequency of, in childhood, 680 + Pharyngeal, buccal, and nasal catarrh a cause of, in children, 680 + Physiological causes of, greater frequency in childhood, 681 + Family predisposition, 681 + Thermometric and barometric changes a cause, 682 + Season as a cause, 682 + Filth as a cause, 682 + Polluted air as a cause, 682 + water as a cause, 683 + milk as a cause, 683 + Contagiousness, 678 + Modes of transmission of poison, 678 + In the lower animals, 683 + Transmission of, from lower animals to man, 683 + Artificial production of membrane, 684 + Invasion, 676 + duration of incubation period, 679 + Symptoms--Prodromal stage, 667 + duration, 667 + localized redness of mucous membranes, 667 + Different manifestations of diphtheritic process, 668 + Severe form, 668 + appearance of membrane in severe form, 668 + Gangrenous condition of membrane, 669 + Swellings of glands at angle of jaw as sign of invasion of nasal + cavities, 669, 670 + Mode of invasion of nasal cavities, 669 + Mode of spread to nasal cavities, 669 + Nasal form, 669 + Conjunctival form, 670 + Aural form, 670 + Laryngeal form, 671 + Formation of membrane in larynx, 671 + Tracheal and bronchial forms, 671 + primary form, 672 + Oral form, 672, 673 + Intestinal form, 673 + Of wounds, 673 + Eruption of, 674 + Vulvar and vaginal forms, 674 + In puerperal women, 674 + Vesical form, 674 + Placental, 674 + Liability of open wounds, 672, 679 + Tendency to second attacks from chronic nasal and pharyngeal catarrh + following, 670 + Complications and sequelae, 672 + complicated by fibrinous pneumonia, 672 + by broncho-pneumonia, 672 + by erysipelas, 673 + by urticaria and purpura, 674 + by kidney affections, 674 + by albuminuria, 674 + by granular degeneration of blood, 675 + by cardiac degeneration, 675 + by symptoms of cardiac degeneration, 675 + by embolism, 675 + by acute endocarditis, 675 + by leucocythaemia and Hodgkin's disease, 675 + by nervous diseases, 675 + by paralysis, 676 + seat of, 676 + date of appearance, 676 + fatty degeneration and atrophy following, 676 + sensory, 676 + Secondary form, 671 + Morbid anatomy--characters of the membrane, 685 + Mode of formation of membrane, 685 + Varieties of membrane in, 686 + Rindfleisch's definition of diphtheritic inflammation, 686 + Changes in the heart, 686 + fatty and granular degeneration, 686 + endocarditis, 687 + cardiac thrombi, 687 + Changes in lungs, 687 + Spleen, 687 + Liver, 687 + Kidneys, 687 + Muscles, 687 + Lymphatic glands, 687 + Mucous membranes, 688 + Influence of different mucous membranes upon characters of false + membrane, 688 + epithelia upon growth and spread of false membrane, 688 + Changes in intestines, 689 + nervous system, 689 + Diagnosis--significance of localized pharyngeal injection, 689 + From muguet or thrush, 690 + Follicular stomatitis, 690 + Significance of glandular swelling, 690 + lymphadenitis in nasal form, 690 + Of laryngeal form, 691 + Significance of absence of fever, 691 + Of paralysis, 691 + Prognosis--symptoms indicating favorable, 692 + unfavorable, 692 + Significance of glandular swelling, 692 + In nasal, 692 + Of fetid and putrid discharges, 693 + Of epistaxis, 693 + In laryngeal, 692 + In tracheal, 692 + Of tracheotomy, 692 + significance of state of pulse after, 692 + of dry respiration after, 692 + of temperature-range after, 692 + of character of membrane, 692 + Influence of temperature, 693 + state of pulse, 693 + complications, 693 + bronchitis and pneumonia, 693 + endocarditis, 693 + albuminuria, 693 + affections of sensorium, 693 + purpura, 693 + icteric discoloration of skin, 693 + Of relapses, 694 + Treatment--hyperpyrexia, 694 + Reflex symptoms, 694 + Vomiting, 694 + Futility of expectant, 694 + Use of stimulants, 694 + Amount of stimulants necessary, 695 + Importance of general treatment, 695 + Futility of venesection, 695 + Prophylactic, 696 + Danger of self-infection, 696 + Prevention of self-infection, 696 + Isolation, 696 + Closure of schools and public places during epidemics, 697 + Disinfection, 698 + Special, 701 + Local, 701, 709 + by steam, 701 + Use of water, 702 + Ice and cold, 702 + Cold baths, 702 + Mode of applying cold, 702 + Contra-indications to use of cold, 703 + Solvents of pseudo-membrane, 703 + Use of lime-water, 703 + Slaking lime, 703 + Lactic acid, 703 + Pepsin, neurin, and chinolin, 703 + Papayotin, 703 + Pilocarpine, 704 + objections to, 704 + Turpentine inhalations, 704 + Ammonium chloride, 704 + Mercury, 705 + Tincture of chloride of iron, 706 + Carbolic acid, 707 + Salicylic acid, 707 + Quinia, 708 + Bromine, 708 + Boric acid, 709 + Sodium salicylate, 709 + Ozone, 709 + Sulphur and cubebs, 709 + Chlorate of potassium, 699 + Dose of chlorate of potassium, 700 + Danger in large doses of chlorate of potassium, 701 + Mechanical removal of membrane, 709 + Cauterization of membrane, 709 + Glandular swellings, 710 + Abscess of glands, 710 + Of nasal form, 710 + danger of permitting sleep in, 712 + local applications, 710 + Of conjunctival form, 712 + Of laryngeal form, 712 + use of emetics, 712 + Of paralysis, 713 + by strychnia, 713 + by electricity, 713 + artificial alimentation, 713 + Of cutaneous form, 713 + +Diphtheria, complicating rubeola, 573 + scarlet fever, 514 + of genitalia in puerperal fever, 1002 + +Diphtheritic endometritis, 987 + exudations, complicating rubeola, 735 + membrane, cauterization, 709 + mechanical removal, 709 + conjunctivitis, 670 + treatment, 712 + inflammation, causes, 51 + distinguished from diphtheria, 50 + paralysis, treatment, 713 + pock in vaccinia, 463 + +Disease, 35 + Causes, 125, 175 + arsenical poisoning, 193 + climate, 185 + cold, 133 + contagion, 135, 200 + epidemic influences, 135 + errors of diet, 135 + exciting, 125 + exercise, abnormal, 134, 198 + deficient, 135 + functional, 134 + habitation, 186 + heat, 133 + hereditary, 132 + humidity of atmosphere, 133 + improper clothing, 198 + impure air, 177 + ice, 185 + water, 182 + ingestive, 135 + intemperance, 197 + mental, 204 + minute organisms, 141 + predisposing, 125 + pre-natal, 126, 175 + poisons and misuse of medicines, 135 + soil, condition of, 187 + Definition of, 135 + Elevation of site, influence of, 134 + Means of discovery, 175 + Abdominal, hot climate as a cause, 133 + Respiratory, cold as a cause, 133 + Prevention, 175 + Respiration in, 156 + Theory of--bioplastic, 140 + chemical, 138, 140 + fermentation, 138 + germ, 138 + points of objection, 142 + undecided state, 147 + Zymotic, table of, 136 + +Disinfectants, varieties, 202 + +Disinfection in anthrax, 937, 943 + in cholera, 758 + in diphtheria, 698 + of glanders, 925 + in the plague, 784 + in puerperal fever, 1025, 1028 + in pyaemia and septicaemia, 980 + in scarlet fever, 201, 538 + in typhus fever, 362 + methods, 201 + practical difficulties, 201 + principles, 201 + +Dissecting poison, relation of, to causation of puerperal fever, 1018 + wounds, relation of, to causation of septicaemia, 962 + +Dissemination of influenza, 863 + in typhoid fever, 249 + of puerperal fever by physicians, 1018 + +Diuretics, use of, in scarlet fever, 555 + in wet beriberi, 1042 + +DRAINAGE AND SEWERAGE, 213 + Back, ventilation of traps, 221 + Disposal of liquid wastes by irrigation, 225 + Frequency of leakage in waste-pipes, 222 + Necessity of, in prevention of typhoid fever, 321 + Of houses, 188 + Necessity of abundant water-supply in, 220 + Of soil, 226 + Perfect, fundamental requirements, 213 + Removal of human excrement, 215 + of liquid household wastes, 220 + Varieties of grease-traps, 221 + Ventilation of waste-pipes, 223 + +Drainage-pipes, effects of large traps, 220 + of too large bore, 220 + of vertical position, 220 + +Drinking-water as a medium of disseminating typhoid fever, 248 + propagation of cholera by, 723 + +Dropsies, 67-71 + +Drugs, use of, in the plague, 784 + +Dry form of beriberi, symptoms, 1040 + treatment, 1043 + +Duration of cerebro-spinal meningitis, 818 + of dengue, 882 + of anthrax, 940, 941 + of acute form of glanders in horses, 915 + of chronic form of glanders in horses, 915 + of acute form of glanders in man, 921 + of chronic form of glanders in man, 922 + of influenza, 865 + of malignant scarlet fever, 508 + of mild scarlet fever, 506 + of prodromal stage of rubeola, 565 + of remittent fever, 602 + of rabies and hydrophobia, 900 + of septicaemia lymphatica, 1012 + +Dysentery complicating relapsing fever, 406 + typhus fever, 355 + +Dysphagia, significance of, in general diagnosis, 162 + +Dyspnoea, causes, 157 + + +E. + +Ear, affections of, in rubeola, treatment, 581 + diseases of, complicating rubeola, 570 + displacement of lobe in idiopathic parotitis, 624 + internal, lesions of, in cerebro-spinal meningitis, 824 + lesions of, in pyaemia, 967 + in symptomatic parotitis, 626 + middle, suppuration of, in cerebro-spinal meningitis, 811 + symptoms of diphtheria, 670 + +Ears, significance of appearance of, in general diagnosis, 151 + +Early stages of yellow fever, treatment, 649 + +Earth-closets, 218 + +Effluvia, offensive, symptoms due to, 181 + +Effusions, 67 + causes, 68-71 + distinguished from exudations, 67 + +Elaterium, use of, in wet beriberi, 1042 + in dry beriberi, 1043 + +Electricity, use of, in diphtheritic paralysis, 713 + +Elevated temperature as a cause of typhoid fever, 246 + +Emaciation, causes, 160 + significance of, in diagnosis, 159 + +Emboli, action of, in production of metastatic abscesses in pyaemia, + 967 + +Embolism, 62 + complicating diphtheria, 675 + from septic thrombus, 66 + hemorrhagic results, 64, 65 + in typhoid fever, treatment, 335 + mechanical effects, 63 + necrosis from, 64, 65 + results, 64 + softening, cerebral, from, 65 + symptoms, 66 + +Embolus, 62 + arterial, 63 + venous, 63 + terminations, 65 + +Emetics, use of, in cerebro-spinal meningitis, 830 + in cholera, 765 + during cold stage of intermittent fever, 595 + in influenza, 876 + in laryngeal diphtheria, 712 + in pertussis, 845 + +Emphysema, aggravation of, by influenza, 870 + significance of, in general diagnosis, 159 + +Endocarditis, acute, complicating diphtheria, 675 + in diphtheria, 687 + in puerperal fever, 990 + +Endo- and pericardium, lesions of, in septicaemia, 972 + +Endocolpitis in puerperal fever, 986, 1005 + +Endometritis in puerperal fever, 986 + +Enthetic febrile diseases, hereditary nature, 130 + +Epidemic causation of disease, 135 + +Epidemics of rubeola, frequency, 560 + frequency in the new-born, 563 + +Epiglottis, symptoms of diphtheria, 671 + +Epistaxis in relapsing fever, 393 + complicating rubeola, 570 + in remittent fever, 602 + in rubeola, treatment, 580 + in typhoid fever, 273 + treatment, 335 + +Epithelia, influence of different, in spread of diphtheritic membrane, + 688 + +Ergot, use of, in cerebro-spinal meningitis, 833 + +Ergotine, use of, in pyaemia, 982 + +Eruption, absence of, in rubeola, 568 + causes of absence of, in mild scarlet fever, 505 + in cerebro-spinal meningitis, 816, 817 + in dengue, 881 + in diphtheria, 674 + in influenza, 866 + in malignant scarlet fever, 507 + in mild scarlet fever, 504 + in pyaemia, 974 + in relapsing fever, 376 + in rotheln, 585, 586 + in rubeola, 566 + peculiarities in character, 569 + in seat, 509 + relapses, 570 + retrocession of, in rubeola, treatment, 580 + in tubercular form of leprosy, 789 + in typhoid fever, 273 + in typhus fever, 351 + in varicella, 487 + in variola, 437 + characters, 438 + position, 438 + in varioloid, 444 + +Eruptive stage of rubeola, duration of, 567 + symptoms of, 565 + of variola, treatment, 452 + +ERYSIPELAS, 629 + Definition, 629 + Synonyms, 629 + Classification, 629 + History, 629 + Etiology, 629 + Unity of the origin, 629 + Age and sex as a cause, 630 + Season as a cause, 630 + Contagiousness, 630 + Nature of contagion, 630 + Manner of propagation, 630 + Relation to childbed fever, 630 + Symptoms--initial, 631 + Characters of cutaneous lesions, 631 + Course of cutaneous lesions, 631 + Severe varieties of cutaneous lesions, 632 + Migration of cutaneous lesions, 632 + Swelling of integument, 632 + Starting-point of cutaneous lesions, 632 + Physiognomy, 632 + Condition of tongue, 633 + of fauces and buccal membrane, 633 + General symptoms of grave form, 633 + pulse, 633 + temperature, 633 + Occurrence of gangrene, 633 + Resolution, 633 + Desquamation, 633 + Complications and sequelae, 633 + Complicated by lymphangitis and adenopathy, 634 + By pneumonia, 634 + By pleuritis, 634 + By inflammation of joints, 634 + By inflammations of serous membranes, 634 + By pyaemia and septicaemia, 634 + By eye diseases, 634 + Followed by seborrhoea of scalp, 633 + By loss of hair, 633 + Modification of previous skin disorders, 634 + Chronic forms, 634 + Variety and nature of chronic forms, 634 + Morbid anatomy, 635 + Changes in skin, 635 + Viscera, 635 + Mucous surfaces, 635 + Diagnosis, 635 + From dermatitis, 636 + From eczema, 636 + From erythema, 636 + From pemphigus, 636 + From scarlet fever, 636 + From urticaria, 636 + Prognosis--symptoms indicating unfavorable, 636 + Treatment--preventive, 636 + Hygienic, 637 + General, 637 + Hyperpyrexia, 637 + Delirium, 637 + Local, 637 + Value of abortive, 638 + Surgical, 638 + Mouth complications, 638 + Nasal complications, 638 + Abscesses, 638 + Value of expectant, 639 + Convalescence, 639 + Diet, 639 + Use of quinia, 637 + tincture of the chloride of iron, 637 + +Erysipelas, complicating diphtheria, 673 + typhus fever, 355 + vaccination, 469 + variola, 445 + relation of, to puerperal fever, 1002 + +Etiology, general, 125 + of anthrax in animals, 928 + in man, 939 + of beriberi, 1038 + of cerebro-spinal meningitis, 801 + of cholera, 720 + of dengue, 883 + of diphtheria, 680 + of erysipelas, 629 + of glanders in horse, 911 + in man, 919 + of idiopathic parotitis, 620 + of influenza, 859 + of leprosy, 787 + of pertussis, 838 + of the plague, 774 + of puerperal fever, 1013 + of pyaemia, 955 + of rabies and hydrophobia, 887 + of relapsing fever, 370 + of remittent fever, 598 + of rotheln, 583 + of rubeola, 557 + of scarlet fever, 487 + of septicaemia, 960 + of septo-pyaemia, 963 + of simple continued fever, 232 + of symptomatic parotitis, 625 + of typhoid fever, 242 + of typhus fever, 341 + of varicella, 481 + of variola, 435 + of yellow fever, 640 + +Eucalyptus, use of, in typhoid fever, 331 + +Excision of cicatrix for prevention of hydrophobia, 908 + of primary nucleus in anthrax, 943 + +Exciting cause, mechanical nature of, in symptomatic parotitis, 626 + of the plague, 775 + of typhoid fever, 248 + of typhus fever, 343 + +Excrement, human, disposal of, by privy-vaults, 219 + dry conservancy, 218 _et seq._ + removal of, by water-carriage, 215 + +Exercise, abnormal, as a cause of disease, 134 + amount necessary for health, 198 + as a part of a systematic education, 199 + deficiency of, a cause of disease, 135 + Du Bois Reymond's definition, 198 + importance of, in preservation of health, 198 + relation of, to mental work, 199 + +Expectant treatment of erysipelas, value, 639 + +Expectoration, significance of, in diagnosis, 158 + +External anthrax, localized, 935 + +Exudation, distinction from transudation, 42 + in inflammation, 42 + in peri- and parametritis of puerperal fever, 1007 + in pelvic peritonitis, 989 + +Eye, affections of, following cerebro-spinal meningitis, 819 + in rubeola, treatment, 581 + condition of, in cerebro-spinal meningitis, 810 + diseases of, complicating erysipelas, 634 + rubeola, 571 + variola, 445 + lesions of, in cerebro-spinal meningitis, 824 + in pyaemia, 967 + +Eyes, appearance of, significance in general diagnosis, 151 + + +F. + +Face, appearance of, in typhus fever, 348 + +Family predisposition to diphtheria, 681 + +Faradization, use of, in rabies and hydrophobia, 907 + +Farcy, 909 + +Fatigue as a cause of typhus fever, 342 + +Fat, sources of, in the body, 74 + +Fatty degeneration, 74 + causes, 78 + following diphtheritic paralysis, 676 + infiltration, 76 + metamorphosis, 74, 79 + +Fauces, condition of, in cerebro-spinal meningitis, 814 + in erysipelas, 633 + in malignant scarlet fever, 508 + in typhoid fever, 286 + inflammation of, complicating rubeola, 571 + significance of appearance of, in general diagnosis, 152 + +Faucial and nasal mucous membrane, condition of, in mild scarlet + fever, 504 + +Febrifuge, use of, in relapsing fever, 428 + +Febrile stage of grave form of the plague, 778 + +Fermentation theory of disease, 138 + +Fever, agents producing heat in, 40, 41 + definition, 38 + inflammatory, 37 + distinguished from idiopathic, 37 + influence of vaso-motor system on production of heat in, 39 + intermittent, 592 + malarial, 589 + pernicious malarial, 605 + puerperal, 984 + relapsing, 369 + remittent, 598 + sanitary effects, 41 + scarlet, 486 + secondary, in variola, 439 + simple continued, 231 + symptoms, 38 + temperature, 38-40 + traumatic, 37 + typho-malarial, 614 + typhoid, 237 + typhus, 338 + yellow, 640 + +Fibrinous degeneration, 80 + inflammation, 49 + +Filtering power of soil, 187 + +Filth as a cause of cholera, 721 + diphtheria, 682 + the plague, 774 + relapsing fever, 370 + +Foetus, effects of maternal impression upon, 131 + +Fomites, propagation of cholera by, 721 + special, of cholera, 723 + +Food, adulterations, 197 + appetite as a guide to necessary amount, 195 + as a cause of disease, 195 + infants, 196 + patient's sensations as a guide to choice of, in disease, 205 + popular errors in regard to, 195 + to overeating, 195 + preparation of, necessity of a physician's knowledge of, 196 + proper, necessity of, in prevention of pyaemia and septicaemia, 980 + transmission of anthrax by, 929 + +Formad on peculiarities of scrofulous habit, 101 + +Forms of anthrax in animals and man, 934, 940 + of leprosy, 789 + of the plague, 777 + of rabies, 895 + of relapsing fever, 395 + of vaccine, 476 + +Fourth ventricle, lesions of, in cerebro-spinal meningitis, 824 + +Fraenum linguae, ulceration of, in pertussis, 841 + +Frequency of puerperal fever, 984 + of typho-malarial fever, 616 + +Frictions, use of, in dry beriberi, 1043 + +Frontal pains in influenza, 867 + +Fruit, propagation of malaria by, 591 + +Fulminant form of the plague, 779 + +Furious form of rabies, 896 + +Furuncles, complicating variola, 445 + + +G. + +Gait, peculiarity of, in beriberi, 1039 + +Gall-bladder, lesions of, in cholera, 746 + in typhoid fever, 266 + +Gangrene, 56 + complicating vaccination, 468 + following typhoid fever, 293 + typhus fever, 355 + in erysipelas, 633 + in symptomatic parotitis, treatment of, 628 + of neck, complicating scarlet fever, 512 + pulmonary, complicating relapsing fever, 404 + +Gangrenous affections following rubeola, 574 + +Gastro-intestinal canal, condition of, in dengue, 881 + condition of, in yellow fever, 644 + lesions of, in anthrax, 936 + in influenza, 872 + in rabies and hydrophobia, 902 + in relapsing fever, 413 + symptoms in influenza, 866 + in mild scarlet fever, 505 + in malignant scarlet fever, 507 + of septicaemia lymphatica, 1011 + +Gelsemium, use of, in yellow fever, 651 + +GENERAL ETIOLOGY, 125 + +General dropsies, 71 + treatment of erysipelas, 639 + of glanders in horse and man, 919, 920 + +Genitalia, gangrene of, complicating variola, 446 + +Geographical distribution of anthrax, 926 + of beriberi, 1038 + of glanders, 909 + of rabies and hydrophobia, 886 + of relapsing fever, 369 + of typhoid fever, 241 + +Germ, specific, of glanders, nature of, 914 + of rabies and hydrophobia, 892 + point of election of, 892 + +Germ-theory of disease, 138 + of scarlet fever, 488 + +Giddiness, significance of, in general diagnosis, 166 + +GLANDERS (FARCY), 909 + Synonyms, 909 + Definition, 909 + History, 909 + Geographical distribution, 909 + Etiology--Contagiousness, 911 + Specific nature, 911 + Predisposing causes, 912 + Ill-health, relation of, to causation, 912 + Cold and damp stables, relation of, to causation, 912 + Debility from chronic diseases, relation of, to causation, 912 + Infection, channels of, 913 + Particular nature of the germ, 914 + Virulence of the germ, 914 + Modes of culture of germ, 914 + Demonstration of bacillus of, 914 + Symptoms--in horses, 914 + Acute form, 914 + Incubation period, 914 + Mode of onset, 914 + Local lesions, 915 + Appearance of nostrils, 915 + of lymphatics, 915 + Enlargement of joints, 915 + Appearance of ulcers, 915 + Mode of death in, 915 + Chronic form, 915 + Premonitory symptoms, 915 + Condition of general health, 915 + Local lesions, 915 + Lymphatics, 915 + Bronchial and pulmonary form, 916 + Acute cutaneous form (farcy), 916 + Local lesions, 916 + Chronic cutaneous form (chronic farcy), 916 + Local lesions, 916 + Duration, 915 + Morbid anatomy, 916 + Nasal lesions, characters of, 917 + Pulmonary lesions, characters of, 917 + Cutaneous lesions, characters of, 917 + Diffuse glanderous swellings, 917 + of nose, 918 + of lungs, 918 + of muscles, 918 + Diagnosis, 918 + Value of inoculation in, 918 + Prognosis, 918 + Unfavorable nature of, 918 + Treatment--in animals, 918 + Not commendable, 918 + Local, 918 + General, 919 + Diet in, 919 + Preventive, 919 + Extermination of disease in animals, 919 + +_Glanders in Man_, 919 + History of, 919 + Etiology, 919 + Modes of infection, 919 + immediate, 919 + mediate, 920 + Influence of occupation, 920 + Influence of ill-health, 920 + Symptoms--incubation period, 920 + Appearance of wound, 920 + General, 920 + Mode of onset, 920 + Character and seat of local lesions, 921 + Appearance of sores, 921 + Condition of nasal mucous membrane, 921 + of submaxillary glands, 921 + of conjunctiva, 921 + Digestive tract, 921 + Nervous system, 921 + Temperature in, 921 + Pulse in, 921 + Chronic form, 921 + General, 921 + Local, 921 + Cutaneous lesion, 922 + Respiratory lesions, 922 + Lymphatic glands, 922 + Digestive tract, 922 + Convalescence, 922 + Duration of acute forms, 921 + of chronic forms, 922 + Morbid anatomy--changes in mucous membranes, 922 + Lungs and pleurae, 922 + Gastro-intestinal tract, 922 + Spleen and liver, 922 + Joints, 922 + Bones, 922 + Brain and membranes, 923 + Microscopy of lesions, 923 + Diagnosis, 923 + Pathognomonic signs in, 923 + From rheumatic fever, 923 + Chronic form, from pyaemia and septicaemia, 923 + From syphilis, 924 + From miliary tuberculosis, 924 + Presence of bacillus not conclusive, 924 + Value of inoculation in, 924 + Prognosis--unfavorable nature of, 924 + Treatment--External cases, 924 + Erysipelatoid swellings, 924 + Abscesses and tumors, 924 + Nasal ulcers, 924 + Importance of general treatment, 924 + Use of antiseptics, 924 + Diet, 924 + Preventive, 925 + Extinction of affection in animals, 925 + Necessity of disinfection, 925 + +Glanderous swelling, diffuse, 917 + +Glands at angle of jaw, swelling of, symptomatic of nasal invasion, in + diphtheria, 669, 670 + +Glandular abscesses in diphtheria, treatment, 710 + degenerations, 72 + swellings in diphtheria, treatment, 709 + +Glycosuria, complicating relapsing fever, 410 + +Gout, hereditary nature, 127 + +Granuloma, 120, 124 + +Grave forms of cholera, physiognomy, 734 + stools, 733 + symptoms, 732 + of the plague, 777 + of relapsing fever, 395 + +Grease-traps, varieties, 221 + +GROWTHS, MORBID, 105 + +Gums, significance of state of, in general diagnosis, 151 + + +H. + +Habits, depressing, as a cause of cerebro-spinal meningitis, 802 + +Haematemesis, significance of, in general diagnosis, 163 + in relapsing fever, 390 + +Haematoidin, 91 + +Haematoma, 115, 122 + +Haematuria in relapsing fever, 390 + +Haemoglobin, 90 + +Haemophilia, hereditary nature, 129 + +Haemoptysis, significance of, in general diagnosis, 163 + +Haemostatics, use of, in yellow fever, 652 + +Hair, appearance of, in typhoid fever, 275 + loss of, following erysipelas, 633 + +Headache in cerebro-spinal meningitis, 808 + in idiopathic parotitis, 624 + in influenza, 867 + treatment, 874 + in relapsing fever, 383 + in typhoid fever, 277 + treatment, 334 + in typhus fever, 348 + treatment, 366 + +Health, importance of exercise in preservation, 198 + +Health-resorts, disease from, 185 + +Hearing, impairment of, following cerebro-spinal meningitis, 819 + disorders of, in relapsing fever, 400 + modifications of, in typhoid fever, 279 + significance of, in general diagnosis, 166 + +Heart, alterations of, in beriberi, 1041 + condition of, in beriberi, 1040 + in cholera, 737 + in pyaemia, 976 + in typhus fever, 351 + disease, complicating influenza, 870 + lesions of, in cholera, 746 + in diphtheria, 686 + in relapsing fever, 411 + in septicaemia, 972 + in typhoid fever, 267 + in typhus fever, 357 + and blood-vessels, lesions of, in rabies and hydrophobia, 902 + palpitation of, in beriberi, 1039 + +Heart-clot, complicating relapsing fever, 402 + rubeola, 672 + scarlet fever, 523 + +Heat as a cause of disease, 133 + use of, in cholera, 769 + +Hemorrhages in dengue, 882 + in hemorrhagic form of pernicious malarial fever, treatment, 612 + in remittent fever, treatment, 605 + in yellow fever, 646 + treatment, 651 + intestinal, in typhoid fever, 287, 288 + treatment, 332 + +Hemorrhagic form of pernicious malarial fever, 609 + causes, 610 + seat of hemorrhages, 610 + symptoms, 611 + treatment, 612 + of scarlet fever, 509 + of variola, treatment, 454 + infarction, 64 + rubeola, 569 + small-pox, 442 + variola, morbid anatomy of pock in, 447 + +Hepatic abscess following typhoid fever, 295 + +Heredity as a cause of disease, 175 + influence of, on marriage, 176 + relation of, to life insurance, 175 + as a cause of leprosy, 787 + +Hereditary diathesis, transmutation, 130 + nature of syphilis, 127 + of non-malignant morbid growths, 129 + of nervous diseases, 129 + of organic disease, 129 + of rickets, 128 + predisposition to disease, 126 + +Herpes labialis, complicating influenza, 874 + +Hiccough in cholera, 762 + in relapsing fever, 405 + significance of, in general diagnosis, 158 + +Histoid tumors, 116 + +History of anthrax in animals and man, 926, 939 + of beriberi, 1038 + of cerebro-spinal meningitis, 796 + of cholera, 715 + of dengue, 879 + of diphtheria, 656 + of erysipelas, 629 + of glanders in horses, 909 + in man, 919 + of influenza, 852 _et seq._ + of pertussis, 836 + of rabies and hydrophobia, 886 + of relapsing fever, 369 + of rotheln, 582 + of rubeola, 557 + of pyaemia and septicaemia, 945-952 + of scarlet fever, 486 + of simple continued fever, 231 + of typhoid fever, 238 + of typhus fever, 338 + of vaccination, 465 + of vaccinia, 456 + of varicella, 481 + of variola, 434 + +Hodgkin's disease, complicating diphtheria, 675 + +Horse-pock vaccine, 473 + +Hospitals for infectious diseases, necessity, 203 + +Hospital, maternity, advantages, 1021 + +Hot stage of intermittent fever, treatment, 595 + +House-drainage, 188 + disconnection of, from sewer, 190 + testing, 190 + +House-plumbing, 190 + +Houses, sanitary inspection, 187, 193 + +House-sewerage, 188 + dangers to health from, 189, 191 + examination of a system, 188 + main points in a good system, 191 + peppermint-test for defects, 190 + +Human excrement, removal of, by drainage, 215 + +Humanized and animal vaccine, relative merits, 473 + vaccine, points of superiority, 473 + +Humidity of air as a cause of disease, 133 + +Hunger, influence of, on causation of rabies and hydrophobia, 888 + +Hyaline degeneration, 80 + +Hydro-bilirubin, 91 + +Hydrocephalus, following cerebro-spinal meningitis, 819 + +Hydrochloric acid, local use of, in puerperal fever, 1028 + +Hydrophobia, 886 + +Hygiene, 173 + importance of perfect, in cholera epidemics, 758 + in pertussis, 848 + public, relation of physicians to, 207 + +Hygienic treatment of erysipelas, 637 + of hydrophobia, 906 + of scarlet fever, 539 + of typhoid fever, 322 + of yellow fever, 654 + +Hygroma, 116, 122 + +Hyperpyrexia in diphtheria, treatment, 694 + in erysipelas, treatment, 637 + in puerperal fever, treatment, 1032 + in relapsing fever, treatment, 426 + in rubeola, treatment, 579 + in scarlet fever, treatment, 541 + in typhoid fever, treatment, 327 + in typhus fever, treatment, 364 + in yellow fever, treatment, 651 + +Hypodermatic injection of anthrax swellings, 938, 943 + + +I. + +Ice, impure, as a cause of disease, 185 + use of, in diphtheria, 702 + in scarlet fever, 542 + +Idiopathic parotitis, 620 + +Idiosyncrasy as a cause of typhoid fever, 245 + influence of, in causation of variola, 436 + +Ill-health, influence of, in causation of glanders, 912, 920 + +Impure air as a cause of disease, 177 + evil effects of, 181 + water, as a cause of disease, 182 + +Impurities of water, from living organisms, 184 + nature, 184 + +Incubation of relapsing fever, 376 + of scarlet fever, 492 + of typhus fever, 346 + of varicella, 481 + of variola, 436 + period of anthrax in animals, 934 + in man, 940 + of diphtheria, duration of, 679 + of glanders in horse, 914 + in man, 920 + of influenza, 863 + of intermittent fever, 592 + of the plague, 777 + of rabies and hydrophobia, 894 + of rotheln, 585 + of typhoid fever, 259 + of yellow fever, 643 + stage of idiopathic parotitis, duration, 621 + of idiopathic parotitis, 621 + of puerperal fever, 1004 + of pyaemia, 973 + of rubeola, 563 + +Indications for treatment of puerperal fever, 1028 + of septicaemia, 982 + of yellow fever, 649 + +Infants' food, 196 + +Infarction, hemorrhagic, 164 + +Infection, 200 + channels of, in glanders, 913 + modes of, in human anthrax, 939 + +Infiltration, albuminoid, 72 + amyloid, 84 + fatty, 76 + +INFLAMMATION, 37 + Characteristics, 37 + Heat, 37 + Redness, 37 + causes, 37 + Pain, 41 + causes, 41 + Swelling, 41 + causes, 41 + Exudation, 42 + Reuss on distinction of exudation from transudation, 42 + Migration of white corpuscles, 42 + Coagulation of exudation, 43 + Changes in the blood-vessels, 43 + Disturbance of functions, 44 + Varieties of--hemorrhagic, 48 + Diphtheritic, 50 + Productive, 51 + Catarrhal, 52 + Phlegmonous, 52 + Acute, 53 + Chronic, 53 + Interstitial, 53 + Parenchymatous, 53 + Termination, 54, 55, 56 + Resolution, 54 + New formations, 54 + Cicatrization, 55 + Abscesses, 56 + Destruction of tissue, 56 + Causes, toxic, 43 + traumatic, 44 + parasitic, 45 + infectious, 45 + constitutional, 46 + trophic, 46 + Course, 46 + Sthenic and asthenic, 46 + Serous, 47 + Typhoidal, 47 + symptoms, 47 + Purulent, 48 + Suppurative, relation of microbia, 48 + Fibrinous, 49 + of fauces, catarrhal and diphtheritic, complicating typhoid fever, + 295 + of neck, complicating parotitis, 511 + simple, complicating vaccination, 468 + +Inflammations, serous, complicating typhus fever, 355 + +Inflammatory fevers, 37 + form of typhus fever, 354 + rubeola, 568 + +INFLUENZA--Definition, 851 + Synonyms, 851 + History, 852 _et seq._ + Etiology, 859 + Predisposing causes, 859 + Age, relation of, to causation, 860 + Social condition, relation of, to causation, 860 + Sex, relation of, to causation, 860 + Occupation, relation of, to causation, 860 + Race, relation of, to causation, 860 + Over-crowding and filth, relation of, to causation, 860 + Season, relation of, to causation, 860 + Climate, relation of, to causation, 860 + Air, condition of, to causation, 860 + Winds, relation of, to spread, 860 + Mode of onset of epidemics, 860, 861 + Duration of epidemics, 861 + Exciting causes, 862 + Specific poison, 863 + Contagiousness, 862 + Dissemination, 863 + Relation of, to other epidemic diseases, 863 + Incubation period, 863 + Clinical history, 864 + Variations in intensity of symptoms, 864 + Symptoms of mild cases, 864 + of severe cases, 864 + Symptomatology, 865 + Analysis of symptoms, 865 + Fever, 865 + Temperature, 865 + Pulse, 866 + Urine, 866 + Skin, 866 + Eruptions, 866 + Gastro-intestinal system, 866 + Nausea and vomiting, 866 + Physiognomy, 866 + Catarrhal symptoms, 866 + Condition of mucous membrane, 866 + Hoarseness, 867 + Cough and dyspnoea, 867 + Nervous system, 867 + Headache, 867 + Frontal pain, 867 + Pains in limbs, 868 + Pleurodynia, 868 + Delirium, 868 + Dizziness, 868 + Sleeplessness, 868 + Hebetude and torpor, 868 + Muscular twitchings, 868 + Mental condition, 868 + Duration, 865 + Complications and sequelae, 868 + Inflammations of lungs, 868 + Bronchitis and capillary bronchitis, 868, 869 + Catarrhal pneumonia, 869 + Lobar pneumonia, 869 + Localized pulmonary collapse, 869 + Gangrene of lungs, 870 + Pleurisy, 870 + Pericarditis, 870 + Laryngitis and chronic bronchitis, 870 + Inflammation of middle ear, 870 + Parotitis, 870 + Herpes labialis, 870 + Phthisis, 870 + Emphysema, aggravation, 870 + Old neuralgias, aggravation, 870 + Heart disease, aggravation, 870 + Bright's disease, aggravation, 870 + Pregnancy, 870 + Intermittent fever, 870 + Morbid anatomy, 871 + Essential lesions, 871 + Appearance of respiratory tract, 871 + Changes in gastro-intestinal tract, 872 + Bronchial glands, 872 + Lung tissue, 872 + Pathology--Not a simple acute inflammation, 871 + Specific character, 871 + Diagnosis--From non-specific catarrhal affections, 872 + From typhoid fever, 872 + Prognosis--Influence of age, 872 + pre-existing organic disease, 872 + of character of epidemic, 872 + Mortality, 872, 873 + Variability in different epidemics, 873 + Rate of, 873 + Cause of death, 873 + Treatment--preventive, 873 + Mild forms, 874 + Catarrh, 874 + Headache, 874 + Cough, 875 + Use of quinine, 874 + Opium, 874 + Fat inunctions, 874 + Diet, 874 + Severe forms, 875 + Indications for treatment, 875 + High temperature, 875 + Cough, 876 + Sub-sternal and chest pains, 876 + Use of diaphoretics, 875 + Bloodletting, 875 + Emetics, 876 + Purgatives, 876 + Quinine, 876 + Mineral acids, 876 + Expectorants, 877 + Opium, 876 + Alcohol, 877 + Chloral, 877 + Diarrhoea, 877 + Debility, 877 + Lung complications, 877 + Diet in, 875 + Convalescence, 878 + Danger of depressing measures, 878 + +Inhalations, use of, in pertussis, 844 + +Initial stage of pertussis, 840 + symptoms of yellow fever, 644 + +Injections, intravenous, use of, in cholera, 768 + in hydrophobia, 908 + in puerperal fever, 1029 + vaginal, use of, in prevention of puerperal fever, 1026 + +Inoculation as a means of diagnosis in glanders, 918 + in hydrophobia, 902 + as a prophylactic in anthrax, 937 + in rabies and hydrophobia, 905 + in scarlet fever, 536 + of leprosy, 788 + of rubeola, 559 + of small-pox, 465 + +Insects, propagation of anthrax by, 929 + +Insomnia in typhoid fever, treatment, 334 + in typho-malarial fever, treatment, 619 + in typhus fever, treatment, 366 + +Inspection of houses, sanitary, 187 + +Insusceptibility to rabies and hydrophobia, 894 + +Intellect, impairment of, following cerebro-spinal meningitis, 819 + following typhoid fever, 292 + +Intellectual condition in typhus fever, 348 + +Intemperance as a cause of cholera, 721 + of disease, 197 + of relapsing fever, 370 + of typhoid fever, 245 + of typhus fever, 342 + +Intermission in intermittent fever, 594 + in relapsing fever, 381 + +INTERMITTENT FEVER, 592 + Incubation period, 592 + Symptoms--prodromal stage, 592 + Paroxysm, 592 + Cold stage, 592 + theory of cause of cold stage, 593 + Hot stage, 593 + duration of hot stage, 593 + relation of type to duration of hot stage, 593 + Sweating stage, 593 + Nausea and vomiting during paroxysm, 593 + Intermission, 594 + Duration of intermission, 594 + Relative frequency of different types, 594 + Convertibility of different types, 594 + Morbid anatomy, 594 + Treatment--cold stage, 594 + Use of quinia, 595 + Opium, 595 + Emetics, 595 + Hot stage, 595 + Use of opium, 595 + Quinia, 596 + Purgatives, 596 + Of convulsions, 597 + Sweating stage, 597 + Use of quinia, 597 + Causes of failure of quinia, 597 + Adjuvants to quinia in preventing return of paroxysms, 598 + Use of nitric acid to prevent return of paroxysms, 598 + +Internal anthrax in animals, 934 + +Interstitial inflammation, 53 + +Intestinal anthrax in man, 941 + canal, lesions of, in cholera, 743 + catarrh, chronic, following rubeola, 574 + complicating rubeola, 572 + tract, lesion of, in typhus fever, 357 + +Intestines, lesions of, in diphtheria, 689 + symptoms of diphtheria of, 673 + +Intravenous injection of warm water in hydrophobia, 908 + +Inunction in scarlet fever, 541 + +Inunctions, use of, in rubeola, 580 + +Invasion of cerebro-spinal meningitis, 806 + of diphtheria, 676 + of variola, 438 + stage of grave form of the plague, 777 + of idiopathic parotitis, duration, 621 + treatment, 624 + of variola, treatment, 452 + of varioloid, 443 + +Iodine as a specific in typhoid fever, 336, 337 + +Iodoform, intra-uterine use of, in puerperal fever, 1025 + +Iron, persulphate, local use of, in puerperal fever, 1028 + tincture of the chloride, use of, in diphtheria, 706 + in erysipelas, 637 + in yellow fever, 652 + +Irregular forms of scarlet fever, 508 + +Irrigation, disposal of liquid wastes by, 225 + +Irritability of nervous system in hydrophobia, 899 + +Irritants, influence of, in production of morbid growths, 108 + +Isolated glands, lesions of, in cholera, 745 + +Isolation in anthrax, 937 + in diphtheria, 696 + in the plague, 783 + in rubeola, 578 + in scarlet fever, 536 + necessity of, in typhus fever, 361 + principles of, in disease, 203 + + +J. + +Jaborandi, use of, in scarlet fever, 552 + in yellow fever, 650 + +Jaundice in relapsing fever, 391 + in septicaemia venosa, 1012 + complicating typhoid fever, 295 + typhus fever, 356 + in remittent fever, 601 + in yellow fever, 646 + +Joints, chronic diseases of, following rubeola, 574 + condition of, in glanders in man, 920 + inflammation of, complicating erysipelas, 634 + lesions of, in pyaemia, 967 + purulent inflammation of, in puerperal fever, 990 + suppuration of, in pyaemia, 976 + swelling of, in cerebro-spinal meningitis, 814 + in relapsing fever, 400 + +Jugular veins, pulsation of, significance in general diagnosis, 156 + +Juniper gin, use of, in wet beriberi, 1042 + + +K. + +Kibbie's fever-cot, use of, in puerperal fever, 1034, 1035 + +Kidney affections, complicating diphtheria, 676 + complications in hemorrhagic form of pernicious malarial fever, + treatment, 612 + +Kidneys, lesions of, in anthrax in animals, 937 + in man, 942 + in cholera, 746 + in diphtheria, 687 + in pyaemia, 969 + in rabies and hydrophobia, 903 + in relapsing fever, 414 + in scarlet fever, 526 + in septicaemia, 972 + in typhoid fever, 268 + in typhus fever, 357 + +Koch's investigation of bacillus tuberculosis, 99 + of cholera bacilli, 745-749 + of bacteria of puerperal fever, 997 + + +L. + +Lactic acid, use of, in diphtheria, 703 + +Lardaceous degeneration, 84 + +Laryngeal diphtheria, local treatment, 712 + prognosis, 692 + +Laryngitis, complicating rubeola, 571 + typhoid fever, 294 + +Larynx, inflammation of, complicating variola, 446 + lesions of, in hydrophobia, 902 + in relapsing fever, 413 + in typhoid fever, 266 + symptoms of diphtheria, 671 + +Latent form of typhoid fever, 300 + +Leeches, use of, in puerperal fever, 1031 + +LEPROSY, 785 + Definition, 785 + Synonyms, 785 + History, 785 + Etiology, 787 + Heredity as a cause, 787, 788 + Contagiousness, 788 + Transmission, by inoculation, 788, 789 + Sex as a cause, 789 + Forms, 789 + Symptoms--prodromal stage, 789 + Duration of prodromal stage, 789 + Tubercular form, 789 + Local, 789 + Eruptions, 789 + Earlier eruptions, 790 + Characteristic eruptions, 790 + General, 790 + Duration, 790 + Anaesthetic form, 790 + Local, 790 + General, 791 + Duration, 791 + Morbid anatomy, 791 + Changes in nerves, 791 + Skin, 791 + Bacteria, 792 + Seat of bacteria, 792 + Diagnosis, 792 + Prognosis, 793 + Treatment, 793 + Futility of specific, in, 793 + Indications, 793 + Prophylaxis, 794 + Segregation of afflicted, 794 + Quarantine in, 794 + Local, 794 + +Lesions characteristic of anthrax, 935 + +Lethargic form of rabies in dogs, 897 + +Leucocytes, death of, as a cause of thrombosis, 57 + migration, 42 + +Leucocythaemia, complicating diphtheria, 675 + +Lime-water, use of, in diphtheria, 703 + +Limbs, significance of appearance in general diagnosis, 160 + +Listerine as a prophylactic in scarlet fever, 537 + +Liver, abscess of, following typhoid fever, 295 + enlargement of, in pyaemia, 976 + lesions of, in cholera, 745 + in diphtheria, 687 + in glanders, 918, 922 + in pyaemia, 969 + in remittent fever, 602 + in relapsing fever, 414 + in scarlet fever, 531 + in typhoid fever, 265 + in typhus fever, 357 + in yellow fever, 649 + +Local dropsies, 71 + lesions of glanders, 915, 921 + symptoms of glanders in animals, 914 + of glanders in man, 921 + treatment of anthrax in animals, 938 + of anthrax in man, 943 + of diphtheria, 701, 709 + of erysipelas, 637 + of glanders in horse, 918 + in man, 924 + of pyaemia, 981 + of septicaemia, 983 + +Lochial discharge, influence of, on causation of puerperal fever, 1015 + +Lung diseases, complicating influenza, 868 + complicating influenza, treatment, 877 + +Lungs, gangrene of, in influenza, 870 + hypostatic congestion of, in typhus fever, 353 + lesions of, in cholera, 746 + in diphtheria, 687 + in glanders, 917, 922 + in influenza, 872 + in pyaemia, 968 + in relapsing fever, 413 + in septicaemia, 972 + in typhoid fever, 266 + +Lymph, dried, use of, in vaccination, 477 + of vaccinia, microscopical characters, 463 + vaccine, proper time for collecting, 479 + +Lymphangitis, complicating erysipelas, 634 + vaccination, 468 + +Lymphatic glands, condition of, in anthrax, 940 + in glanders in horses, 915 + in man, 921 + in malignant scarlet fever, 508 + in rotheln, 586 + lesions of, in human anthrax, 942 + in anthrax of lower animals, 935 + in diphtheria, 687 + in relapsing fever, 417 + pigmentation of, 92 + +Lymphatics, as channel of entrance of poison of septicaemia, 963 + lesions of, in symptomatic parotitis, 626 + +Lymphatic swellings, seat of, in grave form of the plague, 778 + system, lesions of, in the plague, 781 + +Lymphoma, 120, 124 + + +M. + +Magnesium sulphate, use of, in wet beriberi, 1042 + +Malaria, 89 + action of poison on system, 591 + entrance into system, modes of, 591 + communicability by drinking-water, 590 + by fruit, 591 + by milk, 590 + conditions necessary to mature the poison, 589 + duration of incubation of poison, 591 + from impure water, 182 + influence of moisture in production, 187 + means of access of the poison, 590 + nature of the poison, 589 + non-interchangeableness of the poison, 591 + ponderability of the poison, 590 + production, 187 + specific nature of poison, 591 + +MALARIAL FEVER, PERNICIOUS, 605 + Definition, 605 + Varieties, 606 + Algid or congestive form, 606 + Causes, 606 + Frequency, 607 + Cases illustrating clinical history, 606 + Causes of death, 607 + Mortality-rate, 607 + Treatment, 607 + General indications for treatment, 608 + Use of ice and cold in treatment, 608 + Opium, 608 + Alcohol, 608 + Comatose form, 608 + Symptoms, 608 + Previous condition of persons attacked, 609 + Diagnosis from congestive form, 609 + Treatment, 609 + Hemorrhagic form of, 609 + Causes, 610 + Seat of hemorrhages, 610 + Cases illustrating clinical history, 611 + Treatment, 612 + Indications for treatment, 612 + Use of quinia, 612 + Hemorrhages, 612 + Renal complications, 613 + Depurative, 613 + Use of calomel and purgatives, 613 + +Malarial fevers, 589 + definition, 589 + nature of remittent fever, 598 + +Malignant anthrax oedema, 940 + pustule, 926 + tumors, 114 + +Mania following cerebro-spinal meningitis, 819 + +Maternity hospitals, advantages of, 1021 + +Marriages, influence of, hereditary, 176 + of diseased persons, 176 + transmission of hereditary proclivities by, 131 + +Marriages, consanguineous, 131 + +Marson's theory of multiple vaccination, 467 + +Masked forms of yellow fever, symptoms, 654 + +Maturation in variola, 439 + +Measles, 557 + relations of, to idiopathic parotitis, 620 + +Mechanism of transudation, 68 + +Medical diagnosis, general, 148 + +Melanaemia, 92 + +Melanin, 92 + +Membrane, appearance of, in severe form of diphtheria, 668 + diphtheritic, artificial production, 684 + characters, 685 + mode of formation, 685 + varieties, 686 + gangrenous condition of, in diphtheria, 669 + +MENINGITIS, EPIDEMIC CEREBRO-SPINAL, 795 + Definition, 795 + Synonyms, 795 + History, 796 + Etiology, 801 + Seasons as a cause, 802 + Meteorological agencies, 802 + Localities, 802 + Age, influence, 802 + Sex, influence, 802 + Depressing and debilitating habits, 803 + Contagiousness, 803 + Morbific principle, 803 + Pandemic nature, 804 + In the lower animals, 804 + Types, 804 + Forms, 805, 806 + Symptoms--summary of, 806 + Modes of onset, 806, 807 + Individual, 808 + Pain in the head, 808 + spine, 808 + Hyperaesthesia and anaesthesia of skin, 808 + Spinal rigidity or opisthotonos, 809 + duration of, 809 + Convulsions, 809 + Paralysis, 810 + Aphasia, 810 + Condition of eyes, 810 + pupils, in, 810 + strabismus, 810 + blindness, 811 + Deafness, 811 + Suppurative inflammation of middle ear, 811 + Physiognomy, 812 + Delirium, 812 + Coma, 812 + Vertigo, 812 + Debility, 813 + Condition of tongue, 813 + Nausea and vomiting, 813 + Characters of matter vomited, 813 + Appetite and digestion, 814 + Thirst, 814 + Constipation and diarrhoea, 814 + Condition of fauces, 814 + Urine, 814 + Swelling of joints and limbs, 814 + Respiration, 814 + Pulse, 815 + Temperature, 815 + fluctuations of, 816 + Eruptions, 816 + irregularity of, 816, 817 + petechiae and ecchymoses, 816, 817 + bullae and pemphigus, 817 + Cause of death, 818 + Duration, 818 + Convalescence, 819 + characters, 819 + cause of tardy, 819 + Relapses, 820 + frequency, 820 + Sequelae, 819 + Followed by eye affections, 819 + Impairment of hearing, 819 + Deaf-mutism, 819 + Impaired intellect and mania, 819 + Hydrocephalus, 819 + Paresis and paralysis, 819 + Softening of brain, 820 + Difficulty of speech, 820 + Severe neuralgic pains, 820 + Mortality of, 820, 828 + variability of death-rate, 820, 828 + influence of age upon, 828 + Morbid anatomy, 820 + General appearance of body after death, 820 + Changes in the muscles, 821 + in brain and membranes, 821 + Changes due to congestion of brain and membranes, 821 + to inflammation of meninges, 822 + to softening of the brain, 823 + Changes in pia mater, 821 + in brain-tissue, 823 + in spinal cord and membranes, 823 + position of, 823 + in internal and auditory apparatus, 824 + Softening of fourth ventricle and auditory nerve, 824 + Changes in eye and optic nerve, 824 + in the viscera, 824 + Absence of enlargement of spleen, 824 + Changes in blood, 824 + Amount of fibrine in blood before death, 825 + after death, 825 + Changes in blood-corpuscles, 825 + Summary of pathology, 826 + Diagnosis of, 826 + From sporadic meningitis, 827 + Functional and hysterical nervous affections, 827 + Typhoid fever, 827 + Typhus fever, 827 + Prognosis of, 828 + Symptoms indicating unfavorable, 829 + favorable, 829 + Imprudence of absolute, in, 829 + Treatment, 829 + Emetics, 830 + Purgatives, 830 + Futility of venesection, 830 + Local depletion, 830 + Cold applications, 830 + Blisters, 830 + Mode of using blisters, 831 + Of coldness of skin, 831 + Of collapse, 831 + Use of alcohol, 831 + Opium, 832 + Value of opium, 833 + Use of quinia, 833 + Antipyretics, 833 + Mercury, 833 + Calabar bean, 834 + Belladonna, 833 + Ergot, 833 + Potassium bromide, 834 + Hydrate of chloral, 834 + Potassium iodide, 834 + Management of convalescence, 835 + Diet in, 834 + +Meningitis, granular, following rubeola, 574 + +Menstrual disorders, complicating relapsing fever, 410 + typhoid fever, 296 + +Menstruation, complicating typhus fever, 356 + significance of abnormal, in general diagnosis, 165 + +Mental condition in hydrophobia, 899 + in influenza, 868 + in septicaemia lymphatica of puerperal fever, 1012 + in typhoid fever, 277 + disorders following the plague, 781 + impressions, influence of, in causation of yellow fever, 643 + overwork as a cause of typhus fever, 342 + strain, symptoms due to, 205 + work, relation of, to exercise, 199 + +Mercury, use of, in cerebro-spinal meningitis, 833 + in diphtheria, 705 + +Metamorphosis, cheesy, 79 + colloid, 83 + croupous, 80 + fatty, 74, 79 + mucous, 82 + +Metastasis in idiopathic parotitis, 623, 624 + treatment, 625 + in pyaemia, pathology, 964 + of tumors, 110 + +Methods of disinfection, 201 + of vaccinating, 478 + +Metritis in puerperal fever, lesions, 987 + +Meteorism in typhoid fever, 286 + +Micro-organisms of puerperal fever, 1015 + in pyaemia, blood-changes effected, 970 + +Microbes, as poison producers and carriers, 141 + difficulty of separation of, from surrounding material, 146 + liability to error from minuteness, 143 + +Microbia in inflammation, 45, 48 + +Micrococci, 141 + in healthy bodies, 144 + +Microscopic organisms, classification, 141 + +Microscopy of glanderous lesions in man, 923 + +Migration of leucocytes, 42 + +Mild forms of cholera, 731 + character of stools, 732 + number of stools, 732 + of influenza, treatment, 874 + form of typhus fever, 354 + of yellow fever, symptoms, 644 + +Milk, adulteration, 197 + as a cause of disease, 197 + as a medium of dissemination of anthrax, 929 + of malaria, 590 + of rabies and hydrophobia, 891 + of scarlet fever, 491 + of typhoid fever, 252 + as a vehicle of bacillus tuberculosis, 105 + polluted, as a cause of diphtheria, 683 + +Mind, state of, in relapsing fever, 384 + +Miscarriage, complicating typhus fever, 356 + +Modern conveniences questionable benefits, 215 + +Moral sense, perversion of, following typhoid fever, 292 + +Morbid anatomy, of anthrax in animals, 935 + in man, 941 + of beriberi, 1040 + of cerebro-spinal meningitis, 820 + of cholera, 741 + of dengue, 882 + of diphtheria, 685 + of erysipelas, 635 + of glanders in horses, 916 + in man, 922 + of idiopathic parotitis, 621 + of influenza, 871 + of intermittent fever, 594 + of leprosy, 791 + of pertussis, 843 + of the plague, 781 + of puerperal fever, 985 + of pyaemia, 966 + of pyaemia simplex, 970 + of rabies and hydrophobia, 902 + of relapsing fever, 413-417 + of remittent fever, 602 + of rubeola, 575 + of scarlet fever, 530 + of septicaemia, 971 + of septo-pyaemia, 972 + of simple continued fever, 235 + of symptomatic parotitis, 626 + of typhoid fever, 260 + of typhus fever, 356 + of vaccinal pock, 463 + of varicella, 483 + of variola, 446 + of yellow fever, 649 + growths, 105 + classifications, 114, 122 + Cohnheim's theory of origin, 106 + influence of an irritant in production, 108 + method of origin, 106 + non-malignant, hereditary nature, 129 + processes, 35 + +Morbific principle of cerebro-spinal meningitis, 803 + +Morphia, hypodermic use of, in beriberi, 1043 + use of, in rabies and hydrophobia, 907 + +Mortality of anthrax in animals, 936 + in man, 943 + of cerebro-spinal meningitis, 820, 828 + in cholera, 754 + of glanders in man, 924 + of influenza, 872 + of pertussis, 841 + of the plague, 780 + of puerperal fever, 1020 + of rabies and hydrophobia, 894 + in relapsing fever, 422 + of remittent fever, 599 + of rubeola, 577 + of scarlet fever, 534 + of typhoid fever, 316-320 + of typho-malarial fever, 616 + of typhus fever, 360, 361 + of yellow fever, 647, 648 + +Mouth, condition of, in idiopathic parotitis, 622 + of mucous membrane of, in erysipelas, 633 + complications in erysipelas, treatment, 638 + symptoms of diphtheria, 672, 673 + +Mucous degeneration, 82 + membranes of palate and fauces, appearance of, in prodromal stage of + rubeola, 564 + condition of, in confluent small-pox, 441 + in rotheln, 586 + eruptions of varicella on, 483 + influence of different, upon the character of diphtheritic + membrane, 688 + lesions of, in diphtheria, 688 + in glanders in man, 922 + in rabies and hydrophobia, 902 + in erysipelas, 635 + localized redness of, symptomatic of prodromal stage of + diphtheria, 667 + variolous pustules upon, 439 + metamorphosis, 82 + softening, 82 + +Multiple tumors, 110 + +Mumps, 620 + +Murmurs, arterial, in beriberi, 1040 + cardiac, in beriberi, 1040 + +Muscles, alteration of, in beriberi, 1041 + lesions of, in cerebro-spinal meningitis, 821 + in diphtheria, 687 + in pyaemia, 966 + in typhoid fever, 267 + of neck, suppuration of, in symptomatic parotitis, 626 + voluntary, lesions of, in relapsing fever, 410 + +Muscular pains in yellow fever, 644 + paralysis in beriberi, 1039 + rigidity after cholera, 741 + spasm, in typhoid fever, 279 + tenderness in beriberi, 1039 + tremor in typhoid fever, 279 + in typhus fever, 349 + + +N. + +Naevi, vaccination as a means of destroying, 468 + +Nails, appearance of, in typhoid fever, 275 + +Nasal cavities, condition of, in malignant scarlet fever, 508, 520 + mode of invasion of, in diphtheria, 669 + complications in erysipelas, treatment, 638 + diphtheria, local treatment, 710 + prognosis, 692 + form of diphtheria, symptoms, 669 + lesions in glanders, 917 + mucous membrane, condition of, in influenza, 866 + +Nationality in relation to relapsing fever, 371 + +Nature of puerperal fever, views concerning, 990-1004 + of vaccinia, 455 + +Nausea, during intermittent fever paroxysm, 593 + in cerebro-spinal meningitis, 813 + in influenza, 866 + in relapsing fever, 390 + in rubeola, treatment, 581 + in typhoid fever, 285 + in typhus fever, 350 + in yellow fever, treatment, 652 + significance of, in general treatment, 162 + +Negroes, insusceptibility of, to yellow fever, 644 + +Neck, significance of appearance of, in diagnosis, 152 + +Necrosis from embolism, 64, 65 + +Neoplasms, 105 + +Nephritis, complicating scarlet fever, 525 + in scarlet fever, treatment, 550-555 + +Nerves, lesions of, in leprosy, 791 + in symptomatic parotitis, 626 + +Nervous diseases, complicating diphtheria, 675, 676 + hereditary nature of, 129 + influence of, upon susceptibility to rubeola, 561 + symptoms in relapsing fever, 383-385 + complicating scarlet fever, 510 + of dengue, 882 + of influenza, 867 + of malignant scarlet fever, 507 + +Nervous system, chronic diseases of, following rubeola, 574 + condition of, in cholera, 741 + in remittent fever, 602 + lesion of, in diphtheria, 689 + in septicaemia, 972 + +Neuralgia, following cerebro-spinal meningitis, 820 + in yellow fever, 644 + +Neuralgias, old, aggravation of, in influenza, 870 + +Neurine, use of, in diphtheria, 703 + +Nitric acid, use of, to prevent the return of intermittent fever + paroxysm, 598 + +Nitro-muriatic acid, use of, in anthrax, 938 + +Nodule, nasal, in glanders, 917 + +Nomenclature of pyaemia, 953 + of septicaemia, 953 + +Nose, inflammation of, complicating variola, 445 + +Nostrils, condition of, in glanders in man, 921 + +Nourishment, necessity of, in typhus fever, 363 + +Nuisance, legal views as to what constitutes, 182 + + +O. + +Obesity, tendency to, following typhoid fever, 298 + +Obstetrical scarlatina, 498 + +Occupation, influence of, in causation of anthrax, 939 + of glanders, 920 + of influenza, 860 + of typhoid fever, 244 + of typhus fever, 343 + relation of, to relapsing fever, 372 + +Odor of body, significance of, in general diagnosis, 159 + of relapsing fever, 378 + +Oedema, 69 + complicating relapsing fever, 400 + scarlet fever, 529 + typhoid fever, 297 + from nervous influence, 71 + of glottis, complicating scarlet fever, 512, 529 + of lungs, Welch on cause of, 72 + significance of, in general diagnosis, 159 + +Oesophagus, lesions of, in typhoid fever, 265 + +Offensive effluvia, symptoms due to, 181 + +Oil, inunctions of, in the plague, 784 + +Open wounds, liability of, to diphtheria, 679 + +Opisthotonos in cerebro-spinal meningitis, 809 + +Opium, use of, during cold stage of intermittent fever, 595 + during hot stage of intermittent fever, 595 + in algid form of pernicious malarial fever, 608 + in cerebro-spinal meningitis, 832 + in cholera, 767 + in dengue, 885 + in influenza, 874, 877 + in puerperal fever, 1031 + in relapsing fever, 429 + in remittent fever, 604 + in typhus fever, 366 + +Ophthalmia, chronic, following rubeola, 574 + +Optic nerve, lesions of, in cerebro-spinal meningitis, 824 + +Organic disease, hereditary nature of, 129 + +Organisms, microscopic, classification, 141 + minute, convertibility, 145 + +Organoid tumors, 116 + +Origin of vaccinia, 457 + +Origins, specific, of the plague, 776 + +Ossification, 87 + +Otitis, chronic, following rubeola, 574 + complicating scarlet fever, 520 + in scarlet fever, results, 521 + treatment, 547 + +Ovaries, lesions of, in septicaemia, 972 + in pelvic peritonitis in puerperal fever, 989 + +Overcrowding as a cause of cholera, 721 + of typhus fever, 341 + +Overwork as a cause of disease, 204 + of the plague, 775 + +Ozone, use of, in diphtheria, 709 + + +P. + +Pain, in idiopathic parotitis, 623 + in inflammation, 41 + significance of, in general diagnosis, 165 + +Pains, muscular and joint, in relapsing fever, 385 + of general peritonitis in puerperal fever, 1010 + peritoneal, in para- and perimetritis of puerperal fever, 1007 + rheumatic, in relapsing fever, 399 + +Palpitation of heart in beriberi, 1039 + +Pancreas, lesions of, in relapsing fever, 417 + +Pandemic nature of cerebro-spinal meningitis, 804 + +Panum's view of bacteria of diphtheria, 667 + +Papayotin, use of, in diphtheria, 703 + +Papule in variola, morbid anatomy, 446 + +Paralysis, complicating diphtheria, 676 + variola, 445 + diphtheritic, date of appearance, 676 + seat, 676 + treatment, 713 + following cerebro-spinal meningitis, 819 + typhoid fever, 293 + in cerebro-spinal meningitis, 810 + local, in relapsing fever, 398 + motor, in relapsing fever, 385 + muscular, in beriberi, 1039 + sensory, in diphtheria, 676 + +Paralytic form of rabies in dogs, 896 + stage of hydrophobia in man, 900 + +Parenchymatous inflammation, 53 + +Para- and perimetritis in puerperal fever, symptoms, 1005 + +Parametritis in puerperal fever, lesions, 987 + +Paresis following cerebro-spinal meningitis, 819 + +Parotid glands, lesions of, in idiopathic parotitis, 621 + gland, lesions of, in symptomatic parotitis, 626 + in pyaemia, 967 + swelling, character of, in symptomatic parotitis, 627 + complicating typhoid fever, 296 + +PAROTITIS, IDIOPATHIC, 620 + Definition, 620 + Nature, 620 + Etiology--predisposing causes, 620 + Age, influence, 620 + Sex, influence, 620 + Season, influence, 620 + Relation to measles, diphtheria, and scarlet fever, 620 + Peculiarities in mode of occurrence, 621 + Anatomical appearance, 621 + Changes in parotid gland, 621 + Symptoms, 621 + Duration of incubation stage, 621 + Of invasion stage, 621 + Actual attack, 621 + Local, 621 + Physiognomy, 622 + Mouth and tongue, 622 + Digestive tract, 622 + Temperature and pulse, 623 + Respiration, 623 + Pain, 623 + General, 623 + Complications, 623 + Metastasis, 623 + Frequency, 623 + Date of appearance, 623 + Orchitis, 623 + Symptoms, 624 + Diagnosis, 624 + Significance of outward displacement of lobe of ear, 624 + Prognosis, 624 + Result of metastatic orchitis, 624 + Treatment, 624 + Delirium and headache, 624 + Difficult deglutition, 624 + Sleeplessness, 625 + Local, 625 + Suppuration of gland, 625 + Incomplete resolution, 625 + Metastasis, 625 + in females, 625 + with depression, 625 + +PAROTITIS, SYMPTOMATIC or METASTATIC, 625 + Definition, 625 + Etiology, 625 + Mechanical nature of exciting cause, 626 + Altered blood as a cause, 626 + Morbid anatomy, 626 + Changes in parotid gland, 626 + Suppuration of muscles of neck, 626 + Changes in periosteum and cranial bones, 626 + lymphatics, veins, and nerves, 626 + in middle ear, 626 + Thrombi of jugular veins, 626 + Symptoms, 626 + Characters of swelling, 627 + Date of pointing of abscess, 627 + Physiognomy, 627 + Prognosis, 627 + Of bilateral form, 627 + Diagnosis--from idiopathic parotitis, 627 + Treatment of, 627 + Local, 628 + Of incomplete resolution, 628 + Of gangrene, 628 + +Parotitis, complicating cholera, 735 + influenza, 870 + relapsing fever, 404 + typhus fever, 356 + treatment, 367 + +Paroxysm of intermittent fever, 592 + primary, of relapsing fever, 375, 378 + of remittent fever, 599 + +Paroxysms of hydrophobia in man, 899 + of pertussis, characters, 837 + duration, 840 + frequency, 840 + of rabies in dogs, 896 + +Pasteur's experiments as to infectiveness of rabies, 892, 893 + method of inoculation in anthrax, 937 + for prevention of rabies and hydrophobia, 905 + +Pathognomonic lesions of rabies in dogs, 903 + +Pathology of glanders in man, 916, 918 + of influenza, 871 + of pyaemia, 963 + +Pearly distemper, relation of, to tuberculosis, 99 + +Pelvic abscesses in puerperal fever, treatment, 1036 + cellulitis in puerperal fever, lesions, 988 + exudations, treatment of, in puerperal fever, 1036 + peritonitis, in puerperal fever, lesions, 988 + +Peppermint-test for defects in plumbing, 190 + +Pepsin, use of, in diphtheria, 703 + +Perforation, intestinal, in typhoid fever, 289, 290 + in typhoid fever, treatment, 333 + +Pericarditis in relapsing fever, 402 + complicating influenza, 870 + +Pericardium, lesions of, in cholera, 747 + in pyaemia, 968 + +Peri-glandular lesions in the plague, 782 + +Periostitis, complicating typhoid fever, 297 + +Peritoneal effusions, encysted, in puerperal fever, treatment, 1036 + +Peritoneum, lesions of, in relapsing fever, 417 + +Peritonitis, complicating relapsing fever, 406 + typhoid fever, 295 + general, in puerperal fever lesions, 989 + in puerperal fever, symptoms, 1010 + pelvic and diffused, of puerperal fever, 988 + +Pernicious malarial fever, 605 + +Perspiration in pyaemia, 974 + in yellow fever, 645 + +PERTUSSIS, 836 + History, 836 + Definition, 836 + Etiology, 838 + Specific poison, 838 + seat, 838 + period of greatest virulence, 838 + inoculation of animals with, 839 + Childhood, influence of, in occurrence, 839 + Age at which most prevalent, 839 + Sex, influence of, in causation, 839 + Catarrhal affections as predisposing causes, 839 + Symptoms, 840, 841 + Initial stage, 840 + Second stage, 840 + Stage of decline, 841 + Paroxysm, characters of, 837 + duration, 840 + frequency, 840 + Fraenum linguae, ulceration, 841 + Urine, condition, 841 + Mortality, 841 + Morbid anatomy, 843 + Complications, 843 + Prophylaxis, 843 + Treatment, 844 + Inhalations, 844 + Emetics, 845 + Potassium carbonate, 845 + Alum, 845 + Belladonna, 846 + Ammonium bromide, 846 + Chloral hydrate, 846 + Quinia, 847 + Pilocarpine muriate, 847 + Sodium benzoate, 847 + Caustic irritation, 848 + Diet, 848 + Hygiene, 848 + +Pertussis, following the plague, 781 + +Petechiae, characters of, in grave form of the plague, 779 + +Petrifaction, 87 + +Peyer's patches, lesions of, in typhoid fever, 261 + +Pharyngeal spasm in rabies and hydrophobia, 899 + +Pharyngitis in scarlet fever, treatment, 545 + and tonsillitis, complicating relapsing fever, 405 + +Pharynx, lesions of, in rabies and hydrophobia, 902 + in relapsing fever, 413 + in typhoid fever, 265 + +Phlebitis and phlebo-thrombosis, lesions of, in puerperal fever, 989 + +Phlegmonous inflammation, 52 + +Phthisis, complicating influenza, 870 + following typhus fever, 355 + from damp soil, 187 + pulmonary, hereditary nature of, 128 + +Physicians as carriers of contagion in puerperal fever, 1017 + mortality in, 207 + relation of, to public hygiene, 207 + +Physiognomy of cerebro-spinal meningitis, 812 + of dengue, 881 + of erysipelas, 632 + of hydrophobia, 899 + of idiopathic parotitis, 622 + of influenza, 866 + of symptomatic parotitis, 627 + of relapsing fever, 376 + of typhoid fever, 272 + of yellow fever, 644 + significance of, in general diagnosis, 150, 151 + +Pigmentation, 90 + +Pilocarpine, use of, in diphtheria, 704 + in rabies and hydrophobia, 907 + muriate, use of, in pertussis, 847 + +Pitting, frequency of, in varicella, 482 + prevention of, in variola, 452 + +Placenta, symptoms of diphtheria, 674 + +PLAGUE, THE, 771 + Definition, 771 + Synonyms, 771 + Classification, 771 + History, 772 + Etiology--Predisposing causes of, 774 + Poverty and filth, 774 + Bodily and mental overwork, 775 + Sex and age, influence, 775 + Season, 775 + Exciting causes, 775 + Dissemination by bodies dead from, 775 + Specific origin, 776 + Contagiousness, 776 + Nature of the poison, 776 + Air as a medium of transmission, 776 + Period of incubation, 777 + Forms of, 777 + Grave or ordinary form, 777 + Fulminant form, 779 + Abortive form, 780 + Symptoms, 777 + Grave form, different modes of onset, 779 + Invasion stage, 777 + Second stage, or stage of fever, 778 + Stage of fully-developed local manifestations, 778 + Seat of enlarged lymphatics, 778 + of buboes, 778 + Characters of bubonic swellings, 778 + Date of appearance of buboes, 778 + Seat and character of carbuncles, 778 + of petechiae, 779 + Character of vomited matter, 779 + Constipation, 779 + Condition of urine, 779 + Stage of convalescence, 779 + Fulminant form, 779 + duration, 779 + Abortive form, 780 + General duration of, 780 + Complications and sequelae, 780 + Followed by catarrhal pneumonia, 781 + Pertussis, 781 + Mental troubles, 781 + Ulcers and abscesses, 781 + Morbid anatomy, 781 + Changes in lymphatic system, 781 + Appearance of buboes, 781 + Peri-glandular tissue, 782 + Abdominal viscera, 781 + Diagnosis, 782 + Prognosis, 780 + Mortality, 780 + Treatment, 782 + Preventive, 782 + Isolation, 783 + Quarantine, 783 + Disinfection, 784 + Clinical, 784 + Inunction of oil, 784 + Buboes, 784 + Drugs used, 784 + +Pleura, lesions of, in pyaemia, 968 + in relapsing fever, 413 + in septicaemia, 972 + +Pleurisy, complicating typhoid fever, 294 + typhus fever, 355 + in septicaemia lymphatica of puerperal fever, 1012 + +Pleuritis, complicating erysipelas, 634 + influenza, 870 + relapsing fever, 404 + scarlet fever, 523 + in scarlet fever, treatment, 556 + +Plumbing, examination of defects, 190 + of houses, 188 + +Pneumonia, catarrhal, complicating influenza, 869 + following the plague, 781 + complicating erysipelas, 634 + relapsing fever, 404 + rubeola, 571 + typhoid fever, 294 + typhus fever, 355 + fibrinous, complicating diphtheria, 672 + in rubeola, treatment, 581 + in typhoid fever, treatment, 335 + lobar, complicating influenza, 869 + +Pneumonias, nature of, complicating influenza, 870 + +Pock of vaccinia, date of appearance, 459 + depression, 459 + desquamation, 460 + development, 459 + incrustation, 460 + in variola, characters of mature, 439 + +Poison, diphtheritic, fixity, 678 + transmission, 678 + influence of intensity of, on severity of cholera, 730, 731 + of anthrax, modes of transmission, 929 + of cholera, nature, 749 + of malaria, nature, 589, 591 + of the plague, nature, 776 + of yellow fever, birthplace, 641 + characteristics, 641 + influence of heat and cold on development, 641 + transportability, 641 + specific, of beriberi, 1038 + of pertussis, 838 + +Polluted soil as a means of disseminating typhoid fever, 253 + +Potassium bromide, use of, in cerebro-spinal meningitis, 834 + carbonate, use of, in pertussis, 845 + chlorate, danger of large doses, 701 + use of, in diphtheria, 699, 700 + iodide, use of, in cerebro-spinal meningitis, 834 + +Poverty as a cause of typhus fever, 342 + +Predisposing causes of beriberi, 1042 + of cholera, 720 + of glanders in horse, 912 + of idiopathic parotitis, 620 + of the plague, 774 + of typhoid fever, 242 + of typhus fever, 341 + +Predisposition to disease, hereditary nature, 126 + +Predispositions, inherited, evidence, 132 + +Pregnancy, complicating influenza, 871 + typhoid fever, 296 + +Preliminary papule of anthrax, treatment, 943 + +Premonitory symptoms of rabies and hydrophobia, 895 + of scarlet fever, 502 + +Prevention of anthrax by inoculation, 937 + +Preventive treatment of anthrax in animals, 936 + in man, 943 + of cholera, 755 + of erysipelas, 636 + of glanders in horses, 919 + in man, 925 + of influenza, 873 + of the plague, 782 + of puerperal fever, 1021 + of pyaemia and septicaemia, 979, 980, 983 + of rabies and hydrophobia, 903 + of scarlet fever, 536 + of typhoid fever, 321 + of typhus fever, 361 + +Previous attacks of variola, protection from, 436 + +Primary vaccine, 473 + +Privy vaults, contamination of water-supply by, 192 + dangers from, 192 + +PROCESSES, GENERAL MORBID, 35 + +Prodromal stage of diphtheria, 667 + of intermittent fever, 592 + of leprosy, 789 + of remittent fever, 599 + of rotheln, 585 + of rubeola, 564 + of varicella, 482 + +Prognosis, general, 167 + of anthrax in animals, 936 + in man, 943 + of beriberi, 1042 + of cerebro-spinal meningitis, 828 + of cholera, 753 + of dengue, 885 + of diphtheria, 692-694 + of erysipelas, 636 + of idiopathic parotitis, 624 + of influenza, 872 + of intermittent fever, 594 + of glanders in horse, 918 + in man, 924 + of leprosy, 793 + of the plague, 782 + of relapsing fever, 422-425 + of remittent fever, 602 + of rotheln, 588 + of scarlet fever, 533 + of simple continued fever, 235 + of symptomatic parotitis, 627 + of typho-malarial fever, 616 + of typhoid fever, 314-316 + of typhus fever, 359, 360 + of vaccinia, 464 + of varicella, 484 + of variola, 450 + of varioloid, 444 + in yellow fever, 646, 647 + effect of constitution, 168 + of nature of malady, 169 + of present state of patient, 169 + influence of nursing, 169 + modifying effects of medicinal agents, 169 + +Prophylactic treatment of diphtheria, 696 + +Prophylaxis, individual, in contagious diseases, 206 + of leprosy, 794 + of pertussis, 843 + of puerperal fever, 1021 + +Prostration in dengue, 882 + in typhus fever, 348 + treatment, 365 + +Protective power of vaccination, 466 + duration of, 468 + against pertussis, 468 + +Pseudo-membrane, solvents of, 703 + +Psoas abscess in puerperal fever, 1010 + +Psychical treatment of hydrophobia, 906 + +Public sewers, 224 + +PUERPERAL FEVER, 984 + Definition, 984 + Frequency, 984 + Etiology, 1013 + Atmosphere, impure, influence on causation, 1013, 1014 + Malaria, nosocomial, influence on causation, 1013 + Micro-organisms, influence on causation, 1013-1015 + Lochial discharge, influence on causation, 1015 + Atmosphere, peculiar states of, on causation, 1016 + Direct inoculation, 1016 + Contagiousness of, 1017 + Contagion, physicians as carriers of, 1017 + Dissecting poison, 1018 + Self-inoculation, 1019 + Morbid anatomy, 985 + Spiegelberg's classification of puerperal inflammations, 986 + Endocolpitis and endometritis, 986 + Diphtheritic ulceration, 986 + Metritis and parametritis, 987 + Diphtheritic endometritis, 987 + Pelvic cellulitis, 988 + Cellulitis from specific infection, 988 + Peritonitis, pelvic and diffused, 988 + exudation in, 989 + general, 989 + appearance of abdominal cavity, 989 + ovaries, 989 + Phlebitis and phlebo-thrombosis, 989 + Thrombi in uterine and pelvic veins, 989 + Abscesses, 989 + pulmonary, 989 + Veins, inflammation, 989 + Thrombi, growth, 990 + Septicaemia, 990 + Abscesses, metastatic, 990 + Endocarditis, ulcerative, 990 + Pleuritis, 990 + Joints, purulent inflammation, 990 + Earlier views concerning nature, 990 + Modern view concerning nature, 992 + Septic origin, 993-1003 + Bacteria, relation to causation, 994 + Koch's investigations of, 997 + physical characters, 999 + modes of entering the circulation, 1000 + action of, upon the blood, 1000 + Diphtheria of genitalia, characters, 1002 + Relation of, to erysipelas, 1002 + Inflammatory affections of non-specific origin, 1003 + Symptoms, general, 1004 + Incubation period, 1004 + Chill, significance of, 1005 + Of endometritis and endocolpitis, 1005 + temperature, 1005 + Parametritis and perimetritis, 1005 + Incubation, 1006 + Temperature, 1006 + Pulse, 1006 + Relapse, 1006 + Headache, 1007 + Pains, 1007 + Vomiting, 1007 + Duration, 1007 + Exudation, 1007 + Uterus fixity of, 1007 + Tumors in iliac fossa, 1008 + Abscesses, 1008 + location, 1008 + pointing of, 1008 + Local peritonitis, 1009 + Of psoas abscess, 1010 + Of peritonitis, general, 1010 + Pains, 1010 + Abdomen, state, 1010 + Respiration, 1010 + Vomiting, 1010 + Vomit, characters, 1010 + Fever, 1010 + Skin, 1010 + Pulse, 1010 + Pyaemic form, 1011 + Of septicaemia lymphatica, 1011 + Mode of onset, 1011 + Temperature in, 1011 + Abdomen, state, 1011 + Skin, state, 1011 + Vomiting, 1011 + Tongue, condition, 1011 + Pulse, condition, 1011 + Respiration, 1012 + Pleurisy in, 1012 + Endocarditis, 1012 + Mental condition, 1012 + Joint affections in, 1012 + Duration, 1012 + Of septicaemia venosa, 1012 + Chills in, 1012 + Fever in, 1012 + Temperature in, 1012 + Pulse in, 1012 + Abdomen, state of, 1012 + Uterus in, 1012 + Of pure septicaemia, 1013 + Mortality, 1020 + Relation of, to zymotic diseases, 1020 + Prophylaxis, 1021 + Maternity hospitals, advantages, 1021 + Necessity of light and air, 1024 + Antisepsis, value, 1024 + methods, 1025 + Sulphurous acid, use, 1025 + Corrosive sublimate, use, 1025 + Iodoform, use of, intra-uterine, 1025 + Vaginal injections, carbolized, use, 1025 + Tarnier's maternity pavilions for prevention, 1027 + Treatment--indications, 1028 + Disinfection, 1028 + Local, 1028 + Use of hydrochloric acid, 1028 + Persulphate of iron, 1028 + Intra-uterine injections, use, 1029 + dangers of, 1029 + methods, 1029 + Corrosive sublimate, use, 1025, 1029 + Pain, peritoneal, 1031 + Use of opium, 1031 + in pyaemic variety, 1031 + Leeches, 1031 + Turpentine stupes, 1032 + Hyperpyrexia, 1032 + Use of purgatives, 1032 + Quinia, 1032 + Sodium salicylate, 1032 + Veratrum viride, 1033 + Digitalis, 1033 + Alcohol, 1033 + Cold in, 1033 + Cold, method of applying, 1034 + Cold water, intra-uterine injections, 1034 + Baths, cold, use, 1034 + Kibbie's fever-cot, use, 1034, 1035 + Coil, 1036 + Diet, 1036 + Encysted peritoneal effusions, 1036 + Quinia, use, 1036 + Pelvic exudations, 1036 + Pelvic abscesses, 1036 + +Puerperal septicaemia, relations of, to obstetrical scarlatina, 499 + women, general sepsis from diphtheria in, 674 + symptoms of diphtheria in, 674 + +Pulmonary abscess in puerperal fever, 989 + collapse, complicating influenza, 869 + complications of typhus fever, treatment, 367 + oedema, complicating rubeola, 572 + +Pulsation of jugular veins, significance of, in general diagnosis, 156 + +Pulse and temperature, relation of, in yellow fever, 644 + average frequency in health and disease, 154 + characters of, in erysipelas, 633 + in idiopathic parotitis, 623 + in general peritonitis of puerperal fever, 1010 + in septicaemia, 977 + +Pulse, characters of, in septicaemia lymphatica of puerperal fever, + 1011 + venosa of puerperal fever, 1012 + condition of, in acute glanders in man, 921 + in beriberi, 1040 + in cerebro-spinal meningitis, 815 + in cholera, 737 + in dengue, 881 + in influenza, 866 + in pyaemia, 975 + in relapsing fever, 382 + in typhus fever, 351 + significance of, in general diagnosis, 152 + in malignant scarlet fever, 507 + in typhoid fever, 275 + kinds of, 154 + methods of examining, 153 + relation to respiration, 154 + temperature, relation of, in relapsing fever, 382 + +Pupil, significance of state of, in general diagnosis, 151 + +Pupils, condition of, in cerebro-spinal meningitis, 810 + +Pure septicaemia of puerperal fever, 1013 + +Purgatives, use of, during hot stage of intermittent fever, 596 + in cerebro-spinal meningitis, 830 + in hemorrhagic form of pernicious malarial fever, 613 + in puerperal fever, 1032 + in remittent fever, 604 + +Purity of water, standards of, 184 + +Purpura, complicating diphtheria, 674 + +Pus, 48 + influence of, in production of pyaemia, 955 + in stools, significance in diagnosis, 164 + +Pustule, malignant, 926 + +Putrefaction of cadaver, rapidity of, in puerperal fever, 971 + +Putrified flesh as a means of disseminating typhoid fever, 257 + +PYAEMIA AND SEPTICAEMIA, 945-955 + History, 945-952 + Nomenclature, 952 + Pyaemia, 953 + Definition, 953 + Septicaemia, 953 + Definition, 954 + Etiology of pyaemia, 955 + Theories concerning, 955 + Pus, influence of, in production, 955 + Character of production, 956 + Thrombosis, relation of, to causation, 957, 958 + Contamination of blood, influence of, in causation, 958 + sources, 958 + Germs, disease-, influence of, in causation, 958 + Wounds, characters of, influence on causation, 958 + Etiology of spontaneous pyaemia, 959 + Wounds of alimentary canal and genito-urinary apparatus as cause, + 959 + Air, vitiated, influence of, on causation, 959 + Spontaneous origin, 959 + Contagiousness, 960 + Chemical origin, 960 + Living organisms, influence of, on causation, 958-960 + Etiology of septicaemia, 960 + Septic intoxication, relation of, to, 961 + Traumatic fever, relation of, to, 962 + Dissecting wounds, relation of, to causation, 962 + Putrid substances, maximum toxic action of, on the body, 962 + Lymphatics as channel of entrance of poison, 963 + Etiology of septo-pyaemia, 963 + Pathology, 963 + Condition of blood, 963 + in pyaemia simplex, 963 + multiplex, 963 + Metastasis, conditions, 964 + Pus, mode of entering the circulation, 964 + Metastatic abscesses, production, 964 + from primary infection, 964 + from secondary infection, 964 + Emboli, action of, in production of metastatic abscesses, 964 + Thrombi, action of, in production of metastatic abscesses, 965 + Seat of pathological changes, 965 + Fat emboli, influence of, in production, 966 + Morbid anatomy, 966 + Of pyaemia, 966 + Appearance of body, 966 + Rigor mortis, 966 + Lesions of cellular tissue, 966 + Muscles, 966 + Brain and membrane, 966 + Retina and choroid, 967 + Cornea, 967 + Ear, 967 + Bones, 967 + Joints, 967 + Parotid gland, 967 + Arteries and veins, 967 + Blood, 968 + Pericardium, 968 + Pleurae, 968 + Lungs, 968 + Liver, 969 + Spleen, 969 + Kidneys, 969 + Micro-organism in blood, changes effected by, 970 + Pyaemia simplex, 970 + Absence of abscesses in, 970 + Septicaemia, 971 + Putrefaction of bodies, rapidity of, 971 + Blood, lesions of, 971 + Sepsin, nature, 971 + Lesions, nervous system, 972 + Endo- and pericardium, 972 + Lungs, 972 + Pleurae, 972 + Kidneys, 972 + Spleen, 972 + Uterus, 972 + Ovaries, 972 + Bladder, 972 + Of septo-pyaemia, 972 + Symptoms, 972 + Of pyaemia, 972 + Prodromal stage, 973 + Chills, date of appearance, 973 + frequency, 973 + Temperature, 974 + Perspiration, 974 + Eruptions, 974 + Pulse, 975 + Tongue, condition of, 975 + Vomiting, 975 + Singultus, 975 + Diarrhoea, 975 + Stools, character of, 976 + Heart, condition of, 976 + Lungs, condition of, 976 + Liver and spleen, enlargement, 976 + Urine, 976 + Joints, suppuration, 976 + Abscesses, frequency, 976 + Delirium, 976 + Breath, odor of, 976 + Wound, changes, 976 + Of septicaemia, 976 + General, 976 + Wound, condition of, 977 + Temperature, 977 + Abdomen, state of, 977 + Pulse, 977 + Diarrhoea, 977 + Vomiting, 977 + Tongue, 977 + Singultus, 977 + Bronchitis in, 977 + Of gangrene foudroyante, 977 + Skin, condition, 977 + Diagnosis, 978 + Of pyaemia from septicaemia, table showing, 978, 979 + Treatment, 979 + In fully-developed cases unsuccessful, 980 + Preventive, 979, 980 + Cleanliness, necessity of, in prevention, 980 + Atmosphere, pure, necessity of, in prevention, 980 + Food and drink, proper, necessity of, in prevention, 980 + Cheerful and pleasant surroundings, in prevention, 980 + Antiseptics, use of, 980 + Local, 981 + Of wound, 981 + Metastatic abscesses, 981 + Constitutional, 982 + Sulphites of magnesium, sodium, potassium, and lime, use of, 982 + Use of alcohol, 982 + Quinia, 982 + Ergotine, 982 + Diet, 982 + Stimulants, 982 + Of septicaemia, 982 + Indications for, 982 + Local, 983 + Preventive, 983 + Of wound, 983 + Diarrhoea, 983 + Antisepsis, 983 + Sulphites and hyposulphites, use of, 983 + Quinia, use of, 983 + Of puerperal septicaemia, 983 + complicating erysipelas, 634 + typhoid fever, 295 + typhus fever, 356 + +Pyaemic form of general peritonitis of puerperal fever, 1010 + + +Q. + +Quarantine in cholera, 204, 755 + in leprosy, 794 + in the plague, 783 + +Quinia, use of, in cerebro-spinal meningitis, 833 + in dengue, 885 + in diphtheria, 708, 712 + in erysipelas, 637 + in influenza, 874-876 + during cold stage of intermittent fever, 595 + hot stage of intermittent fever, 596 + sweating stage of intermittent fever, 597 + to prevent the return of intermittent fever, paroxysm, 598 + in hemorrhagic form of pernicious malarial fever, 612 + in pertussis, 847 + in puerperal fever, 1032, 1036 + in pyaemia, 982 + in relapsing fever, 426 + in remittent fever, 603 + in rubeola, 580 + in scarlet fever, 543 + in septicaemia, 983 + in typhoid fever, 330 + in typho-malarial fever, 618 + in typhus fever, 365 + in yellow fever, 651 + and opium, use of, in yellow fever, 651 + + +R. + +RABIES AND HYDROPHOBIA, 886 + Synonyms, 886 + Definition, 886 + History, 886 + Geographical distribution, 886 + Etiology, 887 + Climate, relation of, to causation, 887 + Season, relation of, to causation, 887 + Summer heats, relation of, to causation, 887 + Hunger and thirst, relation of, to causation, 888 + Improper food, relation of, to causation 888 + Sex, relation of, to causation, 888 + Liability of special breeds, 889 + From skunk-bite, 889 + Spontaneous origin, 890 + Contagion, 891 + Modes of dissemination, 891 + Milk, propagation by, 891 + Saliva, propagation by, 891 + Specific germ, 892 + Pasteur's experiments as to infectiousness, 892 + Point of election of germ, 892 + Antagonism between blood and germ, 892, 893 + Localization of the virus in the wound, 893 + Relation of successful inoculation to bites, 893 + Insusceptibility to, 894 + Incubation, 894 + Duration of, in lower animals, 894 + in man, 894 + Condition of cicatrix during, 895 + Symptoms, 895 + In dogs, 895 + Importance of recognizing premonitory, 895 + Of prodromal stage, 895 + Of furious form, 896 + During paroxysms, 896 + Between paroxysms, 896 + Of paralytic form, 896, 897 + Of lethargic form, 897 + Popular fallacies regarding, 897 + In horse and other animals, 897 + In man, 898 + Symptoms, 898 + Prodromal stage, 898 + Appearance of wound, 898, 899 + Of paroxysms, 899 + Duration, 899 + Reflex irritability during, 899 + Facies during, 899 + Mental condition, 900 + Delirium during, 900 + Relative severity in men and women, 900 + Paralytic stage, 900 + duration, 900 + Without paroxysms, 900 + Diagnosis, 900 + Pathognomonic features in, 900 + From tetanus, 900 + From diphtheria, 900 + From pharyngeal anthrax, 900 + From acute mania, 900 + From epilepsy, 901 + From hysteria, 901 + From pseudo-hydrophobia, 901 + Inoculation in doubtful cases, 902 + Morbid anatomy, 902 + Post-mortem appearance of body, 902 + Changes in mucous membranes, 902 + Bronchi and pharynx, 902 + Lungs, 902 + Heart and blood-vessels, 902 + Gastro-intestinal tract, 902 + Liver and spleen, 902 + Kidneys, 902 + Bladder, 902 + Brain and spinal cord, 902 + Pathognomonic changes in dogs, 903 + Treatment, 903 + Preventive, 903 + Registration of dogs, 904 + Modes of preventing diffusion, 904 + Inoculation, 904 + Pasteur's method, 905 + Of bites, 905 + Use of caustics, 905 + Excision of cicatrix, 906, 908 + Futility of eliminating measures, 906 + Hygienic, 906 + Psychical, importance of, 906 + Therapeutic, 907 + Use of chloroform, 907 + Chloral, 907 + Pilocarpine, 907 + Curare, 907 + Morphia, 907 + Atropia and daturia, 907 + Vaccine virus, 907 + Warm baths, 907 + Faradization, 907 + Inhalation of oxygen, 907 + Importance of rest and quiet, 907 + Intravenous injections, 908 + Venesection, 908 + +Race, influence of, in causation of variola, 436 + protection as a preventive of small-pox, 130 + relation of, as causation of rubeola, 561 + +Rachialgia in cerebro-spinal meningitis, 808 + +Rash of variola, date of appearance of, 437 + significance of, 437 + variolous, 437 + +Raspberry excrescence in vaccinia, 461 + +Reaction in cholera, 734 + treatment, 763 + +Reflex irritability in hydrophobia, 899 + symptoms in diphtheria, treatment, 694 + +Registration of dogs for prevention of rabies, 904 + +Relapse, in relapsing fever, 381 + +Relapses, cause of, in typhoid fever, 309 + duration of, in typhoid fever, 304 + frequency of, in typhoid fever, 302 + in cerebro-spinal meningitis, 820 + of diphtheria, prognosis of, 694 + in rubeola, 563 + +RELAPSING FEVER, 369 + Definition, 369 + Synonyms, 369 + History and geographical distribution, 369 + Etiology, 370 + Destitution and filth as causes, 370 + Intemperance as a cause, 370 + Starvation and over-crowding as a cause, 371 + Age, relation of, to causation, 371 + Sex, relation of, to causation, 371 + Nationality, relation of, to causation, 371 + Season, relation of, to causation, 371 + Occupation, relation of, to causation, 372 + Specific origin, 370, 372 + Contagious nature, 372 + Transmission of contagion, 373 + Area of contagious atmosphere, 373 + Spirillum, 373 + Mode of detecting, 373 + Inoculation, 374 + Incubation period, 376 + General clinical description, 374 + Invasion, 376 + Special symptoms, 376 + Odor, 378 + Physiognomy, 376 + Bronzing of face, 376 + Eruptions, 377 + Hepatic eruptions, 377 + Sudamina, 377 + Desquamation, 377 + Primary paroxysms, duration, 378 + Temperature, 378 + at crisis, 378 + peculiarities, 382 + Relapse, 381 + Duration, 381 + Absence, 380 + Frequency, 382 + Later relapses, 381 + Cases illustrating frequency of relapses, 394 + Average duration of paroxysms, 381 + Intermission, duration, 381 + Pulse, 382 + Relation of pulse to temperature, 382 + Character of pulse during paroxysm, 383 + Pulse at crisis, 382 + During intermission, 383 + Character of heart-sounds, 383 + Convulsions, 384 + Mental condition, 384 + Headache, 383 + Wakefulness, 384 + Vertigo, 384 + Delirium, 384 + General tremor, 384 + Muscular rigidity, 384 + Muscular and joint pains, 385 + Cause of muscular and joint pains, 385 + Seat of muscular and joint pains, 385 + Motor paralysis, 385 + Debility, 386 + Perversion of special senses, 386 + Respiration, 386 + Relation of respiration, temperature, and pulse, 386 + Bronchitis and pneumonia, 387 + Condition of urine, 387 + Urine of paroxysm, 388 + of intermission, 388 + Thirst, 389 + Anorexia, 389 + Condition of tongue, 389 + Nausea and vomiting, 390 + Haematemesis, 390 + Condition of bowels, 390 + of abdomen, 390 + Spleen, enlargement, 391 + Liver, enlargement, 391 + Jaundice, significance of, 391 + Epistaxis, 393 + Hemorrhages, 393 + Convalescence, 393 + Varieties, 395 + Grave form, 395 + Multiple or protracted form, 395 + Abortive form, 395 + Case illustrating subintrant form, 396 + Complications, 396 + Peculiarities of temperature, 397 + Mental hebetude, 398 + Local palsies, 398 + Severe rheumatic pains, 399 + Disorders of vision, 399 + Ophthalmia, 399 + Disorders of hearing, 400 + Otorrhoea, 400 + Swellings and effusions of joints, 400 + Bed-sores, 400 + Gangrene, 400 + Abscesses, 400 + Anaemia, 400 + Oedema, 400 + Sudden collapse and syncope, 401 + Hemorrhages from mucous surfaces, 401 + Pericarditis, 402 + Heart-clot, 402 + Thrombosis and embolism, 402 + Laryngitis, 403 + Bronchitis, 403 + Splenic enlargement, 403 + Rupture of spleen, 403 + Parotitis, 404 + Pleurisy, 404 + Pneumonia, 404 + Pulmonary gangrene, 404 + Metastatic abscesses of lungs, 404 + Pharyngitis and tonsillitis, 405 + Hiccough, 405 + Diarrhoea, 405 + Dysentery, 406 + stools, 406 + Suppuration of mesenteric glands, 406 + General and local peritonitis, 406 + Emaciation, 407 + Renal disorders, 408 + Albuminuria, 407 + Suppression of urine, 407 + Incontinence of urine, 407 + Haematuria, 409 + Glycosuria, 410 + Metastatic inflammation of kidneys, 410 + Disorders of menstruation, 410 + Pregnancy, 410 + Sequelae, 398 + Local palsies, 398 + Acute miliary tuberculosis, 404 + Dyspepsia, 406 + Anaemia, 400 + Morbid anatomy, 410 + Post-mortem appearance of body, 410 + Changes in voluntary muscles, 410 + Blood, 411 + Granule-cells of blood, 412 + Changes in pericardium, 411 + Heat, 411 + Gastro-intestinal canal, 412 + Solitary and agminated glands, 413 + Mesenteric glands, 413 + Larynx and pharynx, 413 + Pleura, 413 + Lungs, 413 + Brain and membranes, 413 + Liver, 414 + Bile-ducts and gall-bladder, 415 + Spleen and capsule, 416 + Pancreas, 417 + Peritoneum, 417 + Kidneys, 414 + Bladder, 414 + Lymphatic glands, 417 + Marrow of bones, 417 + Diagnosis, 418 + Presence of spirillum as a means, 418 + From typhus fever, 418 + From typhoid fever, 419 + Grave form of, from typhoid fever, 420 + From bilious remittent fever, 420 + Yellow fever, 420 + Small-pox, 421 + Acute gastro-hepatic catarrh, 421 + Simple febricula, 421 + Rheumatic fever, 421 + Acute yellow atrophy of liver, 422 + Parotitis, 422 + Cerebral diseases, 422 + Prognosis, 422 + Symptoms indicating unfavorable, 424 + Influence of variations of temperature, 424 + Cerebral symptoms, 424 + Character of eruption, 425 + Hiccough upon, 425 + Epistaxis, 425 + Cough upon, 425 + Heart complications on, 425 + Hepatic enlargement upon, 425 + Splenic enlargement upon, 425 + Jaundice upon, 425 + Albuminuria, 425 + Mortality--bilious typhoid form, 422 + Influence of type of disease, 423 + Stage of disease, 423 + Season, 423 + Habits and previous health, 424 + Sex, 424 + Age, 424 + Race, 424 + Cause of death in, 426 + Treatment--indications for treatment in regular cases, 426 + Hyperpyrexia, 426 + Cause of failure of antipyretics, 429 + Insomnia, 429 + Headache, 429 + Nausea and vomiting, 430 + Constipation, 430 + Jaundice, 431 + Muscular tremor, 432 + soreness and pains, 432 + At critical fall of temperature, 432 + Renal complications, 432 + Epistaxis, 432 + Collapse, 433 + Necessity of absolute rest in, 432 + Resume of treatment, 432 + Diet, 430 + Special remedies, 431 + Use of antiperiodics, 428 + Arsenic, 427 + Atropia, 429 + Bromide and chloral, 430 + Blisters, 431 + Chloroform, 431 + Cold baths, 428 + Digitalis and other antipyretics, 428 + Hyposulphite of sodium, 428 + Opium, 429 + Quinia, 426 + Salicylic acid and salicylates, 428 + Simple febrifuges, 428 + Stimulants, 430 + Venesection, 431 + +REMITTENT FEVER, 598 + Definition, 598 + Malarial nature, 598 + Etiology, 598, 599 + Relation of, to intermittent fever, 599 + Symptoms, 599 + Prodromal stage, 599 + Paroxysm, 599 + Temperature, 599 + Epistaxis, 602 + State of tongue, 600 + Stomach, 602 + Bowels, 602 + Urine, 602 + Jaundice, 600 + cause, 600 + Nervous symptoms, 602 + Physiognomy, 600 + Pulse in, 602 + Duration of, 602 + Diagnosis, 600 + From intermittent fever, 600 + From typhoid fever, 600 + From yellow fever, 600 + Prognosis, 602 + Mortality, 599 + Morbid anatomy, 602 + Changes in skin, 603 + Liver, 602 + Spleen, 602 + Treatment, 603 + Main indications, 603 + Use of quinia, 603 + Amount of quinia, 603 + Causes of failure of quinia, 604 + Adjuvants to quinia, 604 + Use of depuratives, 604 + Purgatives, 604 + Opium, 604 + Of hemorrhage, 605 + Of tympanites, 605 + Of vomiting, 605 + +Renal disease, complicating relapsing fever, 408 + scarlet fever, 525 + +Residence, change of, in treatment of beriberi, 1042 + +Resolution, incomplete, in idiopathic parotitis, treatment, 625 + of symptomatic parotitis, treatment, 628 + of erysipelas, 633 + of inflammation, 54 + +Respiration in cerebro-spinal meningitis, 814 + characters of, in idiopathic parotitis, 623 + in general peritonitis of puerperal fever, 1010 + in mild scarlet fever, 504 + in relapsing fever, 386 + in septicaemia lymphatica, 1012 + in typhoid fever, 276 + in typhus fever, 352 + in croup, 157 + in disease, 156 + kinds of, 156 + significance of, in general diagnosis, 156 + +Respiratory diseases, relation of, to rubeola, 561 + organs, lesions of, in typhus fever, 356 + spread of diphtheria into, 671 + tract, alterations of, in scarlet fever, 531 + +Rest, necessity of, in cholera, 760 + in rabies and hydrophobia, 907 + in relapsing fever, 432 + in yellow fever, 654 + +Retention-cysts, 116, 122 + +Retro-vaccine, 473 + +Re-vaccination, time of, 467 + +Rheumatic and cardiac inflammation in scarlet fever, treatment, 556 + +Rheumatism, complicating scarlet fever, 521 + +Rickets, hereditary nature, 128 + +Rigidity, muscular, in relapsing fever, 384 + +Rindfleisch's definition of diphtheritic inflammation, 686 + +ROTHELN, 582 + Definition, 582 + Synonyms, 582 + History, 582 + Etiology, 583 + Age as a cause, 583 + Sex as a cause, 583 + Specific origin, 583 + Nature of contagion, 583 + Modes of transmission, 583 + Period of greatest contagiousness, 583 + Distinct nature, 584 + Frequency of second attacks, 584 + Relapses, 584 + Symptoms, 585 + Incubation period, 583, 585 + Duration of incubation period, 583 + Prodromal stage, 585 + Eruption, 585 + Duration of eruption, 585 + Characters of eruption, 586 + Types of eruption, 586 + Condition of mucous membranes, 586 + Swelling of lymphatic glands, 586 + Temperature, 587 + Complications and sequelae, 587 + Diagnosis, 587 + From measles, 587 + From scarlet fever, 587 + From symptomatic skin eruptions, 588 + Prognosis of, 588 + Treatment of, 588 + +RUBEOLA, 557 + Definition, 557 + Synonyms, 557 + History, 557 + Etiology, 557 + Nature of contagion, 558 + Relation of straw fungus, 558 + Mode of entrance into body, 558 + Modes of dissemination of contagion, 559 + Inoculation, 559 + Stage when most easily propagated, 560 + Race, influence of, 561 + Age, influence of, 561 + Sex, influence of, 562 + Climate as a cause, 560 + Pregnancy and parturition as a cause, 561 + Scrofula as a cause, 561 + Diseases of respiratory organs as a cause, 561 + Relation of, to acute diseases, 561 + to chronic diseases, 561 + to whooping cough, 561 + Influence of nervous diseases upon susceptibility, 561 + Frequency of epidemics, 560 + in new-born, 562 + second attacks, 563 + Relapses in, 563 + Symptoms, 563 + Incubation stage, 563 + Duration of incubation stage, 560 + Prodromal stage, 564 + Temperature, 564 + Catarrhal symptoms, 564 + Punctated appearance of palatal and faucial mucous membrane, 564 + Convulsions, 565 + Duration of, 565 + Eruptive stage, 565 + Temperature of, 566 + Character and seat of eruption, 566 + General symptoms, 567 + Symptoms at decline, 567 + Temperature at decline, 567 + Duration of eruptive stage, 567 + Varieties of, 568 + Inflammatory or synochal, 568 + Hemorrhagic (rubeola nigra), 569 + Without eruption, 568 + catarrh, 568 + Deviations from ordinary course, 569 + Peculiarities in seat of eruption, 569 + in character of eruption, 569 + Relapses of eruption, 570 + Complications, 570 + Causes, 570 + Complicated with epistaxis, 570 + Skin disorders, 570 + Pemphigoid eruptions, 571 + Ear diseases, 570 + Eye diseases, 571 + Faucial inflammation, 571 + Laryngitis, 571 + Bronchitis and capillary bronchitis, 571 + Pneumonia, 571 + Pulmonary oedema, 572 + Acute miliary tuberculosis, 572 + Heart-clot, 572 + Intestinal catarrh, 572 + Convulsions, 572 + Diphtheria, 573 + Sequelae, 573 + Followed by general miliary tuberculosis, 574 + Chronic pulmonary tuberculosis, 573 + Coryza, 574 + Ophthalmia, 574 + Otitis, 574 + Intestinal catarrh, 574 + Cutaneous diseases, 574 + Bone and joint disease, 574 + Nervous affections, 574 + Granular meningitis, 574 + Albuminuria, 574 + Gangrenous affections, 574 + Morbid anatomy, 575 + Changes in skin, 575 + Diagnosis, 575 + Value of punctated appearance of palatal and faucial mucous + membranes, 575 + Salient points in diagnosis, 575 + From rotheln, 576 + Scarlet fever, 576 + Variola, 576 + Roseola and erythema, 577 + Typhus, 577 + Roseola syphilitica, 577 + Prognosis, 577 + Factors to be considered in making, 577 + Influence of hygienic surroundings, 577 + previous health, 578 + complications, 578 + Mortality, 578 + Influence of stage of disease, 578 + of age, 578 + Treatment, 578 + Preventive, 578 + Isolation, 578 + Hygienic, 579 + Diet, 579 + Uncomplicated cases, 579 + Results, 579 + Hyperpyrexia, 580 + Retrocession of eruption, 580 + Epistaxis, 580 + Diarrhoea, 581 + Nausea and vomiting, 581 + Constipation, 581 + Cough, 581 + Eye complications, 581 + Aural complications, 581 + Bronchitis and pneumonia, 581 + Convulsions, 581 + Use of aconite, 580 + Inunctions, 580 + Quinia, 580 + Stimulants, 580 + + +S. + +Salicylic acid, use of, in diphtheria, 707 + in relapsing fever, 428 + +Saliva, propagation of rabies and hydrophobia by, 891 + +Salivary glands, lesions of, in typhoid fever, 268 + +Sanitary inspection of houses, 187 + +Sarcoma, 118 + +SCARLET FEVER, 486 + History, 486 + Etiology--Specific origin, 487 + Germ theory, 488 + Microbes, 488 + Modes of cultivation of microbes, 488 + Modes of entering the system, 490 + Modes of communication, 490 + Dissemination of, by milk, 491 + Fixity of the poison, 491 + Solid nature of the poison, 492 + Duration of incubation, 492, 493 + Contagiousness, 494 + Area of contagiousness, 494 + Age, influence of, in causation, 500 + Variations in type, 494 + Surgical, 495 + distinguished from septicaemic efflorescence, 497 + effect of poison upon inflammation of wounds, 498 + Obstetrical, 498 + liability of parturient women to, 498 + relation of, to puerperal septicaemia, 499 + Immunity of infants, 500 + Clinical facts regarding, 501 + Relapses in, 501 + Frequency of second attacks, 501 + Sympathetic sore throat in, 502 + albuminuria in, 502 + Symptoms, 502 + Ordinary form, 502 + Premonitory, 502 + Nervous system, 503 + Vomiting in, significance, 503 + Diarrhoea, 503 + Condition of tongue, 504 + of faucial and nasal membranes, 504 + Respiratory, 504 + Efflorescence, 504 + Seat of greatest intensity of eruption, 504 + Cause of absence of eruption, 505 + Date of desquamation, 506 + Temperature, 505 + Digestive system, 505 + Urine, characters, 505 + Duration, 506 + Malignant or grave form, 507 + Digestive system, 507 + Pulse, 507 + Eruption, 507 + Temperature, 507 + Nervous symptoms, 507 + Condition of fauces, 508 + Of throat, 508 + Nasal cavities, 508 + Lymphatic glands, 508 + Duration, 508 + Irregular form, 508 + Causes, 508 + Absence of eruption, 508 + Hemorrhagic form, 509 + Anginose form, 510 + Complications and sequelae, 510 + Complicated by severe nervous symptoms 510 + Throat symptoms, 511 + Adenitis, 511 + Inflammation of neck, 511 + Gangrene of neck, 512 + Oedema of glottis, 512 + Diphtheria, 514 + course of diphtheria, complicating, 516 + Croupous inflammation of fauces, 516 + Coryza, 520 + Otitis, 520 + course of otitis, complicating, 520 + results of otitis, complicating, 521 + By rheumatism, 521 + By cardiac inflammations, 522 + By dilatation of heart, 523 + By heart-clot, 523 + By pleuritis, 523 + By nephritis, 525 + By glomerulo-nephritis, 527 + By albuminuria, 525 + By anasarca and oedema, 529 + Order and date of appearance of anasarca, 529 + By head symptoms due to uraemia, 530 + Morbid anatomy, 530 + Changes in the blood, 530 + Respiratory tract, 531 + Abdominal organs, 531 + Post-mortem appearance of eruption, 532 + Changes in the kidneys, 526 + hyaline degeneration of kidneys, 527 + intestinal nephritis, 528 + parenchymatous nephritis, 526 + Changes in the liver, 531 + Diagnosis, 532 + From measles, 532 + From erythema, 533 + From rotheln, 533 + From diphtheria, 533 + Prognosis, 533 + Influence of complications upon, 533, 535 + type upon, 534 + age upon, 534 + Of grave cases, 535 + Mortality, 534 + Treatment, 536 + Preventive, 536 + Isolation in, 537 + Inoculation as a prophylactic, 536 + Belladonna as a prophylactic, 536 + Sodium sulpho-carbolate as a prophylactic, 537 + Listerine as a prophylactic, 537 + Boric acid as a prophylactic, 537 + Disinfection in, 201, 538 + Hygienic, 539 + Therapeutic, 539 + Mild cases, 540 + Inunction in, 541 + Hyperpyrexia, 541 + by cold, 541 + Mode of applying cold, 542 + Antiseptic, 545 + Complications and sequelae, 545 + Pharyngitis, 545 + local, 546 + Coryza, 546 + local, 547 + Otitis, 547 + local, 549 + paracentesis of tympanum, 548 + Nephritis and albuminuria, 550 + modes of producing diaphoresis, 551 + local, 555 + Convulsions, 556 + Rheumatic and cardiac inflammation, 556 + Pleuritis, 556 + Convalescence, 544 + Use of aconite and veratrum viride, 543 + Alcohol, 544 + Ammonium carbonate, 544 + Carbolic acid, 545 + Cathartics, 554 + Diuretics, 555 + Digitalis, 543, 555 + Ice, 542 + Jaborandi and pilocarpine, 552 + Sodium salicylate, 543 + Quinia, 543 + +Scarlet fever, relation of, to idiopathic parotitis, 620 + +Scarlatina, disinfection in, 201, 538 + +Schools, closure of, for prevention of disease, 203 + +Scrofula, relation of, to causation of rubeola, 561 + relation to tuberculosis, 96, 101 + +Scrofulosis, hereditary disposition to, 127 + +Scrofulous habit, peculiarities of tissue, 101 + +Scurvy, complicating typhus fever, 355 + +Season, influence of, on causation of anthrax, 931, 940 + of cerebro-spinal meningitis, 802 + of diphtheria, 682 + of typhoid fever, 245 + of erysipelas, 630 + of idiopathic parotitis, 620 + of influenza, 860 + of the plague, 775 + of rabies and hydrophobia, 887 + of relapsing fever, 371 + of typhus fever, 343 + of variola, 435 + on cholera, 720 + proper, for vaccination, 477 + +Seborrhoea, following erysipelas, 633 + +Second attack of rubeola, frequency of, 563 + stage of pertussis, 840 + +Secondary form of diphtheria, 671 + +Segregation of lepers, 794 + +Self-infection, danger of, in treating diphtheria, 696 + prevention of, in treating diphtheria, 696 + +Sensibility, altered, significance of, in general diagnosis, 161 + modifications of, in typhoid fever, 279 + +Sepsin, 971 + +Septicaemia, 945 + complicating erysipelas, 634 + distinguished from pyaemia, 978, 979 + lymphatica of puerperal fever, 1011 + venosa, 1012 + +Sequelae of cerebro-spinal meningitis, 819 + of cholera, 735 + of erysipelas, 633 + of grave form of the plague, 780, 781 + of influenza, 868 + of relapsing fever, 396 + of rotheln, 587 + of rubeola, 573 + treatment, 580 + of scarlet fever, 510 + of vaccinia, 464 + of variola, 445 + +Serous inflammation, 47 + inflammations complicating erysipelas, 634 + +Severe form of diphtheria, symptoms, 668 + of influenza, treatment, 875 + of typhus fever, 354 + +Sewerage, 213 + +Sewer- and soil-pipes, importance of position, 188 + +Sewer-gas, 189 + diseases produced by, 190 + symptoms due to, 189 + +Sewers, characters of efficient, 224 + public, 224 + ventilation of, 224 + +Sewer-traps, test as to their efficiency, 190 + varieties, 191 + +Sex, influence of, on causation of cerebro-spinal meningitis, 802 + of diphtheria, 680 + of erysipelas, 630 + of idiopathic parotitis, 620 + of influenza, 860 + of leprosy, 789 + of pertussis, 839 + of the plague, 775 + of rabies and hydrophobia, 880 + of relapsing fever, 371 + of rotheln, 583 + of variola, 436 + typhoid fever, 243 + relation of, to causation of rubeola, 563 + +Silver nitrate, use of, in typhoid fever, 332 + +Simon's triangles, 437 + +SIMPLE CONTINUED FEVER, 231 + Definition, 231 + Synonyms, 231 + History, 231 + Etiology, 232 + Symptoms, 233 + Asthenic form, 233 + Morbid anatomy, 235 + Diagnosis, 234 + From typhoid fever, 234 + From typhus fever, 234 + From relapsing fever, 235 + From tubercular meningitis, 235 + Prognosis, 235 + Treatment, 236 + +Simple form of yellow fever, treatment, 649 + +Singultus in pyaemia, 975 + in septicaemia, 977 + significance of, in general diagnosis, 158 + +Skin, alterations in sensibility of, in cerebro-spinal meningitis, 808 + anaesthesia of, in beriberi, 1039 + appearance of, in typhoid fever, 273 + character of lesions in erysipelas, 631 + chronic diseases of, following rubeola, 574 + color of, in cholera, 737 + condition of, in cholera, 736 + in influenza, 866 + in septicaemia, 977 + coolness of, in cerebro-spinal meningitis, treatment, 831 + diseases of, complicating vaccination, 471 + effects on course of erysipelas, 634 + following vaccination, 471 + disorders of, complicating rubeola, 570 + eruptions of, complicating cholera, 735 + in pyaemia, 974 + erysipelas of, migration, 632 + hyperaesthesia of, in typhus fever, 352 + lesions of, in erysipelas, 635 + course of, 631 + in leprosy, 791 + in remittent fever, 603 + in rubeola, 575 + morbid anatomy of lesions of, in variola, 446 + odor of, in typhoid fever, 273 + in typhus fever, 352 + significance of color of, in general diagnosis, 159 + swelling of, in erysipelas, 632 + +Skunk-bites as cause of rabies and hydrophobia, 889 + +Slaking lime, use of, in diphtheria, 703 + +Sleep, danger of prolonged, in nasal diphtheria, 712 + +Sleeplessness in idiopathic parotitis, treatment, 625 + +Small-pox, 434 + black, 442 + freedom of liability to, from race-protection, 130 + +Sodium benzoate, use of, in pertussis, 847 + chloride, venous injection of, in cholera, 762, 768 + hyposulphite, use of, in relapsing fever, 428 + salicylate, use of, in diphtheria, 707 + in puerperal fever, 1032 + in scarlet fever, 543 + in typhoid fever, 330 + sulpho-carbolate as a prophylactic in scarlet fever, 537 + +Softening, cerebral, from embolism, 65 + mucous, 82 + +Soil, character of, as cause of disease, 187 + composition of, 187 + diminished dryness of, a cause of phthisis, 187 + drainage of, for prevention of anthrax, 937 + of disease, 226 + examination, 188 + filtering power, 187 + humidity of, as a cause of cholera, 722 + +Soils, alkaline, relation of, to causation of anthrax, 930 + +Soil-pipes, importance of position of, 188 + tests as to their efficiency, 190 + ventilation of, 189 + +Solitary glands, lesions of, in typhoid fever, 261 + +Spasm of pharyngeal and respiratory muscles in hydrophobia, 899 + +Special senses, perversion of, in relapsing fever, 386 + in typhus fever, 349 + +Specific origin of anthrax, 720, 726 + of cholera, 727 + of glanders, 911 + of rotheln, 583 + of yellow fever, 640 + +Speech, impairment of, following cerebro-spinal meningitis, 820 + +Spinal cord, lesions of, in cerebro-spinal meningitis, 823 + marrow, lesions of, in cholera, 746 + rigidity in cerebro-spinal meningitis, 809 + +Spirillum, 142 + of relapsing fever, 373 + +Spleen, condition of, in relapsing fever, 391 + enlargement of, in pyaemia, 976 + lesions of, in anthrax in animals, 935 + in man, 942 + in cholera, 746 + in diphtheria, 687 + in glanders, 922 + in hydrophobia, 903 + in pyaemia, 969 + in relapsing fever, 416 + in remittent fever, 602 + in septicaemia, 972 + in typhoid fever, 264 + in typhus fever, 357 + rupture of, in relapsing fever, 403 + +Spontaneous cow-pox, 456 + origin of pyaemia, 959 + of typhoid fever, 254 + +Stages of yellow fever, 645 + +Standards of purity of water, 184 + +Starvation and over-crowding as causes of relapsing fever, 370 + +Steam, use of, in diphtheria, 701 + +Sthenic inflammation, 46 + +Stimulants, use of, in diphtheria, 695 + in relapsing fever, 431 + in rubeola, 580 + in variola, 453 + +Stomach, lesions of, in cholera, 743 + state of, in remittent fever, 602 + +Stools, as a medium of disseminating typhoid fever, 249 + character of, in cholera, 739 + in pyaemia, 976 + in typhoid fever, 287 + in typho-malarial fever, necessity of disinfecting, 619 + necessity of disinfection in prevention of typhoid fever, 321 + significance of, in general diagnosis, 163 + +Strabismus in cerebro-spinal meningitis, 810 + +Straw-fungus, relation of, to rubeola, 558 + +Strychnia, use of, in diphtheritic paralysis, 713 + in dry beriberi, 1043 + +Stupor in typhoid fever, treatment, 334 + in typhus fever, treatment, 366 + +Subsoil-water, level of, 188 + +Sudamina in typhoid fever, 274 + in typhus fever, 352 + +Sulphites and hyposulphites, use of, in pyaemia, 982 + in septicaemia, 983 + +Sulphur, use of, in diphtheria, 709 + +Summer heats, relation of, to causation of rabies and hydrophobia, 887 + +Suppuration in idiopathic parotitis, treatment, 625 + influence of minute organisms in production of, 144 + +Suppurative stage of variola, 439 + +Surgical scarlatina, 495 + treatment of erysipelas, 638 + +Swelling of parotid glands in cerebro-spinal meningitis, 814 + +Swellings, significance of, in diagnosis, 159 + +Sweating stage of intermittent fever, 593 + of intermittent fever, treatment, 597 + +Symptomatic parotitis, 625 + +Symptomatology, general, 148 + +Symptoms at decline of eruptive stage of rubeola, 567 + constitutional, of vaccinia, 459 + due to sewer-gas, 189 + general, of idiopathic parotitis, 623 + of anaesthetic form of leprosy, 791 + of tubercular form of leprosy, 790 + of confluent small-pox, 441 + local, of anthrax, 935, 940 + of idiopathic parotitis, 621 + anaesthetic form of leprosy, 790 + of glanders, 914, 915, 921 + of tubercular form of leprosy, 789 + nervous, in mild scarlet fever, 503 + in typhus fever, 348 + special, in typhus fever, 347 + of anthrax in animals, 934 + in man, 940 + angina, 941 + intestinalis, 941 + of malignant anthrax, 940 + of beriberi, 1039 + of cerebro-spinal meningitis, 806 + of cholera, 731 + of comatose form of pernicious malarial fever, 608 + of dengue, 884 + of diphtheria, 667 + of endometritis and endocolpitis of puerperal fever, 1005 + of erysipelas, 631 + of glanders in horses, 914 + in man, 920 + of hydrophobia, in man, 898 + of influenza, 865 + of idiopathic parotitis, 621 + of intermittent fever, 592 + of gangrene foudroyante, 977 + of general peritonitis of puerperal fever, 1010 + of leprosy, 789 + of malignant scarlet fever, 507 + of para- and perimetritis in puerperal fever, 1005 + of pertussis, 840 + of the plague, 777 + of puerperal fever, 1004 + of pyaemia, 972 + of rabies and hydrophobia in dogs, 895 + of relapsing fever, 374 + of remittent fever, 599 + of rotheln, 585 + of rubeola, 563 + of scarlet fever, 502 + of septicaemia, 976 + lymphatica of puerperal fever, 1011 + venosa of puerperal fever, 1012 + of simple continued fever, 233 + of symptomatic parotitis, 626 + of typho-malarial fever, 615 + of typhoid fever, 268 + of typhus fever, 346 + of vaccinia, 458 + of varicella, 481 + of variola, 436 + of varioloid, 443 + of yellow fever, 644 + +Synonyms of anthrax, 926 + of cerebro-spinal meningitis, 795 + of cholera, 715 + of dengue, 879 + of diphtheria, 656 + of erysipelas, 629 + of glanders, 909 + of influenza, 851 + of leprosy, 785 + of the plague, 771 + of rabies and hydrophobia, 886 + of relapsing fever, 369 + of rotheln, 582 + of rubeola, 557 + of simple continued fever, 231 + of typhoid fever, 237 + of typhus fever, 338 + of vaccinia, 455 + of vaccination, 465 + of varicella, 481 + of variola, 434 + of yellow fever, 640 + +Syphilis, complicating vaccination, 469 + modes of preventing, 470 + treatment of, 471 + constitutional, hereditary nature of, 127 + + +T. + +Taches bleuatres in typhoid fever, 275 + in typhus fever, 352 + +Tarnier's maternity pavilions for prevention of puerperal fever, 1028 + +Taste, modifications of, in typhoid fever, 280 + significance of modification, in general diagnosis, 162 + +Technics of vaccination, 472 + +Teeth, significance of condition, in diagnosis, 152 + +Temperature in anthrax in man, 940 + at decline of eruptive stage of rubeola, 567 + elevated, influence of, in origin and spread of cholera, 720 + in cerebro-spinal meningitis, 815 + in cholera, 736 + in dengue, 881 + in eruptive stage of rubeola, 565 + in erysipelas, 633 + in fevers, 38-40 + in general peritonitis of puerperal fever, 1010 + in idiopathic parotitis, 623 + in influenza, 864 + in malignant scarlet fever, 507 + in mild scarlet fever, 505 + in para- and perimetritis in puerperal fever, 1006 + in prodromal stage of rubeola, 564 + in pyaemia, 974 + in relapsing fever, 378, 382 + in remittent fever, 599 + in rotheln, 587 + in septicaemia, 977 + venosa of puerperal fever, 1012 + in typhoid fever, 280 + in typhus fever, 349 + significance of, in general diagnosis, 158 + respiration and pulse, relations of, in relapsing fever, 386 + +Tenderness, muscular, in beriberi, 1039 + +Teratoid tumors, 124 + +Test, peppermint, for defects in plumbing, 198 + +Tests as to efficiency of soil-pipes, 190 + +The plague, 771 + +Thermometer, use of, in typhoid fever, 284 + +Thirst in cerebro-spinal meningitis, 814 + in rabies and hydrophobia, 899 + in relapsing fever, 389 + in typhoid fever, 285 + in typhus fever, 350 + treatment, 367 + significance of, in general diagnosis, 162 + treatment of, in cholera, 770 + +Throat symptoms, complicating scarlet fever, 511 + +Thoracic duct, obstruction of, as cause of dropsy, 69 + +Thrombi, action of, in production of metastatic abscesses in pyaemia, + 965 + calcification of, 60, 89 + in uterine pelvic veins, 989 + growth of, in puerperal fever, 989 + +Thrombosis, 56 + relation of, to causation of pyaemia, 957 + and embolism, 56 + causes, 57 + symptoms, 66 + in relapsing fever, 402 + in typhoid fever, treatment, 335 + +THROMBUS, 56 + Calcification, 60, 88 + Characteristics, 59 + Changes, 60 + Composition, 56 + Distinguished from thrombosis, 56 + From compression, 58 + From death of leucocytes, 57 + From dilatation, 58 + From marasmus, 59 + From traumatism, 58 + Mechanical effects, 62 + Organization, 60 + Softening, 61 + Varieties, 57, 58 + +Tongue, condition of, in cerebro-spinal meningitis, 813 + in dengue, 881 + in erysipelas, 633 + in idiopathic parotitis, 622 + in mild scarlet fever, 504 + in typhus fever, 350 + in yellow fever, 644 + state of, in pyaemia, 975 + in relapsing fever, 389 + in remittent fever, 600 + in septicaemia, 977 + in typhoid fever, 285 + signification of state of, in diagnosis, 152 + +Tracheal diphtheria, prognosis of, 692 + +Trachea, formation of diphtheritic membrane in, 671 + +Tracheotomy in diphtheria, prognosis of, 692 + +Transmission of cholera, 721, 723 + of variola, 435 + +Transudation, 68 + causes, 69 + mechanism, 68 + +Traps, ventilation, 221 + +Traumatic fever, relation of, to septicaemia, 961 + fevers, 37 + +Treatment of anthrax in animals, 938 + in man, 943 + preventive, of anthrax, 936, 943 + of beriberi, 1042 + of cerebro-spinal meningitis, 829 + of cholera, 759 + of dengue, 885 + of diphtheria, 694 + general, importance of, in diphtheria, 695 + of erysipelas, 636 + of idiopathic parotitis, 624 + local, of idiopathic parotitis, 625 + of intermittent fever, 594 + of leprosy, 793 + local, of leprosy, 794 + of comatose form of pernicious malarial fever, 609 + of glanders in horse, 918 + in man, 924 + preventive, in horse, 919 + in man, 925 + of influenza, 873 + of pertussis, 844 + of the plague, 782 + of puerperal fever, 1028 + of septicaemia, 983 + of pyaemia, 979 + of rabies and hydrophobia, 903 + preventive, 903 + of relapsing fever, 426-433 + of remittent fever, 603 + of rotheln, 587 + of rubeola, 578 + hygienic, of rubeola, 579 + preventive, of rubeola, 578 + of scarlet fever, 536 + of septicaemia, 982 + of simple continued fever, 236 + of symptomatic parotitis, 627 + local, of symptomatic parotitis, 628 + of typhoid fever, 320 + of typho-malarial fever, 618 + of typhus fever, 361 + of variola, 451 + hygienic, of variola, 451 + of variola, preventive, 451 + of varioloid, 451 + of yellow fever, 649 + +Treeak farook, use of, in wet beriberi, 1042 + +TUBERCLE, 94 + Calcification, 96 + Cheesy degeneration, 96 + Fibrous transformation, 96 + Histology, 95 + Horn-like change, 96 + Infectious origin, 97 + Inoculability, 97 + Miliary and gray, cause of infectious qualities, 99 + Origin of, from absorption of cheesy products, 97 + +Tubercular form of leprosy, 789 + +TUBERCULOSIS, 94 + Bacilli of, 99, 100 _et seq._ + Dissemination, 103 + Hereditary nature, 101 + Primary seat, 104 + Relation of, to pearly distemper, 99 + to scrofula, 101 + +Tuberculosis, acute miliary, complicating rubeola, 572 + chronic pulmonary, following rubeola, 573 + general miliary, following relapsing fever, 404 + following rubeola, 574 + relation of, to pearly distemper, 99 + to scrofula, 96, 101 + +TUMORS, 105 + Method of origin, 106 + Cohnheim's theory of origin, 106 + Influence of irritants in producing, 108 + Growth, 109 + concentric, 109 + continuous, 109 + eccentric, 109 + influence of seat, 109 + rapidity, 109 + Primary, 110, 111 + Secondary, 110, 112 + Metastasis, 110 + Multiple, 110 + Recurrence, 110 + Transplantation, 110 + Embolic nature, 112 + Changes occurring, 113 + inflammatory, 113 + Analogy of structure in primary and secondary, 113 + Benignant, 114 + Cachexia, 114 + Malignant, 114 + Resemblance of, to normal tissue of body, 115 + Histoid, 116 + Organoid, 116 + Relation of, to each other, 117 + Connective tissue, 118, 122 + Cystic, 115, 116, 121 + Influence of age upon development, 119 + Classification, 114, 121 + Infective group, 120, 124 + Epithelial group, 123 + Congenital, 124 + +Turpentine inhalations in diphtheria, 704 + stupes, use of, in puerperal fever, 1032 + use of, in typhoid fever, 326 + +Tympanites in remittent fever, treatment, 605 + in typhoid fever, 286 + treatment of, 332 + in typho-malarial fever, treatment, 619 + in typhus fever, 350 + +Tympanum, paracentesis of, in scarlet fever, 548 + +Types of cerebro-spinal meningitis, 804 + of intermittent fever, 594 + of scarlet fever, 494 + of varioloid, 444 + +TYPHOID FEVER, 237 + Synonyms, 237 + Definitions, 237 + History, 238 + Geographical distribution, 241 + Etiology, 242 + Predisposing causes, 242 + Age, influence of, 242 + Sex, influence of, 243 + Occupation, influence of, 244 + Change of residence, influence of, 244 + Idiosyncrasy, influence of, 245 + Depressing emotions, influence of, 245 + Intemperance, influence of, 245 + Previous ill-health, influence of, 245 + Season, influence of, 245 + Elevated temperature, influence of, 246 + Rise and fall of subsoil-water, influence of, 247 + Exciting causes, 248 + Contagiousness, 248 + Dissemination, 249 + Cases illustrating modes of dissemination, 250 + Dissemination of, by drinking-water, 248 + By stools, 249 + By milk, 252 + By atmosphere, 252 + By bed-linen, etc., 253 + By polluted soil, 253 + By putrefied flesh, 257 + Spontaneous origin, 254 + Duration of virulence of germs, 256 + Bacillus typhosus, 258 + Incubation period, 259 + Morbid anatomy, 260 + Lesions peculiar to, 261 + Changes in Peyer's patches, 261 + Solitary glands, 261 + Softening of Peyer's patches and solitary glands, 263 + Cicatrization of Peyer's patches and solitary glands, 263 + Changes in caecum and colon, 263 + Spleen, 264 + Abdominal glands, 264 + Lesions not peculiar to, 265 + Changes in liver and gall-bladder, 265 + Pharynx and oesophagus, 265 + Larynx and lungs, 266 + Brain and membranes, 266 + Muscles, 267 + Heart and blood-vessels, 267 + Blood, 268 + Salivary glands, 268 + Kidneys, 268 + Symptoms, 268 + Clinical description, 268 + Physiognomy, 272 + Epistaxis, 273 + Condition of skin, 273 + Odor, 273 + Eruption, 273 + Sudamina, 274 + Taches bleuatres, 275 + Condition of hair and nails, 275 + Pulse, 275 + Heart-sounds, 276 + Respiration, 276 + Frequency of bronchitis, 277 + Mental condition, 277 + Headache, 277 + Delirium, 278 + Muscular spasm, 279 + tremor, 279 + Modifications of sensibility, 279 + Hearing, 280 + Vision, 280 + Taste, 280 + Temperature, 280 + State of tongue, 285 + Fauces, 286 + Nausea and vomiting, 285 + Anorexia, 285 + Thirst, 285 + Gurgling, 286 + Meteorism or tympanites, 286 + Diarrhoea, 287 + Character of stools, 287 + Intestinal hemorrhage, 287 + frequency, 288 + causes, 288 + importance, 288 + Intestinal perforation, 289 + frequency, 290 + causes, 290 + date of appearance, 290 + importance, 289 + Condition of urine, 291 + amount of solids, 291 + presence of albumen, 292 + Complications and sequelae, 292 + Complicated by pyaemia, 294 + Laryngitis, 294 + Bronchitis and pneumonia, 294 + Pleurisy, 294 + Jaundice, 295 + Peritonitis, 295 + Catarrhal and diphtheritic inflammation of fauces, 295 + Parotid swelling, 296 + Menstrual disorders, 296 + Pregnancy, 296 + Suppuration of Bartholini's glands, 296 + Periostitis, 297 + Oedema, 297 + Bed-sores, 297 + Followed by impaired intellect, 292 + Perversion of the moral sense, 292 + Paralysis and chorea, 293 + Cardiac degeneration, 293 + Arterial thrombosis, 293 + Venous thrombosis, 294 + Gangrene of vulva and vagina, 293 + Hepatic abscess, 295 + Tendency to stoutness, 298 + Varieties of, 298 + Abortive form, 298 + Latent form, 300 + In children, 301 + In aged persons, 302 + Relapses in, 302 + frequency, 302 + course, 303 + cases illustrating, 304 + causes, 308 + Duration, 310 + Diagnosis, 311 + From typhus, 311 + From influenza, 312 + From relapsing fever, 312 + From epidemic cerebro-spinal meningitis, 313 + From simple continued fever, 313 + From remittent fever, 312 + From the eruptive fevers, 313 + From acute tuberculosis, 313 + From trichinosis, 314 + From the specific inflammations, 314 + From acute tubercular meningitis, 314 + Prognosis, 314 + Symptoms indicating unfavorable, 314 + favorable, 316 + Influence of hyperpyrexia upon, 314 + Nervous symptoms, 315 + Heart symptoms, 316 + Condition of pulse, 316 + Abdominal symptoms upon, 316 + Mortality, 316 + Tables showing, 317, 318 + Influence of season, 318 + Sex, 319 + Age, 319 + Treatment, 319 + Habits, 320 + Social condition, 320 + Recent residence, 320 + Corpulence, 320 + Organic disease, 320 + Childhood, 320 + Treatment, 320 + Preventive, 321 + Necessity of proper drainage in prevention, 321 + Disinfection of stools, 321 + Hygienic, 322 + Importance of ventilation, 323 + administering water, 325 + Diet, 323 + Mild cases, 326 + Hyperpyrexia, 327 + by cold baths, 327-329 + Typho-malarial form, 331 + Vomiting, 331 + Diarrhoea, 331 + Tympanites, 332 + Intestinal hemorrhage, 332 + perforation, 333 + Constipation, 333 + Headache, 334 + Insomnia, 334 + Stupor, 334 + Delirium, 334 + Albuminuria, 334 + Complications, 335 + Epistaxis, 335 + Pneumonia, 335 + Hypostatic congestion of lungs, 335 + Thrombosis and embolism, 335 + Bed-sores, 335 + Convalescence, 335 + Use of alcohol, 324 + Digitalis, 330 + Eucalyptus, 331 + Quinia, 330 + Silver nitrate, 332 + Sodium salicylate, 330 + Turpentine, 326 + Specific, 336 + By calomel, 336 + By iodine, 336, 337 + Use of thermometer, 284 + +Typhoidal inflammation, 47 + +Typhoid state of cholera, 734 + following variola, 445 + +TYPHO-MALARIAL FEVERS, 614 + Definition, 614 + Frequency, 616 + Symptoms, 615 + Diagnosis, 616 + Prognosis, 616 + Mortality, 616 + relative mortality of white and black races, 616 + Treatment, 618 + Of typhoidal element, 618 + Of malarial element, 618 + Use of quinia, 618 + Depurative treatment, 618 + Necessity of disinfection of stools, 619 + Of tympanites, 619 + Of insomnia, 619 + Diet, 619 + +Typho-malarial form of typhoid fever, treatment, 331 + +TYPHUS FEVER, 338 + Synonyms, 338 + History, 338 + Etiology--Predisposing causes, 341 + Over-crowding as a cause, 341 + Age, influence of, 342 + Debility and fatigue, influence of, 342 + Mental and physical overwork, 342 + Intemperance, 342 + Poverty, 342 + Barometric and thermometric variations, 343 + Season, 343 + Occupation, 343 + Individual susceptibility to, 343 + Exciting causes, 343 + Contagiousness, 343 + Nature of contagion, 343 + Modes of transmission of contagion, 344 + Communication of, by fomites, 345 + Period of contagiousness, 345 + Spontaneous origin, 345 + Period of incubation, 346 + Symptoms--Clinical description, 346 + Special symptoms, 347 + Prostration, 348 + Nervous symptoms, 348 + Appearance of face, 348 + Intellectual condition, 348 + Headache, 348 + Delirium, 348 + Wakefulness, 349 + Coma vigil, 349 + Perversion of special senses, 349 + Muscular tremor, 349 + Temperature, 349 + Condition of tongue, 350 + Anorexia, 350 + Thirst, 350 + Nausea and vomiting, 350 + Condition of bowels, 350 + Tympanites, 350 + Gurgling, 350 + Eruption, 351 + Duration of eruption, 351 + Taches bleuatres, 352 + Sudamina, 352 + Hyperaesthesia of skin, 352 + Odor, 352 + Condition of pulse, 351 + of heart, 351 + Respiration, 352 + Pneumonia, 353, 355 + Bronchitis, 353, 355 + Odor of breath, 353 + Hypostatic congestion of lungs, 353 + Changes in urine, 353 + Varieties of, 353 + Mild form, 354 + Severe form, 354 + Ataxic form, 354 + Adynamic form, 354 + Ataxo-adynamic form, 354 + Inflammatory form, 354 + Walking form, 354 + Abortive form, 354 + Complications and sequelae, 354 + Complicated by erysipelas, 355 + Cardiac degeneration, 355 + Bronchitis and pneumonia, 353, 355 + Pleurisy, 355 + Albuminuria, 355 + Bed-sores, 355 + Scurvy, 355 + Dysentery, 355 + Jaundice, 356 + Parotitis, 356 + Serous inflammations, 356 + Pyaemia, 356 + Disorders of menstruation, 356 + Miscarriage, 356 + Followed by pulmonary gangrene and phthisis, 355 + Morbid anatomy, 356 + Alteration of blood, 356 + Changes in respiratory organs, 356 + Heart and membranes, 357 + Liver and kidneys, 357 + Spleen, 357 + Intestinal tract, 357 + Brain and membranes, 358 + Diagnosis, 358 + From typhoid fever, 358 + From meningitis, 358 + From measles, 358 + From typhoid pneumonia, 359 + From delirium tremens, 359 + From purpura, 359 + Prognosis of, 359 + Symptoms indicating favorable, 360 + unfavorable, 360 + Influence of age, 359 + Sex, 359 + Former habits, 359 + Convalescence from previous illness, 359 + Obesity, 359 + Mental and physical overwork, 360 + Social condition, 360 + Race, 360 + Mortality, 360 + Difference of, in hospital and private cases, 361 + Treatment, 361 + Preventive, 361 + Necessity of isolation, 361 + Disinfection, 362 + Diet, 362 + Quantity of nourishment necessary, 363 + Futility of abortive treatment, 363 + General treatment, 364 + Mild cases, 364 + Hyperpyrexia, 364 + By cold water, 364 + By cold baths, 364 + Mode of using cold bath, 364 + Prostration, 365 + Headache, 366 + Delirium, 366 + Insomnia, 366 + Stupor, 366 + Urinary complications, 366 + Thirst, 367 + Vomiting, 367 + Constipation, 367 + Parotitis, 367 + Pulmonary complications, 367 + Use of alcohol in, 366 + Opium in, 366 + Quinia in, 365 + Of convalescence, 368 + Necessity of continuing stimulants during convalescence, 368 + +Tyrosis, 79 + + +U. + +Ulceration, complicating vaccination, 468 + +Ulcers, complicating cholera, 735 + following the plague, 781 + +Umbilication in vaccinia, mechanism of, 464 + in varicella, 482 + in variola, 438 + cause of, 447 + +Uraemia in scarlet fever, 530 + +Urinary complications in typhus fever, treatment, 366 + +Urine, analysis of, importance in general diagnosis, 165 + condition of, in cerebro-spinal meningitis, 814 + in cholera, 739 + in dengue, 881 + in influenza, 866 + in mild scarlet fever, 506 + in grave form of the plague, 779 + in pertussis, 841 + in pyaemia, 976 + in relapsing fever, 387 + in remittent fever, 602 + in typhoid fever, 291, 292 + in yellow fever, 644 + suppression of, complicating relapsing fever, 407 + in cholera, treatment, 764 + in yellow fever, treatment, 653 + +Urination, difficult, significance of, in diagnosis, 164 + +Urobilin, 91 + +Urticaria, complicating diphtheria, 674 + +Uterus, fixity of, in para- and perimetritis of puerperal fever, 1007 + lesions of, in septicaemia, 972 + + +V. + +VACCINIA, 455 + Definition, 455 + Synonyms, 455 + History, 458 + Etiology, 458 + Nature, 455 + Variolous origin, 457 + Meteorological conditions as a cause, 458 + Symptoms, 458 + General course, 458 + Constitutional, 459 + Development of pock, 459 + Date of appearance of pock, 459 + incrustation of pock, 460 + falling off of crust, 460 + Description of cicatrix, 460 + Irregularities in course, 460 + Raspberry excrescence of pock, 461 + Lack of elevation in pock, 461 + Absence of a constitutional infection, 460 + Bryce's test for determining constitutional infection, 461 + Diphtheritic pock, 463 + Catarrhal pock, 463 + Morbid anatomy, 462 + Pock, 463 + Microspheres and vaccinals of lymph, 463 + Microscopical characters of the lymph, 463 + Mechanism of umbilication, 464 + Composition of crust, 464 + Complications and sequelae, 464 + +VACCINATION, 465 + Synonyms, 465 + History of, 465 + Protective power of, 461 + theories regarding, 461 + duration of, 468 + against pertussis, 468 + Marson's theory of multiple insertions, 467 + Time of revaccination, 467 + As a means of destroying naevi, 468 + Complications, 468 + Simple inflammatory, 468 + Complicated by dermatitis, 468 + Treatment of dermatitis, 469 + Complicated by lymphangitis and adenitis, 468 + By ulceration and gangrene, 468 + Erysipelas, 469 + treatment, 469 + Complicated by syphilis, 469 + treatment, 471 + Modes of preventing transmission of syphilis, 470 + Complicated by skin diseases, 471 + by eczema, 472 + Impetigo contagiosa, its relations to, 472 + Followed by cutaneous affections, 471 + by eczema, 472 + Conveyance of constitutional taints in, 471 + Technics of, 472 + Varieties of virus, 472 + Primary vaccine, 473 + Horse-pox vaccine, 473 + Retro-vaccine, 473 + Bovine vaccine, 473 + Variola vaccine, 473 + So-called points of superiority of humanized vaccine, 473 + Relative merits of animal and humanized vaccine, 473 + Advantages of animal over humanized virus, 475 + Forms of vaccine, 476 + Objections to use of crust, 476 + Use of dried lymph, 477 + liquid or tube lymph, 476 + Proper season, 477 + Age, 477 + Part of body most suitable for, 477 + Modes of operating, 478 + applying the virus, 478 + Storage and preservation of virus, 479 + Proper time of collecting lymph for storage, 479 + Proper manner of transporting, 480 + +Vaccination, neglect of, as a cause of variola, 436 + +Vaccine virus, varieties of, 472 + use of, in treatment of rabies and hydrophobia, 907 + +Vagina, symptoms of diphtheria of, 674 + +Vaginal injections, use of, for prevention of puerperal fever, 1025 + +Variations, barometric, influence of, upon course of diseases, 134 + +VARICELLA, 481 + Definition, 481 + Synonyms, 481 + History, 481 + Etiology, 481 + Contagiousness, 481 + Symptoms, 481 + Period of incubation, 482 + General, 482 + Prodromal stage, 482 + Eruption, 482 + Umbilication of eruption, 482 + Date of appearance of desiccation, 482 + Frequency of scarring, 482 + Appearance of vesicles on mucous membrane, 483 + Morbid anatomy, 483 + Complications, 483 + Diagnosis, 483 + From variola and varioloid, 484 + From vaccinia, 484 + From impetigo, 483 + contagiosum, 483 + From eczema pustulosum, 483 + Prognosis, 484 + Treatment, 485 + +_Varicella Prurigo_, nature, 484 + +Varieties of beriberi, 1039 + of grease-traps, 221 + of pernicious malarial fever, 606 + of rubeola, 568 + of sewer-traps, 191 + of typhoid fever, 298 + +VARIOLA, 434 + Definition, 434 + Synonyms, 434 + History, 434 + Etiology, 435 + Contagiousness, 435 + Nature of contagium, 435 + Mode of entrance of contagium, 435 + Duration of activity of contagium, 435 + Period of greatest activity of contagium, 435 + Modes of transmission, 435 + Race, influence of, 436 + Season, influence of, 436 + Sex, influence of, 436 + Neglect of vaccination as a cause, 436 + Individual idiosyncrasy, 436 + Protection from, by previous attacks, 436 + Effect of pre-existing skin disorders, 436 + Symptoms, 436 + Stage of incubation, 436 + Invasion, 436 + Variolous rash, 437 + date of appearance, 437 + significance, 437 + Simon's triangle, 437 + Stage of invasion, 438 + Eruptive stage, 438 + Characters of eruption, 438 + Position of eruption, 438 + Stage of vesication, 438 + Umbilication, 438 + Maturation, 439 + Characters of mature pock, 439 + Condition of patient in suppuration stage, 439 + Pustules on mucous surfaces, 439 + Stage of desiccation, 439 + General, during desiccation, 440 + Secondary fever, 439 + Date of appearance of secondary fever, 439 + Confluent variety, 440 + Seat of lesion, 441 + Condition of mucous surfaces in confluent, 441 + General condition in confluent, 441 + Hemorrhagic variety, 442 + First form, 442 + Second form, 443 + Lesions of, 443 + Variolic purpura, 442 + Complications and sequelae, 445 + Complicated by eye diseases, 445 + Erysipelas, 445 + Nasal inflammation, 445 + Furuncles and abscesses, 445 + Muscular paralysis and hemiplegic attacks, 445 + Laryngitis, 446 + Gangrene of genitalia, 446 + Followed by a typhoid state, 445 + Pathology and morbid anatomy, 446 + Cutaneous lesions, 446 + Formation of papule, 446 + Vesicle, 446 + Cause of umbilication, 447 + Repair of pock, 447 + Hemorrhagic variety, 447 + Changes of viscera, 447 + Diagnosis, 447 + From measles, 448 + From scarlatina, 449 + From pustular skin diseases, 449 + From dermatitis medicamentosa, 449 + From syphiloderm, 449 + From acneform disease, 449 + From typhoid fever, 450 + From typhus fever, 450 + Prognosis, 450 + Symptoms indicating unfavorable, 450 + Influence of sudden defervescence of eruption, 450 + Pregnancy and childbed, 450 + Fatality of, in the unvaccinated, 450 + Influence of vaccination after development, 451 + Treatment, 451 + Preventive, 451 + Hygienic, 451 + Necessity of cleanliness, 454 + Invasion stage, 452 + Eruption, 452 + Exclusion of sunlight for prevention of pitting, 452 + Use of warm baths, 453 + Hot water compresses, 453 + Stimulants, 454 + Hemorrhagic form, 454 + Disposition of clothes and body after death, 454 + +Variola of vaccine, 473 + +Variolic purpura, 442 + +VARIOLOID, 443 + Symptoms, 443 + Invasion stage, 443 + Eruption, 444 + Types of, 444 + Identity with variola, 444 + Treatment, 451 + +Veins, condition of, in cholera, 737 + intestinal, lesions of, in cholera, 745 + jugular, thrombi of, in symptomatic parotitis, 626 + lesions of, in pyaemia, 967 + in symptomatic parotitis, 626 + +Venesection in cholera, 764 + in rabies and hydrophobia, 908 + in relapsing fever, 431 + futility of, in cerebro-spinal meningitis, 830 + +VENTILATION, 177 _et seq._ + Defects, 179 + Distribution of air, 180 + Estimation of carbonic acid in air, 178 + Insufficient, evil effects, 181 + Importance of, in treatment of typhoid fever, 323 + Methods of calculating amount of air-supply, 179 + Modes of investigating merits of a plan, 179 + Of waste-pipes in drainage, 223 + Of soil-pipes, 189 + Proper size of flues and registers, 179 + Relation of, to heating apparatus, 180 + Varieties of ventilators, 180 + Velocity of air, 180 + +Ventilators, varieties, 180 + +Venous emboli, 63 + thrombosis, following typhoid fever, 294 + +Veratrum viride, use of, in puerperal fever, 1033 + in scarlet fever, 543 + in yellow fever, 651 + +Vertigo in cerebro-spinal meningitis, 812 + in relapsing fever, 384 + significance of, in general diagnosis, 158 + +Vesication in variola, 438 + +Vesicle in variola, morbid anatomy of, 446 + +Views, earlier, concerning nature of puerperal fever, 990 + modern, concerning nature of puerperal fever, 992 + +Virus of anthrax, period of greatest virulence, 928 + of rabies, localization of, in wound, 893 + of vaccination, varieties of, 472 + vaccine, manner of transporting, 480 + storage, 479 + +Viscera, lesions of abdominal, in the plague, 781 + in cerebro-spinal meningitis, 824 + in erysipelas, 635 + in variola, 447 + +Vision, modifications of, in relapsing fever, 399 + in typhoid fever, 280 + +Vital statistics, registration, 208 + +Voice, alteration of, in diagnosis, 158 + +Vomit, character of, in cerebro-spinal meningitis, 813 + in cholera, 738 + in grave form of the plague, 779 + +Vomiting during intermittent fever paroxysm, 593 + in cerebro-spinal meningitis, 813 + in cholera, 738 + treatment, 761 + in diphtheria, treatment, 694 + in general peritonitis of puerperal fever, 1010 + in mild scarlet fever, 503 + in para- and perimetritis of puerperal fever, 1007 + in pyaemia, 975 + in remittent fever, treatment, 605 + in rubeola, treatment, 581 + in septicaemia, 977 + in typhoid fever, 285 + treatment, 331 + in typhus fever, 350 + treatment, 367 + in yellow fever, 644 + treatment, 652 + significance of, in general diagnosis, 162 + +Vulva, symptoms of diphtheria, 674 + + +W. + +Wakefulness in relapsing fever, 384 + in typhus fever, 349 + +Walk, significance of, in diagnosis, 161 + +Walking form of typhus fever, 354 + of yellow fever, symptoms, 654 + +Washstands, stationary, dangers from, 216 + +Waste-pipes, effects of large bore in, 220 + leakage in, 222 + tests for, 222 + ventilation, 223 + +Water, collections of, effect upon public health, 187 + fear of, in rabies and hydrophobia, 899 + height of subsoil, influence of, on prevalence of cholera, 722 + importance of, in treatment of typhoid fever, 325 + impure, microscopic characters of, 184 + diarrhoeal affections from, 182 + disease from, 182 + chemical examination of, 183, 184 + value of chemical examination of, 183, 184 + impurity of, from metallic salts, 182 + from organisms, 184 + nature of impurities, 182 + polluted, as a cause of diphtheria, 683 + stagnant, production of malaria by, 187 + standards of purity, 184 + subsoil, level of, 188 + supply, contamination of, from privy-vaults, 192 + cess-pools, 192 + chloride test for detecting impurities in, 192 + tables of analyses, 184 + use of, in diphtheria, 702 + +Water-closets, defects of, 217 + location, 218 + varieties, 191 + ventilation, 192, 217 + +Waxy degeneration, 84 + +Welch on cause of oedema of lungs, 72 + +Wet form of beriberi, symptoms, 1040 + treatment, 1042 + +Whooping cough, 836 + relation of, to rubeola, 561 + +Winds, influence of, on spread of influenza, 860 + +Wound, appearance of, in rabies and hydrophobia, 895, 899 + changes in, in pyaemia, 976 + condition of, in septicaemia, 977 + influence of characters of, in causation of pyaemia, 958 + treatment of, in pyaemia, 981 + in septicaemia, 983 + +Wounds, diphtheria of, 673 + + +Y. + +YELLOW FEVER, 640 + Synonyms, 640 + Definition, 640 + Etiology, 640 + Specific origin, 640 + Poison of, inconvertibility, 840 + Birthplace, 641 + Characteristics, 641 + Ponderability, 641 + Vitality, 641 + Influence of heat and cold on development, 641 + Impossibility of transportation of, by air, 641 + Transportability of, by fomites, etc., 641 + Nature of fomites, 641, 642 + Fixity of, 643 + Slowness of extension, 643 + Medium of admission to system, 642 + Localization of epidemics by atmospheric impregnation, 642 + Anxiety, grief, and fatigue as causes, 643 + Insusceptibility, in negroes, 644 + from idiosyncrasy, 643 + Protective power of previous attacks, 643 + Duration of incubation period, 643 + Symptoms, 644 + Mild cases, 644 + Initial, 644 + Physiognomy, 644 + Neuralgia and muscular pains, 644 + Cerebral, 644 + Condition of tongue, 644 + Gastro-intestinal canal, 644 + Vomiting, 644 + Character of matters vomited, 644 + Condition of urine, 644 + Pulse, 644 + Relation of pulse to temperature, 645 + Perspiration, 645 + Stages, 645 + Masked forms, 653 + Walking forms, 654 + Paroxysmal stage, 645 + Calm stage, 645 + Hemorrhages and jaundice, 646 + Prognosis, 646 + Symptoms indicating unfavorable, 646 + Influence of crowding the sick, 646 + Pregnancy and parturition, 647 + Condition of patient at time of attack, 647 + Temperature, 647 + In hospital cases, 647 + Mortality, 647 + Variableness, 647 + Difference in hospital and private cases, 648 + Diagnosis, 648 + Significance of physiognomy, 648 + State of pulse, 648 + Albuminous urine, 648 + Hemorrhagic tendency, 648 + Yellow discoloration of skin, 648 + Morbid anatomy, 649 + Changes in liver, 649 + Treatment, 649 + Futility of abortive, 649 + Importance of early, 649 + Indications for, 649 + Simple form, 649 + Early stages, 649 + Diaphoresis, 650 + Jaborandi, 650 + Neuralgias and muscular pains, 651 + Hyperpyrexia, 651 + by cold, 651 + Hemorrhages, 651 + by tincture of iron, 652 + Nausea and vomiting, 652 + Urinary suppression, 652 + Failure of reaction from cold stage, 653 + Convulsions and delirium, 653 + Use of digitalis, 651 + Aconite, 651 + Veratrum viride, 651 + Gelsemium, 651 + Haemostatics, 652 + Quinia, 650, 651 + Quinia and opium in combination, 651 + Hygienic, 654 + Necessity of absolute rest, 654 + Diet, 654 + Children, 655 + Typhoid cases, 655 + Time of return to solid food, 655 + + +Z. + +Zymosis, meaning of term, 137 + +Zymotic diseases, relation of, to puerperal fever, 1020 + table, 136 + + + + +END OF VOL. I. + + + + + + + +End of the Project Gutenberg EBook of A System of Practical Medicine by +American Authors, Vol. I, by Various + +*** END OF THIS PROJECT GUTENBERG EBOOK A SYSTEM OF PRACTICAL *** + +***** This file should be named 39157-8.txt or 39157-8.zip ***** +This and all associated files of various formats will be found in: + http://www.gutenberg.org/3/9/1/5/39157/ + +Produced by Ron Swanson (This file was produced from images +generously made available by The Internet Archive/Canadian +Libraries) + + +Updated editions will replace the previous one--the old editions +will be renamed. + +Creating the works from public domain print editions means that no +one owns a United States copyright in these works, so the Foundation +(and you!) can copy and distribute it in the United States without +permission and without paying copyright royalties. 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