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 Infective Micro-organisms. 
 
A 
 
 /VNUAL OF MEDICINE 
 
 EDITED BY 
 
 W. H. ALLCHIN, M.D. (loxND.), F.R.C.P., F.R.S.E. 
 
 SENIOR PHYSICIAN AND LECTURER ON CLINICAL MEDICINE, WESTMINSTER 
 
 HOSPITAL, EXAMINER IN MEDICINE IN THE UNIVERSITY OF 
 
 LONDON, AND TO THE MEDICAL DEPARTMENT 
 
 OF THE ROYAL NA"\-\' 
 
 VOL. I 
 
 GENERAL DISEASES 
 
 DISEASES EXCITED BY ATMOSPHERIC INFLUENCES 
 THE INFECTIONS 
 
 THE MACMILLAN COMPANY 
 
 LONDON: MACMILLAN & CO., Ltd. 
 1900 
 
 All rights reserved 
 
Copyright, 1900, 
 By the MACMILLAN COMPANY. 
 
 Nottoooli ^resB 
 
 J. S. CushiDg & Co. — Berwick & Smith 
 Norwood Mass. U.S.A. 
 
TO 
 
 THE MEMORY 
 
 OF 
 MY TEACHER 
 
 ^ir Milliam lettitsr, §art., (S.Cl. 
 
 M.D., F.R.C.P., F.K.S. 
 
 PHYSICIAN IN ORDINARY TO H.M. THE QUEEN, AND 
 
 TO H.R.H. THE PRINCE OF WALES 
 
 PHYSICIAN TO UNIVERSITY COLLEGE HOSPITAL 
 
 W. H. A. 
 
PLATE I. 
 
 Fig. I. 
 
 Streptococcus Pyogenes in Pus from case of Empyema. Fixed by Wet Method. 
 Stained with Eosin Alum and Methylene Blue, x looo diams. 
 
 Fig. 2. 
 
 Section of Diphtheria Membrane. Bacillus Dipbtherise. Stained by Gram's 
 Method and Saffranin. x looo diams. 
 
 Fig. 3. 
 
 Scraping from Septic Pleurisy, showing Eraenkel's Pneumococci with 
 Capsules. Stained by Muir's Method. x 1000 diams. 
 
 Fig. 4. 
 
 Bacillus of Typhoid Fever showing Elagella. Muir's Stain for Flagella. 
 X 1000 diams. 
 
 Fig. 5. 
 
 Bacillus of Bubonic Plague. 48 hours' Agar Culture ; Flagella seen. Stained by 
 Muir's Method. x 1000 diams. 
 
 Fig. 6. 
 
 Actinomyces in Liver Abscess, showing Filaments and Clubs. Stained by 
 Gram's Method, Saffranin and Eosin. X lOOO diams, 
 
PLATE II. 
 
 Fig. 7. 
 
 Koch's Spirillum of Cholera. 12 hours' Agar Culture ; Flagella. Muir's stain 
 for Flagella. x 1000 diams. 
 
 Fig. 8. 
 
 Bacillus Tetani in scraping from wound (Hand) from case of Tetanus. Fixed by 
 Muir's Method. Stained with Eosin and Methylene Blue. 
 
 Fig. 9. 
 
 Skin from case of Leprosy. Bacilli stained by Ziehl Neelsen Method, with 
 Methylene Blue for contrast stain, x 1000 diams. 
 
 Fig. 10. 
 
 Bacillus Tuberculosis in Lung in Acute Tubercular Broncho-pneumonia. 
 Stained by Ziehl Neelsen Method. x 1000 diams. 
 
 Fig. II. 
 
 Bacillus Anthracis (Spores). 3 days' Agar Culture. Stained by Ziehl Neelsen 
 Method — Fuchsine and Methylene Blue Method, x 1000 diams. 
 
 Fig. 12. 
 
 Amoebic Dysentery. Amoebae in wall of Abscess of Liver. From Specimen 
 
 kindly supplied by Prof Greenfield. Fixed by Corrosive Sublimate 
 
 Method. Stained by Benda Method, x 1000 diams. 
 
CONTENTS 
 
 Contributors 
 
 Introduction 
 
 General Diseases 
 
 Diseases #ue to Atmospheric I 
 
 The Infections 
 
 Fever 
 
 Boil and Carbuncle 
 
 Erysipelas 
 
 Saprremia, Septicaemia, and Pyaemia 
 
 Infective Endocarditis 
 
 Gonorrhoeal Infection 
 
 Typhoid Fever . 
 
 Mediterranean Fever 
 
 Cholera 
 
 Plague . 
 
 Relapsing Fever 
 
 Yellow Fever 
 
 Weil's Disease . 
 
 Anthrax 
 
 Tetanus 
 
 Diphtheria 
 
 Epidemic Pneumonia 
 
 Infective Meningitis 
 
 Influenza 
 
 Glanders 
 
 Tuberculosis 
 
 Leprosy 
 
 Mycoses 
 
 24 
 50 
 59 
 62 
 68 
 
 77 
 82 
 86 
 no 
 1x6 
 128 
 139 
 143 
 149 
 
 152 
 156 
 
 163 
 178 
 182 
 202 
 217 
 220 
 235 
 243 
 
vin 
 
 MANUAL OF MEDICINE 
 
 Typhus Fever 
 
 Measles 
 
 Rotheln 
 
 Scarlet Fever 
 
 Acute and Subacute Rheumatism 
 
 Chicken-pox 
 
 Smallpox 
 
 Vaccinia 
 
 Mumps 
 
 Whooping-Cough 
 
 Dengue 
 
 Beri-Beri 
 
 Epidemic Dropsy 
 
 Oriental Sore 
 
 Verrugas 
 
 Frambcesia 
 
 Syphilis 
 
 Rabies 
 
 Foot and Mouth Disease 
 
 Mixed Infections 
 
 Dysentery 
 
 Malaria 
 
 Hremoglobinuric Fever 
 
 Kala-azar 
 
 Index 
 
 PAGE 
 
 252 
 259 
 
 269 
 
 274 
 
 291 
 310 
 316 
 328 
 
 337 
 340 
 350 
 
 353 
 360 
 362 
 364 
 365 
 367 
 389 
 396 
 398 
 402 
 416 
 429 
 433 
 
 437 
 
 PLATES 
 
 Plates i and 2 : Infective Micro-organisms 
 
 Temperature Curve in a Case of Typhoid Fever — Two Relapses- 
 Recovery ...... 
 
 Facing Title 
 
CONTRIBUTORS 
 
 John Rose Bradford, M. D. , D. Sc. , F. R. C. P. , F. R. S. Physician to University 
 College Hospital ; Professor Superintendent of the Brown Institution. 
 {Mycoses, Rabies.) 
 
 Frederick Foord Caiger, M.D., B.S., M.R.C.P., D.P.H. Medical Super- 
 intendent and Lecturer on Infectious Diseases, South-Western Fever Hospital, 
 Stockwell. 
 
 {Diphtheria, Measles, Rotheln, Scarlet Fever, Varicella. ) 
 
 James Cantlie, M.B., CM., F.R.C.S., D.P.H. Lecturer, School of Tropical 
 Medicine, London ; Surgeon, Seaman's Hospital Society ; Consulting 
 Surgeon, Alice Memorial Hospital, Hong-Kong. 
 
 {Cholera, Plague, Leprosy, Dengue, Beri-Beri, Epidemic Dropsy, Oriental 
 Sore, Dysentary, Malaria, HcBmoglobinuric Fever, Kala-Azar.) 
 
 William Cayley, M.D., F.R.C.P. Senior Physician to the Middlesex 
 Hospital. 
 
 ( Typhoid Fever, Typhus Fever. ) 
 
 Sydney Monckton Copeman, M.D., F.R.C.P., D.P.H. Medical Inspector 
 to H. M. Local Government Board ; Lecturer on Public Health in the West- 
 minster Hospital Medical School. 
 ( Variola, Vaccinia. ) 
 
 John Alfred Coutts, M.B., F.R.C.P. Physician to the East London 
 Hospital for Children. 
 
 ( Tuberculosis, Inhe^-ited Syphilis. ) 
 
 Bertrand Edward Dawson, M.D., B.Sc, M.R.C.P. Assistant Physician to 
 the London Hospital ; Pathologist, Royal Hospital for Diseases of the 
 Chest. 
 
 {Influenza. ) 
 
 Thomas Colcott Fox, M.B., F.R.C.P. Physician to the Skin Department, 
 Westminster Hospital. 
 ( Verrugas, Fravibcesia. ) 
 
 William Wilberforce Goodall, M.D. Medical Superintendent, Eastern 
 Hospital, Homerton. 
 
 {Mumps, Mixed Infections. ) 
 
X MANUAL OF MEDICINE 
 
 Richard Grainger Herb, M.D., F. R.C. P. Secretary, Royal Microscopical 
 Society ; Physician in charge of Out-Patients, and Lecturer on Forensic 
 Medicine, Westminster Hospital. 
 
 (Gonorr/iceal Infection, Epidemic Cei'ebro-Spinal Meningitis, Glanders, Foot 
 and Month Disease. ) 
 
 Matthew Louis Hughes, L.R.C.P., M.R.C.S. Capt. R.A.M.C. (the late). 
 {Mediterranean Fever.) 
 
 David Bridge Lees, M.D., F.R.C.P. Physician and Lecturer on Medicine, 
 St. Mary's Hospital. 
 
 {Acute atid Subacute Rheumatism.) 
 
 William Grant Macpherson, M.B., CM., D.P.H., Major R.A.M.C. 
 { Yellow Fever. ) 
 
 Arthur Newsholme, M.D., F.R.C.P. Medical Officer of Health, Brighton; 
 Examiner in State Medicine, University of London. 
 {Epidemic Pneumonia. ) 
 
 Francis George Penrose, M.D., F.R.C.P. Physician to St. George's 
 Hospital. 
 
 ( Whooping- Cough. ) 
 
 George Newton Pitt, M.D., F.R.C.P. Physician and Lecturer on Pathologj', 
 Guy's Hospital. 
 
 {Anthrax, Tetanus.) 
 
 George Frederick Still, M.D., M.R.C.P. Assistant Physician for Diseases 
 of Children, King's College Hospital ; Assistant Physician to the Hospital 
 for Sick Children, Great Ormond Street. 
 
 {Posterior Basic Meningitis, Suppurative Meningitis. ) 
 
 Alfred Herbert Tubby, M.D., F.R.C.S. Surgeon to the Westminster 
 Hospital. 
 
 {Boil and Carbuncle, Acquired Syphilis. ) 
 
 John Wickenford Washbourn, M.D., F. R.C.P. Physician to Guy's Hospital 
 and Lecturer in the Medical School ; Physician to the London Fever 
 Hospital. 
 
 {Erysipelas, Infective Endocarditis, Relapsing Fever, Weils Disease.) 
 
 William Hale White, M.D., F.R.C.P. Physician and Lecturer on Medicine, 
 Guy's Hospital. 
 {Fever. ) 
 
 German Sims Woodhead, M.D., F.R.C.P., Ed. Professor of Pathology in the 
 University of Cambridge. 
 
 ( The Infections, Sapramia, Septiccemia, atid Pycemia. ) 
 
 and 
 The Editor. 
 
 {Diseases due to Atmospheric Itifluences. ) 
 
A MANUAL OF MEDICINE 
 
INTRODUCTION 
 
 The term " Medicine " is generally understood to denote the study 
 of disease in the various directions which engage the attention of 
 the scientific investigator and the practical physician. Therein is 
 included the inquiry into those precedent conditions commonly 
 known as the causes which determine departures from health 
 — the subject of (f//(?/(907/ the perversions of structure, macroscopic 
 and microscopic, which the tissues and organs exhibit as the 
 result of these recognised or assumed causes — the department of 
 morbid anatomy ; the mode of action of disease processes and their 
 effects on the various organs and functions of the body, the forms 
 of malnutrition, general and local — the subject matter oi pathology 
 in its restricted sense ;^ the signs and symptoms of structural and 
 functional defects ; the manifestations of disease as appearing in the 
 living, — the so-called semeiology or more commonly clmical medicine, 
 in which also is comprised the modes of examination of the patient, 
 the detection of the symptoms, and the drawing of inferences from 
 the evidence so obtained, in short the formation of a diagfiosis and 
 naming the disease, as well as the expression of a forecast or antici- 
 pation of the probable course and ending of the special malady 
 under consideration — the. prognosis ; and finally there is that branch 
 of the subject denominated therapeutics which deals with the //-<?«/■- 
 ;;/(?;z/ of disease, by diet, by general hygiene, and by drugs, M'ith the 
 art of its application ; to which also may be added the prevention of 
 disease and the care of the public health. Extensive as this range 
 of subject matter is, it is far from all that is really involved. The 
 study of disease presupposes a knowledge of the normal, which is 
 
 1 Pathology in its literal significance denotes the study of disease in all its 
 aspects. 
 
 VOL. I B 
 
2 MANUAL OF MEDICINE 
 
 a necessary preliminary to the recognition of variations from the 
 standard of health, and for the full pursuit of this wide scope of 
 investigation there is scarcely any department of natural science, 
 from geology and meteorology to botany and zoology, physics and 
 chemistry, which is not in some degree drawn upon to contribute to 
 the elucidation of the complex problems concerned. 
 
 It might naturally be supposed that in a work professing to deal 
 with the natural history of disease in its various aspects and many 
 forms, that some explanation of what is meant by " disease " would 
 be attempted, and for the purpose of giving some coherence to the 
 descriptions which are to follow, it is desirable that the attempt 
 should be made, premising that any definition is but provisional 
 and subject to correction as greater precision of knowledge is 
 attained, and is only a working hypothesis for the time being. 
 
 Health and disease are correlative terms expressive of certain 
 structural and functional states of the body and its workings, dis- 
 tinguished the one from the other by no clearly recognisable Hne of 
 separation, and neither of them conforming to one fixed and definite 
 type. The standard of bodily health is at present incapable of 
 accurate definition ; its borderland, where it merges into disease, 
 cannot be mapped out, whether it be in the direction of structural 
 changes or of functional manifestations, but it is certain that the 
 limits of this standard are wide, and that there are many ways of 
 being well, many types of health. Marked variations from this ill- 
 defined condition constitute disease, the commencements and 
 slighter forms of which can seldom be formulated. In these modes 
 of living three factors are assumed : the bodily structure, its functional 
 activities, and the environment ; life, whether normal or morbid, is 
 the resultant of their interaction. By observation or by experience 
 there is recognised a certain range of structure, of function, and of 
 environment, as associated with what it is agreed to regard as healthy 
 life, characterised for the most part by a freedom from pain or dis- 
 comfort, departures from which are considered as disease. The 
 notion of disease implies no new element, but simply some per- 
 version of the factors that together make up health. 
 
 The fundamental conceptions of structure and function — what 
 the body is and what it does — are inseparable. We only know the 
 one through the other ; we only recognise the material or structure 
 by the properties which it manifests, and conversely the properties 
 are inconceivable apart from the material through which they are 
 rendered sensible. 
 
 The connotation of " structure " is not to be restricted to the 
 
INTRODUCTION 3 
 
 results of anatomical investigation, whether gross or minute, whether 
 of the fully-formed organ and tissues or of these in the course of 
 their development and differentiation. The actual disposition and 
 arrangement of the component materials of the body is not bounded 
 by what the microscope discloses. There is a further stage in the 
 inquiry into what a Hving (as also a non-living) body or any part 
 of such body really is, known as its chemical composition and 
 molecular constitution, and when that is reached the structure of an 
 object in its fullest sense may be regarded as known. " Chemical 
 structure," which implies not only the chemical elements and pro- 
 portions thereof of which a substance is composed, but also the 
 arrangement of the atoms of these elements in the molecules, and 
 the relations they bear to one another, is the third and final stage of 
 structure, the first and second being gross and minute anatomy 
 respectively. This last stage is still within the realm of theory, 
 but the hypotheses which are current are among the fundamental 
 conceptions upon which all our knowledge of the material world is 
 built. 
 
 Inseparable from the idea of structure are the properties by 
 which it is recognised. Such are weight, hardness or softness, 
 flexibility or rigidity, elasticity, permeability and the like, all de- 
 pendent on the character of the relationships existing between the 
 ultimate constituent molecules of the material. These and others 
 are AtwovcMX'AX.Q.^ physical propei-fies, and are possessed by all matter, 
 whether living or not. Certain substances, however, over and 
 above these quahties, manifest certain specific properties, in virtue 
 of which they are called living, and similarly it is generally assumed 
 that these properties are the outcome of some special molecular 
 structure. These peculiarly vital characteristics may be grouped 
 thus: (1) Those which may be collectively termed "irritability," 
 that is the various forms of response to the application of stimuli 
 (often of external origin) which we recognise as muscular con- 
 traction, nervous energy, glandular secretion, together with the 
 power of multiplication and perpetuation of the race by fission, 
 gemmation, etc. (2) Those comprehended in the processes — other 
 than purely chemical — by which the living material increases in 
 bulk and maintains its structural and functional integrity by the 
 conversion of food into its own substance — the nutritive or meta- 
 bolic processes. (3) Within a variable range, living matter has, as 
 one of its most significant peculiarities, the power of adapting itself 
 to variations of the external conditions subject to which it exists. 
 Within certain Hmits of temperature, barometric pressure, quality of 
 
4 Manual of medicine 
 
 food, etc., living things may adjust themselves, beyond which, how- 
 ever, they succumb. A highly specialised phase of this resisting 
 power of the living tissues is known as immunity. (4) Lastly, all 
 living things, sooner or later, cease to display these vital character- 
 istics and die. 
 
 Much difference of opinion has prevailed as to the nature of 
 these " vital " phenomena. Formerly it was held that life and the 
 manifestations of organism generally were due to a special " vital 
 force " or " principle," fundamentally different from physico-chemical 
 forces, and were not to be investigated by physico-chemical methods. 
 During the last fifty years, however, this vitahstic theory has gradu- 
 ally been displaced by a reference of the manifestations of life to 
 physico-chemical standards, with the important result that very 
 many of the phenomena of the living organism are understood and 
 explained " by comparison with their physical counterparts " (Burdon 
 Sanderson). Extensive and fruitful as the consequences of this pro- 
 cedure have been, there still remain certain living manifestations 
 which are not considered as being capable of either investigation or 
 explanation by these means, which it is further alleged are quite 
 inapplicable. A new vitahsm has been recently promulgated, which, 
 accepting to the full all that physico-chemical methods have done 
 in explaining many of the living activities, aims at investigating 
 those which the physico-chemical physiologist tends to regard as 
 unknowable, by the extension to the study of living things of the 
 principle which, in the hands of the morphologists, has elucidated so 
 many problems of structure, viz. " that each part of an organism is 
 determined as regards its mode of existence by its relation to other 
 parts," which is "just as much a physiological as an anatomical 
 conception" (J. Haldane). 
 
 Consistent with this view a much wider and indeed truer 
 range of meaning must be attached to the notion of environment 
 than that which restricts it to the mere influence of conditions 
 outside the body, cUmatic, telluric, dietetic, occupational, etc., im- 
 portant and subtle as these may be. The functional activity of 
 each organ, of each tissue, and of each cell reacts upon these 
 external influences, the effect of which is conditioned by the state 
 of the organism itself. Moreover, the vitality of each structural 
 element is not to be regarded in its origin or its manifestation as 
 independent of the vitahty of other constituents of the body, but 
 rather that there should be included in the idea of interaction of 
 organism and environment, the mutual effect of living cells and 
 dssues upon each other. 
 
INTRODUCTION 5 
 
 The notion of disease embodied in the foregoing remarks will 
 show that it involves equally a structural and a functional side. 
 Both aspects are included in the expression. There can be no 
 structural abnormality, however minute, without some functional 
 perversion ; and conversely a functional imperfection necessarily 
 implies a structural defect. But just as there are many functional 
 manifestations, both of health and disease, which are not accom- 
 panied by any structural change recognisable by the means at 
 present at our command, so many structural abnormalities may be 
 found post-mortem without any functional defect obviously con- 
 nected therewith. 
 
 The conception of life, whether healthy or diseased, as the result 
 of interaction between the organism and its environment, facilitates 
 the comprehension of the direction in which the so-called causes of 
 disease produce their effects. On the one hand, the disturbance of 
 function may be clearly due to faults in the surrounding conditions 
 — food, temperature, occupation, etc. — constituting the acquired 
 diseases. On the other, the causation of the morbid states is some 
 inherent defect due to imperfection of the organism as derived from 
 the parents — hereditary diseases. It may be that these intrinsic or 
 extrinsic defects are so strong as inevitably to assert themselves and 
 produce disease, or it may be that neither cause may be sufficiently 
 potent to lead to disease of itself, requiring for its efficient action 
 some defect in both. Thus the transmitted Hability or tendency to 
 disease may not assert itself until the external conditions have 
 transgressed the limits ordinarily recognised as normal, or that the 
 latter may be inoperative until the resisting powers of the organism 
 have deteriorated. It is a combination of both kinds of faults that 
 is probably responsible for most cases of disease. 
 
 So far the general nature of disease ; but the perversions of 
 structure and function known as the signs and symptoms of disease 
 are found to occur in groups with more or less constancy and uni- 
 formity, constituting the various diseases to which special names are 
 attached, such as epilepsy, typhoid fever, pneumonia. Occasionally, 
 however, obscure cases are met with which do not conform to any 
 of the recognised special diseases, and cannot be named. When 
 the evidences of disease are primarily or mainly confined to one 
 organ or region, the malady is termed local, but seldom or never is 
 the disease absolutely so restricted ; the rest of the body participates 
 much or httle in the abnormal state. If, however, the signs and 
 symptoms are more generally distributed and no organ appears to be 
 predominantly involved, a general disease is said to exist. Such a 
 
6 MANUAL OF MEDICINE 
 
 distinction, however, is in great measure artificial, and, like the 
 notion of separate diseases, is apt to be pushed too far and lead the 
 beginner to expect a definiteness in the several maladies which does 
 not and cannot exist. The descriptions of disease in text-books on 
 medicine unavoidably tend to favour this mistake, which bedside 
 work alone can avert. 
 
 The investigation of these various diseases in the living is 
 capable of consideration from two points of view. On the one 
 hand may be taken the description of an individual case, the history 
 of the patient as regards his family, his age, occupation, mode of lite, 
 and previous illnesses, whereby an estimate may be formed of his 
 personal health-value in its relation to the special ailment from 
 which he is suffering ; the condition of the patient might be set forth, 
 and the progress of the disease to its termination, together with such 
 treatment as may have been followed, and the effect thereof. Such 
 a description would be one of the disease as manifested by that one 
 individual. But it will be readily understood that the disease would 
 exhibit differences in its symptoms and course, and that in no two 
 persons would it be exactly alike, any more than the normal life of 
 the two would be identical. From the consideration of a large 
 number of individual cases, what might be termed a typical or 
 standard or mean account of the malady might be prepared, to 
 which all cases of the same would correspond in the main, differing 
 in detail as the individuals themselves and their conditions of life, 
 constitution, age, and sex would differ. There is, then, besides the 
 clinical description applicable to each separate case, a general or 
 systematic account of each separate malady collated from a study of 
 many cases. Such an account must necessarily, as knowledge 
 advances and precision of observation extends, be modified from 
 time to time, as the successive editions of current text-books testify. 
 It is well for the student to remember that the description of each 
 disease, as given in systematic treatises, rarely corresponds to any one 
 case, though most cases may be comprehended within it ; and since 
 in the time at his disposal it is impossible for him to form for himself 
 anything like a complete account of the various forms of disease 
 from the observation of individual cases, he must depend on the 
 labours of others. It is as supplementary to his clinical work that 
 text-books and systematic lectures have their use. 
 
 A systematic account of the principles and practice of medicine 
 necessitates a classification of the various morbid states which we are 
 in the habit of regarding as separate diseases. And with classifi- 
 cation — nosology — there at once enters into the question an 
 
INTRODUCTION 7 
 
 artificial disposition of the various phenomena, which is constantly 
 undergoing revision, and at the best must be unsatisfactory, since 
 the material to be classified is so many sided and so complex that 
 no plan, within our present knowledge, can effectively arrange the 
 multitudinous varieties of disease without the occasional violation 
 of any principle of grouping, whatever it be, or the rupture of what 
 are apparently the natural affinities between the various maladies. 
 Doubtless the most satisfactory and most scientific arrangement of 
 the groups of phenomena which constitute the various diseases we 
 are familiar with would be based upon their causation, the circum- 
 stances and conditions that preceded, and, as we say, determined, 
 the departure from the normal standard of health. But our 
 knowledge of this standard, and still more of the intimate nature 
 and mode of working of the causes, is most imperfect, and at 
 present quite unfit to be made the sole ground of classification, 
 the object of which after all is for convenience of record and 
 study, and at the best most imperfectly represents the natural 
 conditions. Or, consistently with the preceding conception of 
 disease, its varieties might be primarily grouped according to 
 imperfections of the fundamental properties, physico-chemical and 
 vital, which the tissues possess. Thus one group of morbid pro- 
 cesses might be due to impaired elasticity, flexibility, permeability, 
 or other such qualities ; another to defects in muscular, nervous, or 
 glandular irritability, whether in the direction of excess, of deficiency, 
 or of perversion ; a third class of maladies are fundamentally im- 
 perfections of the metabolic processes constituting tissue nutrition, 
 whether on the constructive side, that is connected with the due 
 elaboration of the ingesta, or in respect to the subsequent tissue 
 destruction and consequent waste formation and elimination. An 
 altered resisting or adaptive power on the part of one tissue or organ, 
 or of the entire body, characterises a fourth group of infirmities, 
 which would comprise those tissue changes, expressive of a response 
 to an irritant, included within the term *' inflammation." And a 
 proneness to degeneration and premature senility or death is the 
 leading feature at the root of others. At present, however, any such 
 scheme is inapplicable ; our knowledge would not enable an even 
 approximately complete classification to be made, and for purposes 
 of convenience it would be futile. It is, nevertheless, occasionally 
 advantageous to contemplate the general field of disease, or even of 
 individual cases, from some such standpoint, imperfect though it be. 
 No scientific principle therefore is to be looked for in the plan 
 here followed. The old-fashioned separation into "general" and 
 
8 MANUAL OF MEDICINE 
 
 "local" diseases has taken too firm a hold to be lightly discarded 
 in a student's manual, and opinion is not yet prepared for a plan of 
 dealing with the subject which would abolish the time-honoured 
 category of diseases of the various systems of organs, and substituting 
 a grouping under their causal conditions, or as manifestations of 
 general pathological states, rather than under the organs which in 
 many cases, but not always, are mainly or primarily affected. But 
 it may be anticipated that some such arrangement will have to be 
 followed in the future. 
 
 It is obviously impossible within the limits of a single work to 
 treat of all of the many sides of this comprehensive subject, and at 
 once some limitation has to be imposed. In the following pages 
 will be found an account of the various forms of disease, more 
 especially from the point of view of their clinical manifestations and 
 treatment. The subjects of etiology and morbid anatomy are briefly 
 summarised, and for further knowledge of these aspects of disease 
 reference must be made elsewhere. The aim has been to present 
 such a picture of the several maladies as will conform to the appear- 
 ances detected at the bedside, and enable the observer rationally to 
 administer such treatment as our art affords. 
 
 The Editor. 
 
GENERAL DISEASES 
 
 By general diseases — a phrase of no very precise definition — is 
 meant those maladies in which the entire body is more or less 
 concerned, with no preponderance of symptoms in one region, or 
 where any local manifestations are quite disproportionate or secondary 
 to the widespread disturbance of function. They are either, for the 
 most part, associated with fever and acute in character, or are pro- 
 found affections of the general nutrition tending to a chronic course 
 and a fatal termination. 
 
 A grouping of the diseases comprehended within this category 
 is mainly based on grounds of convenience and on no definite 
 scientific principle. As a provisional arrangement the following plan 
 is adopted : — 
 
 I. OF EXTRINSIC CAUSATION. 
 
 1. DISEASES EXCITED BY ATMOSPHERIC IXELUEXCES. 
 
 2. DISEASES CAUSED BY THE IXVASIOX OE LIVIXG 
 ORGANISMS. 
 
 r * Ectophyta 
 1 e.g. Tinea 
 
 Vegetable-^ Entophyta 
 
 I e.g. Bacilli. Actinomycosis 
 
 Entozoa 
 I e.g. Plasmodium MalaricB 
 
 Animal - Intestinal and other worms 
 
 \ *Ectozoa 
 ^ eg. Pediculi 
 
 3. DISEASES DETERMINED B Y POISONS IXTROD UCED IXTO 
 THE BODY AS SUCH. 
 
 e.g. mineral and food poisons, serpent venom, (intoxications.) 
 
 II. OP INTRINSIC ORIGIN. 
 
 1. PRIMARY PERVERSIOXS OF GENERAL NUTRITION. 
 
 2. DISEASES OF THE BLOOD. 
 
 * Will be treated of under Diseases of the Skin. 
 
 Infective diseases. 
 
DISEASES EXCITED BY ATMOSPHERIC INFLUENCES 
 
 The influence of the various factors of the environment, such as 
 temperature, light, moisture, barometric pressure, electrical states, 
 etc., collectively denominated atmosphere, in the production of 
 disease, is undoubted. Oftenest, perhaps, they act by so impair- 
 ing the resisting power of the organism as to permit other morbific 
 agents producing their effect ; sometimes, however, they appear to 
 be mainly, if not entirely, the excitant of definite morbid states or 
 even of death. Co-existing as they do, it is difficult to appreciate the 
 individual share each may take in the causation of disease, their 
 effect in this direction being more probably a combined one. 
 
 I. Temperature 
 
 {a) Heat. — To excessive heat, whether of the sun directly or 
 in the shade, or artificially produced, are attributed very various 
 conditions, to which the terms " heat-stroke," " sun-stroke " (in- 
 solation) , or " heat-apoplexy " are indififerently applied. Considerable 
 difference exists in the resisting power of individuals and of races, 
 and habitual exposure usually confers increased tolerance. The ill 
 effects of heat are much intensified by atmospheric moisture — such 
 as occurs in the stoke-holes of steamships — whereby the loss of 
 heat from the skin is much diminished and the regulation of the 
 body temperature consequently interfered with. Other favouring 
 conditions are unsuitable clothing, great physical exertion, alcoholism, 
 heart disease, or other enfeebled states of health. When the exposure 
 takes place in a confined space or crowded room, the vitiated air 
 doubtless contributes to the result. 
 
 Symptoms, — The chief clinical distinction among cases of 
 heat-stroke depends upon whether the body temperature of the 
 patient is or is not elevated. Sometimes, however, in the milder 
 non-febrile forms pyrexia may develop. 
 
DISEASES EXCITED BY ATMOSPHERIC INFLUENCES ii 
 
 The leading features of the apyretic cases are extreme exhaustion 
 and tendency to syncope, a subnormal temperature and partial 
 collapse, with vomiting, dilated pupils, and small, quick pulse. 
 Milder degrees of these conditions are famiUar to all, from the 
 pleasurable sense of lassitude to the more severe states. In some 
 there are superadded dyspncea and failing respiration ; such cases, 
 being usually more sudden in onset and more fatal, are among those 
 frequently termed " heat apoplexy." 
 
 To those cases of heat- or sun-stroke which are marked by hyper- 
 pyrexia the names " thermic fever " or " siriasis " are specially applied. 
 All degrees of suddenness of attack are met with, from those who 
 are struck down and die within a few minutes or hours to those in 
 whom for several days before the dangerous symptoms appear there 
 is general weakness, headache, nausea, drowsiness, and frequent and 
 copious micturition. 
 
 " Generally," says Dr. Sambon, whose admirably graphic de- 
 scription I quote almost verbatim {Brit. Med. Joiirn. 1898, i. p. 744), 
 "patients are seized with severe headache, an alarming sense of 
 general oppression or exhaustion, or difficulty in breathing, and a 
 distressing burning in the eyes, associated with vertigo and chroma- 
 topsia (surrounding objects appearing of uniform colour, usually red, 
 blue, or purple). The skin is dry and intensely hot; the patient is 
 pale and excessively thirsty. The pulse is full, rapid, and bound- 
 ing; respiration is hurried and oppressed. The temperature rises 
 suddenly to 107° or 108°, or even to 112° or higher. Vomiting is 
 very common, and may be a special feature at the outset ; purging is, 
 in severe cases, almost always present, the motions being watery and 
 colourless. The skin and breath have a peculiar mousy odour. 
 Cramps in the calves of the legs or in the muscles of the back, some- 
 times amounting, it is said, to opisthotonos. A maculo-papular 
 eruption has been described as of occasional occurrence, but it is 
 not characteristic. Insensibility soon sets in, from which at first 
 the patient may be roused, but which soon deepens into profound 
 coma. Convulsive twitchings of the facial muscles, or arms, or even 
 general convulsions may be present ; but frequently the patient lies 
 motionless from the commencement to the termination of the attack. 
 The reflexes are diminished or abolished. The urine is scanty and 
 often suppressed ; it usually contains traces of albumen, a few hyahne 
 or granular casts and blood corpuscles. The breathing becomes almost 
 entirely diaphragmatic ; the patient grinds his teeth and moans loudly 
 at each expiration, loud rales and rhonchi being audible over the chest, 
 with cyanosis of the face. The eyes are fixed and turned slightly 
 
12 MANUAL OF MEDICINE 
 
 upwards ; the conjunctivae are excessively congested, and the pupils 
 are contracted to mere pin points and do not react to light. After 
 a time convulsions and vomiting cease and the patient passes into a 
 state of low muttering delirium ; the skin, still hot, becomes clammy ; 
 the heart's action becomes more rapid, weaker, and irregular, and 
 the respiration slower and stertorous, or of the Cheyne-Stokes' type, 
 with loud, mucous, tracheal rattling. Frothy mucus, often blood- 
 stained, is ejected by mouth and nostrils, and the patient dies from 
 asphyxia. In favourable cases the temperature falls, the pupils 
 relax, and the patient regains consciousness ; the respiration im- 
 proves and the pulse-rate declines ; not uncommonly there is a dis- 
 charge of urine, after which sleep follows. Termination is usually 
 by crisis, and although the prostration is extreme, con\-alescence is 
 rapid." The duration of the symptoms varies from a few hours in 
 the fatal cases to one or occasionally a couple of days. Relapses are 
 frequent, setting in after complete defervescence has occurred. 
 
 Prognosis. — " Taking one type of heat-stroke with another," 
 says Dr. Manson, " the case mortality among English troops in 
 India is about one in four." The highest death-rate is to be found 
 among cases of siriasis. ]Most attacks of heat exhaustion or syncope 
 recover, if treatment be applied. The asphyxial variety of the latter 
 is certainly more fatal. 
 
 Sequelae. — Although recovery from a severe attack may take 
 place, it is commonly the case that the patient's health continues 
 more or less impaired, and often for a long time. Various nervous 
 diseases, such as headache, sometimes severe and persistent epileptic 
 seizures, and even insanity with suicidal or homicidal tendency or 
 mania have been known to follow sun-stroke, and loss of memory, 
 insomnia, and generally deteriorated mental power are frequent. A 
 remarkable intolerance of heat is commonly exhibited by individuals 
 who have once been attacked (see//. Tropical Med., Nov. 1898). 
 
 Post-mortem appearances. — These may be of the slightest 
 and are rarely distinctive. The temperature may continue to rise 
 after death. Rigor mortis supervenes soon, lasts but a short time, 
 and putrefaction rapidly follows. The blood remains fluid, is acid 
 in reactipn, and clots but little ; considerable post-mortem staining of 
 the skin and other tissues is to be seen, and extreme engorgement of 
 the viscera, especially the lungs and whole venous system, with 
 sanguineous effusions into the venous cavities. A marked rigidity 
 of the ventricles is described as existing for a short time after deathc 
 The substance of the brain and spinal cord is not unduly congested, 
 but the ganglion cells are said to exhibit an acute parenchymatous 
 
DISEASES EXCITED BY ATMOSPHERIC INFLUENXES 13 
 
 degeneration ; the meninges are usually hypersemic and appearances 
 of commencing meningitis have been noted. The liver and renal 
 cells show granular degeneration. 
 
 Pathology. — The patholog}' of these conditions is uncertain, 
 as indeed is the explanation of the regulation of the normal body 
 temperature. A consideration of the symptoms would suggest that 
 the extreme heat, especially that of the sun, by which the most 
 severe cases are caused, exerts an injurious influence on the 
 temperature-controhing centres, whether these be "spinal" or 
 those which regulate the loss of heat, \-iz. the vaso-motor and 
 respiratory centres, and those which govern the tissues generally, 
 more particularly the muscles, by which the heat is produced. But 
 there is no knowledge how such assumed influence acts. 
 
 An explanation of another kind has been proposed for those 
 cases marked by hyperpyrexia. Their suddenness of onset and the 
 general character of their course and symptoms, as well as the 
 apparent occurrence of siriasis in epidemics, and the marked 
 tolerance that is exhibited by the natives and old residents in tropical 
 climates, are features that bear a close resemblance to those mani- 
 fested by the acute specific diseases, and Dr. Sambon does not 
 hesitate to include siriasis among the infectious fevers. It may be 
 further observed that it is by no means necessarily in the hottest 
 times of the day, nor in the direct solar rays, but rather at night, that 
 the majority of cases occur. Nor is it equally prevalent in all hot 
 countries, for, according to Dr. Sambon, siriasis is restricted to low- 
 lying, sea-coast districts and certain river valleys, and is never met 
 with much above an altitude of 600 feet — in short, that it is an 
 endemic disease dependent upon extreme heat for its development, 
 but not owing its causation to that condition. 
 
 Treatment. — Much may be done in the way of prevention by 
 the obser\'ance of certain precautions, especially by new-comers in 
 those regions where the hability to attack is greatest. Avoidance of 
 exposure to the sun and protection of the head and neck by suitable 
 cov-erings are essential, and scarcely less so are light, loose, woollen 
 clothing, and free ventilation of the dwelling-rooms, particularly at 
 night. The mode of living should be moderate in all respects — 
 a light diet, a minimum of alcohol, and no excess of bodily or mental 
 labour, but, if possible, a midday rest is most desirable, as well as 
 the encouragement of free skin action by cold baths and simple 
 drinks. 
 
 Success in the treatment of the attack largely depends on 
 promptness of administration. For the syncopal and asphyxial forms 
 
14 MANUAL OF MEDICINE 
 
 stimulants must be given at once and freely by the mouth or 
 rectum, or by subcutaneous injections of brandy, ether or strychnine, 
 as well as sinapisms to the neck or calves. The patient should be 
 kept in the recumbent position and carefully watched for several 
 hours, as there exists a tendency to relapse even in the milder cases. 
 It may be necessary to apply hot bottles or even a hot bath when 
 the surface is very cold. 
 
 Inasmuch as one great danger in the hyperpyrexial attack is 
 failure of the heart, stimulation in these cases is equally necessary, but 
 a valuable and all-important adjunct is the application of cold by 
 affusion, sponging, ice packing and cradhng, ice-water enemata or cold 
 baths, by which the temperature of the patient may be reduced. 
 The various antipyretic drugs, owing to their depressing action on the 
 heart, are contra-indicated. It is seldom that bleeding is permissible, 
 though it may be beneficial in the asphyxial forms. Subcutaneous 
 injections of hydrochlorate of quinine (gr. v.), or of tincture of 
 digitalis (m. xl.), are recommended by Dr. Manson, but strychnine 
 should not be given owing to the liability to convulsive seizures. 
 
 For a person who has experienced an attack of siriasis removal 
 to a temperate climate is imperative, and abstinence from alcohol 
 most desirable. Counter-irritation by blisters to the nape of the 
 neck may be necessary, and benefit follows a course of iodide of 
 potassium or sodium combined with bromides. 
 
 The effects of the solar rays or of great heat upon the skin, such 
 as sunburn, freckles, various forms of erythema, prickly heat, etc., 
 will be referred to elsewhere. 
 
 {b) Cold. — As an etiological factor of disease this has long been 
 recognised, but it is certain that it is not of the importance as a 
 cause that was formerly held — even as a contributory circumstance 
 its influence has been probably over-estimated. It would seem that 
 exposure to an unduly low temperature can rarely be held solely 
 responsible for any special disease, although by diminishing the 
 resistance of the body to microbic invasion, and perhaps of favouring 
 the occurrence of inflammation by vascular disturbance, it may in- 
 directly become an exciting cause, largely influenced by the age, sex, 
 and general condition of the patient. Certain symptoms of disease, 
 however, such as pain, are very liable to increasingly manifest them- 
 selves on exposure to cold, especially if this be associated with 
 dampness. Even the local affection known as chilblain appeals to 
 depend as much for its occurrence upon the state of the individual 
 
DISEASES EXCITED BY ATMOSPHERIC INFLUENCES 15 
 
 as upon cold, but frostbite may fairly be attributed only to this 
 cause, which may also directly lead to death. 
 
 The general effect of extreme cold, according to the degree and 
 duration of exposure, is to repress the vitality until death occurs from 
 coma, or heart failure, or from shock. Previous to this there is 
 successively to be noted, first, a lividity, and then a palloj and 
 wrinkling of the skin, with a feehng of cold and numbness and 
 shivering. The muscular and mental powers gradually fail, the 
 former interrupted by twitchings and even tetanic spasms ; a deepen- 
 ing feeling of languor and loss of sensibiHty, as the senses become 
 dull and the mind cloudy, with a desire for sleep or, as is sometimes 
 the case, a painful wakefulness. As consciousness is lost the 
 sufferer may roar and shout in his delirium, finally, with a failing 
 heart and slowed breathing, to subside into a state of coma which 
 passes into death. An overpowering desire to relieve an intense 
 thirst by eating snow is often a marked and grave symptom of the 
 earlier stages. 
 
 Frostbite is a form of gangrene affecting the extremities, chiefly 
 the fingers, toes, ears, and nose, following on exposure to severe cold, 
 and characterised by a progressive redness of the part with increased 
 sensibiHty and tingling, followed by a change to a bluish or purple 
 colour, and anaesthesia, which becomes more and more intense as the 
 colour is lost ; the tissues later becoming white, hard and blood- 
 less, and, finally, black and shrunken, presenting all the appearances 
 of dry gangrene. According to the degree and duration of the cold, 
 so may any of these stages be reached, and recovery take place with 
 more or less loss of structure and impaired function. 
 
 The local treatment of such a condition consists in endeavour- 
 ing to restore the circulation by the very gradual application of 
 warmth and by friction of the affected part, which, if it have become 
 gangrenous, should be allowed to separate spontaneously. The 
 general condition of the patient may require attention. 
 
 2. Atmospheric Pressure 
 
 Owing to the practical impossibility of isolating the effects of 
 atmospheric pressure, within such ranges of variations as are met with 
 at the sea-level or usually inhabited regions, from the other 
 atmospheric and climatic factors, its causal influence on diseases 
 cannot be affirmed. Nor can it be solely held responsible with 
 certainty for the development of symptoms, such as pain, occurring 
 in the course of already existing disease ; corresponding in this 
 
1 6 MANUAL OF MEDICINE 
 
 respect to the influence of cold, damp, etc. Its importance as a 
 determinant of haemorrhage has been much overstated ; carefully 
 conducted observations going far to prove the contrary. With 
 extremes of pressure, however, such as man is not ordinarily exposed 
 to, there are associated very constant symptoms sufficient to constitute 
 distinct diseases, for which the pressure itself may be properly 
 regarded as the exciting cause, just as definite morbid states are 
 connected with extremes of heat or cold. 
 
 The fluctuations of barometric pressure to which human beings 
 are commonly subjected range between 28 and 31 inches; this, in 
 round numbers, would give a pressure of about 15 lbs. in the square 
 inch, or, on the whole surface of the body of an adult man, upwards 
 of 1 1 tons, of which the individual is ordinarily insensible owing to 
 the pressure being equally exerted in all directions. 
 
 The effects that result from raising or lowering the atmospheric 
 pressure are of chemical, not mechanical, origin, and the individual 
 succumbs to a species of intoxication. The partial pressure of the 
 oxygen is the one factor of supreme importance, and, in this condition, 
 whether it be excessive or deficient, the processes of combustion in 
 the tissues are no longer carried to their final end. 
 
 (a) Increased atmospheric pressure — caisson disease. — 
 Exposure to much increased atmospheric pressure occurs in mines, 
 sinking wells, in diving bells, and more particularly in caissons which 
 are employed for subaqueous tunnelling where the inrushing 
 water is kept back by compressed air. In the latter situation work 
 is sometimes carried on in a pressure of 50 to 60 inches, i.e. three 
 to four atmospheres. A pressure above five atmospheres cannot 
 be tolerated with safety. According to Paul Bert all life is destroyed 
 by an air-pressure of twenty atmospheres. Exposed to this 
 vertebrates die in convulsions ; insects become paralysed ; vegetables 
 shrink up ; grains stop germinating ; bacteria cease to ferment. An 
 atmosphere containing either an oxygen tension of 400 mm. of 
 mercury or a carbon dioxide tension of 30 mm. is absolutely 
 irrespirable. The physiological effects, or those which can scarcely 
 be termed disease symptoms, are briefly a general sense of comfort 
 with distinct increase of muscular power, which is exerted with less 
 fatigue ; the compression of the gases in the stomach and intestines 
 permits a greater descent of the diaphragm, whereby the respirations 
 become fuller and slower ; the pulse is less frequent and of increased 
 volume and higher tension ; the blood is less venous and contains a 
 greater percentage of oxygen and nitrogen than normal ; and the 
 secretions from the skin and kidneys are increased. Opinions differ 
 
DISEASES EXCITED BY ATMOSPHERIC INFLUENCES 1 7 
 
 as to whether there is an increase in the tissue metaboKsm, 
 although the appetite is improved and muscular power increased ; 
 for though there may be a slight rise of temperature, it is not 
 constant nor is there any appreciable excess in the carbonic acid or 
 urinary solids excreted. Since it is the needs of the tissues them- 
 selves which determine their metabolism, and the amount of oxygen 
 in the blood at normal pressure exceeds what is required, it is 
 probable that there is no constant increase in the tissue change, and 
 consequently none in the waste products. 
 
 The incidence of morbid symptoms among w^orkers in com- 
 pressed air is very variable, but appears to be largely conditioned 
 by the degree of pressure, the duration of stay in the altered 
 atmosphere, and the completeness of ventilation, the last named 
 being, according to Dr. Snell {^Compressed Air Illness, by E. H. 
 Snell, M.D., 1896, with complete bibliography), of the utmost 
 importance, whilst he relegates to a position of subsidiary im- 
 portance the rapidity with which the worker passes from the one 
 atmosphere to the other, which has been generally regarded as a 
 dominant factor in the causation of caisson illness. Among pre- 
 disposing causes are age, the older men being more prone, specially 
 if there be signs of degeneration, alcoholism, and previous want of 
 food, whilst those taking exertion immediately after leaving the 
 compressed air appear more liable to become ill. The immunity 
 of certain divers and caisson workers to decompression is note- 
 worthy. This may depend on greater elasticity and width of the 
 capillaries, but more probably on differences in the gaseous absorp- 
 tion in different individuals. On experimental grounds there are 
 reasons to think that this is controlled by some compensating 
 mechanism. 
 
 Symptoms. — These occur almost entirely after the individual 
 has left the compressed air, coming on in from a few minutes to an 
 hour or more, seldom beyond twelve. The most frequent are pains 
 in the limbs or back, especially about the knees, of all degrees of 
 severity, even to being excruciating, sharp, dull, or aching in character, 
 often paroxysmal, and sometimes accompanied by tenderness and 
 swelling. They may be the only symptoms, and usually subside in 
 a few hours, or may be days, seldom lasting longer. In a variable 
 proportion of cases epigastric pain, either alone or with the fore- 
 going, is met with, occasionally accompanied with nausea or vomit- 
 ing. A remarkable and sudden form of paralysis with anaesthesia some- 
 times occurs, generally taking the form of paraplegia, more rarely a 
 monoplegia. This may or may not co-exist with the pains described ; 
 VOL. I c 
 
1 8 MANUAL OF MEDICINE 
 
 sometimes it is spastic in character, sometimes tabetic, with per- 
 manent exaggeration of the reflexes ; the bladder and rectum are 
 frequently involved, and cystitis has been known to supervene. 
 Auditory vertigo, sometimes with deafness of one or both ears, or 
 tinnitus, and in severe cases with a tendency to fall towards the 
 deaf side, has been noticed. Among other symptoms of variable 
 frequency are a marked pallor of the skin, sometimes with 
 mottling or even ecchymoses, cold sweats, formication, deafness, 
 headache, diplopia, epistaxis, haemoptysis, and a peculiar dysphagia 
 and feeling of obstruction in the gullet. If the entrance to the 
 compressed air chamber be sudden, and especially if there be any 
 catarrhal or other blocking of the Eustachian canal and passages 
 leading from the frontal, nasal, and other sinlises, then severe pain 
 in the ear or across the forehead may be experienced until an 
 equilibrium of pressure is established ; occasionally even the mem- 
 brana tympani is ruptured. As a rule, complete recovery takes 
 place from all of these symptoms in the course of a few hours or days ; 
 sometimes, however, it may be weeks before the patient is quite 
 well, and neuralgic pains have been k;nown to persist for longer. 
 Now and then, in a very variable proportion, death occurs very 
 shortly after passing into the normal atmosphere ; unconsciousness 
 deepening into fatal coma is the usual course. Death may be 
 postponed for many days or weeks, and in such cases the patient 
 exhibits the symptoms of acute myelitis. 
 
 Post-mortem, appearances. — Extreme congestion of the brain, 
 cord, and meninges, as well as other viscera is the most constant ; 
 occasionally haemorrhages in the arachnoid space have been met 
 with, and sometimes the appearances of myelitis, with small rents in 
 the substance of the cord suggestive of tearing, as by escaping gas. 
 
 Pathology. — This is undoubtedly obscure, the theories that 
 the condition is due to congestion of the brain and spinal cord from 
 pressure on the surface, or to carbonic-acid poisoning, are inade- 
 quate, if not absolutely incorrect. The most reasonable hypothesis 
 is that in the escape of bubbles of gas from the blood on the 
 removal of the pressure, temporary emboli of the smaller vessels are 
 found, causing transient or more permanent damage of the nervous 
 tissues, the latter probably due to lacerations caused by the forcible 
 escape of the gas. In some measure the ill effects are due, certainly 
 in animals submitted to pressures exceeding five atmospheres, to 
 intoxication from the results of perverted tissue metabolism. 
 
 Treatment. — Since most cases quickly recover, active treat- 
 ment is seldom called for. Recompression by placing the patient 
 
DISEASES EXCITED BY ATMOSPHERIC INFLUENCES 19 
 
 in a suitable chamber where the atmospheric pressure may be 
 increased, and sloivly reducing the pressure to normal, is most 
 effective. Morphia may be required for the pains, or anodyne 
 applications to the affected parts. Some success has been said to 
 follow the administration of ergot, given to cause contraction of the 
 arterioles and so relieve the congestion. For the paralytic symptoms 
 counter-irritation along the dorso-lumbar region of the spine, with 
 strychnine internally, should be employed. It is to prevention, by 
 observance of the precautions indicated, that attention should be 
 specially directed. 
 
 ip) Diminished atmospheric pressure — mountain sickness. 
 — An extreiTiely rarified atmosphere, such as is met with on the 
 highest mountains, or in balloon ascents, causes well-marked symp- 
 toms of a serious character. Differences exist — determined in great 
 measure by the " condition " and fitness of the individual, and the 
 degree of his " vital capacity " — as to the power of resisting a much 
 diminished pressure; but at a height of 16,000 feet and upwards, 
 i.e. at about half the normal pressure, certain symptoms are mani- 
 fested by all. The greatest heights attained have been 23,000 feet 
 in the Himalayas, and 10,000 feet beyond that, or upwards of 6 
 miles, in a balloon. At such altitudes as these the coincident effect 
 of the great cold has to be considered, and it is impossible to separate 
 the influence of this factor from that of the low barometer. Life is 
 absolutely impossible when the partial pressure of oxygen falls from 
 the normal (160 mm. Hg.) to 40-50 mm. Hg. ; but the individual is 
 incapable of muscular activity at an oxygen pressure considerably 
 higher than this. The greater the rate of tissue metabolism the less 
 will be the power of resistance to diminution of pressure ; hence the 
 higher the body temperature, or the lower the surrounding tempera- 
 ture, or the more the amount of associated muscular effort, the greater 
 will be the metabolism, and the sooner will the individual experience 
 symptoms of distress. Thus it is that mountain climbers as a rule 
 commence to suffer at lower levels than do aeronauts. The greater 
 cold, however, to which the latter are exposed at extreme heights, 
 as well as the greater rapidity with which those altitudes are reached, 
 contribute in an important degree to the severity of the symptoms 
 experienced. 
 
 The principal symptoms are connected with the cardio-respira- 
 tory functions, accompanied by extreme lassitude and fatigue, both 
 muscular and mental. The exhaustion is remarkable ; it often super- 
 venes suddenly — as, indeed, do most of the symptoms — and increases 
 as the person ascends, until there is absolute inability to move, or 
 
20 MANUAL OF MEDICINE 
 
 make the slightest effort. After a brief rest progress may be resumed, 
 soon again to come to a standstill ; and this may be repeated until 
 further advance becomes impossible. There may be pains in the 
 muscles of the limbs, and the looseness of the hip-joint from lessened 
 atmospheric pressure has been partly credited with the weakness of 
 the legs. The essential fact, however, is the diminished oxygen 
 tension in the blood, the imperfect removal of the carbonic acid 
 therefrom, and the coincident impaired metabolism, upon which, 
 probably, all the symptoms manifested more or less directly depend. 
 This is especially so in respect to the quickened, shallow breathing, 
 which becomes gasping and difficult, and finally the mouth is kept 
 widely open to facilitate inspiration. The desire for air is insatiable. 
 Sometimes, during the rapid sequence of the respirations, an oppressive 
 pause occurs, and then there arises a terrible feeling of suffocation. 
 The pulse is accelerated and soft ; there is palpitation and liability to 
 syncope, and the individual experiences a throbbing of the vessels, 
 particularly in the head. This condition of the circulation leads to 
 vertigo, headache, and, in extreme cases, to unconsciousness. The 
 skin generally is pale and rugose, whilst the face is cyanotic ; the per- 
 spiration is suppressed, and secretion of urine diminished ; the body 
 temperature falls, and there may be bleeding from the gums and 
 nose. These haemorrhages are due to venous congestion, which 
 results from vaso-motor paralysis and cardiac debility, and these in 
 their turn are primarily due to want of oxygen. The appetite is lost ; 
 but an intense thirst is complained of, apparently connected with the 
 parched state of the throat. Nausea and vomiting are by no means 
 constant in occurrence, as the name of the malady might imply. A 
 feeling of constriction at the epigastrium has been noticed, and also 
 deafness and earache from outward bulging of the tympanic mem- 
 brane. Except at extreme heights, individuals become acclimatised 
 in time to the atmospheric conditions, and experience little or no 
 discomfort. The natives of Thibet maintain an active and vigorous 
 existence at an altitude of 16,000 feet. The co-efficient of absorp- 
 tion of the blood gases is, no doubt, the factor of the greatest im- 
 portance in regard to this immunity, in connection with which it may 
 be mentioned that the number of red corpuscles is increased in 
 animals kept after long periods at greatly diminished atmospheric 
 pressure. 
 
 There are no records of diminished atmospheric pressure causing 
 the death of human beings ; but experimentally it is found that the 
 paralysis deepens, and fatal coma ensues, thus differing considerably 
 from death by asphyxia, which occurs in convulsions. Cadaveric 
 
DISEASES EXCITED BY ATMOSPHERIC INFLUENCES 21 
 
 rigidity is said to supervene at once, and to be extreme, which also 
 does not correspond to asphyxial death. 
 
 Those exposed to these conditions should dress warmly and 
 lightly, spare themselves as much muscular effort as possible, and, 
 when practicable, take with them a vessel of oxygen gas, by the in- 
 halation of which the symptoms are immediately, though temporarily, 
 relieved. 
 
 3. Electricity. 
 
 Lightning stroke. — Nothing is known of the influence on 
 health, whether favourable or the reverse, of the ordinary states of 
 atmospheric electricity. The passage of a powerful current through 
 the body is commonly fatal either at once or after an interval of a 
 few hours or even days ; or it may determine symptoms of a transient 
 or of a permanent character. 
 
 The symptoms exhibited by those who do not succumb at once 
 are those of more or less severe shock, or of cerebral concussion. 
 There is insensibility, with a small, scarcely perceptible pulse, and 
 slowed, deep respiration, not always regular ; the skin is cool, and 
 the body temperature depressed, and the pupils are dilated. A 
 peculiar expiratory cry has been sometimes remarked, not apparently 
 of pain or consciously uttered, but connected with the disturbance of 
 respiration, caused by the electric shock. The patient may slowly 
 recover in a few hours, or it may be a longer time, though death has 
 been known to follow several days later, even after considerable im- 
 provement. When consciousness returns, attacks of intense pain are 
 sometimes complained of, not so much in the neighbourhood of any 
 wound, but in the wrists, or more often in the abdomen and loins. 
 Twitchings of the facial muscles, with extreme loss of power and 
 anaesthesia in the limbs, impaired articulation, deafness or noises in 
 the ears, defects of vision, and haemorrhages from nose, ears, and 
 mouth, and suppression of urine, are symptoms which occur in varying 
 frequency and degree, and may all be quickly recovered from. Some- 
 times, however, more lasting effects result, continuing from the onset 
 or arising much later ; among these are paralysis, hemiplegia and 
 paraplegia, neuralgia, blindness or other defects of sight, loss of taste 
 and smell, or of hearing, impaired memory and mental power, and 
 even insanity. 
 
 Various theories have been put forward as the cause of death. 
 Some have considered that the resistance of the tissues to the 
 current has determined a rise of temperature which is fatal, and 
 though anything like a general charring of the body is unknown. 
 
22 MANUAL OF MEDICINE 
 
 there is usually some local evidence of burning or scorching, and a 
 sufficient rise of body heat might be induced to cause death ; others 
 have attributed the result to a sudden expansion of the gases of the 
 blood and liberation of free gases from decomposition of the tissues ; 
 others again to failure of the respiratory centre ; but careful experi- 
 ments strongly suggest that the main cause is arrest of the heart's 
 action, and that in these cases, when recovery has followed exposure 
 to a discharge sufficient to kill, the current has probably been con- 
 ducted solely by the external surface of the body rather than by the 
 blood and fluids which it usually traverses, owing to their lower 
 degree of resistance. Recorded cases usually, but not always, show 
 that a few respiratory efforts are made after the heart-beat has 
 ceased, and the same has been observed in experiments on animals 
 with currents of high potential, when sometimes simultaneous 
 cessation of heart's action and respiration have been noted, but 
 arrest of breathing was never found to precede stoppage of the 
 heart. The influence of the current in inhibiting the heart's action 
 is considered by Drs. Oliver and Bolam {Brit. Med. Journ. 1898, 
 Jan. 15) to be directly exerted on the organ, and not via the vagus 
 nerve. 
 
 Post-mortem appearances. — These may be exceedingly 
 slight, but generally there are some marks of injury at the point 
 where the current enters the body, and frequently also at the place 
 of exit. These appear as incised or lacerated wounds of the integu- 
 ments and subjacent tissues reaching even to the underlying bones, 
 which are sometimes fractured ; there is frequently a good deal of 
 effused blood, which tends to exhibit undue fluidity ; or there may 
 be only an appearance of bruising and no actual wound. The 
 adjacent hairs may be singed, and some burning and slight charring 
 of the integuments, or sometimes a widespread appearance of 
 scorching with streaks and patches of variable size of intense red- 
 ness, perhaps with blisters. It is seldom that there is any burning 
 of the clothes, which are frequently torn to shreds and stript in part 
 from the body, but it is noteworthy that damage to the garments 
 by no means necessarily corresponds to the situation of the surface 
 lesions. Sometimes remarkable and extensive red or purple dendritic 
 markings are to be seen, and it is probable that the unequal contact 
 and pressure of the clothes has some share in their production. 
 Internally no very constant appearances are recorded ; subserous 
 effusions of blood have been described on the viscera, which are 
 sometimes ruptured, especially the liver and brain, and a similar 
 accident has occurred to the tympanum, I'he lungs are commonly 
 
DISEASES EXCITED BY ATMOSPHERIC INFLUENCES 23 
 
 much congested. Rigor mortis supervenes rapidly, is of very short 
 duration, and is quickly followed by decomposition. 
 
 Treatment. — If the slightest evidence of life be apparent 
 artificial respiration should be at once resorted to and continued for 
 at least twenty minutes ; life has undoubtedly been thus saved. 
 Stimulants, such as ether or brandy, must be administered hypo- 
 dermically or by rectal injection. Morphia may be required for the 
 relief of the excruciating pains above described. 
 
 W. H. Allchin. 
 
24 MANUAL OF MEDICINE 
 
 THE INFECTIONS 
 
 The infections or specific infective fevers form a group of maladies 
 which result from the introduction into the body by wounds, by the air 
 passages, or by the alimentary tract, of specific bacteria, each specific 
 infection being the result of the action of a special microbe, or its 
 poisons, on certain tissues, or groups of tissues. In many instances, 
 e.g. tetanus, typhoid fever, tuberculosis, and diphtheria, the association 
 of cause (the microbe) and effect (the special form of infection) has been 
 so fully and so carefully traced that doubt can no longer exist in the 
 minds of competent observers as to the real cause of each of these 
 diseases. 
 
 In recent years our knowledge of the spread of diseases produced by 
 bacteria has been so far modified that some little confusion has arisen in 
 the minds of various writers as to the meaning of the terms " infectious " 
 and " contagious," and now many avoid the use of either of these words, 
 replacing them by the term " infective." Certain of the diseases pro- 
 duced by micro-organisms which are of course infective can scarcely be 
 looked upon as capable of being conveyed from one patient to another 
 except in a very roundabout fashion ; it has therefore been suggested 
 that these diseases should be spoken of as "non-transmissible," whilst 
 those which pass readily from patient to patient are " transmissible." 
 Most if not all epidemic diseases are transmissible ; so also are some of 
 the endemic diseases, and a few of them, e.g. paludism (malaria) may be 
 said to be transmissible not from patient to patient but through an 
 intermediate host. The distinctions that exist in the mode of trans- 
 mission from patient to patient either directly or indirectly are of great 
 importance, and it is only by a careful study of them that those en- 
 gaged in the prevention and cure of disease can come to understand 
 them. 
 
 In a number of diseases — scarlet fever, measles, smallpox, and others 
 of a similar character — there \s prima facie evidence that similar causal 
 factors are at work in their production, and on the ground of analogy a 
 very strong case for their microbic nature may be made out, but up to 
 the present no conclusive or experimental evidence in support of this 
 has been obtained, and although these and similar conditions are classed 
 with the infections, it is because of the clinical symptoms and of the 
 special transmissibility of these diseases, and not because of any experi- 
 mental bacteriological proof 
 
 In connection with this, Koch, for his own guidance and that of 
 others investigating the specific infections, laid down the following 
 postulates, all of which it is necessary shall be fulfilled before it can 
 
THE INFECTIONS 25 
 
 be said to be proved that a micro-organism is the primary etiological 
 factor in the production of a disease. 
 
 I. The disease must be of well-defined type and invariably accom- 
 panied by {a) symptoms so characteristic as to constitute a specific 
 malady, {d) a micro-organism of constant form and disposed in a con- 
 stant relation to the fluids or solid tissues of the host. 2. Further, this 
 organism must be present in the special disease and in no other. 3. It 
 must be possible to isolate and cultivate this organism outside the 
 animal body, to obtain pure cultivations of such organism, and 4, by 
 means of inoculation thereof to reproduce the disease with all the 
 symptoms of the original complaint, or at least a sufficient number of 
 them to give it the specific character. 5. In the animal so affected, 
 the same organisms must be demonstrable in the same relation to the 
 tissues as was obser^-ed in the original host. In such cases the ex- 
 perimental proof is conclusive. 
 
 Characters of the ^^Iicrobes 
 
 Microbes or bacteria are low forms of plants belonging to the group 
 of the schizomycetes or fission fungi. These organisms consist of minute 
 specks from „ .^^q in. ( = i jj.) in diameter, or short threads or rods from 
 I /i in diameter and from 1.5 or 2 />i up to 6 or 8 /a or more in length, 
 composed of vegetable protoplasm, each usually surrounded by a firmer 
 sheath ; in some instances this sheath is composed of a substance re- 
 sembling cellulose, which in the case of the bacillus tuberculosis has on 
 its outer surface a coating of some fatty acid. 
 
 Multiplication and form. — Bacteria usually multiply by a process 
 of fission or direct division ; each organism increasing in size and then 
 dividing into two, the process under favourable conditions being repeated 
 at short intervals of twenty minutes or half an hour. The fission may 
 be complete, the mother-organism simply dividing into two separate and 
 distinct daughter-organisms; or the two newly-formed organisms may 
 remain in contact, sometimes with a slight bond of union between them, 
 fonning a diplococcus or diplobacillus. When they undergo further 
 division and the slight bonds still remain, the division going on in one 
 plane only — transversely to the longitudinal axis — there is formed a chain 
 or streptococcus or string of round beads like a necklet, or a streptobacillus 
 or streptothrix like a string of elongated beads. In some cases the rods 
 increase greatly in length without undergoing any marked division into 
 short lengths, and a leptothrix or slender thread is formed ; or these 
 threads may assume a spiral or screw form, a spirillian^ this again often 
 subdividing into short cur\"ed segments v.hich are known as " comma- 
 shaped" organisms or vibrios^ e.g. Koch's comma bacillus of cholera. 
 Micrococci may be divided into diplococci (pairs), streptococci (chains), 
 tetrads (the result of division in two planes), sarcince (or packets, the 
 
26 MANUAL OF MEDICINE 
 
 result of division in three planes, in which the groups are composed of 
 at least eight cells), and staphylococci (a mass somewhat like a bunch of 
 grapes). In appropriately-stained specimens there may be seen running 
 out from some of these micro-organisms (B. typhosus, B. tetani, 
 B. choleras asiaticse, etc.) lateral or terminal Jiagella or cilia^ long or 
 short delicate filaments, single or in groups or bundles, some motile and 
 wavy, others rigid and apparently non-motile. 
 
 Although in connection with the infections, specific individual forms 
 of bacteria are described, the fact must not be lost sight of that any 
 form met with in the animal tissues may be merely one of a series, a 
 phase in the existence of one of these vegetative micro-organisms. For 
 example, a coccus under certain altered conditions may become elongated 
 into short rods, and these again may, under different conditions, extend 
 into long threads. In the case of the ray fungus — actinomyces — there 
 may be such swelling of the ends of these threads that they form a series 
 of very characteristic club-shaped organisms, often radially arranged. 
 Similarly the diphtheria bacillus may occur as an exceedingly short 
 pointed rod, or it may grow out into long filaments, or again it may 
 develop into a perfect club-shaped organism. 
 
 The structure of these microbes may be no more complicated than 
 that above described, but in some cases the protoplasm may be granular 
 or it may be divided into segments, as in bacillus diphtherise, or there 
 may be seen clear and refractile bodies (spores, resting spores, or seeds) in 
 the substance of the bacillus, as in the B. anthracis, or at one end causing 
 expansion of the rod, as in B. tetani (drumstick bacillus). From these 
 spores, which are more resistant to the action of antiseptics, heat and 
 the numerous other agencies which tend to interfere with vitahty than 
 are the bacteria themselves, full-grown or vegetative bacteria may be 
 developed. The question of spore-formation is one of special import- 
 ance, especially in relation to the stamping out of epidemics, as it is by 
 spores that disease germs, such as those of anthrax, are able to continue 
 their existence under unfavourable conditions. For example, most non- 
 spore-bearing micro-organisms when dried rapidly lose their vitality ; the 
 cholera bacillus, the typhoid bacillus and others sutcumbing, sometimes in 
 a few hours. Organisms, on the other hand, in which spores are developed 
 may be dried, treated with chemical reagents, frozen, heated almost up 
 to boiling-point, and still afford evidence by their germination that they 
 have retained their vitahty. The bacillus anthracis offers an example 
 of the importance of a knowledge of this matter. When confined to the 
 blood and lymph spaces in the tissues of its host it develops no spores, 
 and if the animal be buried with unbroken skin and before the discharges 
 from the body come in contact with the air, the bacillus dies out, killed 
 by the organisms of decomposition. Should the bacilli, however, gain 
 access to the air, spores which resist the action of putrefactive organisms, 
 and which may remain a source of infection for some time 3,fter the 
 
THE INFECTIONS 27 
 
 diseased carcase has been buried, are very rapidly formed. Splashes of 
 blood or of discharges containing spores represent foci from which the 
 disease may spread, especially in farm-yards, where there is plenty of 
 organic material on which the anthrax bacilli can flourish ; manure- 
 heaps and margins of ponds under these conditions offering specially 
 dangerous centres of infection. For similar reasons the spores of the 
 tetanus bacillus and the bacillus of malignant oedema are also constant 
 sources of danger in any soil to which they gain access. 
 
 Parasitism. — Most micro-organisms that are capable of producing 
 an infective disease are parasitic ; they live, multiply, and carry on their 
 vital activities within the body of a living animal host ; they are not 
 always easily cultivated outside the body, and certain of them {e.g. those 
 producing leprosy and relapsing fever) have not yet been so cultivated. 
 These latter are spoken of as '■'• obligate'''' parasites. '■'■Facultative'''' 
 parasites are those which, though usually found outside the body, are 
 also capable of leading a parasitic existence in an animal host, then 
 usually giving rise to definite pathological conditions. A saprophytic 
 micro-organism is capable of growing on dead organic matter, animal 
 or vegetable. These saprophytic organisms may become parasitic, and 
 some of them, such as the anthrax bacillus, tetanus bacillus, and bacillus 
 of malignant oedema, may lead parasitic and saprophytic lives alternately. 
 
 Although the line of demarcation is never absolute, obligate parasites 
 are usually confined to certain localities where the conditions are such that 
 they can be transmitted directly from individual to individual, whilst the 
 facultative parasites which are able to exist saprophytically (as in the 
 case of the diphtheria bacillus or the typhoid bacillus, which may live in 
 milk and other food substances) are exceedingly dangerous to the health 
 of the community, as are also those which form spores, and are thus 
 capable of continuing their species under unfavourable conditions. It is 
 certainly far more difficult to get rid of them than of the more easily 
 killed non-spore-bearing micro-organisms (such as the cholera bacilli) 
 which can live only under very definite conditions. 
 
 Pathogenetic bacteria exhibit various degrees of parasitism, but it 
 may be accepted generally that even the most parasitic have little 
 power of remaining active in perfectly healthy tissues. Certain of them 
 appear to alternate between a saprophytic and a parasitic existence 
 (bacillus cholerse asiaticas, streptococcus pyogenes, and bacillus coli 
 communis), and during these two phases they exhibit markedly different 
 characteristics which sometimes render it difficult to realise that the 
 differences are not something more than merely variational. If cholera 
 bacilli be examined directly they come from a patient who has succumbed 
 to cholera, it is found that they have, in a high degree, the power of 
 producing very active toxins from albuminous substances. If, now, the 
 conditions be even slightly altered, or comparatively weak solutions of 
 antiseptics be added, the bacilli lose their power of resista,nce and are 
 
2 8 MANUAL OF MEDICINE 
 
 easily killed, although the activity with which they performed their work 
 under favourable conditions appeared to be ver\- great. If these 
 organisms be cultivated outside the body for a prolonged period they 
 soon lose some of their characteristic features. They still grow rapidly 
 but do not liquefy gelatine at the same rate as they do in their first few 
 generations after being taken from the patient. They appear to have 
 become more distinctly aerobic in character and to have lost some of 
 their power of producing large quantities of active toxic substances, 
 but on the other hand they have become much more resistant to the 
 action of antiseptic substances, heat, cold, malnutrition, and the like. 
 They have indeed assumed saprophytic characters, and in so doing 
 have become more resistant to external influences. Although they are 
 now less virulent they are more dangerous to the community, from the 
 fact that they are not nearly so readily got rid of, and are therefore 
 enabled to lie fallow and to await an opportunity of attacking proteid 
 material in a fresh host, and, in their new surroundings, of regaining 
 their more virulent characters and toxin-producing powers. Here then 
 is an organism which in the parasitic stage is active but is readily killed, 
 whilst in the saprophytic stage it is far more resistant but not so active 
 as a disease -producer. It is, for this reason, necessary to deal with 
 such an organism as soon as possible after it comes from the body, as 
 it is during this very active phase that it is least able to defend itself. 
 What applies in the case of the cholera bacillus applies directly to all 
 those organisms which have the power of setting up disease whether 
 they form spores or not, and the fact must never be lost sight of that, 
 although pathogenetic organisms appear to become less virulent, their 
 greater resisting power renders them far more dangerous in the produc- 
 tion of epidemics than are the more active but less resistant forms. 
 
 Cultivation and results. — Such micro-organisms as have been 
 studied at all carefully can be cultivated on sterile media of appropriate 
 nature, broth, peptone-gelatine, agar-agar, solidified blood serum, milk, 
 etc. ; it has thus been determined that they have certain definite require- 
 ments in the way of food, moisture, and temperature, and only when 
 these are complied with can they do their special work. All require 
 oxygen, hydrogen, carbon, nitrogen, and inorganic salts, especially those 
 of lime and potassium. Unlike the higher plants they are unable to 
 assimilate carbon dioxide, which, however, they produce in considerable 
 quantities. Some of them, the obligatory "anaerobes," or those which 
 live only in the absence of air, have the power of extracting their carbon 
 and oxygen from starch, sugars, organic acids, and the glycerines. In 
 rare instances they can derive them only from proteid substances. 
 Others, the obligatory " serobes," can only obtain the bulk of their 
 oxygen from the atmosphere, whilst a third class, the facultative anaerobes, 
 or cerobes, as the case may be, may live under either set of conditions. 
 The more distinctly parasitic an organism is the more necessan,' it 
 
THE INFECTIONS 29 
 
 appears to be that It should have proteid material from which to derive 
 the elements of its nourishment. 
 
 When micro - organisms are cultivated in suitable nutrient media 
 arid growTi en masse it is possible to determine some of their specific 
 functions. Certain of them produce colouring matter through the 
 agency of an oxydase or colour-producing enzyme or ferment : a blood 
 red as in the case of the bacillus prodigiosus, a magenta by the magenta 
 micrococcus, a violet by the bacillus violaceus, a smoky blue by the 
 bacillus pyocyaneus, and other pigments by other organisms. Some of 
 these chromogeiietic bacteria have, in common with others, the power of 
 liquefying a gelatine medium^ and it is supposed that they do this 
 through the agency of a peptonising ferment, which, in the case of the 
 pus-producing organisms, is a most important factor in the liquefaction 
 of devitalised tissues. The anthrax bacillus, especially when highly 
 parasitic, exerts a similar action on gelatine. Acids — lactic acid, etc., 
 ethers, alcohols and other volatile substances, sulphuretted hydrogen, 
 carbon dioxide, ammonia, may all be produced by bacteria, as also 
 may small quantities of antiseptic substances, methylamines, and the 
 like. Beyerinck describes organisms which have the power of pro- 
 ducing a phosphorescent glow — the energy that they derive from their 
 food in this instance assuming the form of light- 
 Bacteria which are the cause of specific infective disease require for 
 their nutrition much the same elements as do other bacteria, but it is 
 a noteworthy fact that most of them require a larger proportion of 
 proteid, especially albumoses or peptones, than do non-pathogenetic 
 forms, especially for the production of toxic substances, the cholera 
 bacillus, again taking it as an example, being most active in producing 
 its toxic substances when it is supplied with a certain proportion of 
 comparatively crude albumen. It is for this reason apparently that the 
 pathogenetic organisms undergo modifications as to their toxin-forming 
 and pathogenetic activity when they are taken from the body and are 
 compelled to live a more or less saprophytic existence, these activities 
 in some instances, as in the case of streptococci, being multiplied to an 
 enormous extent, by continuous passage through a series of animal hosts. 
 In this way may be explained the rapidly increasing severity of cases 
 at certain stages of epidemic outbreaks of such diseases as scarlatina, 
 typhoid, cholera, and plague. 
 
 Toxic products of bacteria. — That exceedingly active soluble 
 poisons are formed by micro-organisms is now fully recognised. Very 
 virulent poisons absolutely separable from the micro-organisms are 
 produced by tetanus and diphtheria bacilli, whilst less active poisons 
 have been obtained from the mahgnant osdema bacillus. The first of 
 such poisons experimentally produced were those separated from septic 
 matter by Panum and described by him as sepsins. At first they were 
 supposed to be substances corresponding to the poisonous vegetable 
 
30 MANUAL OF MEDICINE 
 
 alkaloids, but now they are known to be derived from much more 
 energetic non- crystalline proteid poisons, which on oxidation into 
 alkaloids, lose much of their virulence. These toxins are probably 
 enzymes or ferinents^ separated from the organisms producing them, 
 which, combined with such molecules as globulins, nucleo- albumins, 
 peptones and albumoses, may have very varied characters. The ultimate 
 chemical constitution of these toxins is not yet known. 
 
 These amorphous toxic products or proteid poisons may be grouped 
 as follows — {a) Those substances which may be looked upon as the 
 direct result of the katabolic processes of the micro-organisms, their 
 secretions or rather their excreted waste-products. {b) Those sub- 
 stances, also secreted but still remaining enclosed in the protoplasm, 
 which are built up at the expense of outside materials, and are set free 
 only in very old cultures, or when the bacteria are treated with a very 
 strong alkali or begin to undergo degenerative changes. They may be 
 formed from non-proteid materials, but this is not usually the case. 
 Unlike the enzymes and specific toxins which form the first group, they 
 are extremely resistant to the action of heat, and may even be boiled 
 without their specific properties being altered. When dissolved in 
 alkalis they still retain many of their original properties. When dead 
 bacilli, e.g. tubercle bacilli, are introduced into the body the substance 
 locked up in them, when set free, may give rise to the characteristic 
 local degenerative changes. They then attract leucocytes by their cheniio- 
 iactic power, and, secondly, through the poisons they contain, bring 
 about degenerative changes and death, not only of the tissues in which 
 they are deposited, but also of the leucocytes that are attracted towards 
 them, (c) In addition to these, however, certain substances are the direct 
 result of the re-arrangement of the molecules of the nutrient medium in 
 which the organism is growing, this being usually brought about by the 
 forcible abstraction of certain atoms of the molecule by the micro- 
 organism, {d) Moreover, the action of what is known as the saprophytic 
 function of the organism upon the medium itself, as originally con- 
 stituted, or upon the medium as altered by the micro-organism, may 
 also give rise to certain bye-products. It is evident then that the 
 substances resulting from the action of micro-organisms upon a nutrient 
 medium are not only complex in themselves, but are the result of a 
 series of complex processes which it is often exceedingly difficult to 
 analyse. 
 
 Many of the pathogenetic organisms act under ver}^ special con- 
 ditions and upon very complex proteid substances. The results vary 
 greatly, but disintegration of these proteids is never carried so far as 
 in the ordinary processes of decomposition of dead organic matter, 
 animal or vegetable. Consequently substances are formed character- 
 istic of the earlier stages of breaking down, viz. enzymes (ferments), 
 toxins and tox-albumens (proteid poisons), albumoses (partly digested 
 
THE INFECTIONS 31 
 
 albumen), -ptofnaines (alkaloidal poisons), and similar substances rather 
 than the simpler nitrogenous or carbon -holding substances of more 
 advanced disintegration — water, carbon-dioxide, ammonia, nitrates, and 
 nitrites, etc. In disease processes we have the results of the action of 
 the products of the earlier stages of decomposition of proteid matter, at 
 which exceedingly complex substances are fomied, rather than of the 
 later stages, where decomposition is more fully carried out. By a 
 process of hydrolysis anthrax and diphtheria bacilli and their pro- 
 ducts convert crude albuminous material into substances nearly allied 
 to albumoses. Hankin and Cartwright Wood maintain that these 
 albumoses, when injected into an animal, exert a protective action each 
 against the specific disease with which it is associated. The enzymes 
 or ferments which appear to precede or to be formed along with the 
 albumoses have in most instances a much greater lethal activity, but 
 they appear to exert a comparatively slight protective effect, although 
 when injected sufficiently carefully they give rise to modifications in the 
 protoplasm of the cells, which are thus rendered more resistant to the 
 action of toxins. The albumoses appear to have a similar power of 
 bringing about a modification of the cell, which enables it to resist the 
 attacks of the toxin without at the same time exerting the powerful 
 toxic influence which the enzymes exhibit. This production of albumoses 
 or some similar substance in disease is therefore of vital importance in 
 the production of immunity. A number of enzymes which in many 
 respects resemble the toxins formed by disease-producing organisms 
 have been described — amylase, invertin ; enzymes which split up 
 glucosides, cellulose, urea, and fat ; enzymes which have the power of 
 peptonising albuminous substances and converting them into peptones, 
 albumoses, and similar proteid derivatives ; chromogenetic enzymes 
 which have the power of producing colouring matter, etc. These 
 enzymes may remain and do their work in the cell, hydrolising the cell 
 substance, or they may become separable functions and do their work 
 outside the cell. It has been argued that the so-called anti-toxin present 
 in the blood serum of a patient recovering from an attack of diphtheria 
 or tetanus is simply the accumulation of such a "separated or separ- 
 able function " which can act on the toxin outside instead of within the 
 cell. Upon this the theory of the anti-toxic treatment of these diseases, 
 e.g. tetanus and diphtheria, may be said to depend. The toxins are 
 exceedingly complex substances, and although they are frequently spoken 
 of as being specific poisons, it must be remembered that they are prob- 
 ably combinations of non-specific substances with perhaps a single specific 
 poison (enzyme ^/z/'j globulin, etc.). In diphtheria and tetanus toxins, 
 for example, there are certain common substances by the actioB of which 
 fever, general symptoms, or local swelling may "be -set up, but in 
 addition to these there is in tetanus toxin a specific substance which 
 exerts a selective action on certain ner\'e cells, inducing the specia 
 
32 MANUAL OF MEDICINE 
 
 and characteristic symptoms by which tetanus may be distinguished 
 from almost any other disease. In diphtheria toxin too, along with the 
 substances that produce general effects, are those which pick out 
 portions of the nervous system, and, combining with these, or acting upon 
 them, give rise to the paralytic symptoms so often developed during or 
 after an attack of diphtheria. Now it is evident that in the treatment 
 of disease by anti-toxins it is necessary not only to antagonise the 
 specific but also the general actions of these poisons. It is possible to 
 imagine that substances which only exert a specific effect may be pro- 
 duced along with others which attack the general poisons. The specific 
 action is, however, always the more difficult to obtain. It is possible 
 that by the use of a " general " anti-toxic substance a patient might be 
 helped to tide over the effects of the action of the specific toxic sub- 
 stance ; and the possibility must be recognised that an anti-toxin for 
 diphtheria, for example, might be of such a character that it would 
 enable the patient to recover, still leaving unaffected the specific action 
 on the nervous system. This, however, is not probable. 
 
 It is of course necessary to have this specific " function " as highly 
 developed as possible in all anti-toxins. This can best be effected 
 apparently by first treating the anti- toxin -bearing animal with the 
 albumoses and secondly with the toxins. In the complex tox-albumoses, 
 tox-globulines and tox-peptones it is difficult to make out the exact 
 position of the enzyme-like toxin which has been obtained by Martin, 
 Brieger, Cohn, and others ; but there is undoubtedly a substance (not a 
 proteid) which has most of the characteristics of an enzyme (is very 
 susceptible to the action of heat, etc.), except that it has a much more 
 limited action than has an ordinary enzyme, not going on working con- 
 tinuously and hydrolising almost indefinitely. It is produced only by 
 specific micro-organisms, and appears to have the power of acting upon 
 certain forms of albumens and of producing tox-albumens or proteid 
 toxins. 
 
 Serum, diagnosis. — In addition to the anti-toxic substances present 
 in the blood of immune animals there appears to be one which exerts a 
 peculiar action on the specific microbes associated with the disease for 
 which the immunity has been obtained. This has the power of causing 
 some change in the bacteria, as a result of which they become less 
 motile, and run together to form little clumps. This has been termed 
 an agglo7}i€rati7ig or aggliitinatiftg substance^ and was first pointed out 
 in 1889 by Charrin and Roger in connection with the serum from 
 animals immunised against the bacillus pyocyaneus. It was again 
 observed by Metschnikoff in 1891 in connection with the vibrio 
 Metschnikovii ; this organism losing its motility and becoming agglutin- 
 ated into little masses in the presence of serum from animals made 
 immune to the action of the vibrio Metschnikovii. Three years later 
 Pfeiffer pointed out that bacteria introduced into the peritoneal cavity of 
 
THE INFECTIONS 33 
 
 ■ immune animals became degenerate and less active, but he insisted that 
 this took place only in the peritoneal cavity. In 1895 Bordet and Max 
 Gruber demonstrated that the same change took place outside the body, 
 and in 1896 Durham extended these observations very considerably. 
 Widal was the first observer to publish records of cases in which it was 
 obser>-ed that the agglutinating substances are present in the blood at 
 a very early stage of an attack of the disease. The important point, as 
 first indicated by Gruber, is that as this substance is produced at a very 
 early stage of the disease, the method might be utilised as an early 
 diagnostic method. In the case of typhoid fever, which may be taken 
 as a typical example, it is found that in a certain proportion of cases a 
 dilution of the patient's serum with nine parts of normal saline solution 
 invariably gives the typhoid reaction, i.e. actively growing typhoid bacilli 
 become inert, are massed in clumps, sometimes in as short a period as 
 five minutes, though where the amount of agglutinating substance is 
 small complete agglutination may not occur until the end of the second 
 hour, though usually it is seen within the first. Normal serum, i.e. 
 serum from patients who have never suffered from typhoid, diluted to 
 this extent may also give the reaction with the typhoid bacillus. A more 
 or less perfect reaction is obtained with this dilution (i : 10) of typhoid 
 serum with the bacillus enteriditis. With the bacillus coli no reaction 
 is obtained. With more dilute solutions of the serum, i to 30, healthy 
 blood gives no reaction ; the enteriditis blood may give some reaction, 
 whilst the typhoid reaction is usually obtainable. It is thus evident 
 that these substances have a distinctly specific action, and if the solu- 
 tions are dilute enough the test is very reliable. This serum diagnosis 
 may be applied to other diseases, but it has found its greatest practical 
 application in typhoid fever. 
 
 Resistance of the Tissues 
 
 In considering the infections it is necessary to take into considera- 
 tion two distinct elements : (i) the attacking agency, the micro-organism 
 with its poisons ; (2) the mechanism of defence with which every living 
 tissue is provided, by means of which the invasion of the attacking 
 organisms may be repelled. When infection takes place the attacking 
 powers must be strong or the resisting agencies weak, and as one or 
 other of these preponderates so are the organisms killed and infection 
 prevented, or the parasitic organisms prevail, and make good their 
 position in the body. Every surface and cavity of the body is covered 
 with or lined by well-developed epithelial cells, which have the power 
 when in health of resisting the attack of most micro-organisms. It 
 is only when these epitkelial surfaces become impaired, and their 
 vitality lowered by the action of irritant material or removed altogether 
 by abrasion, that micro-organisms have any chance of getting beyond the 
 VOL. I D 
 
34 MANUAL OF MEDICINE 
 
 surface. Of course in partially closed cavities, where enormous numbers 
 of micro-organisms can accumulate and give rise to their specific pro- 
 ducts, the epithelium may in time become so devitalised by the attacks 
 of the accumulated poisonous products that it can no longer resist the 
 advance of the organisms. 
 
 Within the tissues themselves it further appears that there exists a 
 series of natural protective agencies which play a very important role in 
 the prevention of infection. For example, the blood plasma (Von Foder) 
 and the blood serum (Nuttall) exert a distinct inicrobicidal or bactericidal 
 action upon germs, this action varying apparently with the state of 
 health or special preparation of the individual. 
 
 Then again there is the phagocytic or devouring action of cells, 
 which, at first supposed to be specific, is now coming to be looked upon 
 as a general destroying and scavenging agency. Phagocytic cells go 
 about the body taking up dead or weakened cells and digesting them 
 after withdrawing them from the circulation. Bacteria, foreign particles, 
 pigment and the like, are also taken up by them and carried from point 
 to point or deposited in places where they can do but little damage. 
 These cells are constantly traversing the blood vessels (in increased 
 numbers in leucocytosis) and lymph channels ; they constitute an im- 
 portant protective agency, as it is held that, in addition to the phago- 
 cytic action, there exists a distinct bactericidal substance in the oxyphile 
 granules so numerous in certain forms of leucocyte ; and certainly the 
 greater the need for them the more do they put themselves in evidence. 
 It is perhaps for this reason that we associate them so directly with 
 processes of disease. When pathogenetic organisms — irritating foreign 
 bodies — have made their way into the tissues, attracted there by organ- 
 isms or their products of action and interaction upon the fluids and 
 tissues (chemiotaxis), phagocytes immediately engage the advancing 
 organisms. At those points where there is a constant danger of in- 
 vasion, as at the top of the throat (tonsils) and in the lower part of the 
 intestine (Beyer's patches and solitary glands), accumulations of these 
 cells are met with, which may be looked upon as normal phagocytic 
 structures. In the lymphatic glands in the axilla and groin are similar 
 masses of active cells, which have the power of devouring any foreign 
 particles. When these phagocytic cells are badly nourished or over- 
 worked they are no longer able to cope with the invading disease 
 germs as they are when active and well nourished and with every 
 opportunity of getting rid of their effete products. Nourishment, rest, 
 and the removal of effete products have the same influence upon the 
 condition of the individual cells of the body that they have upon the 
 body as a whole ; such cells require not only exercise, but food and 
 rest, just as surely as do our brains and muscles, and unless they obtain 
 them, and other favourable conditions are maintained, they cannot 
 perform either their scavenging or protective functions properly, and 
 
THE INFECTIONS 35 
 
 they and the individual are laid open to the attacks of pathogenetic 
 germs. 
 
 In recent years so much attention has been directed to the connec- 
 tive tissue protective agencies that there may have been some danger of 
 the importance oi the part that various functionally active organs play 
 ill the preventio7t of disease being overlooked ; but remembering the 
 share that the suprarenal body and the thyroid gland, with their secre- 
 tions, the spleen, the liver, the kidney, the intestine, and the bone marrow, 
 take in the formation of blood, in the elimination of waste products, and 
 in similar operations, one cannot but be struck by the fact that, should 
 any of these have their vitality lowered or their activity impaired, they 
 must necessarily leave the body more open to attack than when they are 
 performing their functions properly. It is therefore necessary to insist 
 not only upon the activity of the disease-producing germs as a causal 
 agent, but also upon the weakness of the tissues, or the functional dis- 
 turbances of the various organs as powerful predisposing causes. The 
 part that the liver plays in protecting the body not only against ingested 
 poisonous substances, but also against certain of the products of diges- 
 tion formed in the stomach and alimentary canal (autogenetic poisons), 
 may be instanced as an example. This organ acts as a kind of storehouse 
 not only for food materials but also for toxic substances, retaining them in 
 bulk as it were, and allowing them to pass into the general circulation 
 only in such amount as may easily be eliminated without much damage 
 being done to the organism as a whole. Again, bile has a very marked 
 effect in destroying or neutralising the activity of certain poisons, e.g. 
 snake venom, and the state of the bile secretion probably has a distinct 
 influence on the destruction both of poisons and micro-organisms that 
 may be found in the intestines. The secretions of the stomach and the 
 intestines, and even those of the salivary- glands exert a germicidal 
 effect on bacteria, so that any alteration brought about in them may 
 readily be a predisposing factor in the production of infective disease. 
 Not only the micro-organisms, then, but also their power of producing 
 poisons, the condition, general health of the patient and his tissues, and 
 the character, normal or abnormal, of the secretions and their power of 
 destroying toxins or the toxin -producing organisms themselves, must 
 all be considered as playing a part in the production of this class of 
 disease. 
 
 Immunity. — It has been obsen-ed in connection with the incidence 
 of the infections that some individuals are decidedly less susceptible to the 
 attacks of certain of them than are others. It has also been noted that 
 certain races resist the attacks of one disease, but are more liable to the 
 attacks of others. For example, it is said that although a negro of West 
 Africa is comparatively immune to the action of the malaria materies inorbi, 
 he may be very susceptible to the action of the tubercle bacillus ; whilst 
 the Indian, though somewhat less susceptible to typhoid than the Anglo- 
 
36 MANUAL OF MEDICINE 
 
 Saxon, is much more readily attacked by bubonic plague. Numerous 
 other examples of racial immunity and susceptibility might be given — 
 as, for instance, the extreme susceptibility of the North American Indian 
 to measles and smallpox. As the conditions are not absolutely sharply 
 defined, and as other factors connected with artificial immunity here 
 come into play, it is perhaps well not to insist too strongly upon this 
 special form of insusceptibility. A single attack of certain diseases 
 induces a most marked protection against future attacks, and now that 
 it is possible, by experiment on animals, to produce by the injection of 
 micro-organisms or their products the important and characteristic 
 symptoms of many of these specific infective diseases, we can gatl er 
 and arrange numerous observations on this point, and draw certain 
 deductions from them. 
 
 It may be well to point out that there is no such thing as absolute 
 immunity, and that the term is used entirely in a relative sense, as 
 indicating a greater or less degree of insusceptibility to the attacks of 
 certain diseases. The hen, for example, is naturally immune or in- 
 susceptible to the attack of the anthrax bacillus, though, when the 
 temperature of the fowl is lowered, it may lose much of this insuscepti- 
 bility. An acquired immunity is really an insusceptibility induced 
 through the production of antitoxin, through the strengthening of the 
 tissues and their cells, or through a specific modification of the cells, as 
 a result of which they are enabled to carry on their work in the presence 
 of parasitic bacteria and their poisons. 
 
 It will be well to take as an example a specific disease for the pur- 
 pose of illustrating the action of micro-organisms in the production of 
 disease, local and general, and t-o show how, in the course of such a 
 disease, there is a development of certain qualities and substances in the 
 tissues and in the blood, by means of which the patient is protected 
 against future attacks for longer or shorter periods. 
 
 If small fragments of the fresh membrane removed from the fauces 
 of a patient sufifering from diphtheria be teased out on a slide, and then 
 pressed out with a cover-glass, and the resulting preparations stained, 
 one in methylene blue and another by Gram's method, there may usually 
 be found in them, on microscopic examination, a number of slightly 
 curved or pointed rod-shaped bacilli, which, in the methylene blue pre- 
 paration, have transverse markings of light and dark bands. Along with 
 these rods, diphtheria bacilli, which are sometimes clubbed at the ends, 
 and occur singly or in small irregular groups, and are the active specific 
 agents in the production of local and constitutional symptoms of diphtheria, 
 there may also be found a number of rounded or ovoid organisms arranged 
 in clumps or chains, these being seen in greater numbers in the methy- 
 lene blue than in the Gram-stained specimen. The diphtheria bacillus 
 carried, directly or indirectly, from some other patient to the mucous 
 membrane of the uvula and tonsils^ especially when these are ulcerated 
 
THE INFECTIONS 37 
 
 or inflamed, produces in the albuminous exudation in and on which it 
 lives and feeds, a series of substances, some of which appear to exert a 
 distinct local necrotic effect ; others again produce rise of temperature, 
 etc. That this is not a fanciful description may be proved by direct 
 experiment, as pure cultures of the diphtheria bacillus, grown in peptone 
 broth, with or without crude albumen, are found to contain all these 
 various substances, even after the bacilli have been removed by means 
 of careful filtration. In the majority of cases the diphtheria baciUi are 
 confined strictly to the lesion in the throat, where, however, they form 
 their toxins in such large quantities that, as they are absorbed, the 
 patient exhibits the constitutional symptoms characteristic of diphtheria. 
 
 How far-reaching and profound is the action of this toxin may be 
 gathered from the fact that as it is excreted by the kidney it gives rise 
 to cloudy swelling of the epithelium lining the convoluted tubules of that 
 organ. It sets up similar changes in the parenchymatous cells of the 
 liver. In the wall of the heart, especially during the later stages of the 
 disease, the muscle fibres are found to be undergoing a fatty degenerative 
 change, in form similar to that following on cloudy swelling, whilst some 
 of the voluntary nerves and muscles, especially those of delicate structure 
 and that are constantly in use, are undergoing similar changes. In the 
 local lesion it is found that the false membrane usually consists of the 
 epithelial cells of the part embedded in fibrinous lymph, with diphtheria 
 bacilli on and near the surface. The cells undergo a rapid degenerative 
 change kno\\"n as " coagulation necrosis," this often at some little 
 distance from the diphtheria bacilli on the surface of the false membrane. 
 
 In very acute cases terminating fatally, this localisation of the 
 diphtheria bacillus may not be maintained ; the toxin breaks down 
 the powers of resistance of the tissues by which the bacillus is kept 
 in check, causing such degeneration of the comparatively resistant 
 cells forming the wall of the minute blood vessels that the blood is 
 allowed to escape from its proper bounds into the surrounding tissues, 
 thus giving rise to what is known as " hsemorrhagic " diphtheria, or 
 diphtheria in which haemorrhages into the skin and mucous membranes 
 constitute a characteristic feature. If, however, recover)^ is rapid and 
 the diphtheria bacilli disappear from the throat, the patient usually 
 possesses a certain degree of immunity against a second attack, though 
 such immune condition is of but short duration. During the attack of 
 the disease certain changes have taken place in the tissues, and substances 
 have been produced and have accumulated in the fluids of the body by 
 means of which the action of the toxin produced by the diphtheria 
 bacillus is neutralised. That this protection is the result of the action 
 of substances produced by the diphtheria bacillus upon the tissues of the 
 body we have evidence in the fact that if small quantities of a filtered 
 broth culture of the diphtheria bacillus, or, still better, a culture growm 
 in serum peptone broth, be injected at first in small quantities and then 
 
38 MANUAL OF MEDICINE 
 
 in gradually increasing doses under the skin of a sheep, rabbit, or horse, 
 care being taken to produce a local swelling and a rise in temperature 
 as the result of each injection, and to make the next injection before the 
 effects of the last has passed off, two things will occur : (i) the tissues of 
 the animal react less and less each time to the same dose or even to 
 increased doses of the toxin ; and (2) the blood of the injected animal 
 or the serum separated from it is found to have acquired the property of 
 neutralising the action of the diphtheria toxin when mixed with that 
 substance before it is injected into the subcutaneous tissues of an 
 experimental animal. It appears that this substance, so long as it 
 remains in the body, has the power of protecting an animal against the 
 action of the diphthejia toxin ; it is an anti-toxin. More than this, 
 however, it has the power, when mixed with the toxin in a test-tube, of 
 completely neutralising the action of this toxin and of rendering it inert 
 when injected into the body — at any rate so far as its lethal and other 
 obvious noxious properties are concerned. The substance contained in 
 the blood has at present not been obtained as a chemically pure sub- 
 stance, but it is evidently a material of very great potency. Its properties 
 have only been studied by their effects in neutralising toxin — hence the 
 name " anti-toxin." The serum in which it is contained is known as 
 anti-toxic serum. Further, by the introduction of small quantities of this 
 anti-toxic serum, animals may be rendered temporarily insusceptible to 
 the action of the diphtheria poison. They are in fact protected against 
 the disease, and are said to have acquired a degree of ^'■passive" 
 iin/iiunily. This passive (or hematogenic) immunity is entirely the 
 result of the presence of an anti-toxic substance, which has been pro- 
 duced in another animal, circulating in the fluids of the body of the 
 new host. It at once seizes upon and neutrahses any toxin that may 
 be absorbed from without, which thus never remains uncombined or 
 free to exert its specific action upon the cells of the body, especially 
 those of the nervous system. As soon, however, as the anti-toxin has 
 been neutralised by a sufficient amount of toxin or has been excreted 
 from the body by the various emunctory channels, the animal or patient 
 is no longer protected. This "passive" (Ehrlich) or "anti-toxic" 
 (Behring) immunity may therefore be characterised as of a purely 
 temporary character, unless the serum injected be derived from an 
 animal of the same species as that which is being treated, when, accord- 
 ing to Ransom, the immunity is more prolonged. 
 
 It is possible, however, to produce in an animal or in a human being 
 an immunity of a much higher order and of a more enduring character. 
 It has already been pointed out that doses of toxin gradually increasing 
 in quantity may be administered to an animal, until enormous doses may 
 be given without producing any very serious effect. . Let a standard 
 lethal dose of diphtheria toxin for a horse be taken as being represented 
 by I c.c. of toxin. One of these animals, by first receiving injections of 
 
THE INFECTIONS 39 
 
 smaller quantities than i c.c, and then of increasingly large doses, 
 may in the course of a comparatively short time be brought to withstand 
 the action not only of i c.c. of the toxin but of as much as 500 or 
 1000 times that quantity. It is found, moreover, that this high degree 
 of immunity may be maintained for a considerable period. Such 
 immunity is spoken of as being '■'■active" (Ehrlich) or '■' isopathic" 
 (Behring), and the reason for this appears to be that it is due not 
 merely to the presence of anti-toxic substances already present in the 
 body, but to the fact that owing to the continued action of large 
 quantities of toxin upon the tissue cells, these cells have, as the result 
 of a special stimulation, acquired the power of producing, even under 
 ordinar)' non-specific stimulation, a considerable amount of anti-toxin, 
 so that as that which is in the circulation is neutralised or excreted, 
 fresh supplies are constantly poured in from the cells that have acquired 
 the habit of producing anti-toxin (histogenous immunity). Let us apply 
 what has been proved in the case of diphtheria to the other febrile 
 diseases, to smallpox, scarlet fever, and similar conditions in which an 
 immunity is produced by one attack of the disease, and we have a good 
 working theory' as to the causation of disease or of certain of the symp- 
 toms and pathological conditions occurring during the course of such 
 disease, and an explanation, as yet more or less imperfect, of the method 
 of production of the resulting immunity. In vaccination as a protection 
 against smallpox, "vaccine" or the fluid from (n^it'^isa' vesicles is used 
 as the immunising substance instead of the more virulent smallpox 
 virus. When the living smallpox virus or other virus is introduced or 
 injected under the skin, the disease is said to be inoculated. 
 
 As already pointed out, in some acute infections a certain degree of 
 protection against any further attacks may be conferred by the first. 
 In typhoid and scarlet fevers, measles and smallpox, the insuscepti- 
 bility may remain with the patient for a considerable period. On the 
 other hand, in such conditions as influenza, a first attack appears to 
 confer little if any immunity ; indeed it appears to be the general 
 experience that the first attack predisposes to a subsequent one, whilst 
 in the case of a number of other diseases, of which diphtheria may be 
 taken as an example, any degree of protection that is usually conferred 
 is very transient. 
 
 Predisposition 
 
 It may be stated generally that the more powerfully parasitic a 
 micro-organism is, and the more luxuriantly it flourishes in the animal 
 body, the less are any predisposing causes required to bring about 
 infection, but the more rapidly should it be possible to cope with an 
 outbreak of the disease, especially if the disease runs a comparativelv 
 rapid course. When the course of a disease is more prolonged, as, for 
 
40 MANUAL OF MEDICINE 
 
 example, in the case of tuberculosis, the infective material is thrown off 
 in considerable quantities over this prolonged period, and the danger of 
 infection is of course increased. Where a disease-producing organism 
 is more saprophytic in character the danger of infection becomes much 
 greater, especially in those localities in which the disease is endemic ; in 
 such a case, however, it will be found that the importance of the ques- 
 tion of predisposition becomes enormously increased, and it may fairly 
 be said that if it were possible for residents to maintain a condition of 
 perfect health apart from the endemic disease, that this latter would 
 have very little power of attacking them. It may be said of almost 
 all infective diseases, however, that they have little or no chance of 
 gaining a foothold in the human body unless there be disease of some 
 kind, or weakening of the tissues, or a distinct lesion, in which the 
 organisms may find a nidus and sufficient and suitable nutriment. 
 
 It is for the physician to consider carefully what these predisposing 
 causes are, as during an epidemic he may at any time be called upon 
 to advise those under his charge as to the best means of avoiding the 
 prevailing disease. It has been pointed out by Koch, and further 
 emphasised by M'Leod, that a normal healthy guinea-pig is absolutely 
 immune to the attacks of the cholera bacillus. When, however, the 
 acid secretion is neutralised by the introduction of an alkaline fluid into 
 the stomach, and when at the same time the peristaltic action of the 
 intestine is interfered with by the exhibition of morphia, the cholera 
 organism is enabled to run the gauntlet of the stomach, and to multiply 
 in the intestine to such an extent that it can produce a sufficient 
 amount of its toxins to kill the guinea-pig with the utmost certainty. 
 Here there has been produced by artificial means a predisposing con- 
 dition, the series of natural resistances being for the time removed. 
 
 Similarly it has been found that animals kept at a low temperature 
 and on starvation diet become extremely susceptible to the action of 
 certain disease-producing germs ; whilst an atmosphere containing sewer 
 gas, or an excessive amount of carbonic-acid gas, and exhaled organic 
 matter, may also predispose to the action, say, of the typhoid germ. 
 Certain rash experimenters, confident of the good condition of their 
 digestive apparatus, have from time to time taken into their stomach 
 cholera and typhoid germs in the form of pills, and the results have been 
 negative ; but it is well known unfortunately through a very large number 
 of well-recorded cases, that these same germs when taken in water have 
 produced very definite disease. During an epidemic produced by water- 
 borne cholera or typhoid organisms, it has often been noted that only a 
 proportion of those who have consumed the infected water are affected. 
 All must have received a dose of the bacilli, but all are not attacked by 
 the disease. This difference must undoubtedly be due in part to a 
 difference in the general resisting power of the patient, though in some 
 cases it may be that a specific immunity has been conferred, sometimes 
 
THE INFECTIONS 41 
 
 by an attack of the disease, and sometimes imperceptibly through a 
 long-continued exposure to gradually increasing doses of the toxin or 
 specific organic substances. I have obtained direct evidence, for 
 example, that the acid gastric juice exerts a most maiked effect in 
 diminishing the activity of the tubercle bacillus and of the cholera 
 bacillus. It has been noted by Metschnikoff that during an epidemic 
 of cholera large numbers of the specific bacilli have been found in the 
 intestines of healthy individuals, and it may be accepted as the outcome 
 of Hueppe and Cartwright Wood's observations that until there is some 
 inflammation of the walls of the intestine, accompanied by the pouring 
 out of an albuminous fluid, such as is contained in serous exudation, no 
 marked multiplication of the cholera organisms and no appreciable 
 quantity of specific toxin is produced in the intestine. 
 
 All the early experiments with the products of micro-organisms were 
 carried out for the purpose of obtaining substances which would act as 
 prophylactics — which would prevent disease ; and vaccination and in- 
 oculations for the production of other immunities were all directed to 
 such prevention. Pasteur's treatment for hydrophobia, however, went 
 far beyond this, and his inoculations were distinctly curative in their 
 action, in so far as the treatment was not begun until the disease had 
 been inoculated by a bite. In the case of the antitoxic sera, however, 
 a still further advance was made ; the diphtheria antitoxic serum, for 
 example, being given for the purpose of neutralising diphtheria toxin 
 and of curing the disease in so far that no further damage is done to 
 the tissues. Such serum is secondarily a prophylactic, but up to the 
 present its main use has been the cutting short of active disease. 
 
 General Course and Characters of the Infective Diseases 
 
 Proceeding to consider the method of production of the specific 
 infective fevers, it may be well to note what takes place when a single 
 germ of yeast, say, is introduced into any fluid which contains the 
 materials necessary for its nutrition. If a suitable temperature be 
 maintained, and no antiseptics are present along with the necessary 
 nutrient substances in the fluid, the germ begins to grow and multiply 
 with great rapidity. It uses up nitrogenous and saccharine matter, the 
 fluid becomes turbid, and alcohol, carbonic-acid gas, and a number of 
 other substances are produced. Other organisms placed under similar 
 conditions produce colouring" matter, others aromatic or exceedingly 
 foul-smelling gases ; others again give rise to the production of enzymes 
 or ferments and peptonising substances. A single organism being in 
 most instances sufficient to start a growth very soon makes itself mani- 
 fest, both by its own presence in large numbers and by the character 
 of its products. Exactly the same sequence of events takes place in 
 the human body when disease germs gain access to its tissues. Such 
 
42 MANUAL OF MEDICINE 
 
 germs, to maintain their position, must be endowed with a certain power 
 of maintaining a parasitic existence. Unlike saprophytic organisms, 
 which, ahhough they may have the power of producing active poisons, 
 are unable to exist in the fluids and tissues of the body, they have the 
 power, especially when the tissues are taken at any disadvantage, of 
 multiplying and of producing their products — sometimes in large 
 quantities — and acute specific fevers, which run a very definite course, 
 are the result. Each fever has its course divided into a series of stages, 
 each one associated with some phase in the action and reaction between 
 the invading micro-organisms and the tissues of the invaded organism. 
 
 Between the time at which a patient is exposed to a definite infection 
 and the period at which the disease manifests itself {stage of invasion) 
 there is a period known as the incubation period. Following this comes 
 Xhe. period of ^'' fever" then a period of lysis in some cases, of crisis in 
 others — i.e. gradual or rapid diminution of the fever {defervescence), and, 
 lastly, a period of convalescence. These periods may be said to cor- 
 respond generally to the phases through which a fermenting or fermented 
 fluid passes. When the single grain of yeast is added, little or no 
 change may be observed for some considerable time, so in the case of 
 the specific infective fever there may be no marked evidence of any 
 kind that a pathogenetic germ has been able to make good its position 
 in the tissues of the patient, although in both instances the organisms 
 are multiplying rapidly, and may be producing their products in con- 
 siderable quantities. This is the period of incubation. It is only 
 after these products begin to exert their gross specific effect on the 
 tissues that any symptoms by which a diagnosis can be made appear. 
 The effects produced vary, of course, with the character of the organism, 
 the rapidity of its growth : these determining within certain limits the 
 length of the period of incubation ; the habitat and nature of the poison 
 determining the character of the symptoms. Thus in scarlet fever the 
 organism apparently affects specially the tonsils and pharynx, the skin 
 and the kidneys, perhaps because the organisms invade the patient by 
 the channels in the former parts, and because of the efforts made by 
 the skin and kidneys to excrete the poison. In the case of typhoid 
 fever the micro-organisms appear to affect the lymphoid tissue of the 
 alimentary tract, especially in the lower part of the intestine ; the spleen 
 is also a seat of election in this condition, whilst the skin is only slightly 
 affected. 
 
 As would be expected, the initial dose of the poison may exert some 
 influence in determining the length of the incubation period. It only a 
 small amount of the poison be introduced, and this holds good, especially 
 in the case of such a disease as scarlet fever, the period of incubation may 
 be prolonged ; while, on the other hand, if a very large dose be absorbed, 
 the period of incubation may be very short. This is due not entirely to the 
 mere number of organisms introduced affecting the period through which 
 
THE INFECTIONS 43 
 
 multiplication must take place to bring the number up to a certain point ; 
 the large number introduced, perhaps, along with a certain proportion 
 of their products, act upon the tissues, and render them less resistant, so 
 that the organisms that have found an entrance are enabled to multiply 
 much more rapidly than when the tissues are not so prepared. Of 
 course dififerent organisms multiply and produce symptoms at very 
 dilTerent rates. For this reason, and because they form their products 
 in different positions, and in varying quantities, marked differences are 
 observed in the lengths of the incubation periods of different diseases, 
 e.g. diphtheria as compared with tuberculosis. 
 
 In the really characteristic stages of a disease the symptoms are, as 
 a rule, the result of the changes induced by the action of micro-organisms 
 on the tissues, and of the tissues on the micro-organisms. For instance, 
 rigors, fever, or an apyretic condition, rapid pulse, increased rate of 
 respiration, conjunctival suffusion, dilatation of the pupil, vomiting, 
 headache, muscular pains, and other ner\-ous symptoms, are attributable 
 to the action of certain of the poisons produced by micro-organisms 
 upon the thermogenic, respiratory, vaso-motor, pneumogastric, and other 
 nerve centres. The swelling of glands, pharyngitis, albuminuria, and 
 the cutaneous rashes occurring in certain exanthematous diseases, on 
 the other hand, are due to the reaction of the cells in the glands, 
 kidney, and skin, to certain others of the poisons as they are being 
 excreted. Proliferation and increased vascularity and joint pains result 
 from stimulation of the cells, ner\es, and walls of the blood vessels by 
 the toxin, whilst, in such a condition as typhoid fever, the increase of 
 the lymphoid tissue in the enlarged lymphatic glands indicates a similar 
 process of reaction to the specific stimulation of the typhoid poison. 
 
 It is to this specific reaction, during the course of the febrile stage, 
 that the patient owes his chance of recovery. WTien septic organisms 
 or the anthrax bacillus are introduced, if no marked tissue reaction is 
 set up, the patient, whether brute or human, usually succumbs very rapidly 
 to septic or anthrax poisoning ; but when local reaction, in the form of 
 swelling, redness, and oedema is marked, and especially where infiltration 
 with leucocytes occurs, the patient usually stands a fair chance of recovery. 
 It seems to be a general law that animal cells, when repeatedly sub- 
 jected to a not too powerful specific stimulation, have the power, first, of 
 becoming so accustomed to this special stimulation when gradually applied, 
 that they may in time become capable of carrying on their special functions, 
 even in the presence of larger and larger quantities of the stimulating 
 substances ; and, second, of producing substances which, separable from 
 the cells, are capable of directly neutralising the action of the special 
 stimulant, i.e. a function of the cell which, under ordinary' conditions, 
 remains in abeyance, or develops only in a very slight degree, becomes 
 developed to such an extent that it overflows, as it were, from th*^. cells, 
 and takes upon itself the special function of so neutralising the toxin that 
 
44 MANUAL OF MEDICINE 
 
 the cell itself is enabled to carry on its functions without being in any 
 way hampered by the presence of the toxin. Every evidence of local 
 reaction, then, whether redness or local swelling, affords an indication 
 that this process of " acclimatisation " and anti-toxin production are going 
 on, and it is only as the cell becomes acclimatised to the presence of the 
 toxin and of the micro-organisms, or, as the anti-toxin is developed in 
 sufificient quantities to neutralise the toxin already formed, or being 
 formed, that the patient recovers, or is protected against future attacks 
 of the disease. 
 
 In typhoid fever, where there is a gradual increase in the severity of 
 the disease, there is also, when the patient recovers, a gradual diminution 
 in the severity of the disease symptoms, this taking place during the 
 period of " lysis." During the rise of the fever there is a gradual increase 
 in the amount of toxin present, even though the production of anti-toxin 
 and the process of accHmatisation of the cells may commence at a very 
 early stage of the disease. After a certain period the ratio between the 
 formation of toxin and the production of anti-toxin is gradually altered, 
 and during the period of lysis the relative amount of anti-toxin to toxin 
 rises, until ultimately the whole of the toxin is neutralised, and the period 
 of convalescence is then entered upon — the period during which the 
 gradual repair of the damage done to the tissues is commenced. Anti- 
 toxin can neutralise the poison, but it cannot undo the damage already 
 sustained by the tissues — a damage which can only be made good by 
 the reparative action of the tissues themselves. In the case of pneumonia 
 the disease runs its course much more rapidly. The period of invasion 
 and that of fever are both comparatively short ; the production of anti- 
 toxin appears to go on very quickly, and recovery is very speedy, by a 
 " crisis " in which there is rapid inversion of the balance between the 
 toxins and the anti-toxins. 
 
 It will thus be evident that in ordinary septicaemias — blood 
 poisonings — bacteria make their way from point to point, carried by 
 the blood through the blood vessels, and the symptoms and lesions are 
 essentially those that one would expect to occur under such conditions. 
 The so-called tissue parasites, on the other hand, appear to be unable 
 to exist in the blood stream itself and only when they come to rest in 
 the tissues. In such a condition as typhoid fever, which may be taken 
 as an example, the parasitic organisms are found specially in the adenoid 
 follicles of- the intestine, in the neighbouring glands, and also in the 
 spleen, whither they appear to make their way from the intestine by 
 the lymphatics. It is probable that they are not confined entirely to 
 the lymphoid follicles, and that much more widespread tissue changes 
 are set up than are usually demonstrated. Typhoid fever, then, cannot 
 be looked upon as an ordinary septicaemia, though, under certain con- 
 ditions, the typhoid organisms may flourish in the blood ; it then becomes 
 truly septicasmic in character. 
 
THE INFECTIONS 45 
 
 The multiplication of the micro-organism, and the formation of its 
 special products, are the real elements that determine the specific 
 character of the disease ; and just as specific fermentations and special 
 colour formations occur, and special gases are formed, so specific diseases 
 may be produced in which the tissues and fluids of the patient are, for 
 the time being, converted into nutrient media, in which micro-organisms 
 can grow and produce their special products, these specific products, by 
 their action on the reacting cells and tissues, giving rise to the specific 
 symptoms. The body of the patient difters, however, in one very im- 
 portant respect from any ordinar}' nutrient medium. The organisms in 
 the artificial nutrient medium grow for a time with ver}' great rapidity, 
 and then by the production of organic acids, phenols, etc., convert this 
 medium into a fluid in which they are incapable of further development. 
 These substances, however, must be present in considerable quantities, 
 and may usually be detected by ordinary chemical examination before the 
 organisms cease to multiply. In the animal body, on the other hand, 
 such substances are not formed in any considerable quantities ; or, at any 
 rate, not in quantities sufficiently large to interfere materially with the 
 growth of the organisms. Nevertheless, the organisms no longer thrive, 
 and the toxins they produce are no longer capable of doing any harm. 
 This appears to be due to the fact that the cells have formed anti- 
 toxins which do not act directly upon the organisms, as do the products 
 of fermentation, but only upon their toxins, with the result that the 
 micro-organisms, with their poisons neutralised, are at once reduced to 
 the level of mere saprophytes ; they are disarmed and fall a prey to the 
 devouring phagocytes, which are constantly on the alert for all " foreign " 
 bodies coming within their sphere of influence. A patient thus recovers 
 from a specific infective fever, and, having suffered from one attack of a 
 specific disease, has acquired against it a marked degree of immunity, 
 which may continue for a very considerable period. 
 
 It is well to bear in mind that mixed infections are of somewhat 
 frequent occurrence. Such infections may be coincident, the organisms 
 finding their way to the tissues at the same time and helping one another 
 to produce their special effects ; for example, the tetanus organism is 
 much more to be feared in the presence of pyogenetic organisms than it 
 is when acting alone. Then again the diphtheria organism, when aided 
 by the pus-producing organisms, is capable of doing far more damage 
 than it is alone ; whilst pus-producing organisms are often enabled to 
 make their way much more readily into the deeper tissues and then to 
 set up a pyaemia, when they are aided by the diphtheria bacillus acting 
 on the mucous membrane or submucous tissue of the throat. The 
 sequelae of the infective fevers are verj' frequently the result of a 
 secondary' infection. Mixed infections, however, may occur from the 
 ver}' commencement of the disease ; the prognosis of such cases is 
 usually much more hopeless than in the case of the simple diseases. 
 
46 MANUAL OF MEDICINE 
 
 Terminations of the Infective Diseases 
 
 It is evident that the acute infective disease must run a rapid course, 
 though that of an exanthematous disease is more rapid than that of a case 
 of acute puhnonary tuberculosis, which latter condition, however, should 
 be looked upon as a chronic disease which runs a comparatively rapid 
 course. Acute diseases may have one of three terminations. If the 
 poison is rapidly excreted and if the degenerative changes brought about 
 by it are not too profound, there may be practically complete recovery. 
 Even when the patient does not succumb, a series of changes which, with- 
 out bringing about actual death, may so alter the conditions of growth, 
 secretion, and excretion through the intercurrence of such states as 
 chronic interstitial nephritis, catarrhal nephritis, chronic interstitial 
 hepatitis and similar lesions, that the health of the patient is materially 
 interfered with. The nutrition of the muscle of the heart may be so far 
 impaired, as in cases of typhoid fever, diphtheria, influenza, or the peripheral 
 nerves or the nerve centres may have been so altered by the action of the 
 poisonous products of the disease, that the patient may die suddenly 
 from heart failure when he appears to be well on the road to recovery. 
 In the third mode of termination, death may supervene during the height 
 of the fever, the patient succumbing directly to the action of the toxin on 
 the nerve centres, on the secretory glands, or on the tissues generally. 
 
 In the chronic infective disease the poison or toxin is as a rule 
 more dilute, acts for a longer period, and appears to affect the connective 
 tissues, especially those associated with excretory epithelial surfaces. 
 It may be accepted generally that the more chronic the disease the less 
 do the epithelial tissues undergo rapid degenerative changes, but the 
 more is fibrous tissue developed at those points at which the poisonous 
 products are being excreted. For example, in syphilis and tuberculosis 
 the formation of fibrous tissue with coincident or subsequent degenerative 
 changes is exceedingly well marked, and is comparable to the fibrosis 
 of lead poisoning and chronic alcoholism. In actinomycosis, where 
 less poison is formed, this tendency to fibrous tissue formation is more 
 distinctly marked, and there is far less tendency to degeneration even 
 than in tubercle. 
 
 The elimination of poisonous products from the body appears to 
 take place by much the same channels as the normal effete matters the 
 result of metabolic processes. The diarrhoea that accompanies the ex- 
 hibition of certain poisons can only be compared to that met with in 
 cholera and typhoid fever as an effort on the part of the intestines to 
 get rid of noxious material. The acute nephrites that occur during the 
 course of scarlet fever and diphtheria are examples of conditions com- 
 parable to that observed in mercury poisoning. The skin also appears 
 to play an important part in getting rid of poisonous products. Typhoid 
 bacilli may be found in the urine and in the bile, and it is probable, as 
 
THE INFECTIONS 47 
 
 pointed out by Sherrington, that not only the products of micro-organisms, 
 but even the micro-organisms themselves may pass out through " intact" 
 mucous membranes, especially in the case of the acute infections. 
 
 Post-mortem Appearances common to the Acute Infections 
 
 In almost all the febrile infective conditions, certain general post- 
 mortem appearances in the patient who has succumbed point to the 
 nature of the disease. In most cases, owing to the degenerative changes 
 that occur in the muscle before death, rigor tnortis is much less perfect 
 and passes off at a much earlier period than in patients who succumb 
 to other diseases. In many of the fevers, especially those of a specific 
 and septic character, the blood is so changed even before death that it 
 does not undergo coagulation, the capillary vessels lose their tonicity, 
 the blood flows through them readily into the dependent parts of the 
 body, and post-mortem lividity is often very marked, the heart and 
 blood vessels and even the skin being blood-stained. In the cases of 
 acute fever resulting from specific infection, the organs are usually in a 
 condition of cloudy swelling ; they are swollen, paler than normal, and 
 exhibit a ven,- characteristic parboiled appearance. The spleen is usually 
 enlarged and pulpy, especially in typhus. The liver and kidneys at the 
 later stages of the disease present, in addition to this, evidence of fatty 
 degeneration, whilst in the former organ distinct necrotic areas of the 
 parenchyma may sometimes be observed. In almost every fever fatty 
 degeneration of the heart of a more or less marked character occurs 
 sometimes during the second week of the affection, and in certain 
 diseases, such as those already mentioned — diphtheria, influenza, typhoid, 
 and also in almost all of the other infective febrile diseases — this is an 
 important clinical fact that is frequently ignored in the treatment of con- 
 valescent patients. Cardiac dilatation is an essential feature of acute 
 rheumatism, due in part to the degeneration associated with myocarditis, 
 and also, it would appear, to a specific toxic effect directly affecting the 
 muscles. The muscles usually participate in the general changes of 
 cloudy swelling and fatty degeneration ; in typhoid and more rarely in 
 other fevers, Zenker's hyaline or vitreous degeneration is also met with. 
 
 Classification 
 
 In recent text -books of medicine the classification of specific 
 infective conditions or " infections " is based not entirely upon the 
 clinical symptoms as in the older works, but partly upon the nature of 
 the etiological factor, — bacteria or their products, — though in only a 
 certain number of these infections has the actual causa causans been 
 demonstrated. 
 
 Diseases may be endetnic or epidemic. An endemic disease is one 
 
48 
 
 MANUAL OF MEDICINE 
 
 that is constantly found in a region in which the " local " conditions 
 appear to be specially favourable to the continuance of the existence of 
 the organism producing such disease. An epidemic disease is a sudden 
 outbreak, either through the conditions becoming specially favourable 
 for the existence, multiplication, and transmission of the disease-pro- 
 ducing organisms or of the introduction of these organisms from the 
 region in which the disease is already endemic. An epidemic outbreak 
 may occur in a locality in which the disease is endemic ; it is then due 
 to the development and bringing into action of special predisposing 
 causes, which do not usually exist, the epidemic character of the disease 
 depending greatly upon the facilities offered for its rapid spread amongst 
 a population specially prepared for its inroads. 
 
 The following classification of infections is founded partly upon the 
 specific nature of the organisms present, partly upon the symptoms and 
 changes that result from such actions and interactions : — 
 
 I. 
 
 Febrile Infective Diseases with which Micro-organisms 
 have been definitely associated 
 
 (A) Acute - 
 
 Local 
 
 General ■< 
 
 f Boil and Carbuncle 
 \ ^Erysipelas 
 
 Septicsemia and Pyaemia 
 Infective Endocarditis 
 *Puerperal Septic Fever 
 Gonorrhoeal Infection 
 
 *Typhoid Fever 
 
 Mediterranean Fever 
 *Cholera 
 
 Plague 
 ^Relapsing Fever 
 
 Yellow Fever 
 
 Weil's Disease 
 
 (B) Chronic 
 
 Anthrax 
 Tetanus 
 *Diphtheria 
 Epidemic Pneumonia 
 Infective Meningitis 
 Influenza 
 Glanders (Farcy) 
 
 Tuberculosis 
 
 Leprosy 
 
 Mycoses 
 
 ^ Due to Pyococci 
 
 Due to Specific 
 Organisms 
 
 * These diseases must be notified to the Medical Officer of Health of the District 
 in which the case occurs, according to the provisions of the Infectious Diseases 
 Act, 1889, Sect. 3. 
 
THE IXFECTIOXS 
 
 49 
 
 II. Febrile Infective Diseases with which Micro-organisms 
 
 HAVE NOT YET BEEN DEFINITELY ASSOCIATED 
 
 [ *Typhus 
 
 Measles 
 
 Rotheln 
 *Scarlet Fever 
 
 Acute Rheumatism 
 
 Chicken-pox 
 *Smallpox 
 
 Vaccinia (Cattle) 
 
 Mumps 
 
 Whooping Cough 
 
 Acute and Chronic 
 
 Dengue 
 Beri-Beri 
 Epidemic Dropsy 
 Oriental Sore 
 Verrugas 
 Fraraboesia 
 
 Syphilis 
 
 Rabies 
 
 Foot and Mouth Disease (Cattle) 
 
 Mixed Infections 
 
 III. Febrile Infective Diseases due to Protozoa 
 
 Dysentery 
 Malaria 
 
 Hsemoglobinuric Fever 
 Kala-azar 
 
 * These diseases must be notified to the Medical Officer of Health of the District 
 in which the case occurs, according to the pro\-isions of the Infectious Diseases Act, 
 1889, Sect. 3. 
 
 G. Sims Woodhead. 
 
 vol. I 
 
5° 
 
 MANUAL OF MEDICINE 
 
 FEVER 
 
 The word fever is employed to designate a certain assemblage of 
 symptoms. These are a rise of the internal temperature of the body 
 (pyrexia), a quickened pulse, rapid respiration, loss of appetite, malaise, 
 furred tongue, scanty, high-coloured urine, often containing a trace of 
 albumen, and, allowance being made for the diet, an excess of urea, 
 constipation, a flushed skin, sweating, headache and delirium. It is by 
 no means necessary that all these symptoms should be present in the 
 same person for us to say he has fever, and in the above list the symp- 
 toms are roughly placed in their order of frequency. Pyrexia is, how- 
 ever, constant, and a patient cannot be said to have fever unless it 
 exists. How far the other symptoms are the result of the pyrexia, or 
 the result of the cause of the pyrexia, is at present undetermined, but 
 many are certainly at times merely dependent upon the temperature, and 
 therefore the terms fever and pyrexia are occasionally loosely used as 
 though they were interchangeable ; this is inexact and to be deprecated, 
 but as pyrexia is the only constant sign of fever, and has been more 
 studied than any other sign, in describing fever it is the pyrexia to 
 which reference will chiefly be made. In this article the slight rises of 
 temperature which follow exercise and may be considered physiological 
 will not be considered. 
 
 The internal temperature of the human body may be taken in the 
 rectum, the vagina, the stream of urine as it issues from the bladder, 
 the axilla or the mouth : the two first situations give the most 
 accurate results. The mean daily rectal temperature of a healthy adult 
 is 98.96° F., that of the stream of urine is 98.56° F., that of the axilla 
 is 98.45° F., and that of the mouth is 98.36° F., and in each of these 
 cases the temperature in health may be half a degree Fahrenheit 
 below the figure given in the early morning, and half a degree above the 
 figure given in the evening between 6 and 7 P.M. It is more important 
 that the temperature should be taken carefully with an accurate thermo- 
 meter, than that any particular site for observing it should be chosen. 
 Mistakes most readily occur in the mouth from not keeping it shut, not 
 keeping the thermometer under the tongue, and not noticing whether 
 the mouth has been recently locally heated or cooled ; and in the axilla 
 from not keeping the thermometer well in position. The grom is an 
 excellent situation for taking the temperature of children. The healthy 
 temperature of different adults diff'ers slightly, but only a fraction of 
 degree, for one of the striking characteristics of the higher warm- 
 blooded animals is the uniformity of the temperature of different adult 
 individuals of th" same species. With children this power of maintain- 
 
FEVER 5 I 
 
 ing a fixed temperature is not so striking. The foetus in the early 
 months of intrauterine life is cold-blooded, and it is only gradually that 
 the individual acquires the power of so controlling the balance between 
 loss and production of heat that the temperature is constant. Therefore 
 in children slight causes, which would in an adult be inoperative, may 
 cause considerable pyrexia, perhaps without other signs of fever ; even 
 simple constipation may cause the temperature to rise to 104° F. 
 Hence it is that pyrexia is often less alarming in children than in adults. 
 
 It is conceivable that the temperature of the body might rise because, 
 other things being equal, its specific heat decreased, but there is no 
 evidence that this ever occurs. 
 
 The temperature remains nearly constant in health, because the 
 production of heat which takes place chiefly in the muscles is exactly 
 counterbalanced by the loss which takes place chiefly from the skin by 
 radiation, and by evaporation of sweat, and the fundamental problem 
 in the study of any case of pyrexia is, whether the temperature has 
 risen because the loss of heat has diminished while the production 
 remains the same, or whether the production has increased, the loss 
 being unaltered, or, lastly, whether both production and loss having 
 varied the temperature has risen because the two classes of variations 
 have not counterbalanced each other. 
 
 Three chief methods have been employed in attacking this problem, 
 {a) the calorimetric ; (1^) the chemical ; and (1;) the clinical ; and full 
 accounts of each will be found in my Croonian lectures on " The Means 
 by which the Temperature of the Body is maintained in Health and 
 Disease," 1897. The calorimetric is so complicated and so full of 
 fallacies that it cannot be described here, and the chemical, which has 
 yielded some most important results, is very difficult to apply at the bed- 
 side, but its results show that in animals some fevers are certainly 
 accompanied by a considerable increased production of heat. Probably 
 we must be especially cautious in applying to man conclusions about 
 fever arrived at by experiments on animals, for as many of them do not 
 sweat and have thick fur, their loss of heat must differ from that of 
 man. The method which I have called the clinical depends upon the 
 following considerations. It is clear that when the surface temperature 
 of the body rises the loss of heat by radiation and conduction will be 
 increased, and that when the amount of sweat secreted is increased, 
 the loss of heat from evaporation is increased, so that if in any case 
 it can be shown that the internal temperature has risen and at 
 the same time the surface temperature has risen and the amount of 
 sweat secreted has increased, the production of heat must have in- 
 creased, provided that the temperature of the surrounding air is 
 constant, and in the wards of a hospital it is kept nearly so. The 
 internal temperature is registered with an ordinary accurate clinical 
 thermometer, and the surface temperature is taken with special flat 
 
52 MANUAL OF MEDICINE 
 
 bulbed thermometers. The sweat is estimated by using calcium chloride 
 as an absorbent. It is fused into the bottom of a glass box which 
 has an air-tight lid ; the box and its lid are weighed ; the box with its 
 lid off is then inverted at a given spot on the skin for a given time, the 
 lid is at once put on, the box is again weighed, and the gain in weight 
 represents the amount of sweat absorbed. There are many small details 
 to be attended to which I described elsewhere. A series of observations 
 are made on the patient when his temperature is raised, and another 
 series when he is well and his temperature has become normal. A 
 comparison will show whether, when the temperature was raised, the loss 
 of heat by radiation and evaporation was more or less during fever than 
 during health. If it was more the production of heat must have been 
 enormously increased during the febrile period, for not only was the 
 internal temperature raised, but the loss of heat was greater. But if it 
 was less it must have been that some at least of the rise of internal 
 temperature was due to a diminution in the loss of heat. A series of 
 observations carried out by this method showed that in typhoid fever the 
 pyrexia was largely due to a lessened loss of heat, that in pneumonia 
 there is a very considerable increased production of heat, that in 
 erysipelas there is also an increased production of heat, and that in 
 suppuration there is a diminution in the loss of heat. These results 
 show that sometimes the pyrexia of fever is due to an increased pro- 
 duction of heat, and that sometimes it is due to a diminution of the loss, 
 that is to say that different toxins produce fever in different ways. This 
 is a different view from that of some older writers, who endeavoured to 
 explain all fever by the same process. 
 
 It is interesting to note that typhoid fever, although a long-lasting 
 disease with a high temperature, has a low mortality ; the reason for this 
 may be that, as the loss of heat is diminished, the temperature is raised 
 with the least expenditure of energy, and it is also interesting to observe 
 that experience has shown that the best way to reduce pyrexia in typhoid 
 fever is by the external application of cold water, that is by increasing 
 the loss of heat. On the other hand, pneumonia is a disease in which 
 the pyrexia lasts but a little while compared with typhoid fever ; as it is 
 due to an increased production of heat the patient could hardly survive 
 a long-continued fever accompanied by such a loss of energy. 
 
 Pyrexia occurs chnically either (i.) as a result of disease or damage of 
 the central nervous system, e.g. that which follows haemorrhage into the 
 pons or (ii.) as a result of the introduction of a poison into the body, e.g. 
 the pyrexia produced by atropine poisoning or that of the specific fevers 
 in some of which, e.g. diphtheria, the toxin which causes the pyrexia has 
 been isolated. Cases often occur, especially in children, in which the 
 only evidence of toxaemia is pyrexia and other febrile symptoms ; usually, 
 however, there are other associated phenomena, e.g. the rash of scarlet 
 fever, the physical signs of pneumonia, the inflammation of the joints in 
 
FEVER 53 
 
 rheumatic fever, by which we can distinguish the disease, and some- 
 times, as in the case of diphtheria, malaria, or tubercle, recognise the 
 micro-organism which, by its power of manufacturing toxins, causes the 
 febrile symptoms. 
 
 (i.) That damage to the central nervous system will cause pyrexia has 
 been shown chiefly by experiments upon the corpus striatum and spinal 
 cord. I have published twenty-seven experiments in which the corpus 
 striatum of rabbits was experimentally damaged. The rise of the rectal 
 temperature was sometimes over 4° or 5° F., and the average rise was 
 2.74° F. This was always after a unilateral lesion, and the pyrexia 
 never lasted more than a day or two. 
 
 In clinical medicine lesions in the following positions will cause 
 pyrexia. (Full references will be found in an article in the Brit. Med. 
 Jour)ial., Nov. 17, 1894.) 
 
 (A) Cortex. — Dr. J. H. Bryant has shown that out of a hundred cases 
 of hyperpyrexia {i.e. temperature over 106° F.), in eight it was due to injury 
 of the cerebral cortex. Usually there was also meningeal hcemorrhage, 
 but in one there was only laceration of the cortex. The temperatures 
 were 109'', 108.4', 107.8", 107.4", ^o?') loj j lo?', and 106.6°, and it 
 is by no means uncommon to meet with pyrexia after lesions of the cortex. 
 
 (B) Corpus striatum. — So many cases have been referred to by 
 myself and others, that it is now known that haemorrhage into the 
 corpus striatum is frequently followed by pyrexia, unless the excessive 
 loss of blood keeps the temperature down. The rise may be as high 
 as 108" F. If only one corpus striatum is damaged the rise of tempera- 
 ture is often higher in the a.xilla of the paralysed limb, that is to say 
 the one opposite the lesion, than in that on the sound side. By com- 
 paring the variations in the loss of heat on the two sides of the body I 
 have been able to show that the loss is greater on the paralysed side ; 
 therefore, as the axillarj' internal temperature is raised on this side, it 
 follows that the production of heat is increased on the paralysed side, so 
 that in this form at least of cerebral pyrexia the production of heat is 
 increased. The usual course of the axillary temperature after an ordinar}' 
 cerebral hsemorrhage implicating the corpus striatum is that for the first 
 few hours there may be a fall below normal, owing to the shock and loss 
 of blood, but as the effects of this pass off the rise shows itself. The 
 maximum is usually reached within twenty-four hours. The temperature 
 then slowly falls, the normal point being reached in a few days. After 
 this it generally falls a degree or so below normal, and remains subnormal 
 for a few days before attaining the healthy standard. When it is sub- 
 normal it is still a little higher on the side opposite to a unilateral lesion. 
 Other lesions of the corpus striatum will produce pyrexia. 
 
 (C) Crura. — Lesions of these may cause a rise of temperature ; for 
 instance a case is recorded in which a tumour pressed on the crus, and 
 a temperature of 107.4' was reached. 
 
54 MANUAL OF MEDICINE 
 
 (D) Pons — (E) Spinal cord. — It is so well known that damage to 
 these structures will cause pyrexia that it is hardly necessary to quote 
 cases. 
 
 Therefore it appears that fibres proceed from the cerebrum, probably 
 the corpora striata, and pass down by way of the crura, pons and cord to 
 the muscles to influence their thermogenetic function. The cortex too 
 clearly has some influence ; how it acts we hardly know ; it may be that 
 it influences the corpus striatum, or that there are thermic fibres pro- 
 ceeding directly from the cortex. It must be remembered that the 
 mechanism by which heat is lost is also under the control of the central 
 nervous system, but the observations just quoted upon the temperature 
 in hemiplegia, the absence of any visible diminution in the radiating and 
 evaporating power of the skin even in some cases of hyperpyrexia, 
 and the very suddenness and great extent of the rise in some cases of 
 damage to the central nervous system all point to the fact that, in some 
 cases at least, the pyrexia that follows it is due to an increased thermo- 
 genesis. 
 
 After what has been said the reader will hardly be surprised to hear 
 that sometimes the temperature rises in cases o{ fimctioiial disease of the 
 central nervous system. Occasionally severe epileptic fits may be 
 followed by pyrexia. A temperature of 109° has been recorded, and 
 pyrexia may be observed in the status epilepticus. Delirium tremens 
 too may have pyrexia as a symptom ; it has been observed in severe 
 chorea and it may undoubtedly be a symptom of hysteria, but the 
 diagnosis of hysterical pyrexia should only be made after several 
 thorough examinations, after observation for at least a fortnight, and 
 after every other possible cause for the pyrexia has been excluded, for 
 certain specific fevers, especially typhoid fever and tuberculosis, are very 
 liable to mislead. 
 
 The central nervous system is more often damaged in cases of hyper- 
 pyrexia than in cases of pyrexia, for Dr. Bryant has shown that out of a 
 hundred consecutive cases in which the temperature rose over 106°, 
 eleven were due to injury to the brain, three to cerebral tumour or 
 haemorrhage, six to injury to the spinal cord, and one to myelitis, in all 
 21 per cent, and hyperpyrexia occurred in 2.18 per cent of all 
 cases of fractured skull. The hyperpyrexia of meningitis (it occurs 
 in 3.4 per cent of all cases of meningitis) may be partly due to direct 
 injury to the central nervous system. It may be well here to remind 
 the reader that hyperpyrexia is most common in the hottest months of the 
 year. Out of Byrant's hundred cases twenty occurred in August and fifty- 
 one in the months of June, July, August, and September. But this is 
 not surprising, for it is then that the central nervous system has greatest 
 work, even in health, in adjusting the production of heat to the loss. 
 
 Many writers have thought that the pyrexia which follows severe 
 peripheral irritation, viz. that which occurs during gallstone colic, or 
 
FEVER 55 
 
 that of catheter fever, is due to the action on the central nervous system 
 of the strong peripheral impulse. 
 
 (ii.) The second variety of pyrexia, that which results from the intro- 
 duction of a poison into the body, acts through the circulation carrying 
 the poison either to the parts of the body connected with the production 
 of heat or to those connected with the loss. The most active known 
 pyrexial-producing poison is B. tetrahydronaphthylamine ; I have seen 
 the injection of it subcutaneously into a rabbit cause a rise of io° F. in 
 one and three-quarter hours. But, as already mentioned, the most 
 interesting cHnically of the fever-producing agents are micro-organisms 
 and the toxins they manufacture. 
 
 Much attention has been directed to the question whether the 
 pyrexia in these cases is beneficial to the sufferer, and it is obvious that 
 this question is of the highest importance. Some micro-organisms, 
 which are very harmful to the human body, have their activity much 
 lowered by a temperature not very greatly in excess of that of health ; 
 thus Koch found that if tubercle bacilli were kept at a temperature of 
 107.5° F. for three weeks their development was much hindered, whilst 
 the best temperature for them was 99.5° F. Parallel observations have 
 been made upon the pneumococcus and the spirillum of relapsing fever. 
 Pasteur and Wagner observed that fowls, ordinarily refractive against 
 anthrax bacilli, succumbed if their temperature was artificially lowered. 
 On the other hand, other observers have shown that animals artificially 
 warmed seemed able better to withstand certain specific fevers. Loewy 
 and Richter state that rabbits whose temperature is raised by damage to 
 their corpora striata are the better able to resist diphtheria, fowl cholera, 
 swine erysipelas, and pneumonia. These observations, although not 
 proving that the production of pyrexia is a protective mechanism, certainly 
 suggest that it is, and the fact that antipyrin, acetanilide, phenacetin, and 
 other antipyretic drugs have not been found in any way to benefit fevers, 
 though possibly lowering the temperature, points in the same direction. 
 It is true that ague is benefited by quinine, and rheumatic fever by 
 salicylates, but these drugs are not of use because they are antipyretic, 
 but because they are direct poisons to the cause of the disease. Typhoid 
 fever is certainly benefited by the reduction of fever by cold, but there 
 may be a special reason for this. Of course, it does not follow from 
 this view (that the production of pyrexia is a protective mechanism) 
 that the higher the temperature of the body the better the prognosis, for 
 the higher temperature might be taken to indicate that the dose of in- 
 fection was very severe, and that therefore the body did all it could to 
 resist the invasion, nor would it follow that if the temperature did not 
 rise much the dose of infection was slight, for it might be that the body 
 was feeble, and had but httle power of raising its temperature and there- 
 fore defending itself 
 
 Much attention has been directed to the disorder of nutrition in 
 
56 MANUAL OF MEDICINE 
 
 fever. Some attempts have been made to find out whether the amount 
 of CO2 exhaled during specific fevers is increased. Many more ob- 
 servations will have to be made on different fevers before the results can 
 be accepted as final, but so far as they go they show that in man the 
 amount of COg excreted during fever is not increased. Thus Loewy, 
 experimenting on a patient suffering from typhoid fever, found that 
 when the temperature was raised the output of COg in cubic centimetres 
 per minute was on different occasions 183, 221, 190, 205, 198, 248. 
 Three weeks later, when the temperature was normal, the output was 
 277. The balance of evidence, too, is that in fever the respiratory 
 quotient is unaltered. 
 
 Here, in passing, I should like to call attention to the fact that Mr. 
 Hopkins and I found that there was also no increased excretion of COg 
 when the temperature was raised by lesions of the corpus striatum ; on 
 the other hand. Dr. Pembrey and I found that when the temperature rose 
 coincident with the awakening of a hybernating dormouse, there was an 
 enormous increase in the output of CO,. This goes to confirm the view 
 that the metabolic processes of fever are not merely an exaggeration of 
 normal processes, but of a different nature, and if this view should 
 prove to be true it is of primary importance in the consideration 
 of fever. 
 
 The discharge of nitrogen by the kidneys in fever has long 
 been known to be greater than it would be in health on the same 
 diet. This, of course, points to an increased destruction of proteid 
 tissues ; in itself it does not necessarily show that the increased proteid 
 katabolism leads to a total greater production of heat, for there may be 
 a lessened katabolism of fats. May has, however, recently worked 
 out the subject most thoroughly in the case of rabbits affected with 
 swine erysipelas. It will be remembered that the complete burning of 
 a gramme of albumen liberates 5550 gramme calories (centigrade), but 
 in our bodies albumen is only broken down as far as urea, and a gramme 
 of albumen broken down thus far yields about 4000 gramme calories. 
 The energy-yielding power of a gramme of fat is about 9500, and that 
 of a gramme of carbohydrates about 4000 gramme calories. If we 
 know the amount of nitrogen and carbon excreted by an animal, we 
 can calculate back what must have been the amounts of proteid and 
 fat to produce these quantities of carbon and nitrogen, and then we see 
 how much energy this breaking down must have yielded. We can 
 compare results if the animals are kept quiet in a cage, and the energy 
 of the cardiac and respiratory muscular contractions need not be 
 considered, for that chiefly becomes heat as it has to overcome friction. 
 Working on these hnes. May has shown that when a starving rabbit's 
 temperature is raised by swine erysipelas, there is an increased katabolism 
 which falls exclusively on the proteid tissues, and represents an increase 
 of about 30 per cent in the liberation of gramme calories. The fat 
 
FEVER 57 
 
 metabolism is unaltered, therefore we learn that there is in these 
 animals an increased production of heat in swine erysipelas due to an 
 excessive destruction of proteid. 
 
 Appearances after death. — The cells of the tissues, especially 
 the muscles and glands, are after death often cloudy, somewhat swollen, 
 and appear to have undergone parenchymatous degeneration. The 
 heart may be dilated, and this has been ascribed to degeneration of the 
 cardiac muscle. The spleen is frequently enlarged and soft, the blood 
 may be imperfectly coagulated, and sometimes post-mortem staining of 
 the heart and large arteries is very evident. But any or all of these 
 changes may be absent, and we know nothing of their cause ; some- 
 times it would appear that they are due to the direct action of the 
 microbic poisons on the tissues. 
 
 Treatment of fever. — Unless the pyrexia is very trifling, the 
 patient must remain in bed. He should have milk and light farinaceous 
 foods, partly because his powers of digestion are very impaired, and 
 partly because May has shown that the administration of carbohydrates 
 most markedly saves the destruction of proteid tissues. The quantity 
 will depend upon his power of taking food, but all fevered patients 
 require as much as they can take without upsetting them, therefore 
 meals should be very frequent but small, and it should never be for- 
 gotten that Dr. Todd has made himself immortal because he " fed 
 fevers." Constipation often requires relieving by some mild aperient, 
 and sleeplessness may necessitate giving a hypnotic, and as a general 
 rule opium is the best. Barley water and lemonade or imperial drink 
 (acid tartrate of potassium 60 grs., gluside i gr., oil of lemon 3 m., 
 water i pint) often relieve the distressing thirst of fever. 
 
 The sickroom should be light, airy and quiet. Its temperature 
 should be about 55° to 60° F., and whenever possible the windows 
 should be open. 
 
 If any drugs are required they will be mentioned in the description 
 of each fever. Those, such as antimony and aconite, formerly given 
 with the object of reducing the pulse, should never be ordered, and 
 antipyretic drugs do harm. 
 
 Whatever the fever, if the temperature be so high as in itself to be 
 dangerous to the life of the patient, the condition is called hyperpyrexia, 
 and usually this term is applied to any temperature over 106° F. 
 The prognosis is then very grave ; 84 per cent of all patients whose 
 temperature exceeds 106° die, and unless the patient is obviously at his 
 last gasp cold must be applied promptly and resolutely. Occasionally 
 in children, in whom the temperature fluctuates easily, cold sponging 
 may suffice. For instance, a child aged five was under my care for 
 pneumonia ; the temperature was often between 104° and 105°, and on 
 one occasion 106.4°. Under treatment by cold sponging and ice 
 poultices the patient recovered. But in nearly all cases a cold bath 
 
58 MANUAL OF MEDICINE 
 
 must be employed. For an adult, whose temperature is over io6°, 
 that of the bath should be between 70° and 75° ; for children it may be 
 a little higher. The patient should be lifted into it in a sheet. The 
 water should be stirred, and when the rectal temperature is 100° or 
 101° he should be taken out and put back to bed with a sheet over him. 
 The usual duration of the immersion is ten minutes, but it is often longer. 
 If he is collapsed after the bath, hot-water bottles and strong brandy 
 and water are necessary. In private practice a cold bath may be 
 improvised by putting a large mackintosh sheet under the patient, 
 banking it up with pillows so that he lies in a trough, raising the head 
 end of the bedstead, and pouring cold water in at the head of the trough, 
 and letting it run out at the foot into a pail. For hyperpyrexia the 
 cold bath, unless the shock of it is too severe, is much more efficacious 
 than the tepid bath (90-95° F.) gradually cooled. 
 
 W. Hale White. 
 
BOIL AND CARBUNCLE 59 
 
 BOIL AND CARBUNCLE 
 
 Pathology. — Formerly boil ('furuncle) and carbuncle were 
 described separately, but it is no longer necessar}', since they are 
 similar affections, arising from the same causes, and differing merely 
 in degree. All intermediate stages may be seen, from the simple 
 boil to the difluse and destructive carbuncle. The exciting cause 
 in all cases is the staphylococcus pyogenes aureus. If the inflammatory 
 and necrotic changes remain localised to a hair papilla and its 
 sebaceous glands a boil results, but if they extend widely to the 
 neighbouring cellular tissue and cause it to die en masse a carbuncle 
 follows. In 1880 Pasteur showed the existence of a microbe in 
 boils which he believed to be identical with that found in osteo- 
 myelitis, and his obser\-ations were confirmed by Ogston and 
 others. It is an interesting clinical fact that patients the subjects 
 of acute osteomyelitis have often had at some previous period a 
 crop of boils. Such also may be experimentally produced by 
 rubbing the skin, on the back of the forearm for example, with 
 osteomyelitic pus. In some cases, if the local infections become 
 confluent, a carbuncle results. Some stress has been laid on the 
 fact that if in acute osteomyelitis the infection be of a mixed 
 nature, i.e. if streptococci as well as staphylococci are found, the 
 disease is more intense, and it is possible, but not yet clearly 
 proven, that such is the case in carbuncle of the diffuse variety, 
 which often runs a fatal course. 
 
 It is, therefore, evident that the clinical distinctions made 
 between bofls and carbuncles as to shape, size, and the number of 
 openings, have lost their significance, except the fact that the area 
 of inflammation indicates the extent of subcutaneous tissue in- 
 volved, and therefore the gravity of the affection. 
 
 There are certain etiological points of interest and importance 
 in addition to the rok played by the staphylococcus pyogenes aureus. 
 Both boil and carbuncle are more common in the male sex, and 
 affect regions where the pilo-sebaceous follicles are most numerous 
 and have large orifices. Such regions are the back of the neck, 
 the back, the gluteal region, the perinseum, the axillae, and the 
 dorsal aspect of the first phalanges of the fingers. Boils are often 
 seen on the face in the male sex, and if on the upper lip and of 
 large size may develop into facial carbuncle. It is a curious fact, 
 
6o MANUAL OF MEDICINE 
 
 however, that carbuncle is occasionally seen on the palms of the 
 hands and soles of the feet, which are quite hairless, but have 
 large, widely open, sudoriferous glands. In some occupations boils 
 are common : thus cavalry soldiers and rowing men are prone to 
 furunculosis on the gluteal region ; infantry men to boils on the 
 neck from the rubbing of the stiff " stock " ; tanners and post- 
 mortem attendants on the backs of the hands. In the case of the 
 first two the staphylococci are present in the clothes, and are 
 rubbed into the pilo-sebaceous follicles by constant friction. Indi- 
 vidual liability is well marked. One man will suffer if he eat too 
 much meat, another if he eat too little, while a third may indulge 
 in all vagaries of diet and not have a single boil. In others, a 
 dyspeptic attack or prolonged constipation is surely followed by 
 fu'runcles. After typhoid fever, furunculosis and carbuncle are not 
 uncommon. 
 
 The chief interest, from a medical point of view, lies in the 
 association of boil, carbuncle, and glycosuria. It has been shown 
 that if to a dose of staphylococcus culture, too feeble by itself to 
 provoke suppuration, a certain quantity of grape sugar be added, 
 the culture rapidly acquires marked pus-producing properties, and 
 it is a noteworthy fact that boils are very common amongst those 
 engaged in sugar refining. So firmly has the connection between 
 carbuncle and glycosuria, whether diabetic or not, been insisted 
 upon, that it is often the presence of the former which calls for an 
 examination of the urine. It must, however, be remarked that 
 sometimes no sugar is discovered, or, if it be, its presence is merely 
 temporary, and it disappears when the carbuncle has healed. In 
 many instances it is impossible to doubt the connection between 
 the two, but reliable statistics are required to show the exact 
 frequency of the incidence of carbuncle in diabetes, and how often 
 sugar is temporarily present in cases of carbuncle. Some other 
 abnormal states of the urine are also found when carbuncle is 
 present, notably albumen, excess of phosphates, excess of uric acid, 
 and diabetes insipidus. Alcoholics often suffer from boil and 
 carbuncle ; and finally a hemiplegic limb is not seldom the site of 
 an eruption of boils. 
 
 Symptoms. — These affections are characterised by the follow- 
 ing symptoms : — A boil commences as a small itching red papule, 
 with a depression at its summit, from which a hair is seen issuing. 
 In about four days the swelling has much increased, and is conical, 
 and the seat of considerable boring pain. Up to this time the 
 swelling is indurated. In som.e cases no softening occurs, and the 
 
BOIL AND CARBUNCLE 6i 
 
 boil is then said to be blind ; but more frequently pus begins to 
 form from the fourth to the sixth day, and on the ninth or tenth 
 day the slough, consisting of the necrosed hair follicle and sebaceous 
 gland, and some surrounding tissue, is discharged. The constitu- 
 tional symptoms are not, as a rule, marked. The onset of a 
 carbuncle is often preceded by some malaise, and the general 
 symptoms are well defined. In some instances there are rigors and 
 fever, and the symptoms are of a pyemic character ; in others there 
 is a condition of collapse, subnormal temperature, and feeble pulse. 
 Locally, the site of the impending carbuncle feels hot and is painful, 
 and soon becomes red ; then swelling of the skin occurs, at first 
 limited, but slowly increasing. This swelling is hard and red, and 
 gradually becomes dome-shaped. In four to six days several vesicles 
 containing blood-stained pus and serum appear ; these vesicles 
 break, and soon openings leading to the subcutaneous slough are 
 formed. Meanwhile, the area of redness, oedema, and pain has 
 increased, and the parts present the appearance of acute inflamma- 
 tory tension. The openings may coalesce, and a large crater, with 
 the slough at the bottom, is formed ; or, if it is thought expedient, 
 the skin between the orifices may be divided, and a free aperture 
 made for the exit of the slough. 
 
 Complications and prognosis. — A boil situated over a large 
 venous trunk becomes dangerous on account of the possibility of 
 phlebitis ; and the so-called malignant facial carbuncle, beginning as 
 a boil on the upper lip, may result in septic phlebitis of the labial, 
 angular and orbital veins, and of the superior longitudinal sinus. 
 If the head, chest, and abdomen are affected, especially in diabetic 
 subjects, meningitis, pleurisy and empyema, and peritonitis may 
 ensue. One case is recorded where a carbuncle sloughed through 
 the whole thickness of the abdominal wall, exposing the \ascera. 
 The prognosis of these affections, therefore, depends upon the region 
 affected, the extent of surface involved, and the general condition 
 of the patient, especially as to glycosuria, albuminuria, gout, and 
 alcoholism. It is in diabetic subjects that the diffuse, very virulent 
 carbuncle is occasionally seen. Diagnosis must be made between 
 boil or carbuncle and anthrax. In the latter no pus is found, and 
 the appearance is characteristic — a central black slough, a ring of 
 vesicles, and a hard inflamed base. 
 
 Treatment must be general and local. Careful, well-regulated, 
 and easily assimilated diet, avoidance of constipation, fresh air and 
 exercise, and frequent skin bathing, are called for. Intestinal anti- 
 septics, such as /5-naphthol, salicylate of bismuth, are of value, and 
 
62 MANUAL OF MEDICINE 
 
 later iron and quinine. Yeast has been vaunted as a specific, and 
 nuclein internally may be of value. Alcohol, in the form of 
 Burgundy, or port wine, or stout, is useful in feeble subjects ; but 
 it should be prohibited in those given to excess. For the diabetic, 
 opium and codein are indicated. Locally, the treatment of boils 
 must be on antiseptic lines, and poultices are to be avoided ; the 
 surest means to ensure crops of boils is to use poultices. The skin 
 in the neighbourhood of a boil must be protected by collodion, and 
 the boil should be fomented with hot boracic lotion, and, when ripe, 
 incised. Hot lead and opium lotion will often relieve pain. 
 
 The local treatment of carbuncle presents many difficulties. On 
 the one hand we have to guard against, especially in diabetics, the 
 effects of prolonged pain and the possibilities of septic absorption, 
 owing to the retention of the slough ; and, on the other hand, an 
 incision is often fraught with danger owing to the haemorrhage. 
 Some have thought injection of carbolic acid and glycerine to be of 
 service ; but, with damaged kidneys, it is not advisable to do this. 
 It seems that in localised carbuncles frequent hot antiseptic appli- 
 cations will facilitate the separation of the slough, and if much pus 
 be present, a limited incision is advisable. In large diffuse carbuncle 
 a small, not crucial, incision in the centre may be called for ; and, 
 to avoid the risk of hemorrhage, the various apertures may be joined 
 by the thermo-cautery. Every effort must be made to sustain the 
 patient's strength, but many patients with diffuse carbuncles resist 
 all treatment. 
 
 A. H. Tubby. 
 
 ERYSIPELAS 
 
 Er}'sipelas is an infective inflammation of the skin caused by the 
 invasion of the lymphatics by the stj-eptococcus erysipelafos, accom- 
 panied by pyrexia and other constitutional disturbances. The in- 
 flammation may spread from the skin to the adjacent mucous 
 membranes, or it may start in the latter and extend thence to the 
 skin. 
 
 Pathology. — The relationship between erysipelas and various 
 forms of cellulitis, septicaemia, and pyaemia is still a debatable 
 question. Some hold that erysipelas is a distinct disease, while 
 others consider it to be a variety, due to special localisation, of a 
 
ERYSIPELAS 63 
 
 disease which has other manifestations. The latter view is adopted 
 here for the following reasons, viz. first, that erysipelas does not 
 always " breed true," for instance, a case of erysipelas may give rise 
 in other patients to cellulitis, puerperal fever, or some other form 
 of septicaemia ; secondly, that a case of typical erysipelas may 
 gradually develop into one of cellulitis, or even of pyaemia ; and, 
 finally, that the streptococcus erysipelatos, which is the cause of 
 erysipelas, is identical with the streptococcus pyogenes, which is the 
 cause of many forms of septic disease. 
 
 A section through the affected skin shows that the lymphatic 
 vessels and spaces at the spreading margin of the inflamed area are 
 filled with micrococci arranged either in pairs (diplococci), or in 
 chains (streptococci). In the rest of the affected area there will be 
 found a serous and cellular infiltration, by means of which the 
 micrococci are ultimately destroyed. The inflammation spreads 
 along, and as a rule remains limited to the skin, because the 
 micrococci can travel more readily along the lymph spaces than in 
 any other direction. Should they reach the subcutaneous tissue, a 
 cellulitis is produced ; and should they get into the circulation, a 
 septicaemia or pyaemia will arise. 
 
 Bacteriology. — From the affected skin it is easy to cultivate 
 the streptococcus erysipelatos causing the disease, which possesses the 
 following characters : — It consists of cocci arranged in pairs and in 
 chains, the latter being frequently very long and convoluted. It 
 stains with the ordinary dyes, and is not decolorised by Gram's 
 method. It grows readily in all the ordinary media, both in the 
 presence and in the absence of oxygen, either at the usual tempera- 
 ture of the air, or at the temperature of the body. On the surface 
 of solid media, the colonies are characterised by being small and 
 discrete ; and they do not liquefy gelatine. In broth the growth 
 sometimes occurs as a uniform turbidity, more frequently as a 
 flocculent mass which falls to the bottom of the tube, leaving the 
 supernatant liquid clear. 
 
 Fehleisen, by successfully inoculating individuals with pure culti- 
 vations, in the hope of curing them of malignant tumours, furnished 
 the direct proof that the streptococcus is the cause of erysipelas. 
 
 So far as animals are concerned, the virulence of the strepto- 
 coccus, and consequently the effect produced by inoculation, varies. 
 In rabbits inoculation of the skin of the ear may produce a condition 
 similar to that of erysipelas in the human subject, while septicEemia 
 or suppuration may be produced by subcutaneous inoculation with 
 cultivations of appropriate virulence. Frequently a streptococcus 
 
64 MANUAL OF MEDICINE 
 
 isolated from a severe case in the human subject is found to be 
 almost harmless to laboratory animals. The streptococci obtained 
 from various cases of erysipelas differ from one another not only in 
 virulence, but also to some extent in cultural characteristics. It 
 would, however, appear that these different varieties can be reduced 
 to a uniform type by special means. 
 
 By some the streptococcus pyogenes, which gives rise to septicsemia, 
 puerperal fever, etc., and the streptococcus erysipelatos are considered 
 to be distinct micro-organisms. This view is based partly upon the 
 different effects produced in animals by inoculation, and partly 
 upon differences in cultivations. The more we know about the 
 various types of both micro-organisms, the less important do these 
 differences become ; and the most generally accepted view at the 
 present time is, that the streptococcus erysipelatos and the strepto- 
 coccus pyogenes are identical. Consequently, erysipelas cannot be 
 looked upon as a distinct specific disease, although it may be- 
 described as a clinical entity on account of the special symptoms 
 produced by the localisation of the micro - organisms in the 
 skin. 
 
 Etiology. — Erysipelas occurs in almost all parts of the world ; 
 it attacks persons of all ages and of either sex, and it appears to 
 be more prevalent during the colder seasons of the year. Patients 
 suffering from chronic Bright's disease, or from the effects of chronic 
 alcoholism, and those living under bad hygienic conditions are 
 especially liable to be attacked. Some individuals are exceedingly 
 susceptible, and are attacked again and again. It is difficult to 
 decide whether such cases are due to fresh infection, or whether 
 they are recrudescences of the disease. Whatever may be the 
 explanation, the protection afforded by one attack is but slight, 
 and of short duration. 
 
 The most common mode of infection is by means of a wound 
 in the skin ; and, before the days of antiseptic surgery, erysipelas, 
 when introduced into a surgical ward, rapidly spread, the virus 
 being no doubt conveyed to the wounds by the fingers of those in 
 attendance. At the present time erysipelas is almost unknown 
 after surgical operations. It occasionally follows on vaccination. 
 
 Patients are sometimes attacked when there is no obvious 
 wound for the entrance of the virus. Probably in such there was 
 some abrasion of the skin, which had disappeared at the time of 
 observation. In some cases the virus enters through the mucous 
 membrane of the fauces or other parts, and spreads by direct con- 
 tinuity to the skin. 
 
ERYSIPELAS 65 
 
 After infection there is an incubatioa period of from one to 
 three or four days, during which no symptoms are observed. 
 
 Apart from wounds, the face is most frequently affected, although 
 any part of the body may be attacked. In the face the disease 
 usually arises at the junction of the skin and the mucous membrane, 
 near the side of the nose, the inner canthus of the eye, or the 
 margins of the lips. The affected skin becomes red, swollen, pain- 
 ful, and tender. The inflammation spreads by direct continuity to 
 the adjacent skin, the edge dividing the aifected from the healthy 
 skin being raised and well defined. In parts where the skin is 
 closely adherent to the subjacent tissues, the spread of the inflam- 
 mation is arrested. As the inflammation advances the redness 
 disappears from the part first affected. Where the skin is loose, as 
 on the eyelids and the scrotum, the swelling is intense. Vesicles 
 and bullae frequently appear over the affected area. The inflam- 
 mation lasts for about a week, and, as it subsides, the skin becomes 
 flaccid and shrivelled, the vesicles dry up, and desquamation occurs. 
 When the scalp is affected there is considerable oedema, but not 
 much redness. The lymphatic glands in the neighbourhood of the 
 affected skin are usually tender and slightly enlarged. 
 
 When a mucous membrane, such as that of the fauces, is 
 attacked, it becomes swollen, and brawny, and of a deep red 
 colour. 
 
 Symptonis. — The onset of the disease is usually quite sudden, 
 with rigors and vomiting. The temperature quickly rises to about 
 104° F., and there are the usual accompaniments of fever, headache, 
 loss of appetite, etc. Albuminuria is generally present, and nephritis 
 is by no means uncommon — blood and casts appearing in the urine. 
 Diarrhoea is often a troublesome symptom. Herpes labialis and sore 
 throat are of occasional occurrence. 
 
 In favourable cases the temperature falls in about six or eight 
 days, either by lysis or more frequently by crisis ; the inflammation 
 of the skin ceases to spread, and the other symptoms quickly sub- 
 side. In unfavourable cases the pyrexia may be high, or the patient 
 may fall into a typhoid condition, becoming wildly delirious, and 
 succumb with severe nervous prostration, or he may die from ex- 
 haustion with vomiting and diarrhoea. 
 
 In addition to the acute form of the disease, a more chronic 
 form occurs. In this type the inflammation of the skin may wander 
 about from one part of the body to another ; the constitutional 
 symptoms are not as a rule severe, and there is often little or no 
 pyrexia. 
 
 VOT. I F 
 
66 MANUAL OF MEDICINE 
 
 Relapses occurring shortly after the first attack are not at all 
 uncommon. With the relapse the temperature rises, and fresh in- 
 flammation of the skin sets in. 
 
 Certain complications may arise during an attack of erysipelas. 
 The inflammation may spread to the larynx, causing serious obstruc- 
 tion to the respiration ; or it may spread to the lungs, producing 
 bronchitis and pneumonia. By the escape of the streptococci into 
 adjacent parts, various septic conditions may arise. The most fre- 
 quent of these is diffuse cellulitis ; but other septic conditions, such 
 as meningitis, peritonitis, pericarditis, pneumonia, or even pyaemia, 
 are by no means unknown. 
 
 An attack of erysipelas may give rise to a blocking of the lymph- 
 atics, and thus cause permanent oedema. This is especially frequent 
 in the subcutaneous tissues below the eyes, where large bladder-like 
 swellings may occur. Erysipelas of the scalp often causes loss of 
 hair. Sloughing of the cornea and suppurative otitis have been met 
 with as later results. 
 
 A beneficial influence is sometimes exerted by an attack of erysi- 
 pelas upon chronic skin diseases and certain varieties of sarcoma ; in 
 fact a complete disappearance of the latter may occur, so that inocu- 
 lation of patients with erysipelas has been performed with a therapeutic 
 object. It was found, however, that the erysipelas thus set up was 
 too severe to justify a continuation of the treatment. The toxines 
 produced by the streptococcus erysipelatos are now employed with 
 the same object. The toxines are prepared by cultivating the 
 streptococcus and the bacillus prodigiosus together in broth. The 
 bacteria are separated by filtration through porcelain, and the filtrate 
 used for injection (Coley's fluid). The effect of the injections is to 
 cause pyrexia and general malaise, and in a number of instances the 
 tumours have disappeared. 
 
 Diagnosis.— Erysipelas is usually quite easy to diagnose, the 
 red swollen skin, with a well-defined raised edge, accompanied by 
 pyrexia and constitutional symptoms, being quite unmistakable. 
 The difficult cases are those in which the disease assumes a chronic 
 type, with slight or no pyrexia. Commencing herpes on the face may 
 resemble erysipelas, but the rapid appearance of vesicles and their 
 distribution quickly clears up the diagnosis. Various forms of ery- 
 thema can be distinguished by the absence of severe constitutional 
 disturbances, and by some distinctive peculiarity in the character and 
 distribution of the patches. An erythema occurring during the 
 course of Bright's disease may give rise to difficulties in diagnosis. 
 Acute eczema is easily distinguishable by the nature of the lesions. 
 
ERYSIPELAS 67 
 
 In cases of doubt, a cultivation taken from the affected area of skin 
 will settle the diagnosis. 
 
 It is not proposed to discuss the differential diagnosis between 
 erysipelas and diffuse cellulitis, as the diseases are considered to be 
 etiologically identical. 
 
 Prognosis. — In the aged, and in patients suffering from Bright's 
 disease, chronic alcoholism, or some other debilitating disorder, the 
 prognosis is unfavourable. It is less favourable in patients suffering 
 from wounds than in those in whom the disease appears to be " idio- 
 pathic." Erysipelas starting at the umbilical cord in infants is of 
 bad prognosis. Unfavourable symptoms are severe pyrexia, delirium, 
 the typhoid state, severe vomiting, and diarrhoea. 
 
 Treatment. — The treatment of erysipelas falls under three head- 
 ings — general, local, and specific. The general treatment is such as 
 is applicable to all fevers. The patient should be put upon a light 
 nutritious diet, and stimulants should be administered as may be 
 necessary. Drugs do not cut the disease short, but iron is stated to 
 be beneficial. The best local treatment is to apply a powder, con- 
 sisting of zinc, starch, and boracic acid, over the inflamed skin, and 
 to exclude the air by lint and a bandage, or, in the case of facial 
 erysipelas, by a mask. Lead and opium lotion is useful for relieving 
 pain. Painting a band with solid nitrate of silver at the edge of 
 the affected area sometimes prevents the spread of the inflamma- 
 tion. Should diffuse cellulitis arise, incisions may be required. 
 
 The specific treatment consists in the injection of antistrepto- 
 coccic serum. This serum is that of the horse, immunised to the 
 streptococcus by repeated inoculations. It should be injected into 
 the subcutaneous tissue once or twice a day, in doses of 20 c.c, 
 strict antiseptic precautions being taken. In some forms of strepto- 
 coccal infection the serum is certainly beneficial, but at present the 
 results with erysipelas are somewhat doubtful. It may reasonably 
 be expected that a more efficacious serum will be ultimately ob- 
 tained. 
 
 J. W. Washbourn. 
 
6g MANUAL OF MEDICINE 
 
 SAPR^MIA, SEPTICEMIA, PYEMIA 
 
 Until a comparatively recent period any description of pyaemia 
 and the allied diseases would have been almost out of place in a 
 text-book of medicine, but in the present day, when antiseptic 
 methods have practically revolutionised surgery, it has come to be 
 recognised that many of the septic conditions— the so-called blood 
 poisonings — have to be reckoned with chiefly as the result of absorp- 
 ■ tion from internal cavities rather than as arising from absorption 
 from external wounds produced by accident or by the surgeon ; and 
 although in certain cases it may be necessary for the surgeon to 
 interfere, most of the cases of so-called blood poisoning, now recog- 
 nised, come under the observation of the physician or the obstetric 
 physician rather than into the province of the pure surgeon. 
 
 During the early transition period of bacteriology, and as the 
 result of the work of Panum with his "sepsines," and Selmi with 
 his "ptomaines," there crept into medical momenclature two terms 
 to indicate what originally was spoken of as " blood poisoning " — 
 pyaemia and septicsemia, the former including acute pyaemia, in 
 which metastatic, usually miliary, abscesses are formed in different 
 organs and parts of the body, and a chronic form in which abscesses 
 appear fewer in number, of larger size and slower growth, and 
 often localised around the joints. Under septicaemia were in- 
 cluded all other cases of septic poisoning not followed by the 
 formation of purulent foci. This was a most useful classification 
 from the clinical point of view, and especially when our knowledge 
 of the action of microbes and their products was both more re- 
 stricted and less accurate than it now is. With our present know- 
 ledge of the relations of micro-organisms and their products to 
 disease processes it is necessary to divide into three groups the 
 constitutional and general symptoms produced by the entrance of 
 the products of these microbes, alone or along with the organisms 
 that produce them, into the living body. First are those states 
 determined by the absorption of the poisonous products of bacteria 
 from a localised manufactory, the organisms remaining locahsed but 
 the poisons being absorbed and carried to various parts of the 
 body. This condition, known as saprtemia, or true toxaemia, 
 depends entirely on the iiivasioti of the system by the poisonous 
 products of bacteria. The organisms themselves remain in the 
 
SAPR^MIA, SEPTICEMIA, PYEMIA 69 
 
 wound, or it may be in the hollow organ in the altered secretions 
 of which they are flourishing, but they produce active toxic agents 
 which are rapidly absorbed into the fluids and tissues. Kill the 
 organisms in the wound, or wash out the cavities in which they 
 are flourishing, and the sapraemic or toxic symptoms are immedi- 
 ately relieved or entirely removed. The poison does not multiply 
 in the blood ; it simply acts as an absorbed chemical substance, 
 and unless the initial dose be large or of exceedingly lethal 
 character the patient may recover as soon as the local manufactory 
 is closed or done away with. Examples of this sapraemic condition 
 are diphtheria and tetanus, although multiplication of the poison- 
 producing organisms may sometimes take place in the tissues. The 
 real sapraemic condition is that in which there is absorption of the 
 formed poison from without, as in very acute cases of tetanus, 
 where the poison is produced entirely outside the body, or in 
 cases of absorption from the intestines of the poisonous substances 
 produced by rapidly multiplying organisms, which may be likened 
 to the vegetable alkaloids as regards the toxic effects they set up. 
 Exactly the same process may be observed in the post-partum 
 toxaemias or saprasmias, resulting from the putrefactive changes 
 that occur in remnants of the placenta, or in clots left in the uterus ; 
 or again as the result of absorption from a localised abscess, or any 
 mass of dead and decomposing tissue within the body. When 
 operations were performed without antiseptic precautions, toxic 
 absorption was one of the causes of the fever and collapse that so 
 frequently and shortly supervened. 
 
 The organisms which produce many of these poisons are 
 entirely saprophytic and can never invade the body themselves ; 
 their products, gaseous or liquid, however, appear, as already men- 
 tioned, to have the power of poisoning tissue cells and thus of 
 preparing the way for the advance of the true pathogenetic 
 organisms into the tissues. Panum, Selmi, Burdon Saunderson 
 and Koch ascribe certain very definite symptoms and conditions 
 to what are called sepsines or ptomaines (alkaloids which are pro- 
 duced by the action of putrifying organisms on animal tissues or 
 fluids). Putrid solutions containing these substances still remain 
 poisonous after they have been boiled, showing that the action is 
 not due to the presence of micro-organisms, or even of enzymes, 
 but to other more stable chemical substances produced by them. 
 It is probable that in addition to those that are unaltered by heat, 
 there are others similar to the diphtheria and tetanus toxins, which 
 contain, in addition to ptomaines, enzymes or ferments, some of 
 
70 MANUAL OF MEDICINE 
 
 which have a very poisonous action, although it takes some time 
 for this action to become fully developed. It is interesting to 
 notice that these ptomaines injected into animals give rise to fever, 
 gastric and intestinal disturbance, muscular irregularity, weakness, 
 and increased, or sometimes diminished rate in respiration and pulse, 
 not always but frequently similar to those met with in the human 
 subject in cases of sapraemia, the differences being apparently due 
 to the difference in dose. Collapse in the ordinary sense of the 
 term may be said to be the most marked feature following the in- 
 jection. Certain of these poisons apparently exert a direct action 
 on the endothelium of the blood vessels and even upon the cor- 
 puscles, these cells undergoing marked degenerative changes. 
 
 Symptoms. — As in cases of diphtheria, the poison formed by 
 the organisms at the seat of the wound exerts a depressing influence 
 not only on the tissue near the wound, but also in distant parts of 
 the body, with the result that these tissues are rendered much less 
 capable of resisting the invasion of other organisms that have found 
 their way to the wound. Similarly absorption of toxic substances by 
 the walls of the larger cavities may produce marked depression and 
 materially diminish the general powers of resistance, sometimes even 
 causing collapse or recurrent shock, where the absorption goes on very 
 rapidly, but intermittently. It has been noted by the surgeon that 
 where absorption has taken place from a wound that has not been 
 kept clean, the first symptoms make their appearance soon after 
 any change is observed in the wound itself; the temperature rises 
 three or four degrees ; rigors often occur (though these may be 
 absent) ; afterwards headache, vomiting and great thirst supervene ; 
 the skin, at first pallid, becomes flushed, hot and dry, and the pulse 
 and respirations increase in rapidity. Beyond these and some 
 symptoms of intestinal irritation, nothing may be observed, and the 
 patient may quickly recover. In more marked cases the patient 
 becomes rapidly worse. Watson Cheyne, in describing this con- 
 dition, says : " There is excessive muscular weakness, as evidenced 
 by tremors ; the tongue is now dry, brown and very tremulous ; the 
 mouth and lips are covered with sordes ; diarrhoea may come on 
 and motions and urine be passed unconsciously. The skin may 
 be slightly jaundiced and petechiae may appear. The temperature 
 may fall even to subnormal ; coma comes on and gradually deepens 
 into death. Death usually occurs about the second or third day of 
 the disease, but in other cases may be postponed for another week, 
 the patient passing into a typical ' typhoid state ' and dying of 
 exhaustion." 
 
SAPR^MIA, SEPTICEMIA, PYEMIA 71 
 
 The diagnosis is comparatively easy from the fact that the 
 symptoms are so marked and bear such a definite relation to 
 changes in wounds, accumulation and decomposition of secretions, 
 etc., in cavities and the like. It is maintained that the shock which 
 makes its appearance where large surfaces are exposed to the action 
 of septic material, especially when it occurs on the second or third day 
 of such exposure, is due almost entirely to this sapraemic condition. 
 
 If it is possible to remove the local source of the poison, or to 
 remove the substances in which the organisms are growing, the 
 prognosis should always be favourable, except in patients of low 
 vitality. The saprsemic condition, however, by increasing the 
 vulnerability of the tissues, renders the patient peculiarly hable to 
 be attacked by septicaemia. 
 
 The treatment in such cases is evident. Remove, as carefully 
 as possible, by curetting, free drainage, and by constant irrigation 
 with warm sterile water or weak antiseptic lotion, the substances in 
 which the organisms are growing. General medical and surgical 
 treatment should also be attended to, and the strength of the 
 patient kept up by means of nourishing, but non-stimulating diet. 
 
 Septicemia differs in certain essential details from saprsemia, 
 although it must really be looked upon as an extension of that 
 condition. The characteristic feature of septicaemia is that it is 
 brought about by the entrance into the vascular system of active 
 micro-organisms a/otig with their poisons ; consequently the con- 
 dition may be very prolonged, the prognosis as a rule being much 
 more grave. The gravity of the condition consists in the fact that 
 the active micro-organisms are able to exist and multiply within the 
 body where it is impossible to get at them for the purpose of 
 diminishing their vitality, and of there continuing to carry on the 
 manufacture of the poisonous substances which are the active agents 
 in bringing about devitalisation of the tissues. 
 
 In a case of saprsemia, as soon as the local manufactory of the 
 poison is removed, the patient, if the process has not gone too far, 
 commences to recover, since there is no further production of 
 poison. In the case of septicaemia, on the other hand, the original 
 local manufactory may be removed, but the formation of the poison 
 is still continued by the organisms that have found their way into 
 the body. The onset of the disease may be much slower, as the in- 
 vading organisms may take some time to make good their position 
 in the tissues and fluids of the body, and until they are able to do 
 this they are incapable of manufacturing any very large quantities of 
 
72 MANUAL OF MEDICINE 
 
 poison. It is quite possible that the distinction between saprsemia 
 and septicaemia might be broken down, were it not that in cases of 
 septicaemia pyogenic cocci, few in number, no doubt, may usually 
 be found in the blood ; though, did not the production of the 
 poison go on after the local manufactory had been removed, one 
 might imagine that the presence of such organisms was merely 
 accidental. On examining the organs of such a case of septicaemia, 
 however, long before the abscesses have been found, there may 
 usually be demonstrated in the kidneys, sometimes in the liver and 
 lungs, and more frequently in the tissues of the heart, a number of 
 micro-organisms usually staphylococci or streptococci, though here 
 and there bacilli may be found. In one case of haemorrhagic septi- 
 caemia that I examined, both bacilli and cocci, singly and in masses, 
 were present in large numbers in the capillary vessels. Perhaps 
 the most common of the septicaemias are those of purulent origin; 
 those following certain specific infective febrile diseases, especially 
 of the exanthematous type ; those following wounds, particularly 
 post-mortem and dissecting wounds, the septic organisms appearing 
 to assume a special virulence in the tissues and fluids of dead 
 bodies, and of patients that have suffered from purulent inflam- 
 mation of the serous surfaces of the joints, peritoneum or pleura. 
 In certain cases, lowered vitality of the tissues appears to be almost 
 an essential predisposing cause ; devitalisation of the tissues, whether 
 by injury, malnutrition, or action of poisons, seems to play a very 
 important part in the production of these septicaemias ; whilst, as 
 in the case of sapraemia, anything that interferes with the free dis- 
 charge from the surface of the wound, or from the cavities of the 
 body, is also a powerful predisposing agent. 
 
 Septicaemia as a special condition is now seldom observed ; but 
 even within the last twenty-five years deaths from septicaemia follow- 
 ing operations and in the maternity hospitals were by no means un- 
 frequent. Badly ventilated and dirty hospitals, infected instruments, 
 imperfect antiseptics and the like, now comparatively rare, then played 
 an exceedingly important part in the production of this condition. 
 
 The diagnosis of septicaemia is, as a rule, either very easy or 
 very difficult : easy where there is an evident wound, sometimes a 
 very small one, merely a pin-prick, and when the process comes on, 
 perhaps, at first slowly, but afterwards rapidly. It may commence 
 within twenty-four hours of inoculation, with rigors, sometimes re- 
 peated, followed by a rapid rise of temperature of from 4° to 6° F. ; 
 the pulse "becomes rapid, feeble, and irregular, and the heart weak ; 
 vomiting, headache, delirium, at first acute, and latterly of the low 
 
SAPR^MIA, SEPTICEMIA, PY.EMIA 73 
 
 muttering typhoid type, almost always occur ; and the lungs become 
 congested, or the patient suffers from bronchitis — in fact the patient, 
 as in sapraemia, frequently passes into the " typhoid condition." 
 The skin has a peculiar pallid, yellowish tinge, especially about the 
 angles of the nostril and mouth, and there may be small subcutane- 
 ous hcemorrliages. The breath has a peculiarly sweet, new-mown-hay 
 smell. In milder cases the symptoms are simply less marked, the 
 skin does not become so markedly yellow, and the small haemor- 
 rhages so characteristic of the very acute cases are not seen. Rigors 
 also are less characteristic of the milder than of the more acute forms. 
 Where septicsemia is the result of a small or punctured wound the 
 organisms sometimes seem to spread, especially along the lymphatic 
 channels, v/hich may then become acutely inflamed, appearing as 
 distinct red hues on the surface of the skin. There is often acute 
 pain ; and in consequence of the changes that occur in the lymphatic 
 vessels the tissues of the limb become oedematous, the glands become 
 tender, and afterwards may suppurate. This is not really a septi- 
 Ccemia, but an acute lymphangitis. If the process is not arrested at 
 the glands nearest to the wound, the patient usually succumbs very 
 rapidly to an acute septicaemia or pyaemia. 
 
 The prognosis in acute cases of septicaemia is very unfavourable. 
 Those in robust health have a better chance of recovery than those 
 weakened by disease, bad hygienic conditions, or impaired nutrition. 
 
 Treatment is directed to the amelioration of the symptoms ; the 
 removal of the local cause by excision, thorough drainage and irriga- 
 tion, and, if necessary, cauterisation. The strength of the patient 
 should, as far as possible, be maintained by the exhibition of suitable 
 food, by controlling the temperature, and by relieving the pain. 
 
 In all cases of either septicaemia or pyaemia where streptococci 
 can be demonstrated in the blood or in the tissues, or even when 
 their presence is suspected, full doses of antistreptococcic serum 
 should be injected as early as possible, and should be repeated as 
 often as may be found necessary. 
 
 Pyaemia. — It has been stated that in septicaemia micro-organisms 
 may be found in the blood ; but no metastatic abscesses were de- 
 scribed, the patient usually succumbing to the action of the acute 
 specific poison before there has been time for the formation of 
 abscesses. 
 
 In pysemia, as early indicated by Lister, and later by Ribbert, it 
 is probable that septic inflammation of a vein or veins is usually set 
 up in the immediate neighbourhood of a septic wound. As the result 
 
74 MANUAL OF MEDICINE 
 
 of the changes that take place in the endothehum of the vein so 
 affected, there is usually a local deposition of fibrin in which strepto- 
 cocci or staphylococci may develop, sometimes in large numbers. 
 A septic thrombus is thus formed which naturally undergoes soften- 
 ing, the clot going through what may almost be spoken of as suppu- 
 rative changes ; and as this continues, and the clot softens and breaks 
 down, fragments set free are carried as emboli to the capillaries, 
 where, becoming impacted, they form foci around which abscesses — 
 sometimes very small, at other times running together into larger 
 suppurating masses — are formed. 
 
 It was pointed out by Koch that micro-organisms finding their 
 way into the blood may multiply or be massed together, entangling 
 blood corpuscles, into small floating agglomerations which, carried 
 into the capillary system, become impacted, and so form the centres 
 of abscesses. 
 
 Here it should be borne in mind that the healthy tissues of the 
 body have a great power of destroying micro-organisms, and to this 
 must be attributed the fact that although septic organisms must be 
 distributed throughout the body, and to all the organs, abscesses may 
 be met with only in a single organ, or in the synovial membrane of 
 a single joint. It is supposed, indeed, that by some means or other 
 the organ affected has been deprived of its resisting power, or the 
 tissues of the joint have had their vitality lowered by an old inflam- 
 matory condition, a bruise, or a wound. In certain cases of acute 
 pyaemia following surgical operations, the kidneys only may be 
 affected. For this two reasons have been assigned : the first is that 
 in this organ there is a double set of capillaries, and that consequently 
 the small masses of organisms which might pass through a single set 
 of capillaries are entangled by a second set, because of the extreme 
 slowness of the circulation at this point. A second explanation is 
 one which receives some countenance from the experiments carried 
 out by Sherrington and others, that the micro-organisms making 
 their way from the capillary system into the tubules are allowed to 
 rest, especially at points where the tissues have their vitality in any 
 way impaired ; here they increase in number, and become the centres 
 of abscess formation. 
 
 That pyccmic abscesses are in many cases, though not invariably, 
 the result of emboli, must now be generally accepted. They may 
 follow on alterations in the endocardium, and the settling of micro- 
 organisms upon the altered tissues, with a subsequent increase 
 in size and softening of the vegetation. The secondary abscesses, 
 the result of the impaction of emboli, are usually first manifest in the 
 
SAPR.-EMIA, SEPTICEMIA, PY.EMIA 75 
 
 lungs, especially when the pysemic process commences in connection 
 with the bones or periosteum, where apparently the emboli are larger, 
 and are, therefore, caught more certainly in the comparatively wide 
 pulmonary capillaries. Multiple abscesses in such cases are formed ; 
 but it is only when they are of some size, and are near the surface, 
 that any definite signs and symptoms are obtained, being mainly 
 those of pleuro-pneumonia and empyema. 
 
 Once a mass of pyogenetic organisms, detached from such a 
 thrombus in a vessel or vegetation, becomes impacted, it may be the 
 centre of a pyemic abscess from the fact that these organisms form 
 substances which exert a marked devitalising effect on the wandering 
 cells which attempt to get into the neighbourhood of the organisms, 
 and on the fixed cells that are there already. The wall of the vessel 
 in which the micro-organisms are fixed is similarly devitalised, and 
 the pyogenetic cocci gradually make their way through the dead 
 tissue or vessel wall into the surrounding area, their advance being 
 Hmited only by the presence of an enormous number of leucocytes 
 which are found wandering towards them. The leucocytes near the 
 organisms are involved in the general death of the tissues ; but 
 others come up to take their place, and gradually, if these and the 
 tissues are moderately healthy, they form a zone of active resistant 
 cells. In addition to the poison that causes the death of the 
 leucocytes, the pysemic organisms secrete a substance which has the 
 power of peptonising or digesting the dead tissues and cells, both 
 those originally constituting the part and the leucocytes that have 
 come to reinforce them. 
 
 Pyaemia is now comparatively rarely met with, except as following 
 diftuse suppurating cellulitis, ulcerative conditions of the internal 
 organs, or suppurations near large veins, in bones, and in cavities 
 which may become closed, or that have bony walls, such as the 
 middle ear, the antrum or frontal sinuses, or in thrombosis of the 
 cerebral sinuses. 
 
 Sjnnptoms. — From the nature of the process, pysemia must be 
 expected at a somewhat later period than either saprsemia or septi- 
 csemia, but it usually occurs, as pointed out by Watson Cheyne, 
 "within the first week of injur}' or operation." 
 
 The first symptom, of course, in surgical work, is the unhealthy 
 appearance of the wound. The veins leading from the wound may 
 become indurated and painful, and the area of connective tissue 
 drained by the wound inflamed and cedematous. Before this, the 
 patient is uneasy and feverish, loses his appetite, and usually suffers 
 from great thirst. The bowels may be constipated, or there may 
 
76 MANUAL OF MEDICINE 
 
 be persistent diarrhoea. After a slight rise in temperature, rigors 
 occur, during which the temperature may rise 5° or 6" F., or even 
 more. The rigors are followed by very profuse sweating, during 
 which the temperature may fall to 100° or 101°, or may become 
 subnormal. Vomiting is a fairly common symptom. There is furring 
 of the tongue, which later becomes brown, dry, and hard — the so- 
 called " parrot's tongue " ; the teeth and the lips are covered with 
 sordes. The action of the heart becomes weakened, the pulse very 
 rapid, soft, feeble, and irregular. The respirations are increased in 
 number. The muscles become soft and flabby. The patient becomes 
 intermittently delirious, and ultimately falls into the " typhoid state." 
 There may, however, be a more acute delirious condition, the patient 
 usually complaining greatly of headache. Rashes resembling the 
 scarlet-fever rash are described as occurring, first in the large folds 
 of skin spreading up and down the limbs. Sometimes there is a 
 "pustular rash," and "in the later stages of the disease petechise are 
 not uncommon, or extensive cutaneous haemorrhages may occur." 
 The yellowness of the skin and the sweet-hay smell of the breath, 
 described in septicaemia, are also present in this condition. The 
 patients usually succumb to the disease at about the eighth to the 
 twelfth day, though they may live longer. They die of exhaustion, 
 and are usually comatose before death, though some such condition 
 as meningitis, cerebral abscess, congestion of the lungs, ulcerative' 
 endocarditis, may be the immediate cause of the fatal issue. 
 
 The spleen usually becomes enlarged and tender. Abscesses may 
 be formed, which, bursting into the peritoneal cavity, set up peri- 
 tonitis. There may be multiple abscesses in the kidneys, or in the 
 brain, often accompanied by purulent meningitis. Sudden blind- 
 ness, due to plugging of the central artery, or optic neuritis with 
 retinal haemorrhages, may also occur. Suppuration of the serous 
 membranes of the joints and peritoneal and pericardial cavities is 
 frequently met with. Suppurations of the cellular tissue are fairly 
 common. 
 
 The Diagnosis of pyaemia, apart from the condition of a surgical 
 wound, an injury, or middle-ear suppuration, is often very difficult, 
 and unless some local mischief can be traced, pyaemia may readily 
 be mistaken for typhoid fever. Apart from the source of infection, 
 the temperature charts are, however, usually quite different and 
 characteristic — in the case of pyemia the curve being irregular, 
 whilst in the case of typhoid there is the typical evening rise and 
 the gradual upward, but remittent, tendency of the curve during at 
 least the first week. In typhoid fever the rigors and sweating 
 
INFECTIVE ENDOCARDITIS 77 
 
 do not recur, and as a rule no suppurative changes supervene. 
 The rose rash of the latter is perfectly distinct from the petechial 
 haemorrhages so characteristic of pysemia. 
 
 The prognosis is invariably grave, especially where the disease 
 takes the form of ulcerative endocarditis or of pyEemia of the portal 
 system, where the secondary deposits occur in the liver. 
 
 Where no vital organs are affected, the patient may recover ; 
 but there is often considerable loss of tissue or adhesion of joint 
 surfaces, so that deformed and stiff joints may remain. 
 
 The treatment of such a fatal disease is naturally of little effect ; 
 but when such cases do get well, it is because the strength of the 
 patient is kept up, and because there is a free excision of the suppu- 
 rating surfaces, a destruction of the micro-organisms in discharges by 
 a free use of antiseptics, and in extreme cases by the removal, by 
 dissection, of the thrombosed vein or veins, with their contained 
 abscess-producing organisms, and thoroughly draining and washing 
 out the resulting wounds with warm, weak antiseptic solutions. 
 
 G. Sims Woodhead. 
 
 INFECTIVE ENDOCARDITIS 
 
 The term malignant, ulcerative, or infective endocarditis, is 
 applied to a form of* septicaemia or pyaemia in which the virus 
 especially attacks the endocardium. The inflammatory lesions in 
 the endocardium differ essentially from those of a simple or benign 
 endocarditis, such as is associated with acute rheumatism, in con- 
 taining bacteria of various kinds. It is to the presence of these 
 bacteria that the septic character of the symptoms is due. 
 
 Pathology and post-morterQ appearances. — The bacteria 
 most commonly present are the streptococcus pyogenes, the pneu- 
 mococcus, and the staphylococcus pyogenes aureus. Much less 
 frequently other bacteria, such as the gonococcus, the typhoid 
 bacillus, and the tubercle bacillus are present. 
 
 These different bacteria may enter the body through the various 
 portals by which the body is usually invaded by bacteria, through 
 the respiratory or the digestive tract, the ureihra or vagina, or 
 through the skin. As a rule, there is some primary lesion at the 
 seat of inoculation, and thus infective endocarditis is commonly 
 
78 MANUAL OF MEDICINE 
 
 preceded by and occurs as a complication or sequela of such 
 diseases as pneumonia, puerperal fever, septic wounds, etc. Less 
 frequently there is no obvious primary lesion, and therefore no 
 evidence of the mode by which the virus has gained entrance to 
 the body. 
 
 A previous injury to the valves is an important factor in 
 determining their invasion by the bacteria which have gained access 
 to the circulation. Consequently infective endocarditis usually 
 attacks a patient who is suffering from old or even recent valvular 
 disease. Nevertheless, in some cases a previously healthy heart 
 may be attacked. The valves on the left side of the heart — the 
 aortic and mitral — are the parts most frequently affected, either one 
 or the other, or both. Occasionally the valves on the right side 
 are affected, though much oftener than from simple endocarditis, 
 and very rarely there is mural endocarditis without lesion of the 
 valves. 
 
 The inflammation of the endocardium leads to the formation of 
 " vegetations " of a grayish colour, which may be small, or may form 
 large fungating masses. A section through the lesion shows that 
 it consists of a round-celled infiltration. The tissue on the surface 
 of the valve undergoes coagulative necrosis, and a layer of fibrin 
 is deposited upon it from the blood. In the fibrin and necrosed 
 tissue, and to a less extent between the cells, are found the bacteria, 
 which are the cause of the inflammation. Ulceration frequently 
 occurs, and this may be so extensive as to cause perforation 
 of a valve or separation of a large segment. In some cases .a 
 deep ulceration at the base of a valve may lead to aneurysmal 
 bulging. The lesions in the endocardium differ from those of 
 simple acute endocarditis in containing bacteria, in the tendency to 
 necrosis and ulceration, and in the absence of reparative processes. 
 The effects of infecti%-e endocarditis upon the patient are of two 
 kinds, the one being due to the mechanical injury to the valves, and 
 the other to the injurious influence of the bacteria. Valvular in- 
 competency caused by infective endocarditis produces the same effect 
 upon the heart and the other organs as does valvular incompetency 
 caused by simple endocarditis, i.e. h}-pertrophy and dilatation of the 
 heart, congested liver, oedema, and other effects of " backward 
 pressure." 
 
 The bacteria give rise to the usual effects of septicaemia, "cloudy 
 swelling " of the cells of the organs, haemorrhages into the skin and 
 other parts, acute haemorrhagic nephritis, etc. Emboli are frequently 
 carried from the heart to distant parts. If the embolus contains 
 
INFECTIVE ENDOCARDITIS 79 
 
 bacteria it causes inflammatory changes where it lodges. The 
 lungs, spleen, liver and kidneys may thus be riddled with small 
 abscesses similar to those met with in pysemia, and haemorrhagic 
 patches of inflammation may be found in the intestines. The effect 
 of a septic embolus in a medium-sized artery may be to cause 
 ulceration of the wall, which yields to the pressure of the blood, and 
 thus a small aneurysm is produced. If the embolus should be free 
 from bacteria the same effects are produced as in the case of simple 
 endocarditis, i.e. infarcts in the spleen, kidneys, and lungs, cerebral 
 softening, etc. 
 
 It will thus appear that a large number of lesions may be found 
 at a post-mortem examination of the body of a patient dying of 
 infective endocarditis. It is also not uncommon for a secondary 
 lobar pneumonia to develop during the last few days of life. 
 
 With regard to the distribution of the bacteria through the body, 
 they may be found in small numbers in all the organs and in the 
 blood ; but, as a rule, they are limited to the affected valves, and 
 to the secondary lesions in the organs, where they are present in 
 abundance. 
 
 The symptoms of the disease may be divided into two broad 
 groups — cardiac and septic — sometimes the one and sometimes the 
 other predominating. It will be unnecessary to detail here all the 
 symptoms that may arise ; it will be sufficient to mention the more 
 important, a fuller description of those directly due to the heart 
 being set forth elsewhere. 
 
 The cardiac symptoms comprise the usual manifestations due 
 to valvular disease, dyspnoea, dropsy, albuminuria, enlargement of 
 the liver and spleen, etc. On account of the progress of the 
 endocarditis, the bruits are apt to change somewhat rapidly in 
 character and fresh ones may develop. The partial detachment 
 of a valve may give rise to a high-pitched or musical bruit. 
 
 The septic symptoms include pyrexia, which may be continuous, 
 but is much more frequently intermittent and accompanied by 
 rigors ; profuse sweating ; petechiae and haemorrhages into the skin, 
 the mucous membranes, and the retinae ; the presence of blood, 
 albumen, granular and epithelial casts in the urine ; and perhaps 
 evidence of suppuration in the lungs, abdominal viscera, the joints, 
 or the meninges of the brain. 
 
 The occurrence of an embolism may give rise to the charac- 
 teristic symptoms of infarction. If a branch of the splenic artery 
 is blocked, the spleen becomes enlarged and tender ; if the middle 
 cerebral artery is blocked, hemiplegia occurs ; and if a branch of 
 
So MANUAL OF MEDICINE 
 
 ihe pulmonary artery is occluded, pulmonary apoplexy arises, causing 
 haemoptysis and signs of consolidation of the lung. Should the 
 embolus contain bacteria it will set up septic inflammation in the 
 part in addition to its mechanical effect. 
 
 Certain clinical types of the disease may be recognised, but it 
 would be unwise to attempt to draw a too definite line of demarca- 
 tion between them. These types are the cardiac, the septic or 
 pyaemic, and the cerebral. 
 
 In the cardiac type the infective process is engrafted upon an 
 old valvular disease. A patient who has been suffering for some 
 time with cardiac symptoms begins to manifest pyrexia, and be- 
 comes aucemic. For some days, or even weeks, the causation 
 of the pyrexia may remain obscure, but after a time other symptoms 
 develop which point to the nature of the case. The spleen perhaps 
 becomes enlarged and tender ; petechiae appear in the skin ; blood 
 and casts appear in the urine ; or the pyrexia assumes a septic type 
 with rigors and profuse sweating. The cardiac symptoms undergo 
 aggravation, and embolism may occur. The patient gradually fails, 
 and usually dies after some months from the combined effects of 
 the cardiac affection and of septicaemia. 
 
 The septic or pyce7)iic type may occur in patients suffering from 
 old cardiac mischief, or in those with hearts previously healthy. In 
 either case the septic symptoms are the most prominent feature 
 of the attack, the cardiac symptoms remaining in the back- 
 ground. If the heart was previously healthy, bruits indicative of 
 lesions of the infected valves generally develop sooner or later, but 
 in some rapidly fatal cases no evidence of cardiac affection is forth- 
 coming during life. The principal symptom is severe fever with 
 rigors and sweating. Haemorrhages frequently appear in the skin, 
 the retinae, and the mucous membranes. Blood and casts appear 
 in the urine. The joints may suppurate and there may be cough 
 with blood-stained sputum. The spleen is usually enlarged. There 
 are the usual symptoms of high fever, a rapid pulse, a dry brown 
 tongue, hurried respiration, delirium, diarrhoea, and so on. Such 
 cases usually take a rapid course, the patient dying in a few weeks 
 after the onset. In some cases the pyrexia is continuously high, 
 105° or higher, and the patient falls into a "typhoid state," so that 
 a typhoid type has been described, but such a distinction seems to 
 be unnecessary. 
 
 In the cerebral type the principal symptoms are cerebral, con- 
 vulsions, headache, etc. ; and in these cases meningitis is usually 
 present. 
 
INFECTIVE ENDOCARDITIS gi 
 
 The prognosis of infective endocarditis is always grave. The 
 majority of cases end fatally. Nevertheless, recovery may ensue 
 with permanent injury to the valves. In many cases the patient 
 apparently recovers, but after some time — it may be months — a 
 fatal relapse occurs. 
 
 The diagnosis of infective endocarditis is often difficult. Con- 
 tinued pyrexia arising in the subject of old cardiac disease should 
 always be regarded with suspicion, but until more definite symptoms 
 arise a diagnosis can hardly be made. In addition to pyrexia the 
 most important symptoms for diagnostic purposes are petechiee in 
 the skin, the presence of blood and casts in the urine, and tender- 
 ness and enlargement of the spleen. Profound ansmia is also a 
 sign of some value. 
 
 In the septic type of the disease the cardiac symptoms may be 
 so slight that a diagnosis from septicsemia is impossible. This, 
 however, is a matter of but little importance ; for we must regard 
 the affection of the endocardium as an accidental, rather than an 
 essential feature of this type of the disease. The occurrence of 
 embolism and the development of cardiac bruits render the 
 diagnosis clear. 
 
 In any case the discovery of some source of infection, such as a 
 previous pneumonia, or a septic wound, should aid in forming an 
 opinion, but it must be remembered that a primary lesion is by 
 no means always to be detected. 
 
 Perhaps typhoid fever is the disease most frequently mistaken 
 for infective endocarditis. The tumidity of the abdomen, the 
 presence of spots, and the temperature curve in the former, and the 
 occurrence of emboli, a petechial eruption, and cardiac bruits in the 
 latter, are distinguishing features. Rigors are much more frequent 
 in infective endocarditis than in typhoid fever. In doubtful cases 
 the blood should be tested for the "typhoid reaction," which, if 
 present, is almost absolutely distinctive. 
 
 A bacteriological examination of the blood in infective endo- 
 carditis may enable us to say what bacteria are causing the infection. 
 But unfortunately for diagnostic purposes the bacteria are usually 
 absent from the circulating blood, and at the best are only present 
 in very small numbers during life ; consequently the examination 
 frequently fails to reveal their presence. The best prospect of 
 success is to examine a large quantity of blood — five or ten cubic 
 centimetres. Such a quantity can readily be obtained by means of 
 a sterile syringe from one of the superficial veins in the arm. 
 
 In the treatment of ulcerative endocarditis, quinine, arsenic, 
 
 VOL. I G 
 
82 MANUAL OF MEDICINE 
 
 and sulpho-carbolates have in some cases appeared to be beneficial, 
 and when there is high fever the usual antipyretics may be ad- 
 ministered. If we have evidence, either from the source of infection 
 or from a bacteriological examination, that the endocarditis is due 
 to the streptococcus pyogenes, antistreptococcic serum should be 
 administered. In one case under the care of the writer, the daily 
 administration of the serum for some weeks apparently led to the 
 recovery of the patient. An antipneumococcic serum will probably 
 be found useful in cases caused by the pneumococcus. 
 
 J. W. Washbourn. 
 
 GONORRHCEAL INFECTION 
 
 In addition to the urethral discharge and those more immediate 
 complications which are treated of in surgical works, gonorrhoea is 
 not unfrequently accompanied or followed by affections of distant 
 parts, and occasionally of internal organs. The structures most 
 commonly affected are the joints, tendons, and fasciae, while less 
 frequently observed or diagnosed as specifically gonorrhoeal are 
 such complications as iritis, conjunctivitis, sclerotitis, myositis, 
 pleuritis, neuritis, meningomyelitis, endocarditis, and arteritis. In 
 some instances of these metastatic or secondary inflammations the 
 presence of the gonococcus has been demonstrated and the fact of 
 their specific origin established. The infection is, therefore, on 
 septicsemic lines, that is to say, the specific organism finds its way to 
 distant parts through the blood or lymph channels, and having 
 arrived at its ultimate destination, excites secondary local mischiefs. 
 It is possible, however, that the circulation of gonotoxin is re- 
 sponsible for at least some of the symptoms and phenomena of 
 secondary gonorrhceal infection. In this connection it may be 
 mentioned that the infection may be acquired accidentally or 
 imparted experimentally either by inoculation with gonorrhoeal 
 discharge, e.g. on the conjunctiva, or by means of pure cultures of 
 the coccus. 
 
 Of these secondary infections by far the most common or most 
 noticed is arthritis., so much so that " gonorrhoeal rheumatism " so- 
 called was until quite recently the recognised term used to express 
 the generalisation of the gonorrhoeal virus. Though any and every 
 
GONORRHCEAL INFECTION 83 
 
 joint may suffer, those most frequently attacked are the knees, after 
 which come the ankle and wrist joints, then those of the elbow, 
 hands, and feet, and the sterno-clavicular, temporo-maxillary, and 
 sacro-iliac. 
 
 The affection may commence at any time in the course of the 
 urethral discharge, whether the flux be in the acute or chronic 
 stage. Thus it may manifest itself a few days after the first appear- 
 ance of the discharge, or not until this has been existing for weeks, 
 and sometimes sets in after the complete disappearance of the 
 urethritis. 
 
 Sjrmptoms. — As a rule the arthritis appears suddenly, and is 
 marked by swelling of a joint or joints, often, but not always, with 
 redness of the skin over them, and pain and tenderness, frequently 
 worse at night. The swelling is due to exudation not only into, but 
 around the joint or tendon (periarthritis). The onset may be associ- 
 ated with constitutional symptoms, such as pyrexia, furred tongue, 
 malaise, general pains, and other febrile phenomena. These general 
 symptoms, however, may be absent or but little marked, more 
 especially if the arthritis supervene when the more active stage of 
 the discharge has passed away. The pain, though it may be severe, 
 is usually of a dull, aching character. Inspection of an affected 
 joint or tendon usually indicates the presence of effusion into the 
 joint or within the sheath, and while palpation confirms this, it 
 invariably imparts the notion of exudation into the capsule or the 
 sheath and the adjacent parts. This condition lasts for some time, 
 usually weeks, or even months, and the subsidence of the swelling 
 is almost invariably accompanied by weakness and stiffness of the 
 joint. The stiffness, partly due to exudation into the capsule of 
 the joint and partly to adhesions, may in severe cases terminate in 
 ankylosis and chronic osteo -arthritic changes. Though stiffness 
 and ankylosis of joints are not uncommon sequelae, suppuration is 
 rare, and its occurrence may be regarded as indicating a mixed 
 infection. 
 
 The arthritis may be multiple and is often symmetrical, as seen 
 in affection of both knees, ankles, or hands, but this is by no means 
 always the case, for the inflammation may be limited to one joint, 
 tendon, or fascia of one side, and this is m.ore common in the 
 knee and elbow. As a general rule, when the inflammation has 
 subsided in the affected part there is little tendency to recurrence, 
 unless there be a simultaneous recrudescence of the discharge or 
 the patient again contract a gonorrhoea. 
 
 Inflammations of tendons and their sheaths, of fasciae, especially 
 
84 MANUAL OF MEDICINE 
 
 of the back, of the thigh, and of the soles of the feet, are quite 
 common as comphcations of gonorrhoea, and what has been said 
 with regard to joints will equally well apply to them. 
 
 Though arthritis and synovitis are by far the most frequent 
 expressions of generalised gonorrhoea! infection, yet the other com- 
 plications already enumerated should not be lost sight of. During 
 the onset of gonorrhoea! arthritis the patient may suffer from 
 catarrhal ophthalmia, sometimes accompanied by iritis and sclero- 
 titis. The injection of the sclerotic, which is quite distinct from 
 the gonorrhoeal ophthalmia due to direct infection with the urethral 
 discharge, is regarded by some as almost pathognomonic of 
 gonorrhoeal arthritis in adults. Of recent years attention has been 
 called to more severe and important complications, such as 
 pleuritis, peri- and endo - carditis, and though affection of the 
 heart is regarded as a symptom diagnostic of " rheumatism," it 
 has been rendered certain that valvulitis may be the result of 
 gonorrhoea, indeed one such case was followed by gangrene of 
 one of the lower limbs, presumably embolic in nature. The writer 
 has for years expressed the opinion that many examples of chronic 
 arteritis, especially some cases of atheroma of the aorta, are in all 
 probability due to gonorrhoea. Cases of myositis, neuritis, and 
 meningo-myelitis as complications or sequelae of gonorrhoea have 
 been recorded. In the character of its complications it will be 
 noted that gonorrhoea closely resembles other specific infections. 
 
 In most cases the prognosis is favourable, but the course of 
 the disorder is not unfrequently lengthy and tedious. There is, 
 however, little tendency to relapse or recrudescence. There is 
 always the possibility of permanent stiffness, and even of ankylosis, 
 to be reckoned with, while the occurrence of damage to vital organs 
 should be borne in mind. Death with hyperpyrexia has been known 
 to occur. 
 
 The diagnosis of the arthritis, or other secondary morbid 
 development, must principally depend on the coexistence or recent 
 occurrence of a gonorrhoeal discharge. The evidence to be derived 
 from a bacterioscopic examination of the urethral or vaginal discharge 
 is of less practical value than might be hoped ; for in the earlier 
 stages there is little need for such confirmation, and in the later 
 or chronic stages there is much difficulty in demonstrating the 
 gonococcus. Still, it might have a negative value in cases of gouty 
 urethritis and balanitis associated with arthritis. 
 
 The remote results of gonorrhoeal infection, arthritic and other, 
 are met with in both sexes, though probably with greater frequency 
 
GONORRHCEAL INFECTION 85 
 
 in the male. Difficulties, due to ignorance or purposed conceal- 
 ment, frequently arise in connection with obtaining precise knowledge 
 in the case of females. The various manifestations predominate in 
 young adult life, but may be met with at all previous ages. In 
 females the coexistence of chronic uterine affection, vaginal dis- 
 charge, and arthritis may suggest the real nature of the disease. 
 
 The conjunction of ophthalmia and arthritis is almost sufficient 
 evidence in itself of gonorrhoeal infection. It is in this form that 
 the disease manifests itself in infants. Inoculation of the conjunc- 
 tiva takes place at birth, a few days after which the ophthalmia 
 appears, to be followed in two or three weeks by the arthritis. Even 
 in such cases there is the same preference exhibited by the knees as 
 seen in adults, and the general features of the joint affection corre- 
 spond to the above description. In very young subjects the disease 
 seems to be more amenable to treatment, and to run a course of a 
 few weeks only, without the obstinate persistence so characteristic 
 of its occurrence in the grown up. In older children the affections 
 of the joints, tendons, or fasciae may follow on accidental conjunct 
 tival inoculation or criminal vulvo-vaginal infection. 
 
 The affection of certain joints, such as the sterno-clavicular, 
 sacro-iliac, and temporo-maxillary, which are less frequently attacked 
 in ordinary rheumatism, should give rise to suspicion. Though 
 gonorrhoeal arthritis is not unfrequently polyarticular, it exhibits 
 less tendency than articular rheumatism to shift from one joint (or 
 joints) to another. 
 
 Treatment. — No specific to abbreviate the tedious and pro- 
 tracted course of the disease has yet been discovered. The treatment 
 must be palliative, symptomatic, and chiefly on surgical lines ; 
 indeed the very story of the disaster clearly indicates that any 
 urethral discharge should receive special attention. Painting a 
 joint or tendon very freely with liq. iodi fort, sometimes has a 
 good effect, while the withdrawal of fluid from joints which exhibit 
 little tendency to resolution and irrigation with a solution (i in 
 4000) of perchloride of mercury is to be recommended. In some 
 cases the application of belladonna or of Scott's dressing is useful. 
 It may be necessary to apply splints in the acute stage to keep the 
 joints at rest, and afterwards to use friction or massage, which may 
 be advantageously combined with the local application of dry heat. 
 Sometimes it is necessary to break down adhesions under an 
 anaesthetic. Should any of the more serious complications of the 
 infection manifest themselves, e.,i,': pleurisy, pericarditis, or endo- 
 carditis, these must be treated on appropriate lines. The diet should 
 
86 MANUAL OF MEDICINE 
 
 be nutritious and not too stimulating; the bowels must be carefully 
 regulated. For the pain, it is best to rely on opium or morphia. 
 The most approved internal remedies are quinine, with potassium 
 iodide and arsenic, though occasionally guaiacum and sarsaparilla 
 seem to do good. Ordinary anti-rheumatic remedies, such as the 
 salicylates, have no effect. 
 
 R. G. Hebb. 
 
 TYPHOID FEVER 
 Syn. Enteric Fever 
 
 An infectious fever characterised by inflammation and sloughing 
 of the solitary and agminate glands of the small intestine, enlarge- 
 ment of the mesenteric glands and spleen, and a roseolous rash. 
 The disease is caused by the invasion of a specific microbe — the 
 bacillus typhosus, or Ebertlis bacillus. 
 
 Bacteriology. — The bacillus typhosus is a flagellated bacillus 
 usually 2 /i, to 4 /A long and 0.5 /x. thick. In liquid media it shows 
 active movements (Plate I.). It presents a very close resemblance both 
 in structure and habit to the bacillus coli cojmnunis, from which, how- 
 ever, it is specifically distinct. It may readily be cultivated in the 
 usual artificial media, both liquid and soHd, in which it multiplies 
 freely. It flourishes best at about the temperature of the body, 37° C. 
 (98.6" F.). It ceases to grow below 9° C. (48.2° F.), or above 42° C. 
 (107.6° F.). It is killed by a few minutes' exposure to the boiling 
 point, or by half-an-hour's exposure to a temperature of 60° C. 
 (140° F.). It will maintain its vitality for a considerable time, many 
 days or even weeks, in water both fresh and salt, especially when 
 sterilised, but it does not multiply in water. It will also maintain 
 its vitality for many weeks when mixed with sand or earth and dried, 
 and may then be blown about as dust. In soils contaminated with 
 animal matter it will continue to grow and spread indefinitely at 
 the ordinary temperature of the air, but in virgin soils it dies out. 
 Exposure to sunlight impairs its vitality. It has been found alive 
 in the pallial cavity, and in the rectum of oysters and other bivalve 
 molluscs living in water contaminated with sewage, and it has been 
 found to be capable of penetrating eggs immersed in liquid cultures, 
 
TYPHOID FEVER 87 
 
 It grows freely in milk and butter. When cultivated in artificial 
 media it very rapidly loses its virulence, which can be restored and 
 intensified to the highest pitch by passing it through the peritoneal 
 cavity of successive animals. 
 
 When cultivated the bacillus generates poisons which are both 
 contained in its substance and diffused in the medium. These 
 present some differences of action, but generally when injected into 
 the animal body they cause fever, followed by collapse, injection of 
 the mucous membrane of the intestine, mucous diarrhoea, and fatty 
 degeneration of the heart. The bacillus itself, when introduced 
 either into the peritoneal cavity or subcutaneously, is capable, when 
 virulent, of becoming diffused, and may be found in the blood, 
 spleen, liver, and other internal organs, but shows no predilection 
 for the intestinal glands, and does not produce the specific intestinal 
 lesions of human typhoid, though the poisons generated by it 
 cause intestinal injection and diarrhoea, as do those of many 
 other pathogenetic organisms. So that it is possible in the human 
 subject for the symptoms of enteric fever to occur without intestinal 
 lesions being found on post-mortem examination ; and such cases 
 have been reported. It was for a long time doubtful whether the 
 lower animals were capable of acquiring the human form of typhoid, 
 recently, however, Remling appears to have succeeded with rabbits 
 and rats by giving intensely virulent cultures with the food, and so 
 produced infiltration and ulceration of the agminate glands. It 
 would appear, therefore, that in the human subject the bacillus is 
 introduced by swallowing, and that the intestinal glands are primarily 
 affected as being the seat of absorption and not secondarily as the 
 result of a blood infection. 
 
 In man the typhoid bacillus occurs in the inflamed intestinal and 
 mesenteric glands ; in the spleen ; less abundantly in the intestinal 
 contents and the faeces ; it has also been found in the liver, the 
 bile, the urine, the blood, the cerebral meninges and ventricles, and 
 in secondary abscesses of distant parts where it has been found still 
 alive, even as long as seven years after the attack. It is, therefore, 
 evident that though chiefly located at the seats of absorption it 
 becomes more or less diffused through the system. It does not 
 usually cause suppuration, and the secondary abscesses are mostly 
 due to pyogenic microbes, but in some cases these abscesses have 
 been found absolutely sterile as regards other than the typhoid 
 organisms. 
 
 Etiology. — First to be considered are {a) the conditions which 
 favour the multiplication of the bacillus and facilitate its entrance j 
 
88 MANUAL OF MEDICINE 
 
 and, secondly, (^) those which affect the susceptibihty of the in- 
 dividual. 
 
 (a) We may regard the bacillus either as a saprophyte which 
 naturally lives in soil contaminated by animal matter, but which is 
 capable of becoming parasitic when it obtains entrance into the 
 body — a facultative parasite ; or more probably as an organism which 
 only obtains its full development and properties in the animal body, 
 but which can maintain an existence outside — a facultative sapro- 
 phyte. It is evident that no sharply-defined line of demarcation 
 can be drawn between these two classes, but the question is im- 
 portant with regard to the occurrence of apparently spontaneous or 
 ^e novo outbreaks of the disease. 
 
 The bacillus in all probability obtains entrance into the system 
 by being swallowed, either with the food or drink, or by putting 
 into the mouth some contaminated object, as, for instance, a soiled 
 finger, or by drawing into the mouth or pharynx the germs suspended 
 in the air. 
 
 The most common cause of outbreaks of typhoid is contamina- 
 tion of the drinking water. This may be due to soakage of sewage 
 or feeces into wells, sewage contamination of rivers, lakes, ponds, 
 springs, reservoirs. Permanent infection of the soil by the typhoid 
 bacillus may render the disease endemic in a locality, and give 
 rise to outbreaks without any fresh importation of the poison. 
 Faulty construction of cisterns, waste pipes, water closets, will cause 
 localised outbreaks by contaminating the house supply. 
 
 Milk and articles of food containing or derived from milk, as 
 butter, creams, ices, frequently spread the disease. There is no 
 reason for supposing that the milk as passed from the cow is ever 
 infected ; in most cases the contamination is due to the water used 
 to wash the dairy utensils, or which has been mixed with the 
 milk. Not only does the bacillus maintain its vitality but freely 
 multiplies in milk. Many other articles of food which are eaten 
 uncooked are liable to spread the disease, especially oysters cultivated 
 in estuaries which receive sewage, water cresses grown in ditches 
 contaminated by sewage, lettuces, and other salads watered with 
 polluted water. It is probable that articles of food, especially in hot 
 countries, may be contaminated by flies to whose feet the typhoid 
 germs may easily adhere. Outbreaks of typhoid have been ascribed 
 to eating diseased meat, but some doubt exists as to the exact nature 
 of the disease in these outbreaks. In a recent one a specific bacillus, 
 closely resembling but distinct from the typhoid bacillus, the bacillus 
 enteritidis of Gartner, was discovered. 
 
TYPHOID FEVER 89 
 
 Typhoid fever may also be acquired through aerial infection, by 
 inhalation of emanations from drains, sewers, water closets, privies, 
 dust heaps, faecal discharges which have been allowed to dry on the 
 patient's linen or person, or in receptacles. Probably in these cases 
 the bacillus has become dried and disseminated as dust, but experi- 
 ments have shown that a very slight current of air, 4 metres per 
 second, will raise germs into the atmosphere from the surface of 
 liquids or wet ground, and a current of 30 metres per second from 
 dry surfaces. It is not, however, probable that any distant infection 
 can take place in this manner, as free dilution with air renders the 
 virus inert. 
 
 Direct contagion from the sick to the healthy plays but a small 
 part in the spread of the disease. There is no reason to suppose 
 that the poison is given off in the breath or emanations from the 
 body, but is contained only in the fteces and to a less degree in the 
 urine, and if these be properly disinfected and disposed of, strict 
 cleanliness be observed, and attention be paid to the disinfection 
 of the soiled linen, the risk of contagion may be reduced to a 
 minimum. Nevertheless, it has not been found possible entirely 
 to prevent the spread of the disease to the attendants. It seems 
 probable that the alvine discharges are less virulent when first passed 
 than after the lapse of some little time. The conditions which 
 favour the multiplication of the bacillus and the intensification of 
 its virulence outside the body are still imperfectly known. 
 
 The disease appears to occur in all climates, but is most 
 prevalent in temperate and subtropical regions. In temperate 
 climates it is especially an autumnal disease. In this country 
 it is most prevalent during the months of September, October, 
 November ; least so in April, May, and June. A hot dry summer 
 increases the autumnal prevalence. Great importance was attached 
 by Pettenkofer to the height of the ground water, a low ground 
 water coinciding with outbreaks of the disease ; whether this be due 
 to this condition favouring the contamination of the water supply, 
 or to its facilitating soil pollution and the rising of the germs into the 
 air is uncertain. In England this relation of the height of the 
 ground water to outbreaks of the disease has not been observed. 
 
 (b) The conditions affecting the susceptibility of the individual 
 are as follows : — 
 
 Typhoid fever occurs at all ages, but is most frequent between 
 five and thirty -five. Exceptional cases have been met with as 
 young as three months, and as late as seventy years. It is equally 
 common in both sexes, and attacks persons in all ranks of life. 
 
90 MANUAL OF MEDICINE 
 
 One attack confers immunity, though not an absolute one, against 
 a second. New-comers into infected localities are generally con- 
 sidered to be more susceptible than old residents ; probably these 
 have been rendered more or less immune by repeated slight in- 
 fections. In India, where the disease is extremely common and 
 fatal among the English sojourners, especially the new-comers, the 
 natives used to be regarded as very little susceptible, but recently 
 the observations of Major Frazer, M.D., founded on Widal's test, 
 tend to show that this immunity of the native population is due to 
 a large proportion of them having been attacked in early childhood, 
 when the disease is rarely fatal. European troops, when campaign- 
 ing in tropical and subtropical climates, are very subject to typhoid, 
 but the causes of this prevalence are still obscure. 
 
 Morbid anatomy. — Together with the lesions due to the 
 typhoid bacillus there are usually others caused by other patho- 
 genetic organisms, streptococci, staphylococci, etc. 
 
 The characteristic typhoid lesions are acute inflammation, usually 
 terminating in necrosis and ulceration of the agminate and solitary 
 glands of the small intestine, and sometimes of the solitary glands 
 of the large bowel ; inflammatory infiltration of the mesenteric 
 glands ; and parenchymatous swelling of the spleen. 
 
 The changes in the glands consist of hyperaemia, with hyper- 
 plasia and exudation of lymphoid cells. The agminate glands in 
 this stage form raised patches of a pinkish-gray colour, with reticu- 
 lated, rugose, or smooth surfaces, accordingly as the infiltration is 
 uniform in all the tissues of the patch, or is greater in the follicles, 
 or in the intervening tissues. This stage usually attains its maximum 
 development in about ten days. The solitary glands present similar 
 changes. The next stage consists of necrosis of many of the 
 patches and solitary glands, the swollen tissues become converted 
 into yellowish-brown sloughs, the separation of which, by a process 
 of ulceration, occupies the third and often part of the fourth week. 
 After the separation of the sloughs the typhoid ulcers are left. 
 Those corresponding to the agminate glands are oval in shape, 
 their long diameter corresponding to the direction of the intestine ; 
 they are situated on the side of the bowel opposite to the attach- 
 ment of the mesentery ; those corresponding to the solitary glands 
 are circular in shape. The surface of the ulcers is smooth, their 
 edges undermined ; their depth depends on the extent of the 
 previous inflammatory infiltration. The floor may be formed by 
 the muscular or the peritoneal coat, or the latter may itself be in- 
 volved in the sloughing process, and as the slough separates per- 
 
TYPHOID FEVER 91 
 
 foration may take place. As the ulcers heal the undermined edges 
 become adherent to the subjacent tissues, the surface granulates, 
 the epithelial covering is restored, and no contraction takes place. 
 This healing process occupies an uncertain time, usually a week or 
 ten days, but the ulcers may pass into what is termed an atonic con- 
 dition and become chronic, and sometimes even extend and give 
 rise to haemorrhage or perforation when the patient is apparently 
 convalescent. These changes are always most marked and most 
 advanced in the lower part of the ileum. Sometimes the solitary 
 glands throughout the whole course of the large intestine are 
 similarly affected. 
 
 The mesenteric glands corresponding to the affected part of the 
 intestine become swollen by cellular hyperplasia and exudation, and 
 are very hypersemic. Sometimes they soften, break down, and may 
 burst into the peritoneal cavity ; generally resolution takes place, 
 and they get restored to their normal condition. Occasionally they 
 become caseous, or ultimately atrophy. 
 
 The spleen becomes greatly enlarged from cellular hyperplasia 
 and hyperaemia ; it is softer and redder than in health. With the 
 subsidence of the fever it returns to its normal condition. Both 
 the spleen and the mesenteric glands contain the bacilli in large 
 numbers. 
 
 There is usually more or less cloudy swelling of the secreting 
 cells of the glandular organs. 
 
 The liver often presents interstitial deposits of leucocytes. In 
 rare cases the gall-bladder has been found ulcerated, and even 
 perforated. 
 
 Occasionally there is parenchymatous nephritis, more often the 
 renal change does not go beyond cloudy swelling of the epithelium. 
 
 The heart is often softened, the muscular fibres granular, or 
 even fatty, and the striation obscured. 
 
 There is usually hypostatic congestion of the lungs ; sometimes 
 lobular or lobar pneumonia. Occasionally there are deep ulcers in 
 the larynx, usually on the posterior surface between the vocal cords, 
 but the epiglottis and the mucous membrane covering the arytaenoid 
 cartilages may be affected ; these ulcers may extend to and cause 
 necrosis of the cartilages. 
 
 Many of the voluntary muscles, especially the recti abdominis 
 and the adductors of the thigh, often show the changes termed 
 Zenker's vitreous degeneration, or myositis typhosa, though they are 
 not peculiar to typhoid fever. The muscular fibres undergo coagula- 
 tion necrosis ; they swell up, lose their striation, become homogeneous, 
 
92 MANUAL OF MEDICINE 
 
 so as to resemble cylinders of wax, and then break up into fragments 
 by transverse fissures and are absorbed ; at the same time there is 
 an interstitial exudation of leucocytes. If recovery takes place the 
 fibres are regenerated by a cell growth within the tube of sarco- 
 lemma. Sometimes this process is accompanied by heemorrhage 
 into the muscle. 
 
 Other secondary inflammations and degenerations may occur. 
 Superficial osteitis causing subperiosteal suppuration is not very 
 infrequent ; abscesses may form in various parts ; venous thrombosis, 
 peripheral neuritis, degenerations of the spinal cord, but none of 
 these are special to typhoid fever. 
 
 Incubation. — The usual period of latency or incubation after 
 infection varies from ten to fourteen days, but it may be as short as 
 five, or as long as twenty-one days, or even longer. Usually this 
 period is free from symptoms ; sometimes there is some degree 
 of malaise present, which may gradually deepen and pass into 
 the febrile stage. Occasionally at the commencement there is 
 diarrhoea, and sometimes, especially in children, vomiting, these 
 symptoms subsiding after a few days. 
 
 Symptoms and course. — The onsef of the disease is often 
 somewhat insidious, the patient feels chilly, complains of languor 
 and weariness, suffers from headache and pains in the limbs, passes 
 restless nights with sleep disturbed by dreams, the tongue is coated, 
 red at the tip and edges. Frequently there is slight bronchitis. The 
 temperature rises gradually, often by regular gradations, a degree 
 or more every successive night, the morning temperature being a 
 degree lower than the evening one. These symptoms sometimes con- 
 tinue five or six days before the patient is compelled by increasing 
 debility to take to his bed. In other cases the onset is more sudden ; 
 there are initial rigors, severe headache and pains in the back and 
 limbs, with rapidly increasing prostration, so that the patient has to 
 lie up at once. 
 
 By the end of the first week the characteristic symptoms of the 
 disease are usually well marked. The patient has a depressed 
 languid aspect ; he complains of headache, thirst and general 
 malaise ; the cheeks often show a circumscribed pink flush ; the 
 pupils are somewhat dilated, but there is no injection of the 
 sclerotics so often present in typhus. The lips are dry and 
 parched, often desquamating ; the tongue coated on the dorsum with 
 a white fur, red at the tip and edges. In most cases the bowels are 
 relaxed, two to four loose light yellow motions, resembling pea-soup, 
 are passed daily, but not unfrequently there is constipation, and the 
 
TYPHOID FEVER 93 
 
 motions are solid. The abdomen is usually somewhat distended ; 
 often there is gurgling on palpation in the right iliac fossa. On 
 percussion the spleen is found to be enlarged, perhaps measuring 
 five inches in the vertical line, but not usually projecting below the 
 costal arch. The pulse varies from 100 to 120; it is moderately 
 full but very compressible, the arterial tone being low. Often 
 drawing the back of the finger across the skin of the trunk pro- 
 duces a well-marked red tachc with a pale border. The iemperattire 
 varies from 102° to 104° at night, and is a degree or less in the 
 morning, but it is very labile, i.e. easily affected by transient con- 
 ditions. The skifi is dry, but occasional perspirations are not in- 
 frequent. Sometimes there is a slight general febrile blush, and as 
 the throat is often dry and a little reddened, and the tongue also 
 red, a suspicion of scarlatina may be excited. Occasionally there is 
 epistaxis, which may be very profuse and occur at any period of 
 the fever. 
 
 The characteristic rash of typhoid usually makes its appearance 
 between the seventh and twelfth days, but may be seen as early as 
 the fifth, or delayed till the fourteenth day or later. The rash con- 
 sists of slightly elevated circular papules of a rose colour, which dis- 
 appear with pressure and reappear when the pressure is removed ; 
 their number varies greatly ; there may be only three or four visible 
 on the abdomen, or they may be thickly scattered over the trunk 
 and extend to the limbs, and in rare cases they are seen on the face. 
 They have a circular outline, and are regular in form, measuring 
 two or three lines in diameter. When the rash is very intense, they 
 may be darker in colour and persist on pressure, owing to some 
 effusion of the colouring matter of the blood, but they never become 
 converted into petechiae. Occasionally a minute vesicle forms on 
 them. They are developed in successive crops, each spot lasting 
 three or four days, and the total duration of the eruption is usually 
 from ten to twenty-one days, less in children, but they may con- 
 tinue to come out during convalescence, and usually recur when a 
 relapse takes place. The rash is not invariably present, especially 
 before the age of ten or after that of thirty. There is no necessary 
 connection between the amount of the rash and the severity of the 
 attack. 
 
 Pale bluish spots are occasionably visible, which are not raised 
 and do disappear on pressure, the tache bleuatre of Trousseau. 
 Their most frequent seat is the abdomen and thighs ; they have 
 been attributed to lice, but are not necessarily associated with them! 
 
 Sometimes, as in other infectious fevers, the disease assumes a 
 
94 MANUAL OF MEDICINE 
 
 hsemorrhagic form and purpuric spots appear on the skin, and there 
 may be haemorrhages from the mucous membranes. Though the 
 prognosis in these cases is unfavourable, nevertheless recovery may 
 take place. 
 
 The iirine presents the usual characters of febrile urine : it is 
 concentrated, diminished in quantity and of high specific gravity ; it 
 contains an excess of urea and uric acid, and of the sulphates 
 and potassium salts, and a diminished amount of sodium chloride. 
 In severe cases it is often albuminous. 
 
 EhrlicKs test—Diazobenzol reaction. — In a large proportion of 
 cases this reaction is present, and is not without value as a diagnostic 
 sign. Two solutions called A and B are prepared. A consists of 
 a 20 per cent solution of hydrochloric acid saturated with sulphanilic 
 acid. B^ of a half per cent solution of sodium nitrite. Immedi- 
 ately before using, one part of B is mixed with twenty-five parts of 
 A^ an equal volume of urine is added in a test-tube and strong 
 liquor ammonia is dropped into the mixture or allowed to flow 
 down the side of the tube. At the junction a crimson ring forms ; 
 if the tube be shaken the froth is coloured pink ; ordinary urine 
 gives a more or less deep orange colour. In applying the test care 
 should be taken to mix the solutions accurately. The reaction is 
 seldom absent in typhoid, even in mild cases, and is valuable as a 
 negative test ; it is, however, occasionally present in other diseases, 
 especially measles, pneumonia, tuberculosis. Liquid cultivations of 
 the typhoid bacillus are said to give it. 
 
 The urine in typhoid fever possesses highly toxic properties, and 
 the typhoid bacillus appears to be usually present in it. 
 
 The blood in the later stages of typhoid shows important changes. 
 The red cells and the haemoglobin are much diminished ; the 
 leucocytes are also usually rather decreased in number, though 
 only slightly ; these changes are most marked in the third and 
 fourth weeks. Secondary inflammations will cause an increase in 
 the leucocytes. This absence of leucocytosis in typhoid may have 
 a diagnostic value and help to distinguish it from inflammatory and 
 septicsemic fevers. 
 
 During the second and third weeks the symptoms become more 
 severe, the prostration increases, there is rapid wasting, the tongue 
 often becomes denuded, red, glazed and transversely fissured, the 
 lips are dry and cracked ; often there are sordes on the teeth. The 
 pulse becomes dicrotic from loss of arterial tone ; it may vary in 
 frequency from 1 1 2 to 140; if persistently above 120 it is an un- 
 favourable sicrn. The first sound of the heart becomes altered in 
 
"TYPHOID FEVER 95 
 
 quality, becoming short, more like that of the second. Signs of 
 hypostatic congestion of the lungs may appear, increased frequency 
 of breathing, duskiness of the countenance, crepitations over the 
 back of the chest. Delirium is not infrequent, at first on waking 
 out of sleep ; it is usually of a quiet muttering character, sometiaies 
 noisy and violent. In very severe cases the patient may pass into 
 what is called the " typhoid state " ; there is delirium with stupor, 
 great prostration, the patient sinking down in the bed, and sub- 
 sultus tendinum ; the urine and motions are passed in the bed, or 
 the bladder may be paralysed. Bed-sores are liable to form. The 
 patient may die in a state of coma. These severe symptoms are 
 only occasionally present. 
 
 During the third week the diarrhoea usually becomes more 
 severe ; there may be six or eight motions in the twenty-four hours ; 
 they are often very offensive, alkaline, and may contain shreddy 
 sloughs. Hsemorrhage, slight or profuse, is liable to occur, or 
 perforation. 
 
 The temperature during the third week becomes more remittent 
 in type, and towards the end or the beginning of the fourth begins 
 to fall, the morning temperature falling more rapidly than the even- 
 ing. It is, however, by no means unusual for the temperature to 
 keep up during the first part or the whole of the fourth week, or 
 even longer. In favourable cases, during the fourth week defer- 
 vescence is completed, and the temperature usually remains sub- 
 normal for some time, but is easily sent up by slight causes ; the 
 appetite returns, often before the temperature has fallen to normal, 
 and convalescence is established, though liable to be interrupted by 
 many accidents. 
 
 Typhoid fever presents great variations in its characters and 
 severity, and many forms are described, which, however, are not 
 distinguished by any strict line of demarcation. Considerable 
 difference has been noted in the prevalence of certain symptoms in 
 various epidemics. In some the symptoms due to the blood-poison- 
 ing are predominant, in others those caused by the local lesions. 
 
 Among the more common forms are :— 
 
 1. The acute form. — This is characterised by sudden onset, 
 severe febrile symptoms from the first, rigors, rapid rise of tempera- 
 ture, headache, oppression, early delirium, and death may take 
 place, though this is very exceptional, during the second week. The 
 intestinal lesions are not necessarily excessive, and the later stages 
 of the fever may be less severe. 
 
 2. The abortive form. — Here the earlier symptoms may be 
 
96 MANUAL OF ^lEDICINE 
 
 severe, but sometime between the eighth and fourteenth days a 
 rapid defervescence takes place. Probably in these cases the 
 intestinal lesions are slight and have not gone on to the sloughing 
 stage. 
 
 3. The latent or ambulant form. — Here the general febrile 
 disturbance is comparatively slight, but the intestinal lesions present 
 the usual characters. In consequence the patient continues to 
 follow his usual avocation and walks about during the whole or a 
 great part of his illness, though suffering from malaise and diarrhoea. 
 The neglect of proper precautions renders these cases very liable to 
 haemorrhage and perforation. 
 
 4. The afebrile form. — Cases have been observed where the 
 temperature has remained normal or subnormal throughout the 
 attack. This has been especially noticed where there had been 
 previously exposure to great hardships. 
 
 Mild forms of typhoid are often called febricula, gastric fever, 
 bilious fever, simple continued fever, remittent fever, but these 
 terms should be avoided as much as possible. 
 
 Complications and sequelae. — Of the complications of 
 typhoid fever those due to the intestinal lesions are the most 
 important, and of these the most serious are hccmorrhage and 
 perforation. They may occur at two periods, most commonly 
 during the separation of the sloughs in the latter half of the third 
 or the first half of the fourth week. But they may take place much 
 later, during the stage of convalescence, in consequence of the 
 ulcers not having healed. H(Emor7-hage occurs in about 6 per 
 cent of the cases ; the amount may vary from a slight oozing to 
 several pints of arterial blood. The blood may be either dark or 
 bright red according to the time it has remained in the bowel before 
 being evacuated, and is often clotted. When profuse it causes a 
 sudden fall of temperature, pallor, and collapse ; it may be repeated 
 several times. A moderate haemorrhage does not exercise any 
 injurious effect on the course of the disease, but indicates deep 
 ulceration. A profuse hccmorrhage may be immediately fatal. 
 Hcemorrhage as well as perforation may occur when the bowels 
 have been previously constipated. 
 
 Perforation has been estimated to occur in about 3 per cent of 
 all cases. It manifests itself by sudden pain in one part of the 
 abdomen, followed by signs of general peritonitis, diffused abdominal 
 pain, tenderness, distention, and collapse. The temperature often 
 falls and then again rises. The pulse is very frequent and small, the 
 countenance pinched \ there is often hiccough and vomiting. Death 
 
VOL. I 
 
98 MANUAL OF MEDICINE 
 
 usually occurs from within twenty-four to forty-eight hours. Some- 
 times when the patient is in a typhoid state these severe symptoms 
 are absent, and the chief indications are great distention v/ith in- 
 creased prostration and some abdominal tenderness. The abdominal 
 distention is usually due mainly to inflation of the intestine, but 
 sometimes considerable quantities of gas escape into the peritoneal 
 cavity and cause obliteration of the liver dulness, an important 
 diagnostic sign. Perforation and peritonitis cause a great increase 
 in the number of leucocytes in the blood. Recovery may take 
 place after symptoms of acute peritonitis have occurred ; possibly 
 in these cases there has not been actual perforation, or extravasa- 
 tion has been prevented or limited by adhesions. Peritonitis may 
 also be caused by the breaking down and rupture into the peri- 
 toneal cavity of the infiltrated mesenteric glands. 
 
 Ulceration of colon. — Occasionally the solitary glands through- 
 out the colon and rectum are affected in a similar manner to those 
 of the ileum, and the whole of the large bowel riddled with circular 
 sloughing ulcers. This condition is one of great gravity, and is 
 manifested by the severity and long persistence of the diarrhoea, 
 the highly offensive motions, which often contain mucus, and by 
 the pain and sometimes the tenesmus which accompany them. 
 There may be distinct tenderness along the course of the colon, 
 Haemorrhage and perforation are liable to occur. 
 
 Gastric disturbance. — Severe gastric disturbance occasionally 
 occurs ; there is flatulent distention, sometimes acute dilatation and 
 frequent bilious vomiting, so that the patient can retain no food. 
 These symptoms are often associated with severe headache. The 
 term bilious typhoid has been applied to this form. 
 
 Jaundice occasionally occurs in the later stages of the disease 
 and the case often terminates fatally, the motions remaining bile- 
 stained. Its pathology is not certainly known. The liver is often 
 found to be fatty with exudation of leucocytes between the lobules. 
 
 Tympanites. — This, when great, is both a distressing and dangerous 
 symptom. When it occurs early it is an indication of great nervous 
 depression ; later it is usually associated with extensive ulceration, or 
 it may be a sign of peritonitis. The distention may affect both the 
 large and small intestine. It tends to embarrass the patient's respira- 
 tion, and increases the risk of perforation by stretching the intestinal 
 wall. 
 
 Respiratory complications. — Some degree of bronchitis is usually 
 present. In severe cases, in the later stages there is often hypostatic 
 congestion of the lungs due to weakness of the heart, and favoured 
 
TYPHOID FEVER 99 
 
 by the dorsal decubitus of the patient. It is manifested by frequent 
 shallow breathing and some duskiness of countenance ; the physical 
 signs are some degree of impairment of resonance over the back, 
 with rather fine crepitant rales. 
 
 Lobar pneumonia is an occasional complication. It is most 
 common in the third or fourth week of the disease, and is due to 
 invasion by the pneumococcus, and not to the direct action of the 
 typhoid bacillus. Occasionally it occurs at the outset, and is 
 possibly due to a primary infection of the lung, the intestinal 
 symptoms developing later. Cases of pneumonia have been met 
 with during an epidemic in persons who have been exposed to the 
 contagion without any other symptoms of typhoid developing. 
 When it occurs late in the disease many of the usual symptoms 
 may be absent ; there is often little cough and no expectoration, 
 but the breathing is quickened, the countenance dusky, the alae nasi 
 often dilate, and there may be pain in the side. Though a very 
 serious complication, it is not necessarily fatal. 
 
 Embolic and pysemic processes in the lungs are liable to occur, 
 and may give rise to abscess, empyema, or pneumothorax. 
 
 Ulceration of the larynx., originating in the lymph follicles, is 
 not infrequent ; often it gives rise to few symptoms, in other cases 
 there is huskiness or stridor of the voice and cough, pain in 
 swallowing, and tenderness, on pressure, over the larynx. Generally 
 the ulcers heal without causing any serious mischief They may, 
 however, extend deeply, and cause necrosis of the cartilages, oedema, 
 and stenosis of the glottis, and necessitate tracheotomy ; sometimes 
 they cause profuse hsemorrhage. 
 
 Cardiac complications. — Endo- or pericarditis are rarely met with, 
 but in severe cases the muscular wall is softened and the cavities 
 dilated. This condition is indicated by a short, rather sharp, first 
 sound, feeble impulse, and perhaps slight extension of the area of 
 cardiac dulness. Sometimes there is a systolic apex murmur due to 
 the dilatation and to the weakening of the musculi papillares. When 
 recovery takes place, the heart usually returns to its normal condition. 
 Sometimes sudden death occurs during convalescence, probably due 
 to this condition of the heart. Thrombosis of the cavities of the 
 heart or pulmonary artery may occur from stagnation of the circu- 
 lation. 
 
 Thrombosis of the veins., chiefly the saphena, the femoral, and the 
 iliac veins, often occurs during convalescence. It may begin in the 
 intramuscular veins as the result of the myositis typhosa, and extend 
 to the larger veins. Generally, in a variable time, from three to six 
 
lod MANUAL OF MEDICINE 
 
 weeks, the thrombus gets absorbed, and the calibre of the vein is 
 restored. Sometimes the obstruction remains permanent ; occasion- 
 ally it gives rise to pulmonary embolism. The affection is marked 
 by swelling of the leg, pain, and tenderness along the course of the 
 affected vein, which can often be felt as a hard cord. 
 
 Renal complications. — Albumen is often present in the urine in 
 severe cases, but disappears as defervescence takes place. Occa- 
 sionally acute tubular nephritis occurs, characterised by scanty, 
 bloody, highly albuminous urine, containing epithelial casts. There 
 may be dropsy and ursemic symptoms. The term nephrotyphoid 
 has been given to these cases. 
 
 Nervous complications. — Various disturbances of the nervous 
 system may occur during and after the attack. The headache, 
 delirium, subsultus, and floccitatio or picking at the bedclothes, of 
 severe cases are not accompanied by any appreciable lesions of the 
 nerve centres, and are probably toxic in their nature. Sometimes 
 spasmodic and convulsive affections, as retraction of the head, 
 rigidity of the trunk or limbs, strabismus, trismus, take place, 
 without any lesion being detected. 
 
 Meningitis is a rare complication, and is usually of septic origin ; 
 but in some cases the typhoid bacillus has been found in the exuda- 
 tion. Thrombosis and embolism of the cerebral arteries may occur, 
 and cause hemiplegia and aphasia, which are usually recovered from. 
 
 Peripheral neuritis affecting the nerves of the extremities some- 
 times manifests itself during convalescence. Pain, tenderness, loss 
 of power, numbness, and tingling, are observed. A common seat is 
 the ulnar nerve, causing numbness, tingling, and loss of sensation in 
 the little and ring fingers ; this is probably due to pressure on the 
 nerve behind the condyle of the humerus, from the arm being con- 
 stantly kept in one position owing to the apathy of the patient. 
 Extreme tenderness of the toes may occur, lasting a week or ten days, 
 probably due to peripheral neuritis. The symptoms in some cases 
 suggest the possible implication of the vagus. 
 
 Another extremely painful affection during convalescence, which 
 is probably of a neuralgic nature, has been termed the typhoid spine. 
 There is extreme pain over the lower part of the back and the sacral 
 region, especially on movement ; moving the legs also causes great 
 pain. There is no paralysis, or alteration of the electrical reactions. 
 The condition may last for several weeks. 
 
 Occasionally serious lesions of the spinal cord have followed 
 typhoid, as poliomyelitis, and disseminated sclerosis. 
 
 Melancholia, dementia, and sometimes mania, are liable to follow 
 
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TYPHOID FEVER loi 
 
 typhoid. They are generally only temporary, but may necessitate 
 putting the patient under restraint. 
 
 Organs of special sense : a temporary deafness is often present 
 during the attack ; occasionally a suppurative otitis media occurs. 
 Double optic neuritis may be present, without there being any 
 intracranial disease. 
 
 Recurrent rigors are sometimes observed during the attack, 
 without any suppuration following. Occasionally, however, pyaemia 
 occurs. More frequently external suppurations manifest themselves, 
 often during convalescence ; among these is a suppurative parotitis, 
 the gland probably getting infected by germs entering from the mouth 
 through the duct. 
 
 Sometimes there is a superficial suppurative osteitis affecting 
 especially the ribs, femur, and tibia. The typhoid bacillus has been 
 discovered in the pus of these abscesses. Sometimes the affection 
 has a rheumatic character ; there are aching pains, especially at 
 night, swelling of the epiphyses with irregular fever, and the affection 
 may last for weeks without suppuration taking place. 
 
 Relapses are very common ; their frequency has been estimated 
 at 5 to I o per cent. Most commonly the relapse takes place within 
 fourteen days after defervescence, but the interval has been known 
 to be as long as ten weeks. In the relapse all the symptoms recur, 
 and the rose spots come out again, and fresh infiltration and ulcera- . 
 tion of the intestinal glands takes place. Most commonly, but by 
 no means always, the relapse runs a shorter course than the primary 
 attack. The fever attains its maximum between the fourth and sixth 
 days, and defervescence begins before the end of the second week ; 
 but the attack may last the usual time. A second, and even a third, 
 relapse may take place. Relapses are often attributed to errors of 
 diet during convalescence, but they frequently occur when all pre- 
 cautions have been strictly observed. Besides these relapses after 
 defervescence, intercurrent relapses, or recrudescences, may take 
 place before the temperature has become normal ; they are indicated 
 by an exacerbation of the febrile symptoms and the appearance of a 
 fresh crop of rose spots. In this way an attack of typhoid may be 
 indefinitely prolonged. 
 
 Desquamation of the cuticle sometimes takes place after typhoid. 
 Occasionally the hair falls out ; the nails may show a transverse 
 groove, indicating cessation of growth during the attack. 
 
 A condition of marasmus may follow, due, possibly, to atrophy 
 of the mesenteric glands. 
 
 Pregnant women very commonly, but not always, miscarry. 
 
I02 MANUAL OF MEDICINE 
 
 The child, if near the full time, may be born alive and healthy ; 
 but it has been found infected with typhoid bacilli in the blood 
 and spleen. 
 
 Diagnosis. — The chief points to be noted in the diagnosis of 
 typhoid fever are : the rose spots, the diarrhoea, the enlarged spleen, 
 the tumid abdomen, the characters of the tongue, and the duration 
 and course of the fever. In temperate countries, a fever which lasts 
 a week without the appearance of any characteristic rash, or any local 
 inflammation, is almost always typhoid. 
 
 To these points must be added the diazobenzol reaction of the 
 urine, and Widal's serum test. This last depends on the fact that the 
 blood serum of persons suffering from typhoid, or who have been 
 rendered immune by a previous attack, impairs the vitality of the 
 typhoid bacilli, and causes them, when cultivated in a liquid 
 medium, to clump together and become motionless. In applying 
 Widal's test the points to be especially observed are — first, to use 
 only a fresh bouillon culture, as the typhoid bacillus rapidly loses its 
 potency. Secondly, to dilute the serum or adjust its proportion to 
 the culture, as the clumping action may be produced by healthy 
 serum if too concentrated ; the proportion must not exceed one 
 drop of serum to ten drops of the culture ; in the second week of 
 typhoid I to loo is often sufficient. Thirdly, to note the time 
 required to effect the clumping ; this should not exceed half an 
 hour, often a few seconds are sufficient ; healthy serum may produce 
 the reaction in the course of a few hours (see p. 33). 
 
 The most convenient method of procedure is as follows : — The 
 lobe of the ear should be punctured and a little blood squeezed out 
 into a small tube, or sucked out by means of a capillary pipette and 
 expelled into the tube. It should be allowed to coagulate, and by 
 means of a platinum loop a drop of the serum added to lo^ or, 
 better, 20 or even 30 drops of the culture and examined at once 
 under the microscope between a cover-glass and slide. The pro- 
 portion of I to 10 is open to many fallacies. The blood as drawn 
 may be used, but the corpuscles are apt to obscure the microscopical 
 appearances. No antiseptic precautions are necessary, as there is 
 not time for other organisms to grow. Dried blood or dried serum 
 can be employed after dissolving in water, but it is difficult to 
 estimate the degree of dilution. If the blood has to be sent away 
 for examination it should be withdrawn with antiseptic precautions 
 and sealed up in a capillary tube furnished with a bulb. The 
 reaction may usually be obtained by the seventh day, and has been 
 found as early as the fifth ; but its appearance may be delayed till 
 
TYPHOID FEVER 103 
 
 a much later period, even as late as the twentieth day. It may 
 continue for a few days after convalescence to many years, or 
 possibly the remainder of the patient's life. It may be temporarily 
 absent and appear again, so that if a negative result is obtained it is 
 necessary to repeat the test several times. On the whole, it may be 
 said that the presence of the reaction in a person who has not had 
 a previous attack is an almost certain indication of the disease ; but 
 its absence on any given occasion does not necessarily exclude it. 
 
 In certain cases, exhibiting all the clinical features of typhoid 
 fever, when the Widal reaction has been wanting, the B. typhosus 
 has not been found, but another organism differing both in morpho- 
 logical and cultural characters from the typhoid microbe and from 
 B. coli. 
 
 The diseases with which typhoid is most likely to be confounded 
 are, first, acute tuberculous affectio?is, especially meningitis, general 
 miliary tuberculosis, and tuberculous affections of the abdominal 
 viscera. 
 
 In tuberculous meningitis vomiting is a more prominent symptom. 
 The abdomen is usually retracted instead of being tumid ; the bowels 
 are commonly constipated ; the tongue is not red ; the spleen is not 
 enlarged ; the pulse is often infrequent ; the temperature is more 
 irregular ; the tache cerebrale better marked. The knee jerk is often 
 absent, whereas in typhoid it is often exaggerated. Later on there 
 may be the hydrocephalic cry, spasm, or paralysis of the cerebral 
 nerves ; but it must be remembered that in typhoid there may be 
 inequality of the pupils, strabismus, twitching of the muscles, double 
 optic neuritis. " Stocker's symptom " is of some value ; in typhoid, 
 if the bedclothes be pulled down the child is indifferent, but in 
 tuberculous meningitis he resists and immediately draws them up 
 again. In typhoid the decubitus is usually dorsal, in meningitis 
 lateral. The presence of tubercles in the choroid would be a 
 valuable diagnostic sign. 
 
 In acute miliary tuberculosis the pulmonary symptoms are usually 
 much more severe than in the early stage of typhoid. There is 
 usually great rapidity of the breathing ; the alse nasi dilate ; the face 
 is somewhat cyanosed ; fine crepitant rales are audible over the chest ; 
 the temperature is much more irregular, and may be of the inverse 
 type, i.e. higher in the morning than in the evening. • If there is also 
 tuberculosis of the intestine, there may be diarrhoea, and a swollen 
 abdomen. 
 
 Tuberculous peritonitis may resemble typhoid, but is usually 
 much more chronic, and often there are signs of peritoneal effusion. 
 
I04 MANUAL OF MEDICINE 
 
 Pneumonia of the asthenic type may closely resemble typhoid, but 
 may be distinguished by the physical signs. When it occurs as a 
 complication of typhoid, other symptoms must be looked to — the 
 rose spots, the enlarged spleen, the diarrhoea, etc. Most commonly 
 pneumonia occurs in the later stages of typhoid, so that the duration 
 of the attack will have been longer than is usual in primary 
 pneumonia. 
 
 The fever which accompanies appendicitis and perityphlitis often 
 resembles typhoid, but the local pain, tenderness, and swelling will 
 serve to distinguish them. 
 
 Typhoid fever is very liable to be mistaken at the onset for 
 influenza. The invasion of the latter is usually more sudden, and 
 the early symptoms more severe. The temperature reaches its maxi- 
 mum much sooner. The pains in the head and limbs are more 
 intense, and of a more neuralgic character ; and unless some local 
 complication interferes, defervescence takes place in the course of 
 a few days. If the fever persists without any local cause, the case 
 is probably typhoid. 
 
 Ulcerative endocarditis and pycemla may closely resemble typhoid, 
 and the former may even cause intestinal haemorrhage from embolism. 
 The greater irregularity of the temperature, the signs of embolism, as 
 purpuric spots and blotches on the skin, hgematuria, and the cardiac 
 signs, are the chief points of distinction. 
 
 In children acute gastric and Intestinal catarrh may simulate the 
 milder forms of typhoid ; but the febrile disturbance is of shorter 
 duration, the spleen is not enlarged, and there are no spots. A suit- 
 able purge will often remove the symptoms. 
 
 In tropical climates, in malarial districts, there may be great 
 difficulty in distinguishing malarial reinlttents from typhoid, and no 
 doubt both infections may be present together. 
 
 For the diagnosis from typhus, see the latter disease. 
 
 Prognosis. — The rate of mortality of typhoid fever varies so 
 much in different epidemics and under different modes of treat- 
 ment, that it is impossible to give any average generally applicable. 
 In the general hospitals of London it is about i6 per cent; in the 
 Fever Hospitals of the Metropolitan Asylums Board somewhat 
 higher ; in private practice probably less, and often much less in 
 extensive epidemics. 
 
 It is claimed that systematic cold bathing will reduce the 
 hospital mortality to less than half that given above. An equally 
 great reduction is claimed by the advocates of the antiseptic treat- 
 ment. 
 
TYPHOID FEVER 105 
 
 Age. — The influence of age in the rate of mortahty of typhoid 
 is much less than in typhus, but the mortahty in childiiood is less 
 than in adult life, and after thirty -five is decidedly higher than 
 below that age. Sex. — The mortality of females is slightly higher 
 than that of males. Bodily habit. — Great obesity and also great 
 muscular development are unfavourable. 
 
 Antecedent and general conditiotis. — Intemperate habits, too high 
 living, organic disease, as of the heart or kidneys, delay in the com- 
 mencement of treatment, increase the rate of mortality. It has often 
 been observed that among the Irish, who are comparatively ill-fed 
 and live largely on potatoes, the rate of mortality is very low. 
 
 Unfavourable symptoms. — The more important among these are 
 indications of severe intestinal lesions, as urgent diarrhoea, haemor- 
 rhage, abdominal pain, great tympanites, disturbance of the nervous 
 system, as muttering delirium, tendency to stupor, muscular twitch- 
 ings, a pulse persistently above 120, indications of heart failure, 
 hypostatic congestion of the lungs, a persistent high temperature, 
 especially if accompanied by disturbance of the nervous system. 
 Mere temporary rises of temperature are of comparatively little 
 moment. 
 
 Prophylaxis of typhoid. — This is mainly a question of public 
 hygiene and sanitation, to ensure that the water supply is not con- 
 taminated by sewage ; that the sanitary arrangements are in good order 
 and do not allow the emanations from drains and soil pipes to escape 
 into houses and foul the cisterns ; to prevent the contamination of 
 milk and shell fish, and other articles of food. If there is any reason 
 to suspect contamination, milk and water should be boiled. 
 
 To prevent the spread of contagion from individual cases, the 
 following precautions should be followed : — The room should be 
 kept well ventilated, and abundant cubic space should be allowed, 
 1500 cubic feet if possible. The strictest cleanliness should be 
 observed. After handling the patient, the attendants should dip 
 their hands in an antiseptic solution, as hydrarg. perchlor. i to 1000, 
 a basin of which should be placed on a table near the bed. If the 
 hands get soiled, they should be washed with carbolic acid soap. 
 After every motion the parts should be sponged or wiped with some 
 antiseptic lotion, as weak condy or carbolic acid. Soiled linen should 
 be steeped in some disinfecting solution before being sent to the 
 laundry. 
 
 The disposal of the excreta is a matter of much importance, as 
 it is by them that the disease is chiefly spread. The safest way of 
 dealing with them — but this is seldom practicable — is to burn them ; 
 
io6 MANUAL OF MEDICINE 
 
 they may be mixed with sawdust, oil of turpentine or naphtha poured 
 over them, and set on fire. Under ordinary circumstances they 
 should be disinfected before being thrown down drains or buried, by 
 being mixed with crude carbolic acid, or perchloride of mercury, or 
 some other disinfectant, and allowed to stand for an hour or two. 
 The urine, also, should be disinfected. Earth closets are not suit- 
 able for typhoid evacuations. 
 
 The nurses should not eat or drink in the sick-room, and never 
 without washing their hands. 
 
 Protective inoculation and semm treatment. — Inoculation of living 
 or sterilised cultures of the typhoid bacillus renders animals immune 
 against the action of the typhoid bacillus and its toxines, and the 
 serum of animals thus rendered immune confers immunity when 
 injected subcutaneously. According to Pfeiffer the action of such 
 serum is rather bactericidal than antitoxic, and this militates against 
 its curative powers. 
 
 Sterilised cultures may be employed as a protective vaccine, and 
 the serum of immunised animals as a curative agent. The subject 
 is still in the experimental stage, but the evidence for the preventive 
 action of the vaccine is much, stronger than that for the curative 
 action of the serum, which latter must be regarded as still unproved. 
 The inoculation of sterilised cultures appears to be free from risk, 
 and deserves trial during epidemics and in the case of persons like 
 nurses who are especially exposed to infection. 
 
 Treatment. — As soon as the diagnosis of typhoid becomes 
 probable, the patient should be strictly confined to bed, and should 
 pass his evacuations in a bed pan and urine glass. The room should 
 be kept cool ; the temperature should, if possible, not exceed 60^. 
 The bed should be narrow, with an elastic mattress, and a water- 
 proof cloth under the sheet. He should be lightly covered wiih a 
 sheet and thin coverlet, with a blanket over his feet. The diet 
 should be liquid, administered at regular intervals every four hours, 
 or oftener if there is much prostration, and he should have 
 abundance of drink given him to assist elimination through the 
 kidneys. It should be remembered that the digestive and assimilat- 
 ing powers are much impaired ; it is not therefore advisable to over- 
 task them by an excess of food. The chief articles of food employed 
 are milk, two to three pints of which may be given in twenty-four 
 hours, together with animal broths and solutions of meat ; ordinarily 
 about a pint of beef tea may be given ; beaten-up eggs, or egg 
 albumen mixed with water, thin gruel and arrowroot may be ad- 
 ministered. Plain water, barley water, acidulated drinks, weak tea, 
 
TYPHOID FEVER 107 
 
 ■which last is an excellent diuretic, may be allowed in small quantities 
 at a time, according to the patient's liking. It is also advisable to 
 give an ounce of glucose daily to supply the liver with glycogen, 
 which under ordinary diets disappears from the liver cells in septic 
 fevers, but which may be restored by administering glucose, and so 
 the wasting may be diminished. It may be used to sweeten milk, 
 tea, arrowroot, acid drinks. 
 
 When the patient is fed largely on milk the motions should be 
 .carefully inspected to see that they do not contain curds ; if this is 
 the case the amount of milk must be diminished, or it must be given 
 •diluted with barley water or lime water, or it may be peptonised, or 
 humanised milk substituted. 
 
 In severe cases, when signs of prostration show themselves, — a 
 dicrotic pulse, weak action of the heart, congestion of the lungs, 
 delirium, tremors, — alcoholic stimulants should be freely administered, 
 and it is better to anticipate rather than to defer their use. Brandy 
 is perhaps the one most to be relied on, but the patient's pre- 
 dilections, if he has any, may be deferred to. The amount must 
 depend on the age and condition and previous habits of the patient, 
 and the effect produced. Young subjects require less than older 
 persons. From three to eight ounces or more of brandy are often 
 required in twenty-four hours. 
 
 To combat the disease three chief methods are employed, which 
 may be termed the antipyretic, the antiseptic and the eliminative. 
 The first consists in keeping the temperature through the whole 
 course of the disease below a moderate fever height. The most 
 effectual method of doing this, and the one which gives the best 
 results, is by bathing the patient in tepid water. Whenever the 
 temperature rises above 102.5'' Fahr., he should be lifted into a bath 
 of a temperature of 80° Fahr. and kept immersed for about fifteen 
 minutes, or till shivering sets in. In some cases baths of a lower 
 temperature may be employed or the temperature of the water cooled 
 by ice after the patient's immersion. The temperature will continue 
 to fall for some time after removal from the bath. When taken out 
 the patient should be laid on a blanket, wiped dry, and lightly 
 covered ; a little alcohol should be given before the bath. A^'herever 
 this mode of treatment has been systematically carried out it has 
 always been found to effect a great decrease in the rate of mortality. 
 The good effects produced are by no means confined to the lower- 
 ing of the temperature. The pulse is reduced in frequency, its tone 
 is improved, the respirations are deepened, headache, delirium, 
 insomnia, subsultus, are prevented or relieved, the amount of the 
 
io8 MANUAL OF MEDICINE 
 
 urine is increased, and its toxicity during the fever period is greatly 
 intensified, while in the stage of convalescence it is diminished, 
 showing that this mode of treatment is powerfully eliminative, and it 
 is probable that this is one of its chief advantages. Haemorrhage 
 and peritonitis, but not congestion of the lungs, contra-indicate 
 bathing. 
 
 Where bathing cannot be employed recourse may be had to cold 
 sponging ; sometimes where there is much collapse and cold sponging 
 is greatly objected to by the patient, sponging with very hot water, 
 1 1 o° Fahr., and afterwards leaving the patient lightly covered, will 
 bring down the temperature. Packing in a wet sheet or applying 
 iced compresses to the chest and abdomen are also useful means. 
 Another method is to put a cradle, merely covered by a sheet, over 
 the patient, inside which may be placed trays of ice, and so keep- 
 ing him in a bath of cool air. Many drugs have the effect of 
 reducing temperature ; the most important are quinine in large doses, 
 antipyrine, acetanilide, phenacetine, but their use for this purpose, 
 except an occasional dose, which sometimes produces good effects, 
 is not to be recommended owing to their depressing action on the 
 heart. Quinine in smaller doses may be given with advantage in 
 the later stages of the disease. 
 
 The antiseptic treatment consists in administering remedies to 
 destroy or render inert the typhoid and septic microbes in the 
 intestinal canal. A large number of such remedies have been em- 
 ployed, among them calomel, perchloride of mercury, iodine, carbolic 
 acid and the sulpho-carbolates, salol, /3-naphthol, guaiacol, turpentine, 
 and many others. By their use the putrefactive and fermentative 
 changes in the intestinal canal may be arrested and the faeces 
 deprived of their offensive smell, but no effect is produced in 
 destroying either the saprophytic germs which are free in the 
 intestine, or the typhoid bacilli which are lodged in the glands 
 and spleen ; these remedies have been largely used in America, and 
 very successful results are claimed for them. 
 
 The practice has been recently revived of treating typhoid by 
 purgatives with the object of eliminating the toxines and getting rid 
 of the bacillus. The typhoid bacilli are, however, mainly embedded 
 in the tissues and glands and are therefore unaffected by purgatives, 
 and there are obvious dangers in stimulating an ulcerated bowel to 
 active peristalsis. Many physicians, however, consider a calomel 
 purge beneficial in the early stage of the disease. 
 
 Apart from attempts to control the general course of the disease, 
 the special symptoms require treatment. 
 
TYPHOID FEVER 109 
 
 With regard to the bowels, it is safer not to give purgatives by 
 the mouth after the first week or ten days. If there is constipation, 
 enemata should be employed, as it is evidently inadvisable to leave the 
 bowels full of putrefactive and fermenting faeces. Commonly there 
 is diarrhoea ; if the motions do not exceed three or four in the twenty- 
 four hours no special treatment is required. If they much exceed 
 this opium may be administered either by the mouth or as an 
 enema, and care should be taken to adapt the diet ; sometimes milk 
 disagrees, sometimes beef tea. 
 
 If a profuse hsemorrhage occur the patient should be kept 
 perfectly still ; he should pass his motions into a draw sheet ; the ad- 
 ministration of food should be suspended for some hours. Opium 
 should be given to arrest peristalsis, and in addition styptics may be 
 had recourse to, though their efficacy is somewhat doubtful. The 
 best are perhaps turpentine, acetate of lead and ergot ; the last may 
 be administered subcutaneously. If the patient appears to be in danger 
 of sinking, transfusion of a saline solution into the veins should 
 be resorted to. 
 
 Perforation is almost always fatal ; if diagnosed early and the 
 patient's general condition is still fairly good, the best chance is 
 to perform laparotomy, wash out the peritoneum and close the 
 perforation. A sufficient amount of success has now been obtained 
 as to justify the operation in all favourable cases, and it should 
 always be performed when perforation occurs during convalescence. 
 If the operation is not deemed advisable opium should be ad- 
 ministered in full doses. 
 
 For the treatment of meteorismus stimulants may be administered 
 when there are signs of nervous prostration, together with strychnia ; 
 cold compresses may be applied to the abdomen, an enema of rue 
 or ol. terebinth administered. Sometimes relief may be obtained 
 by introducing a rectal tube. 
 
 Ulceration of the large intestine, which will cause the diarrhoea 
 to persist after defervescence, requires careful regulation of the diet ; 
 acetate of lead may be given combined with opium ; large doses of 
 subnitrate of bismuth are sometimes useful. 
 
 Hypostatic congestion of the lungs and pneumonia require 
 alcoholic stimulants, together with ammonia and ether ; mustard and 
 linseed meal may be applied, but the chest should not be blistered. 
 
 Heart failure may be treated by ether and strychnia administered 
 hypodermically. Digitalis and ammonia may be given. 
 
 Nervous symptoms, as sleeplessness, delirium, headache, are 
 often relieved by bringing down the temperature by bathing, sponging, 
 
110 MANUAL OF MEDICINE 
 
 the application of cold to the head. For sleeplessness, which should 
 never be allowed to persist, the safest drug is opium. 
 
 Thrombosis of the veins of the lower extremity should be treated 
 by keeping the leg still by means of sandbags laid on each side, and 
 extract of belladonna may be applied along the course of the affected 
 vein. 
 
 Great care is required during convalescence ; solid food should 
 be resumed very gradually, and not until the temperature has been 
 normal in the evening for several days ; if there have been marked 
 signs of ulceration, for at least a week. At first a rusk or a sponge 
 cake may be allowed, and a piece of chocolate, which children 
 especially eat with relish ; then a lightly poached egg and a thin piece 
 of bread and butter ; next a little boiled fish ; later tender meat and 
 potatoes mashed or made into a puree. The temperature, which is 
 usually at first subnormal, remains for a considerable time in a very 
 unstable state, the resumption of solid food, constipation, any mental 
 excitement will often cause a temporary febrile exacerbation ; the 
 heart too remains weak, and any strain or over-exertion may cause 
 a fatal syncope or lead to dilatation. After an attack of typhoid the 
 patient should always have a period of rest at a health resort or 
 convalescent institution before resuming his ordinary mode of life. 
 
 W, Cayley, 
 
 MEDITERRANEAN FEVER 
 ■ Syn. Malta, Rock or Neapolitan Fever ; Undulant Fever 
 
 Definition. — An endemic pyrexial disease, occasionally pre- 
 vailing as an epidemic, having a long and indefinite duration and 
 an irregular course, with an almost invariable tendency to undu- 
 latory pyrexial relapses, and a constant occurrence in certain 
 tissues of a definite species of micro-organism, which fulfils Koch's 
 postulates. 
 
 Geographical distribution. — It is widely distributed in the 
 countries bordering upon the Mediterranean, south of latitude 
 46° N., and along the Red Sea littoral. Analogous forms of fever, 
 giving a serum reaction with the micrococcus of this disease, are 
 also met with in parts of India, China, Africa, and America. 
 
MEDITERRANEAN FEVER . iii 
 
 Etiology. — The disease is the result of the entrance of the 
 micrococcus melitensis Vel Brncii into the tissues of the human body. 
 This organism is constantly present in the spleens and other organs 
 of fatal cases, can be indefinitely cultivated artificially, and is also 
 pathogenic to monkeys. 
 
 The disease is not directly infectious from man to man. There 
 is no evidence that it is usually disseminated by food or drink, nor 
 has it been traced to inoculation by insects or otherwise. There 
 is, however, a close connection between the occurrence of the 
 disease and pollution of the soil in or around dwelling rooms or 
 under tents, with the fgeces or urine of patients suffering from this 
 fever. 
 
 Its prevalence in the Mediterranean coasts is in exact inverse 
 proportion to the amount and continuance of the rainfall, and in 
 direct proportion to the average air temperature above 60° F. 
 The disease attacks all ages, but more especially those between ten 
 and thirty, who have not previously suffered from it. Sex, length 
 of residence, and station in life, have apparently only an indirect 
 influence on its prevalence. The initial symptoms, the above facts 
 and other circumstantial evidence, lead one to suspect that the 
 virus usually enters the body by the inspired air, and leaves it by 
 way of the fseces (and urine ?). Though not present in clean soil, 
 the micrococcus seems able to live as a saprophyte in faecally 
 polluted soil. It is not supposed that the virus is carried far 
 through the air, a distance of from 3 to 10 feet being sufficient to 
 account for the majority of the cases. 
 
 The incubation period is probably between three and ten 
 days. 
 
 Symptoms. — The writer has, for convenience, divided over a 
 thousand cases he had treated into three clinical types, indicative of 
 variations in severity of the fever, one type often passing into 
 another. In the malignant type the onset is almost sudden ; the 
 patient complains of severe headache, "pains all over him," nausea 
 or even vomiting, his tongue being foul, coated and swollen, and 
 his breath soon becoming very offensive. The temperature reaches; 
 104° or 105° and remains more or less continuously high.. 
 Diarrhoea, with most offensive stools, may be present. After a few 
 days in this condition the patient passes into the " typhoid state,"' 
 the lungs become choked, the pulse weak, and hyperpyrexia and. 
 death ensue. The bodies of such fatal cases are often most 
 offensive and described as "rotten." In these days of energetic- 
 treatment such cases-are happily rare.- . - - 
 
112 
 
 MANUAL OF MEDICINE 
 
 Temperature Curves in Two Cases of Mediterranean 
 
 Fever. 
 
 Case I. 
 
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 Case II. 
 
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 Undulatory type with well-marked waves. 
 
MEDITERRANEAN FEVER 113 
 
 In the imdidatory type the case usually commences like one of 
 enteric fever with constipation, followed by numerous relapses. 
 It is thus marked by a series of waves or undulations of remittent 
 pyrexia, separated by periods of abatement or absence of symptoms. 
 At any stage the case may take a malignant and fatal turn, or the 
 pyrexia may gradually subside into a daily intermittence before 
 convalescence. The pyrexial curves average 10 days, the primary 
 one being usually the longest (18-23 days), there being from one to 
 seven waves in an attack. This is the commonest type of the fever. 
 
 In the intermittent type the temperature usually falls daily be- 
 tween midnight and 2 a.m. to or below normal, accompanied by 
 profuse diaohoresis, rising slowly but steadily about 1 1 a.m. next 
 day to var}'ing heights, without rigor. This type much resembles 
 the hectic pyrexial curve of phthisis or other suppuration. If the 
 maximum temperatures be accurately recorded each day, they will 
 be found to form undulations similar to those met with in the 
 former type. 
 
 Pyrexia of an undulator}- character, unaccompanied by suppura- 
 tion, is the one constant feature of this disease. The initial 
 symptoms are tightness about the throat, often redness of the 
 tonsils, and slight swelling of the submaxillary and cervical glands, 
 pain in the muscles of the neck and back, nausea, anorexia, epi- 
 gastric tenderness, headache and foul tongue. The usual signs of 
 fever supervene with especially marked dyspeptic symptoms and 
 constipation. Remissions of temperature are accompanied by 
 most profuse perspiration. The reflexes are increased ; and at any 
 stage, but usually later in the attack or during convalescence, acute 
 sciatica or other localised neuritis may occur in any position. 
 Or there may be acute effusion into one or more joints, or acute 
 orchitis. Finally, long cases may be reduced to an anaemic, 
 emaciated and bed-ridden condition, the patient being sub'ect to 
 attacks of bronchial catarrh, cardiac palpitation or neuralgic com- 
 plications on the slightest chill, change of weather or even excite- 
 ment. Disappointed at each relapse and his hair fallen off, his 
 whole expression becomes the picture of despondent apathy, his 
 only wish being to get away to England. His emaciated appear- 
 ance, profuse night sweats with intermittent pyrexia and cough, 
 remind one forcibly of phthisis, a diagnosis which is often errone- 
 ously made. However, in time the tongue shows signs of cleaning, 
 the temperature falls to subnormal and the corner is turned, after 
 which, under judicious dietar}- and plenty of fresh air, he regains 
 weight and strength with wonderful rapidity. 
 
 VOL. I I 
 
114 MANUAL OF MEDICINE 
 
 Prognosis. — Favourable as regards danger to life or health, 
 the case mortality being only about two per cent, but most 
 unfavourable as regards the length of attack and consequent 
 interference with livelihood until convalescence is complete. The 
 pyrexial duration (20 to 300 or more days) averages 60 to 70 days. 
 Previous history of tuberculous, cardiac or pulmonary disease, is 
 unfavourable ; while the actual presence of cardiac or renal disease, 
 of concurrent anaemia, of phthisis or of great nervous excitability, 
 indicates a serious prognosis. The only reliable sign of approach- 
 ing convalescence is a subnormal temperature for a few days, 
 followed by a normal, steady temperature when accompanied by a 
 clean or rapidly-cleaning tongue. 
 
 Second attacks are rare. It is not certain to what extent one 
 attack protects against another, but it seems that it confers some 
 immunity. 
 
 Morbid anatomy. — The naked eye post-mortem appearances 
 of acute and rapidly fatal cases are those of intense congestion, 
 especially marked in the internal organs, the spleen being enlarged, 
 often disorganised, and almost liquefied within its capsule. In 
 chronic cases there are the signs of long-continued irritation of the 
 tissues, similar to the fibrotic changes consequent upon chronic 
 alcoholism or plumbism. 
 
 Diagnosis. — The disease can be definitely diagnosed from 
 enteric fever, paludism, phthisis, liver or pelvic abscess, empyema 
 and other suppurating diseases, rheumatic affections and croupous 
 pneumonia, etc., by the reaction of the blood serum of true cases, 
 upon living or dead cultures of the micrococcus melitensis ; ^ also 
 by the local and special symptoms of these diseases, and the 
 absence from the blood of malarial parasites. The serum reaction 
 is often the only reliable sign, so closely does the aisease resemble 
 enteric fever as met with abroad. 
 
 Prophylaxis. — The institution of sound water drainage, the 
 avoidance of contaminated ground for camping purposes, the 
 prevention of pollution of the soil round camps and buildings, 
 due attention to all latrines and urinals, proper ventilation, avoid- 
 ance of damp and overcrowding, and destruction of infected stools 
 and urine are the most effectual means of prevention. It is also 
 desirable to avoid Mediterranean towns between the months of 
 May and October, and to remember that this region is, except in 
 
 ^ For technique, see Mediterranean, Malta or Undulant Fever (author), p. 158 ; 
 Macmillan and Co. 1898 ; and Wright in Brit. Med. Journal, 1897, vol. i, pp. 
 139. 258. 
 
MEDITERRANEAN FEVER 115 
 
 the hot summer months, subject to sudden changes of temperature 
 and that the air is very moist, necessitating the possession of the 
 warmest clothes, an extra cloak at sundown, and of always sleeping 
 in flannel, and wearing it next the skin. 
 
 Treatment. — No agent having a specific action upon this virus 
 is known at present. We have primarily to treat a pyrexia, and 
 secondly such local symptoms as may be present. First remove the 
 patient to sanitary surroundings ; when the diagnosis is certain open 
 the bowels with a smart purgative, calomel with compound jalap 
 powder for choice. Confine the patient to bed so long as the high 
 temperature continues. Let him have as much fresh air as is com- 
 patible with avoidance of chills and the fatigue of moving, placing 
 him, when possible, in his bed, at least during the daytime, out in the 
 open air on a verandah or elsewhere. Provide an ample supply of 
 night clothes of some absorbent material for the changes necessitated 
 by the excessive diaphoresis. Keep the temperature at or below 
 103° F. by means of tepid or cold sponging or packing. Treat any 
 tendency to pneumonic congestion or weak cardiac action at once and 
 energetically. Attend to the skin, washing it daily with tepid water 
 containing a little ammonia or vinegar. Diet to be fluid so long as 
 fever is present, restricted in amount when that is high and abundant 
 when low. Chronic cases, with mild intermittent temperature, can 
 often digest and benefit by scrambled eggs, or fish, etc., for breakfast 
 when the temperature is normal, but not later in the day when it 
 rises. The tongue is the best guide as to the suitability or otherwise 
 of dietary. In the early morning, about 5 or 6 a.m., a glass of 
 milk should be given (with or without whisky) as a routine practice, 
 the patient being extremely depressed at that time. Subnitrate of 
 bismuth should be given for gastritis or vomiting, combined if 
 necessary with beef juice, peptonised foods and champagne. If 
 diarrhoea is present, beef tea is contra-indicated. For diarrhoea 
 resulting from irritation in the colon, warm enemata of starch and 
 opium are useful. Fresh fruit and lemonade should be given, stewed 
 prunes and baked apples being utilised to lessen constipation. 
 Eff'usion into joints and neuralgic pains are best treated by moist 
 warm local applications, followed by belladonna and by placing the 
 patient between blankets and enveloping the part in cotton wool and 
 flannel. Though the bed pan is necessary during acute pyrexia, the 
 close stool may be used in the chronic intermittent stages, provided 
 the patient's hips, etc., are carefully protected from cold. Quinine 
 and arsenic do harm in the acute stages ; but during convalescence 
 quinine may be given in small doses as a tonic, or better still 
 
ii6 MANUAL OF MEDICINE 
 
 Blaud's pills, with plenty of out-door air, full diet and stout, but 
 fatigue and mental worry must be avoided. 
 
 During the autumn and winter months cases do better away from 
 England and where they can be out of doors, in hill towns of Italy or 
 Sicily, or in the dry climate of Egypt. During spring and summer a 
 change to England, Switzerland, the Italian Alps or similar places is 
 most important after the first acute stage has passed. A dry place 
 is essential, bracing but not exposed. A sea voyage is often most 
 beneficial to long chronic cases, especially when the patients are 
 able to get on deck. 
 
 Other treatment should be on general lines, such as is usual in 
 enteric fever, for the acute stages, and that now recommended for 
 phthisis during the chronic stages. 
 
 M. Louis Hughes. 
 
 CHOLERA 
 
 An acute infectious disease, determined by a specific organism 
 termed the "comma" bacillus, which is met with on and between 
 the epithelial cells of the intestinal mucosa and in the contents of the 
 bowels, and characterised by intestinal evacuations of a watery con- 
 sistence, by violent vomiting, by muscular cramps, by suppression 
 of urine, by extreme and rapid prostration, and by a high mortality. 
 Endemic in Lower Bengal, and perhaps in other parts of Asia, 
 cholera frequently assumes an epidemic character, spreading to 
 almost every part of the world. 
 
 History. — Although cholera was well known in Asia and Europe 
 from early times, the disease was first definitely described during 
 the epidemic of 1817 by Europeans in India. In 1830 the disease 
 visited Europe for the first time during the present century, and 
 since then it has reappeared in the following years: 1845, 1853, 
 1863, 1873, 1884, 1892, on each occasion lasting for one, two or 
 three or more years before it finally disappeared. The first three 
 epidemics only were general, every nation in Europe being severely 
 visited by cholera, but since 1865 the outbreaks have been very 
 limited, a few towns only in several countries being the sole sufferers. 
 
 Geographical distribution. — Cholera is an Asiatic disease, 
 and belongs more particularly to certain areas in Lower Bengal, so 
 much so that in this region cholera is held to be endemic. The 
 
CIIJLERA 117 
 
 attempts to focus the origin of all cholera epidemics in Bengal is 
 probably based on ignorance, as cholera is prevalent in many other 
 Asiatic countries at some period of almost every year. Geological 
 conditions play, if any, but a secondary part in determining the 
 presence of cholera ; elevation per se has less influence than used 
 to be assigned to it. It is a disease that travels along the lines 
 of human traffic be they by road or rail, by steamships or river 
 boats. Cholera has visited both hemispheres and spread almost 
 universally, yet there are some regions even in India, such as 
 Mooltan and Pondicherry, where immunity is more or less com- 
 plete. Australia, New Zealand, the Cape of Good Hope, the 
 Andaman Islands in the Bay of Bengal, and the majority of the 
 islands of the Pacific have never been visited by cholera in an 
 epidemic form. 
 
 Etiology. — Predisposing causes: season, exercises, a direct in- 
 fluence on the presence of cholera in all countries to the north of 
 the Equator. July and August are the months during which it 
 attains its maximum of virulence ; but it may, and does occur during 
 the winter months in India and in Russia, where it has continued 
 throughout the snow and Arctic cold of the severest winters. In- 
 sanitary localities are, as a rule, subject to be severely visited by 
 cholera ; whether the insanitary state be due to overcrowding, foul 
 drains, water-logged soil, absence of drains, polluted water supply, 
 leaking cesspits, or to all combined, each is warranted when cholera 
 is imminent to increase the death-rate in direct ratio to the amount 
 of insanitation. A new arrival is more liable to be attacked than 
 the native or old-time European resident when cholera is prevalent. 
 Women are less liable to cholera than men, and infants enjoy a 
 marked immunity. Alcoholic intemperance, bad or insufficient 
 food, fatigue from whatever cause, fear of infection, debility brought 
 about by illness from any cause, be it climatic, malarial or " con- 
 stitutional," predisposes the individual to attacks of cholera when it 
 is epidemic. Europeans are most liable to a seizure of cholera 
 during the night, and natives after a full meal. In the tropics 
 the former, intolerant of the heat at night, unconsciously, it may 
 be, throws off his bed clothing and renders himself more liable to 
 abdominal chill at a period when his own temperature is at its 
 lowest and the temperature of the air is at its minimum. The 
 native is seldom so affected, and it has been repeatedly observed 
 that a full meal, especially of fish or oysters, serves as a predis- 
 posing cause. 
 
 An attack of cholera affords protection for a time only. A 
 
ii8 MANUAL OF MEDICINE 
 
 second attack during any single epidemic is well-nigh unknown, 
 but a previous attack confers no immunity from cholera during 
 future outbreaks. 
 
 The means by which tlie poison is i?itrodiiced into the body is 
 at the present day held to be by pollution of the drinking water 
 by cholera evacuations. In 1854, Dr. Snow, by his careful investi- 
 gations, estabUshed the power of water contaminated by cholera 
 evacuations to cause cholera, and many instances could be cited 
 in proof of the principle which he first enunciated. 
 
 It is possible also that food, merchandise, insects such as flies, 
 clothing, etc., may serve as a medium whereby cholera can be com- 
 municated, but although these may serve to infect individuals, they 
 cannot ser\-e as a general infecting agency, unless the stools of one 
 or more of those so suffering reach the drinking water used by the 
 community. 
 
 Bacteriology. — The introduction of the specific toxin into the 
 body is the one exciting cause of cholera. Koch, during the 
 Eg}-ptian epidemic in 1883, separated a bacillus from the stools 
 and intestines of persons suffering from Asiatic cholera. This micro- 
 organism is known from its shape as the " comma " bacillus, and 
 its presence in the stools in quantity is a conclusive proof that the 
 person is suffering from Asiatic cholera. 
 
 Methods of microscopic examination. — {a) Smear a small quantity 
 of, or a mucous film from, a cholera evacuation on a warm slide ; allow 
 this to partially dry ; drop a few drops of a weak, freshly prepared, 
 watery solution of methyl violet on the specimen, and after fifteen 
 seconds run the staining fluid off; superimpose a cover-glass, pressing it 
 down lightly ; lay a piece of filter paper on the cover-glass and slide, so 
 that the superfluous fluid at the cover edge is absorbed ; examine with a 
 one-tenth or one-twelfth inch oil immersion lens. By this procedure 
 the bacilli are stained, their vitality and power of movement are not 
 checked, more especially if the slide be maintained at a temperature 
 slightly above that of the body. 
 
 {b) Place a small quantity of the cholera evacuation on a cover- 
 glass ; superimpose another clear cover-glass and pull the two asunder ; 
 dr\' the specimen in the usual way ; float the cover-glasses, smeared 
 side downwards, on a watery solution of fuchsin in a porcelain dish, 
 and warm over a spirit-lamp flame for ten minutes. Dry the pre- 
 paration and mount it for microscopic examination. 
 
 (<:) For more precise investigation the bacillus may be stained by 
 Loffler's method, which, though a tedious process, gives more precise 
 results, and by it the flagella are best defined. 
 
CHOLERA 119 
 
 The comma bacillus^ cholera vibrio, or spiriihwi chokrcB AsiaticcE, 
 present in the stools and in the intestines of cholera patients, but 
 never found in the blood or tissues, has the following microscopic 
 characters : — 
 
 The typical bacillus measures i to 2 /x in length and 0.5 to 0.6 /x 
 in thickness. When stained the parasite shows one, two, or three, 
 more deeply coloured spots, suggesting spores, although sporulation 
 has never been observed. The bacilli, which are usually seen to be 
 separate, may coalesce so as to form an arc ; but when the commse 
 are joined with their curves in a reverse direction the body appears 
 curved like an " S." In some preparations from cultures the bacilli 
 may coalesce by their extremities, so as to form an undulating 
 thread-like line (Plate II.). 
 
 When stained the comma bacillus exhibits, during certain as yet 
 undetermined periods of its existence, extremely fine flagella. In 
 some specimens but one is met with, although a flagellum at each 
 end would seem to be the rule. The flagella may exceed in length 
 the body of the bacterium, and, although very delicate, confer upon 
 the organism active " spirillum-like " movements. 
 
 But the comma bacillus is not the definite entity one anticipates 
 from reading Koch's original description. In the first place, there 
 are several bacilli which bacteriologically and anatomically resemble 
 the comma bacillus of Koch. Of these the best known are the 
 bacilli of cholera nostras, certain bacilli met with in the mouth, and 
 even in so-called " fresh " water. Nor do the comma bacilli of 
 cholera always maintain the power of infection claimed for them. 
 Cultures of the comma bacilli from cholera stools have been 
 swallowed by several experimenters with negative results. Again, 
 the bacilli have not always been met with in the stools of cholera 
 patients, and moreover bacilli, comma in shape and bearing 
 seemingly specific characteristics, have been frequently met with in 
 the stools of healthy persons. An accumulation of observations of 
 a like nature have thrown doubt upon Koch's dogma that the 
 comma bacillus is the only essential element required to produce 
 an attack of cholera. Still, for clinical purposes the presence of the 
 comma bacillus in quantity in the stools justifies the conclusion 
 that a specific disease — Asiatic cholera — is present. 
 
 Culture, methods a/td characters. — The cholera bacillus yields a 
 well-nigh specific appearance in culture media. It will not grow on 
 sour or acid media but thrives luxuriantly on broth, milk, or serum that 
 has been rendered alkaline. Agar -agar is not liquefied during the 
 process, but gelatine is so readily, and it is for purposes of diagnosis 
 
I20 MANUAL OF MEDICINE 
 
 tlie most suitable culture medium. When gelatine is seeded by 
 punctures and maintained at a temperature of 20° C, within twenty-four 
 hours a delicate white cloud forms along the puncture tracts. The 
 gelatine liquefies, and in forty-eight hours the liquefied areas assume a 
 characteristic funnel shape at the upper part. By the fourth day a 
 pronounced thread-like process extends downwards into the medium. 
 The thread is spiral and presents enlargements in its length like the links 
 of a cable. The whole of the upper or seeded portion of the gelatine 
 liquefies, and the contents of the tube present the following appearance: — 
 Lying on the top is a grayish scum consisting of involuted or 
 degenerate forms of the comma bacillus ; beneath the scum is the clear 
 liquefied gelatine ; and below this, and resting on the solid gelatine, 
 is a yellowish-white layer of cholera bacilli. When gelatine plate- 
 cultures are employed, the various colonies are seen to be irregular in 
 shape and size, and to give a granular, shining, ground -glass -like 
 appearance to the gelatine medium. A faint roseate tinge is imparted 
 to the growth in the later stages, a colour considered to be characteristic 
 of cholera bacilli. When grown on sections of sterilised potatoes, at a 
 temperature of between 30" C. and 35° C, the exposed surface of the 
 potato is speedily covered by a copious moist-looking growth of a dirty 
 gray or light brown colour, altering to colours of varying tints m the 
 course of a few days. 
 
 Incubation. — After exposure to cholera, infectious symptoms 
 may develop in a few hours. Three days is the usual period of 
 incubation, but it may extend to as many as ten days. This 
 question has a direct bearing on qiiara7iti7ie^ in fact all quarantine 
 regulations against cholera are founded on the determination of this 
 period. Should a ship be ten days out from a cholera-infected port, 
 and no cases of cholera have occurred on board during the voyage, 
 it is foolish to impose a further period of quarantine upon the 
 passengers. 
 
 Symptoms. — It is customar}' to divide an attack of cholera 
 into four stages, viz. : (i) the Premonitory stage; (2) the Evacuation 
 stage ; (3) the period of Collapse or Algide stage ; and (4) the stage 
 of Reaction. These are more or less fanciful divisions, as in a large 
 number of cases the onset is sudden, the development explosive, 
 and death a matter of a few hours. 
 
 T\\^ premojiitory diarrhcea of cholera is a condition more often 
 described than seen, and how far it is an essential stage of the 
 disease or an accidental predisposing condition is doubtful. 
 
 The onset of cholera is marked by a violent intestinal flux, 
 attended by a feeling of sinking in the epigastrium and a marked 
 loss of strength. 
 
CHOLERA 121 
 
 The siools in cholera are characterised by their consistence, 
 bulk, frequency, and the force with which they are expelled. At first 
 they consist of copious watery evacuations bearing a resemblance to 
 faeces, but they speedily lose every trace of faecal matter and become 
 the typical " rice-water " stools characteristic of the disease. These 
 evacuations, on being allowed to stand, separate into a sediment 
 and a whey-like fluid. The former consists of active amoeboid cells, 
 epithelium, hyaline, and granular cells, the bacteria which usually 
 inhabit the intestine and the specific comma bacillus. The fluid 
 has a specific gravity of 1005 to 10 10, and gives a neutral or faintly 
 alkaline reaction, and contains a little albumen. The bulk of the 
 motion is at times surprising ; well-nigh a quart may be passed at 
 a time. The frequency of the calls to defecate allows of but little 
 time to remove one bed pan before another is wanted. Owing to 
 the violent contractions of the muscular walls of the intestine the 
 contents of the bowel are expelled with great force, leaving the 
 patient prostrate for a few minutes, or until the next motion threatens. 
 
 Copious vomiting without great effort sets in, the vomited matters 
 being first the stomach contents, but afterwards consisting of thin 
 fluid containing a little mucus. Cramps in the limbs and muscles 
 of the abdomen give rise to considerable pain, the patient crying 
 out in dread when a muscular spasm comes on. Thirst is present 
 almost from the first, but the patient vomits whatever he drinks to 
 relieve it. After a few hours the strength of the patient reaches a 
 low ebb. The tongue looks sodden, the gums pale ; the surface of 
 the body feels cold, and if the temperature is taken in the axilla it 
 will be found lowered ; it may be two, three, or four degrees below 
 the normal. The pulse, which is accelerated from the onset, soon 
 becomes feeble, then thready, and in very serious cases cannot be 
 felt at the wrist or even in the arm. The heart sounds, when the 
 disease is well -advanced, are scarcely to be heard, and the cardiac 
 impulse disappears. The breathing is disturbed, becoming gasping, 
 the patient calling out for air ; the voice is reduced to a whisper ; the 
 expired air is cold ; there is much restlessness, tossing about, and 
 throwing off the bed-clothes. The urine, which is at first high 
 coloured, soon becomes scanty and albuminous, and may be 
 altogether suppressed. Should this state continue, a grave con- 
 dition is indicated. 
 
 When the stage of collapse supervenes the evacuations may cease, 
 though the vomiting may continue, and the cramps give rise to 
 no expression of pain. The skin appears cyanosed and wrinkled, 
 and when seized between the finger and thumb the fold disappears 
 
122 MANUAL OF MEDICINE 
 
 quite slowly. The face looks shrivelled and lined, the eyeballs 
 sunken, the eyelids are but half closed, and the nose looks pinched 
 and pointed, the features being so changed as to render the indi- 
 vidual well-nigh unrecognisable. The mental condition, which in 
 the early stage is quite clear, in the later stages changes to one of 
 apathy. Whilst the thermometer in the mouth and axilla registers 
 4° F. to 6° F. below the normal, the rectal temperature rises usually 
 to 103° F. or 105° F. In several instances, in the experience of the 
 writer in Egypt and China, the rectal temperature reached to be- 
 tween 108" F. and 109'^ F. half an hour before death. 
 
 Should death be delayed beyond the stage of collapse, what is 
 termed the " tepid " stage supervenes. The body temperature rises 
 to about the normal : even the pulse may return at the wrist ; the 
 purging and vomiting entirely cease and the patient's features and 
 complexion become more natural; but the pupils remain fixed, the 
 cornea hazy, the eyeballs sunken, and in a comatose state life 
 becomes extinct. There are practically no recoveries from this 
 stage, although to the inexperienced it would seem that a favourable 
 turn has set in. 
 
 When the attack is followed by reaction., the surface of the body 
 becomes warmer, the colour begins to return, the pulse and voice 
 recover, urine is passed, and after a sleep the patient wakes refreshed. 
 On the other hand, when the stools are passed involuntarily, when 
 the brachial pulse or even the carotid pulse disappears, when 
 hiccough becomes distressing, and the temperature falls to, say, 94°, 
 whilst the temperature of the rectum rises perhaps to 105° or 107° 
 F., a fatal issue is at hand. 
 
 Sequelse. — Convalescence, following an attack of cholera, 
 depends upon the duration and acuteness of the attack. In mild 
 cases convalescence is rapid, but in severe and prolonged cases the 
 intestines may remain irritable for months. Many ailments and 
 conditions may succeed an attack of cholera, such as an urticaria 
 or roseola choleraica, convulsions, especially in children, enteritis, 
 haemorrhage from the bowel, parotitis, anaemia, insomnia, al- 
 buminuria, sloughing of the cornea and scrotum, and pulmonary 
 thrombosis. Females frequently abort during, or very soon after an 
 attack. 
 
 Diagnosis. — Diarrhoea from any cause, which is attended by 
 lividity of complexion, mental anxiety and epigastric sinking, is 
 apt to be styled " choleraic." Any septic or poisonous material 
 taken as food may set up symptoms simulating Asiatic cholera; 
 but it is only by bacteriological cultivation and by microscopic 
 
CHOLERA 123 
 
 examination of the intestinal dejecta that the actual existence of 
 true (Asiatic) cholera can be conclusively diagnosed. 
 
 Prognosis. — Persons attacked by cholera at the commence- 
 ment of an epidemic are in greater danger than those seized when 
 the epidemic is on the wane. Children, persons in advanced years, 
 chronic sufferers from any form of visceral disease, are less able 
 to withstand the onset of cholera than are young and middle-aged 
 persons in good health. Yet the strongest men may succumb 
 speedily. The writer knew of an engine-driver, in Eg}'pt in 1883, 
 who started on his engine at Alexandria in perfect health, die 
 before he reached Kaffir-Zayat, halfway to Cairo, the journey lasting 
 only two and a half hours. 
 
 Mortality. — The death-rate of different epidemics varies, and 
 the case mortality at the commencement and end of an outbreak 
 shows different degrees of virulence. It may be taken as a rule 
 that half the persons attacked by cholera die, the proportion during 
 the earlier part of the epidemic being about 65 per cent of those 
 attacked, and during the later stages 35 per cent. 
 
 Post-mortem appearances. — As may be gathered from the 
 symptoms, the body generally will present a shrunken appearance 
 after death. The rectal temperature usually rises for the first half 
 hour ; rigor mortis sets in ver}' early — within an hour or two, and 
 muscular contractions may distort the limbs and cause them to 
 change their position. The stomach is usually empty, though a 
 considerable quantity of food may remain in it in spite of in- 
 cessant and copious watery vomiting. The intestines contain 
 some fluid matter with mucous material intermixed. The mucous 
 surface of the alimentar}- canal looks sodden, bleached in parts, 
 and congested in others, and the mucous and submucous coats 
 may be easUy peeled from the intestinal walls. The solitary and 
 agminate glands are swollen. The gall bladder is distended with 
 bile, the liver and kidneys appear duskily congested and full of 
 blood, and the spleen of the same colour may be either enlarged 
 or diminished in size. The large veins of the trunk, the right 
 side of the heart, and the pulmonar}' arteries are usually distended 
 with blood, whilst the limb veins are empty. The lungs are 
 pale, and seem as if contracted and drawn in towards their 
 roots ; the muscles of the limbs and trunk, when cut into, present 
 at times a dark, violet-tinged appearance, but in other cases they 
 look pale and bleached. It is not uncommon to find muscles 
 ruptured, the result of the severe cramps and spasms during life. 
 Should the patient not have succumbed until the period of reaction 
 
124 MANUAL OF MEDICINE 
 
 has set in, symptoms of congestion in the lungs, and of the 
 intestines, or even inflammation of these organs, may be met with. 
 
 Treatment. — Prophylactic treatment during a threatened epi- 
 demic of cholera resolves itself into the individual efforts of house- 
 holders to procure boiled water for drinking, for washing utensils, 
 and for baths. Milk should be scalded or boiled before being 
 consumed, and locally manufactured aerated waters should be 
 eschewed. The further care to be taken is strict attention to diet, 
 which should be as simple as possible, and well cooked. Unripe 
 and rotting fruit should be forbidden, but fruit in season and in 
 good condition should be allowed. The writer, by removing the 
 restrictions against the consumption of fruit in good condition, 
 in the towns under his care in Egypt in 1883, found immediate 
 benefit therefrom. To the poor in Egypt and most Oriental 
 countries fruit is a stable means of subsistence, and by withholding 
 it entirely the native is more or less reduced to wcU-nigh starvation 
 point ; and inanition is the handmaiden of cholera. 
 
 Above all is it imperative to disinfect the dejecta of cholera 
 patients ; and not only should the stools be dealt with, but even 
 the vomited matters, the soiled clothing and bedding. The 
 utensils into which the patient evacuates should contain a potent 
 disinfectant such as perchloride of mercury (1-2000), or carbolic 
 acid (1-20). The evacuations must be covered completely by the 
 disinfecting fluid, removed from the sick-room, and, where possible, 
 buried at least three feet deep in the ground in a place remote 
 from possibility of contaminating wells. On no account must the 
 evacuations be thrown on the surface of the ground near the house, 
 into open drains, cesspools or middens. Where a water carriage 
 system is effective they may be consigned to the sewer, which 
 ought to be frequently flushed by a disinfectant ; the ferrous 
 sulphate (i oz. to i pint) is eminently satisfactory for the purpose. 
 Clothing and bedding are to be burnt ; and should the patient die 
 the body ought to be cremated, or, when that is inexpedient, the 
 remains should be coffined in charcoal, buried at least six feet in the 
 ground and covered by lime before the earth is replaced. 
 
 Treatment by anti-chokraic inocii/ations. — As a preventive measure 
 in cholera, inoculations by a specially prepared virus have been 
 systematised and practised by Haffkine in India. By his method 
 protection against cholera is afforded by " acclimatising " the 
 system, first to a weak, and afterwards to a strong cholera poison. 
 A pure culture of the weak or attenuated virus is grown in a 
 medium (agar), at a temperature of 39° C, ; a constant aeration being 
 
CHOLERA 125 
 
 maintained during the process. The strong or " exalted " pure 
 culture is grown in the peritoneal cavities of a series of guinea-pigs. 
 As each animal dies the fluid in the peritoneal cavity is removed 
 and transferred to another, and so on through a series of t\Yenty or 
 thirty guinea-pigs, until a maximum toxicity is obtained. From 
 the pure cultures the respective "weak" (first) and "exalted" 
 (second) vaccines are prepared by cultivation on agar and conversion 
 into emulsions by superimposing a layer of broth with which the 
 growth is intimately mixed. In this form the respective " vaccines " 
 may be used, — " Uving vaccines " ; or they may be treated before 
 being injected by the addition of dUute carbolic acid, " carbolised 
 vaccine," by which process the bacilli are killed. In the one case 
 the baciUi and their toxins are injected together, and in the other 
 the toxins, deprived of their bacilli, are employed. As in the 
 " living vaccines " the bacilli die immediately after the fluid is in- 
 jected subcutaneously, the choice of either form seems immaterial. 
 
 Under strict precautions to ensure sterility during the operation 
 the attenuated vaccine is injected under the skin of one flank, 
 and on the fourth or fifth day afterwards the stronger vaccine is 
 injected into the opposite flank. The quantity used is one cubic 
 centimetre for an injection. 
 
 The signs and symptoms produced by inoculation with Haffkine's 
 serum appears some three hours after the hypodermic injection has 
 been given. Tenderness is experienced at the seat of the puncture 
 and a slight oedema extends for some little distance around ; a febrile 
 disturbance and consequent headache, loss of appetite, and general 
 feeling of lassitude is set up, which, however, pass off within forty- 
 eight hours, and by the fourth day all the signs at the seat of injection 
 disappear. A similar train of symptoms is set up after the second 
 inoculation, but the febrile disturbance, although of shorter duration, 
 is more acute. 
 
 Repeated and careful experiments in animals con\-inced Haffkine 
 of the efficacy and safety of the remedy, and, seeing that up to the 
 present moment well-nigh 100,000 persons have been inoculated 
 without any untoward result, the safety of the remedy may be 
 regarded as proved. Haffkine published the results of his 
 inoculations in a paper read before the Royal Society (June 1899). 
 He states that some 8000 persons w-ere inoculated with the 
 prophylactic serum in Calcutta, and for two years observations 
 were made as to the relative advantages derived therefrom. The 
 majority- of the inoculated resided in the san"e neighbourhood, and 
 in many instances in the same house with members of the family 
 
126 MANUAL OF MEDICINE 
 
 who had not been inoculated. Whilst the uninoculated developed 
 cholera in a marked manner, the inoculated showed practically 
 complete protection until the 420th day, when cholera began to 
 spread amongst them. Moreover, Haffkine showed that it was only 
 as a temporary prophylactic that the inoculation served, for the 
 proportion of deaths to cases amongst the inoculated and the 
 uninoculated remained the same. The efficacy of the remedy 
 against cholera is still on its trial, but there is every indication 
 that a prophylactic remedy of great value has been discovered. 
 
 Medicinal treatment. — When diarrhcea occurs whilst a cholera 
 epidemic is incident means should be taken to check it. For such 
 purposes many drugs are recommended ; some authorities claiming, 
 quite unjustifiably, well-nigh specific action for their plan of treatment. 
 The writer can speak from experience, approvingly, of Macnamara's 
 pill of I grain of opium and 4 grains acetate of lead given early in 
 the disease. Chlorodyne in 30 drop doses has many, perhaps most 
 advocates ; others recommend 5 to 10 grains tannic acid, whilst some 
 prescribe 20 minims of spirit of camphor, or 10 grains of Dover powder, 
 or 20 minims laudanum with 3 grains of Cayenne pepper; the drug 
 being repeated at short intervals as symptoms necessitate. There is 
 no doubt that diarrhoea can be arrested by one or other of these 
 remedies during a cholera epidemic, as at other times, but whether 
 the flux of true cholera can thus be checked is doubtful. 
 
 When cholera has reached the second or evacuation stage no 
 medicinal or other forms of treatment, if we exclude anti-choleraic 
 inoculations, possess a specific action. The medicinal treatment of 
 cholera is purely empiric, and one has to fall back on the time-worn 
 expedient of treating symptoms as they arise. 
 
 Attempts to stem the intestinal flux by astringents are, at this 
 stage of the disease, useless ; their powers are rendered abortive by 
 the rapidity with which they are hurried along the canal. In fact, 
 purgatives have more advocates than astringents at this phase of 
 cholera. Dr. George Johnson endeavoured to place the purgative 
 plan of treatment on a scientific basis, and administered moderate 
 doses of castor oil frequently repeated. The rationale of this 
 treatment is that the cholera poison is thereby eliminated from 
 the intestines and nature is aided in her attempts at so doing. 
 Reasonable as this treatment might seem to be, experience has 
 declared against it. There is the danger of the purgative continuing 
 the purgation at a period of possibly natural abatement of the 
 disease, when rest and quiet to the intestines and the body is of vital 
 consequence. Rest in bed, warmth with free circulation of warm 
 
CHOLEEA 127 
 
 air is essential. Trie patient should not be allowed to get up to 
 stool, nor sit up in bed to drink. Ice to suck, or, in its absence, 
 hot (not cold) water to drink should be freely supplied, and will help to 
 allay thirst and vomiting. A mustard plaster to the pit of the stomach 
 and hypodermic injections of morpliia with atropine will tend to 
 allay vomiting and relieve epigastric pain and restlessness. Cramps 
 are to be relieved by firm rubbing by the hands, and cardiac weak- 
 ness by hypodermic injections of ether or digitalin. Placing the 
 patient in a recumbent position in a warm bath 103° F. is an 
 excellent form of treatment ; and may be supplemented by injecting 
 ice-cold water into the rectum whilst the patient is immersed in 
 the hot water. Slow intravenous injection of a saline fluid con- 
 sisting of 60 grains of common salt and an equal quantity of 
 carbonate of soda, dissolved in a quart of boiled water at a 
 temperature of 100°, 103°, or even 105° F. has been administered 
 with advantage. Of other methods the wet sheet, spinal ice-bags, 
 intraperitoneal injections of warm water and hot-air baths, have 
 perhaps most to recommend them. 
 
 Suppression of urine must be treated by dry cupping over the 
 kidneys, or by poultices or hot fomentations round the waist ; 
 intestinal irritabiUty may be counteracted by bismuth and opium, 
 and by the wet pack to the abdomen. 
 
 All food should be withheld during the stage of vomiting and 
 purging, and, should the stage of collapse supervene, food given by 
 the mouth can do nothing but harm. Stimulants, champagne 
 especially, are indicated. 
 
 When the stage of reaction sets in, hastiness in administering 
 " nourishing " foods is to be condemned. Milk-whey, white-wine 
 whey or koumiss should be given in teaspoonful doses at frequent 
 intervals, every few minutes in fact. Freshly-made tea, with or 
 without a small quantity of whisky or brandy, sipped slowly and 
 either warm or iced, is grateful to the patient. Rice tea (boiling 
 water poured over rice roasted brown) is a pleasant and nourishing 
 drink with or without lemon. Soon more substantial food is wanted. 
 Starchy foods are to be avoided and a meat diet commenced at 
 first. Raw meat juice, scraped beef, plain jellies, etc., are to be 
 given in small, even minute quantities, and frequently repeated. In 
 a day or two, finely- minced beef hastily and very lightly cooked 
 * may be relished. Of starchy foods, well-boiled rice is the first to 
 be given, and then bread which has been well baked. 
 
 James Cantlie. 
 
128 MANUAL OF MEDICINE 
 
 PLAGUE 
 
 The term plague was employed in ancient, and up to quite 
 modern times to signify the prevalence of any epidemic disease 
 attended by a high rate of mortality. The word is now, however, 
 no longer used in a general sense, but as the name of a definite 
 disease bearing specific characters. There is in consequence con- 
 siderable confusion in determining the accurate history of the actual 
 disease, as many ancient and mediaeval writers employed it indis- 
 criminately. The "black death" which devastated Europe in the 
 fourteenth century, and the "great plague" which raged in London 
 in 1665, were without doubt plague as it is now understood. 
 
 Plague is a specific, acute, contagious disease, appearing in 
 epidemic form, attended by a high mortality and with a tendency 
 to linger and recur once it has attacked a community. It is 
 characterised by a febrile state, by the development of buboes in 
 the deep and superficial glands, and by changes in the lungs, 
 spleen, and other organs. A specific diplococcus is met with in 
 the blood, excretions and viscera of persons suffering from, or who 
 have died of plague. 
 
 Geographical Distribution. — During the latter half of the 
 nineteenth century plague has been met with in Europe, Asia, and 
 Africa. In 1853, and again in 1873 ^^^ 1897, plague existed in 
 Western Arabia; in 1858 and in 1874 it appeared in Tripoli; the 
 northern part of Persia was severely visited in 1863, and again 
 in 1870. Mesopotamia from 1874-1877 proved the centre of a 
 widespread epidemic which reached nortliwards to the Caspian 
 shores, advanced up the Volga in 1878, and extended westwards 
 as far as Syria and eastward to Persia. 
 
 Since plague appeared in South-Eastern China in 1894, it has 
 been met with in Formosa, Annam, and the Bombay Presidency as 
 a severe epidemic ; in Southern India, Calcutta, on the shores of 
 the Persian Gulf, at the port of Mecca, in the islands of Mauritius, 
 Reunion, Madagascar, and Penang, and in the towns of Alexandria 
 and Oporto it existed in a mild form during 1 898-1 899. Koch? 
 has demonstrated the presence of plague in the districts of Bukoba 
 and Kitengule in German East Africa; and from the hinterland of 
 the French possessions in West Africa plague was reported during 
 
PLAGUE 129 
 
 1899. The malady first reached the American continent in 1899, 
 appearing at Santos, a seaport town of Brazil. 
 
 The disease has been long known as Mdhdmari in the districts 
 of Kumaon and Ghurwal in the north-west provinces of India 3 and 
 in the Chinese provinces of Sze-chuen and Yunnan on the borders 
 of Thibet many writers have described it under the name of 
 "Yunnan" plague. Hence Kumaon and Ghurwal in India, and 
 Sze-chuen and Yunnan in China, are held by many to be the endemic 
 seats o^ ])lague. 
 
 Etiology. — Plague is held to be one of the "filth" diseases, 
 and it attacks principally the least sanitary parts of every city. In 
 proportion to the extent of insanitation, so does the severity of the 
 outbreak vary. Infants and aged persons are less likely to contract 
 plague than are the others of the community, but sex seems to be no 
 protection. Plague prevails as a rule during the cool weather in 
 tropical countries, great heat causing a subsidence in its virulence. 
 In contradistinction to this general rule there are several exceptions, 
 for in Hong-Kong and Poona in 1899 plague was at its maximum 
 during the hottest part of the summer. Europeans dwelling in close 
 proximity to plague-stricken areas in Asia, suffer or escape in pro- 
 portion as they live after the manner of the natives, or in the more 
 sanitary state of Western Europe. 
 
 Bacteriology. — In 1894, during the epidemic of plague in 
 Hong-Kong, Professor Kitasato of Japan discovered the plague 
 microbe, and since then the presence of the organism has been 
 noted in the blood, secretions, and organs of persons suffering 
 from plague wherever the disease has prevailed. Experimental 
 investigations show that the disease can be communicated to 
 several of the lower animals, and all observation goes to show that 
 the bacterium known as the plague bacillus (Kitasato) is the cause 
 of the disease. 
 
 Simultaneously with, if not antecedent to, an outbreak of plague 
 rats are attacked by all the symptoms of plague, and die in great 
 numbers. Other animals may also be attacked, but none are so 
 prominently or so constantly affected. 
 
 The bacillus of plague has been found in the dust and filth of 
 infected houses, but the exact relation of the disease to the soil, if 
 indeed the soil bears any part in the life-history of the parasite, 
 has not been ascertained. Certain it is, however, that the bacillus 
 thrives better in some localities than in others, where there is but 
 little difference in latitude or sanitation. This is well instanced in 
 the cases of Bombay and Calcutta. In the former, plague at once 
 VOL. I K 
 
I30 MANUAL OF MEDICINE 
 
 became severely epidemic, whilst in Calcutta the disease for several 
 years appeared in a mild, almost a sporadic form. 
 
 The microbe of plague is met with in the fluids which surround 
 an inflamed gland, in the gland itself, and in the pus from a newly- 
 opened bubo. The bacillus is also found in the spleen, lungs, 
 liver, kidneys, stomach, and intestinal walls. In the saliva, the 
 expectoration, the faeces, and the urine the micro-organism has 
 been shown to exist. In the blood the bacillus is easily demon- 
 strated in the later stages of fatal cases, but frequently it is only to be 
 found in infinitesimal numbers in the earlier stages of the disease. 
 
 The plague bacillus is readily stained by all basic aniline dyes, when 
 it is to be seen as a short flagellated rod with rounded ends measuring 
 I yu, in length and 0.3 /x in breadth (Plate I.). At each end the bacillus 
 stains more deeply than in the centre, and sometimes a clear area round 
 the bacillus can be seen. In stained cover-glass preparations the bacillus 
 resembles a diplococcus, but occasionally four to six of the bacilli in 
 culture preparations are seen to form a chain simulating streptococci. 
 The microbe does not sporulate ; in fresh specimens it is seen to be 
 motile. The best culture medium is one composed of "a 2 per cent 
 alkaline solution of peptone containing i per cent gelatine " (Wilm). 
 A temperature between 36° C. and 39° C. is the most favourable for the 
 growth of the bacillus. At a temperature below 25° C. and above 40° C. 
 a decline in the rapidity of the growth becomes apparent. " On gelatine 
 plates the bacillus grows without liquefying the medium, and produces 
 in forty-eight hours small, round, grayish-white colonies " (Wilm). On 
 bouillon the growth of the bacillus forms at the bottom and along the 
 sides of the test-tube as a granular or flocculent precipitate, whilst the 
 bouillon itself remains clear. When the tube is shaken the precipitate 
 is distributed through the fluid. On potato, at blood-heat, a very delicate, 
 scanty, grayish-white or white crusted growth is formed after thirty-six 
 hours. On agar plates two forms of colonies are met with, a large 
 and small, and, when puncture cultivations in agar tubes are made, the 
 seed from the smaller colonies shows a scantier growth than that from 
 the larger. This variability of the plague organism in regard to growth 
 is borne out experimentally in regard to its toxic power. 
 
 CorainumcabLlity. — Plague can be carried by persons or 
 animals suffering from plague, and by articles of clothing, food, or 
 water which have become contaminated. Although the disease is 
 to some extent transmissible, it appears that, with ordinary care, 
 there is no great danger of contracting it. It is seldom that either 
 doctors, nurses, or sick attendants are attacked through attend- 
 ance at plague hospitals, provided precautions are taken, such as 
 
PLAGUE 131 
 
 sleeping in good quarters, taking meals away from the hospital, etc., 
 etc. The disease is, however, certainly contagious and inoculable. 
 A nursing sister in Hong-Kong who had been through two epidemics 
 of plague succumbed to the disease brought on by receiving the 
 expectoration of a delirious patient on her conjunctiva. Two of the 
 Japanese physicians, studying plague in Hong-Kong in 1894, were 
 inoculated at a post-mortem examination, and suffered severely. 
 Animals, such as cattle, pigs, dogs, and especially rats and mice, 
 contract plague, and, possibly by their, contaminating human food, 
 become a source of infection. This fact accounts, no doubt, for 
 the belief that grain is a source of infection. Food may also be 
 rendered infectious by flies. The clothes of persons suffering 
 from plague harbour the virus, as shown by Wilm, who succeeded 
 in cultivating the bacillus from portions of clothing that had been 
 soiled by the urine or fgeces of plague patients. The water of 
 various wells was found to contain the plague bacillus in Hong- 
 Kong during 1896. The plague bacillus may enter the body by 
 the skin. This belief was surmised owing to the frequency with 
 which the bare-footed coolies in China showed groin buboes. There 
 is reason to believe that flies and fleas may communicate the disease. 
 It is presumed that the virus can be inhaled, owing to the frequency 
 with which primary pneumonia appears during some outbreaks. The 
 bacillus may also enter the body by the alimentary canal. This is 
 known to be the case as the result of feeding animals with cultures 
 or infected food. 
 
 Incubation. — From three to five days is the usual period of in- 
 cubation. Statements that incubation may vary from a few hours 
 to eight days, or even longer, are probably to be explained by the 
 source of infection having been mistaken. 
 
 Symptoms. — Frodrojnal sympto?ns are seldom observed, but 
 for a day or so before the disease sets in, lassitude, loss of appetite, 
 and pain in the loins have been recorded. 
 
 Livasmi. — The symptoms of plague are generally ushered in 
 suddenly by a rigor accompanied by a hot and dry skin, headache, 
 and marked prostration. The face is dusky, the eyes sunken, the 
 features drawn, and the expression vacant. Mental ineptitude is 
 shown from almost the first onset of the disease. Fever is a con- 
 stant symptom in all cases of plague. In a certain proportion the 
 temperature runs up in an hour or two to 104° F. or higher, but the 
 maximum is usually attained on the third or fourth day, when the 
 thermometer registers frequently 106" F. or over. Very high 
 temperatures are not, however, by any means constant \ the thermo- 
 
132 MANUAL OF MEDiCINE 
 
 meter may never register over loi" F. After a sudden initial rise 
 the temperature in a day or two may fall below normal ; on the 
 other hand, it may remain high till death occurs, or in cases of 
 recovery fever may continue for weeks. Curiously enough the pre- 
 sence or absence of high fever gives no guide to the chance of 
 recovery, as many patients in whom the temperature fell to the 
 , normal after a day or two succumbed, or, on the other hand, re- 
 ! covered as readily as those in whom the fever continued high. 
 
 Variations in Type. — Several terms are employed to denote 
 varieties in the signs and symptoms of plague : bubonic, intestinal, 
 pneumonic, convulsive, toxic, typhus type, pestis siderans, pestis 
 ambulans, pestis minor. These terms, for the most part, explain 
 themselves. The viscus indicated may alone show signs and 
 symptoms of being affected. A toxic form implies that the symp- 
 toms resemble a septicaemia, no local signs developing. Siderans 
 indicates a rapidly fatal form, and ambulans a mild type, during 
 which the patient may not even be confined to bed. The last 
 mentioned however, pestis minor, may be, and probably is, a disease 
 quite apart. It consists of a prevalence of non- venereal buboes 
 which, although noted during, before, or after epidemics of plague, 
 may exist independently of the more severe illness. 
 
 The Lymphatic System. — Although plague is frequently termed 
 "bubonic plague," buboes are by no means invariably present. In 
 73 per cent of the cases, however, they are readily detected in 
 one or more parts of the body in almost every epidemic. Visible 
 swelling of the glands may usher in the disease, may appear during 
 the first twenty-four hours, may defer its appearance until the fifth 
 day, or may never become evident. The groups of glands attacked 
 in order of frequency are, the inguinal (vertical and oblique), the 
 axillary, and the cervical ; internal glands are also frequently involved. 
 Buboes develop with amazing rapidity; in a few hours they 
 may increase from the size of a hazel nut to a pigeon's egg, and in 
 the course of a day or two become as large as an orange. The 
 inflammation extends rapidly to the periglandular tissues, causing 
 oedema, subcutaneous hemorrhage, and finally suppuration of the 
 tissues around. The skin becomes raised, red and oedematous ; the 
 subcutaneous tissues become infiltrated, widely obscure the glandular 
 swelling and cause extensive discoloration and induration. If the 
 gland is deep-seated, pain is seldom complained of, unless firmly 
 pressed upon ; but the patient maintains the limb in that position 
 best calculated to relieve tension. In 90 per cent the buboes sup- 
 purate, the result of a mixed infection with pyogenetic organisms ; 
 
PLAGUE 133 
 
 the skin dies, and a slough, several inches in diameter, separates, 
 exposing a deep, rugged cavity, discharging pus, and presenting in 
 many instances the necrosed gland at the bottom of the space. As 
 a rule sloughing of the cutaneous structures takes place from the 
 tenth to the fourteenth day. Buboes which do not suppurate retain 
 a well-marked induration for some time and disappear slowly. The 
 presence or absence of buboes in no way affects the mortality. 
 
 Digestive system. — It would seem that in a certain proportion of 
 cases the gastro-intestinal tract is the seat of acute and primary 
 symptoms, more especially in instances in which buboes are not a 
 prominent feature. The lips become speedily dry and cracked ; the 
 tongue is at 6rst red at tip and edges, and covered on the dorsum 
 by a fur which changes from a grayish-white to a mahogany-brown 
 or even black crust. The tongue appears swollen and indented or 
 shrivelled and fissured. The mucous membrane of the mouth 
 and fauces are unnaturally dry and redder than usual, there is 
 great thirst at the onset, loss of appetite, and at times persistent 
 vomiting of a watery, bilious, or coffee-ground fluid. The bowels 
 during the acute illness are usually constipated, the faeces being 
 hard, dark yellow or brown in colour, and later, loose dejections of 
 a mustard colour occur, with occasionally blood and mucus in the 
 stools. 
 
 The liver is often enlarged, and the spleen always so. It is 
 seldom that pain can be elicited over either by percussion or 
 palpation. 
 
 The respiratory tract. — Although a pneumonic variety of plague 
 prevails, more especially during certain epidemics, the lungs in the 
 ordinary type of plague show but few symptoms of being affected. 
 Evanescent patches of congestion occur, which seem to come 
 and go according to the position of the patient. In some 10 per 
 cent of cases a bronchial catarrh supervenes and occasionally the 
 sputum is bloody. The purely pneumonic type is characterised by 
 the usual signs and symptoms of lobar pneumonia and is exceed- 
 ingly fatal. 
 
 The heart and circulation. — The pulse at the commencement of 
 the illness is full and tense as a rule, and at times irregular. As the 
 strength fails the pulse becomes quick (140), feeble, and fluttering. 
 Percussion frequently reveals the right side of the heart to be dilated, 
 and systolic cardiac murmurs over the apex may be said to be 
 common. With these exceptions heart lesions are extremely rare. 
 
 HcE-morrhages from one or other of the mucous surfaces, or into 
 the skin, are common, and may appear early in the disease. 
 
134 MANUAL OF MEDICINE 
 
 The urinary system. — The urine, during some of the recorded 
 epidemics, remains, as a rule, unaltered, but in others marked 
 abnormalities are met with. During the 1896 recrudescence in 
 Hong-Kong, Wilm states that, in 95 per cent of the cases, the urine 
 at the outset of the disease contained albumen, and in many 
 instances indican. Suppression of urine is a frequently observed 
 condition at the commencement of the illness, but with the decline 
 of the fever, the quantity becomes normal and the albumen dis- 
 appears, although, on the other hand, albumen has continued to 
 appear in the urine for months subsequently. Granular casts and 
 red blood corpuscles are frequently found microscopically. 
 
 The nervous system. — Plague is associated with a peculiar mental 
 state. When first seized the patient may become wildly delirious. 
 The usual form it takes is that he rushes from his room to the 
 verandah, or into the street, but the will power soon falls into 
 abeyance and he can assign no reason for his act when interrogated. 
 Instead of furious deUrium, or subsequent to it, the patient may be 
 apathetic, hstless, and but semi-conscious of what is said to him or 
 what goes on around him. His features become expressionless, and 
 when spoken to he turns towards the speaker with a dazed look, his 
 gaze resting for a moment, and then by feature, voice, or movement 
 it is apparent he is but semi-conscious. In children muscular 
 twitchings and convulsions are frequently seen. 
 
 Convalescence. — A slow recovery is the rule after plague. It is 
 usually two or three months before the patient's strength is fairly 
 restored. Relapses of the nature of fresh adenitis, carbuncles, 
 abscesses, pneumonia, nephritis, meningitis, keratitis, and various 
 forms of paresis, although seldom fatal, delay complete recovery. 
 
 Recurrence. — There are but few examples of recurrence. In the 
 experience of the writer but one case is known. A nursing sister in 
 Hong-Kong recovered from a severe attack of plague in Hong-Kong. 
 Two years after she had a second attack, from which she also 
 recovered. 
 
 Diagnosis. — When, during an epidemic of plague, a patient is 
 found with fever, a dazed appearance, a furred tongue, when he 
 maintains his limbs in a position to afford relief from pain, and when 
 in the groins, axilla, or neck enlarged and tender glands are found, 
 a diagnosis of plague may be made. Mistakes are, however, possible, 
 although not frequent. One of the most marked occurred to the 
 writer. During the 1894 epidemic in Hong-Kong the writer was 
 called to see a Parsee who had high fever, great thirst, a coated 
 tongue, vomiting, and enlarged and tender groin glands. A diagnosis 
 
PLAGUE 135 
 
 of plague was made, the conclusion being no doubt contributed to 
 by the fact that on the previous day a Parsee had died of plague in 
 the same house. The diagnosis, however, was wrong, as subsequent 
 examination of the man's blood showed that he was the subject of 
 filaria. The only evidence to be relied on is the presence of the 
 plague bacillus in the blood or the secretions of the patient. 
 
 Morbid anatomy. — In bodies of persons dead of plague 
 rigor mortis sets in early, and is quite moderate in degree. The 
 skin occasionally shows petechiae, carbuncles, and haemorrhage into 
 the subcutaneous tissues. 
 
 The lymphatic glands. — Almost every lymphatic gland in the 
 body may be found to be swollen and hyperaemic. The most in- 
 tensely affected glands are of a deep violet colour throughout, or 
 flecked by white foci of purulent matter. Around the glands the 
 tissues are matted together, and a serous, sero-sanguineous, or 
 purulent fluid extends widely at times into the neighbouring 
 structures. It is usual to find chains of enlarged glands matted 
 together, and in the groin they may be found extending upwards 
 beneath Poupart's ligament to the iliac fossa, and even to the lumbar 
 and retro-peritoneal glands generally. The mesenteric glands are 
 frequently found affected, although no lesion is to be met with in the 
 intestine. 
 
 The heart. — The pericardium occasionally shows petechial or 
 ecchymosed spots, but the pericardial fluid is not abnormal. The 
 heart muscle, when cut into, appears towards its inner aspects pale 
 and soft, and the fibres exhibit a cloudy appearance or fatty degenera- 
 tion. The right side of the heart and the great venous trunks of 
 the thorax and abdomen are to be seen distended with dark fluid 
 blood. The lungs. — The lower lobes of the lungs especially are, as 
 a rule, congested and oedematous ; pneumonia occurs in a certain 
 number of cases, and much more in some epidemics than in others. 
 The mucous membrane of the respiratory tract seems affected by an 
 oedematous condition of the submucous coat with occasional petechiae. 
 The pleurae are occasionally ecchymosed, but the pleural fluid is 
 usually unaltered in quantity or consistence. The stomach con- 
 tents are small in amount, and of a dark -brown colour. The 
 longitudinal ridges present injected crests and a pale grayish-white 
 colour in the depressions ; multiple small haemorrhages into the 
 coats of the stomach are fairly constant. The intestine is usually 
 hyperaemic throughout ; the mucous coat presents small haemorrhages 
 and ecchymosed spots ; the solitary glands are swollen ; Peyer's 
 patches are enlarged and raised, and are frequently the seat of 
 
136 MANUAL OF MEDICINE 
 
 haemorrhages or ulcers. The mesentery frequently contains exten- 
 sive extravasation of blood ; it is, in the majority of cases (60 per 
 cent, Wilm), studded with enlarged glands of various sizes ; and, 
 as in other parts of the body also, hcemorrhages occur around the 
 glands. The intestinal and mesenteric lesions are always most 
 marked in cases in which external buboes are not met with. The 
 liver is slightly enlarged, firm, and on section of a whitish- pink 
 tinge with, at times, small hemorrhages beneath the capsule. The 
 gall bladder is fairly full in all cases, and tightly distended in 
 many cases. The spleen is enlarged to as much as twice or more 
 ts natural size ; beneath the capsule haemorrhages are common ; 
 the consistency varies, being at times firm, at other times quite soft 
 and diffluent. The kidneys are congested ; the stellate vessels are 
 pronounced ; and the parenchyma is in a state of cloudy swelling. 
 Around the kidney the loose connective tissue is the seat of large 
 extravasations of blood which frequently extend down into the pelvis. 
 The pelvis, the ureters, and the bladder contain small coagula of 
 blood. The brain. — The only changes met with are occasionally 
 cedema of the brain substance with oedema, congestion, and small 
 ecchymoses in the pia mater. 
 
 Prognosis. — The prognosis of bubonic plague is bad in the 
 extreme ; neither age nor sex is exempt, nor do either avail in pre- 
 venting a fatal issue. 
 
 Persons living in insanitary abodes, where over-crowding and 
 insufficiency of food prevail, are most liable to infection. Europeans 
 in tropical countries, no doubt on account of their superior housing 
 and mode of living as compared with the natives, seem to enjoy a 
 certain immunity. Race may have something to do with immunity. 
 Of the seven Japanese doctors engaged in scientific work during the 
 plague in Hong-Kong three contracted plague, whilst of eleven 
 British doctors engaged in treating plague patients not one caught 
 the disease. In Egypt (1899), however, the residents of European 
 extraction seemed as liable to the disease as the native Egyptian. 
 This is due in all probability to the fact that many of the former 
 live after the manner of the native Egyptians. 
 
 A bad prognosis is indicated when high fever appears early, 
 when severe epigastric pain and vomiting prevail, when the urine is 
 suppressed, and when buboes rapidly develop with extensive sub- 
 cutaneous haemorrhage. A better prognosis is justifiable when the 
 initial temperature rises gradually, when buboes but slightly or very 
 gradually develop, when the patient survives the sixth day, and when 
 the urinary secretion remains normal. 
 
PLAGUE 137 
 
 Mortality. — The death-rate amongst the Chinese, treated 
 according to native fashion, numbered about 95 per cent (1884). 
 In European hospitals the mortality was less by some 15 per cent. 
 Death in 70 per cent of the cases occurs during the first six days of 
 the illness, but it may be delayed to the second, third, or, in rare 
 cases, to the fifth week. 
 
 Europeans stand a better chance of recovery, some 50 per cent 
 only of those attacked dying. Death may suddenly occur any time 
 after the onset; convulsions or a comatose state may supervene early 
 in the disease: or, with signs of deep nervous depression, the patient 
 collapses. Later, death seems to result from exhaustion, the result 
 of a pysemic condition. 
 
 Prophylaxis. ^ — Seeing that rats and mice are the animals which 
 convey plague, and by which human beings become affected, their 
 destruction before a threatened invasion of plague is an absolute 
 necessity if the disease is to be averted. Should, however, plague 
 develop it is necessary to isolate the sick, segregate those who have 
 lived with or near them, and thoroughly disinfect or destroy their 
 houses, furniture, and clothing, whilst at the same time war is still 
 waged against the rat. Special prophylaxis may be obtained by in- 
 pculation with one of the several "sera" prepared for the purpose. 
 Of these Haffkine's is the one which seems to have stood a practical 
 test. Haffkine found different media to afford rich cultures of 
 plague bacilli. The virulence of these was such that one or two 
 minims were sufficient to kill the largest rodents. To lessen the 
 virulence Haffkine resorted to destruction of the bacilli by heat, 
 but the liquid thus deprived of its bacilli proved to possess but 
 slight powers. 
 
 " In order to accumulate for the plague prophylactic a large 
 amount of extra-cellular toxins, the baciUi are cultivated on the 
 surface of a liquid medium, where they are suspended by means of 
 drops of clarified butter or of cocoa-nut oil. The bacilli grow down 
 in long threads into the depth of the liquid, and produce what we 
 have termed a stalactite growth in broth, an appearance singularly 
 peculiar to this microbe, and which, I hope, will be, till further dis- 
 covery, accepted as the exclusive diagnostic feature of this microbe. 
 The products of their vital exchanges — the toxins — are secreted by 
 the stalactites into the liquid and accumulated there. The growth 
 is periodically shaken off the drops of oil, after which a new crop 
 appears underneath the surface of the liquid " (Haffkine on Pre- 
 ventive Inoculation). In this manner the bodies of the microbes 
 collect at the bottom of the cultivation vessel, and the liquid 
 
138 MANUAL OF MEDICINE 
 
 around becomes permeated with toxins. The process is kept up 
 for five or six weeks, when " the bodies of the microbes become 
 extremely deteriorated." In order to render harmless the inocula- 
 tion of the virus thus prepared, Haffkine determined to kill the 
 microbes by heating the whole up to 65° or 70° C. 
 
 The minimising effect of the prophylactic thus prepared by 
 Haffkine was first tested on rabbits, and its powers of protection 
 proved. Then the perfect harmlessness of the inoculation was 
 demonstrated on Haffkine himself and a number of Europeans in 
 Bombay who submitted to the inoculation. Many thousands of 
 persons have been "protected" by this prophylactic, and the ques- 
 tion now is not does the fluid procure immunity, but only how long 
 does the conferred immunity last. As a temporary expedient the 
 Government of India grant certificates entitling inoculated persons 
 to exemption from plague rules for six months. In all probability 
 this time will be extended as experience aids theory in the matter. 
 
 The dose of prophylactic administered is usually three cubic 
 centimetres. The operation is followed by slight fever, with head- 
 ache, nausea, loss of appetite, lassitude, and swelling at the seat 
 of puncture. In two to three days all feeling of discomfort 
 subsides. 
 
 Treatment. — In plague, perhaps more than any other disease, 
 symptoms have to be treated as they arise. Calomel in lo-grain 
 doses, followed by a saline purge, may be given in the initial stages. 
 The rationale of this treatment is founded upon the fact that 
 constipation usually prevails, that the conjunctivae are yellow, the 
 gall bladder full, and that the bacilli are naturally eliminated by the 
 bowel. Instead of calomel a continued action of the bowels may 
 be kept up by 2-drachm doses of sulphate of magnesium twice or 
 thrice daily. When, in the later stages, diarrhoea occurs, appropriate 
 remedies are demanded should it prove excessive. High tempera- 
 ture is best combated by phenacetin in 5 to i o-grain doses, repeated 
 as required, and by the wet pack. To calm the delirium, an ice-bag 
 to the head is to be applied, and narcotics employed. Of these 
 morphia (gr. ^), hyoscine (j-g-oth gr.), may be administered hypo- 
 dermically, or bromides given internally. The practitioner, however, 
 must devote his attention to combating heart failure ; alcohol, 
 ammonia, with or without digitalis, strychnine, hypodermics of ether 
 and camphor are the cardiac stimulants mostly in vogue. Carbonate 
 of ammonia in 5 -grain doses, combined with decoct: cinchonse 
 CO. §1 every four hours is a convenient formula, the more specific 
 drugs being administered when urgent symptoms arise. When 
 
RELAPSING FEVER 139 
 
 pneumonia or bronchitis is present expectorant remedies are to be 
 employed. Two-grain doses of carbolic acid are recommended. 
 
 Gland swellings are dealt with according to their stage of develop- 
 ment. When just formed glycerine and belladonna is a favourite 
 application, and liniment of iodine may be painted on the skin over 
 the bubo, or the substance of the gland is injected with pure carbolic 
 acid, or a preparation of corrosive sublimate and iodide of potassium. 
 When the glands soften and threaten to suppurate wet compresses 
 or poultices are applied in a conventional way ; but, finally, the 
 abscess has to be opened, the gland removed, and the abscess cavity 
 packed with antiseptic dressing. 
 
 Yersin introduced a curative preparation derived from the serum 
 of horses. Successive horses were inoculated, and the potency of 
 the fluid reduced to a form in which it could be safely introduced 
 into the human body. The Pasteur Institute in Paris has elaborated 
 Yersin's method, and the report of Professor Calmette as to the 
 efficacy of this preparation in Oporto is most encouraging. 
 
 Quarantine. — The ordinary rules of quarantine are applicable 
 in plague. It seems to be based on sufficiently widespread observa- 
 tion that incubation is a matter of five days, and that in the cargo 
 of ships the bacillus can survive for a few days only. An individual 
 who has recovered is considered as being capable of communicating 
 the disease for three weeks after the subsidence of the acute symp- 
 toms, and isolation of the patient should be maintained for at least 
 a month. 
 
 James Cantlie. 
 
 RELAPSING FEVER 
 
 Syn. Famine Fever 
 
 Relapsing fever is an infectious disease caused by the presence 
 of a micro-organism — the Spirillum Obermeieri — in the blood. 
 Epidemics were frequent in Ireland and Scotland during the early 
 part of the century ; of late years the disease has rarely appeared 
 in the United Kingdom. The poor and destitute are the principal 
 sufferers, and, like typhus fever, epidemics have been most prevalent 
 during times of famine. The majority of cases occur in patients 
 between the ages of fifteen and twenty ; children under five years 
 
I40 MANUAL OF MEDICINE 
 
 of age are rarely attacked. One attack confers a very limited pro- 
 tection against future invasion. The contagion is usually conveyed 
 directly from patient to patient, less frequently by means of 
 fomites. 
 
 Period of incubation. — The incubation period varies between 
 one and twenty-one days. In monkeys the first symptoms appear 
 from thirty hours to five days after inoculation. 
 
 Clinical course and symptoms. — The disease takes a 
 characteristic course, divided into the following stages : — An attack 
 of fever lasting a week or thereabouts ; an intermission of about a 
 week, during which the patient is free from symptoms ; a second 
 attack of fever, the relapse, of some three days' duration. 
 
 The attack begins suddenly with a rigor or shivering, the 
 temperature quickly running up to between 102" and 106' F. With 
 the rise of temperature the usual symptoms of fever supervene, thirst, 
 headache, loss of appetite, etc. Severe pains in the back and limbs 
 are often prominent symptoms. In spite of the high temperature, 
 delirium and other mental disturbances are uncommon. The skin 
 becomes of a yellow tint, and there may be distinct jaundice, with 
 bile in the urine, the stools being of normal colour. The liver and 
 spleen, especially the latter, become enlarged and tender. There 
 is often vomiting, sometimes diarrhoea. The pulse is increased in 
 frequency out of proportion to the gravity of the case ; it may be 
 as high as 140 or 160 without necessarily indicating danger. The 
 respirations are hurried, and there is often a distressing cough, with 
 rales and rhonchi in the chest. The urine may be albuminous. In 
 a small proportion of cases a transient rash, consisting of minute 
 rose spots smaller than those of typhoid fever, appears over the 
 trunk and limbs. 
 
 After these symptoms have continued for about a week the 
 attack terminates by crisis, the temperature suddenly falling to a 
 degree or two below normal. The onset of the crisis may be 
 ushered in by profuse sweating, by diarrhoea, or by haemorrhage 
 from the nose, bowel, or uterus. After the crisis all the symptoms 
 rapidly subside, and the patient soon feels so well that he is with 
 ditificulty convinced that the disease is not yet over. The period 
 of intermission continues for about a week ; then the relapse sets 
 in, the temperature again rises, and the original symptoms recur. 
 The relapse lasts for some three days, and ends, like the original 
 attack, by crisis. In the majority of cases the disease is now over, 
 but second, and even third, relapses, with inter\"ening intermissions, 
 have been known 10 occur. In rare instances there is no relapse. 
 
RELAPSING FEVER 141 
 
 the patient recovering after the subsidence of the primary f^.ver. 
 Convalescence is always slow and tedious. 
 
 Such is the usual course of the disease ; several complications 
 may, however, arise. The most important are : collapse, generally 
 setting in about the crisis ; severe diarrhoea ; purpura with 
 haemorrhages into the skin and from the mucous membranes; 
 suppression of urine ; and pneumonia. Any of these conditions 
 may prove fatal. The pains in the limbs may be very severe, and 
 may continue during the intermission and after the relapse. 
 Bronchitis is sometimes of sufficient severity to rank as a com- 
 plication. In some epidemics ophthalmia has been common in the 
 early days of convalescence ; the inflammation starts in the ciliary 
 region, and ultimately may involve all the structures of the eye ; 
 permanent blindness may ensue, but fortunately both eyes are 
 seldom affected. Parotitis was frequently observed in one epidemic 
 in Russia. Pregnant women almost invariably abort when attacked 
 with relapsing fever. 
 
 The Spirillum Obermeieri, often in large numbers, is present in 
 the blood during the febrile stages. During the intermission it 
 disappears from the blood, and probably collects in the spleen. 
 
 Pathology. — -The spirilla are fine corkscrew -shaped bodies 
 with pointed ends, twice to five times as long as the diameter of a 
 red blood corpuscle. They are actively motile, and retain their 
 motility from several hours up to as long as fourteen days after 
 removal from the body, according to the temperature at which they 
 are kept. Attempts to cultivate them outside the body have hitherto 
 failed ; so that we still lack the absolute proof that they are the 
 cause of the disease, although there can be but little doubt that this 
 is the case. The disease has been conveyed both to the human 
 being and to monkeys by the injection of blood containing the 
 spirilla. In monkeys the disappearance of the spirilla from the 
 blood during the intermission has been proved to be due to their 
 accumulation in the cells of the spleen. We know nothing definite 
 about the mode of multiplication of the spirilla or of their life 
 history outside the body. From analogy with the malaria parasite, 
 it is probable that the period of fever corresponds to a particular 
 stage in the development of the spirilla, and that other stages take 
 place during the intermission. As the spirilla are not found in the 
 secretions or excretions, it is difficult to explain the conveyance of 
 the disease from patient to patient. There is, however, some 
 experimental evidence of conveyance by means of insects, which 
 would be quite compatible with the habits of the patients among 
 
142 Manual of medicine 
 
 whom the disease is most prevalent. It is not improbable that the 
 organism may ultimately be found to belong to the Protozoa. 
 
 Diagnosis. — Relapsing fever may be mistaken for typhoid 
 fever, smallpox, typhus, influenza, or Weil's disease. The onset of 
 typhoid is gradual, while that of smallpox, typhus, influenza, and 
 relapsing fever is sudden. Typhoid fever can be distinguished by 
 the long duration of the pyrexia ; smallpox and typhus by the 
 appearance of the eruption on the third and fifth day respectively ; 
 infl-ienza by the absence of enlargement of the spleen and liver; 
 and Weil's disease by the absence of severe nervous symptoms. In 
 doubtful cases the diagnosis can be cleared up by placing a drop 
 of the blood under the microscope and examining for motile 
 spirilla. If the blood cannot be examined fresh, a cover-glass 
 preparation should ba made by allowing a thin film of blood to dry 
 on a cover-glass. The film is fixed by passing the cover-glass 
 rapidly through the flame, the haemoglobin is extracted with i per 
 cent solution of acetic acid, and the spirilla stained by immersion 
 for a few minutes in one of the aniline dyes. 
 
 Prognosis. — The fatality of the disease, according to Murchison, 
 is 4 per cent. Most of the fatal cases occur in patients over 
 thirty; in patients below this age the fatality is only 0.5 per cent. 
 
 Post-mortem appearances. — The spleen is large and soft, 
 with yellow areas the size of a horse-bean scattered throughout 
 its substance. These areas, which consist of necrosed tissue, con- 
 tain a large number of spirilla. Rupture of the organ, with escape 
 of blood into the peritoneal cavity, has been recorded. The liver 
 is enlarged ; under the microscope its cells show cloudy swelling, 
 and sometimes a small celled infiltration around the portal veins. 
 The kidneys exhibit cloudy sweUing of the epithelium, coagulation 
 casts in the tubules, and perhaps an accumulation of small cells 
 in the interstitial tissue. Fatty degeneration occurs in the muscle 
 of the heart and in the voluntary muscles. 
 
 Treatment. — The patient should be isolated and kept in bed 
 until convalescence is well established. The various symptoms 
 must be treated as they arise ; pyrexia by cold sponging ; suppres- 
 sion of urine by poultices and dry-cupping to the loins ; collapse 
 by stimulants ; diarrhoea by opium and astringents ; ophthalmia by 
 ths instillation of atropine and by the application of leeches to the 
 temples. Murchison recommended the routine administration of 
 such drugs as acetate of potash and digitalis, with the object of 
 preventing suppression of urine. 
 
 J. W. Washbourn. 
 
YELLOW FEVER 143 
 
 YELLOW FEVER 
 
 A miasmatic contagious disease, caused by specific microbic 
 infection and characterised by an acute febrile paroxysm, followed 
 by pathognomonic symptoms indicative of toxaemic jaundice, with 
 renal, gastro-intestinal and hsemorrhagic complications. It occurs 
 in endemic form in some areas, elsewhere in epidemics. 
 
 Geographical distribution. — Its endemic areas are a few sea- 
 coast towns in the West Indies, jNIexico, Brazil, and Gulf of Guinea, 
 notably Vera Cruz, Havana, Santiago de Cuba, San Domingo, and 
 Rio de Janeiro. Epidemic outbreaks are of frequent occurrence 
 in populous centres in communication with these cities, but rarely 
 extend far inland, or to high altitudes, or where the temperature is 
 below 75° F. and the humidity low. Outbreaks do occur, however, 
 at high altitudes and in temperate zones. Arid and sparsely 
 populated districts do not suffer. Asiatic and other Eastern 
 countries are, as yet, exempt, but, given the necessary conditions, 
 any populous centre may become attacked and form a fresh endemic 
 area. Thus Rio de Janeiro, which was first attacked in 1849, has 
 never since been free. 
 
 The American Atlantic littoral between 35° S. and 45° N. 
 latitude, and Sierra Leone, Senegal and Gambia in Africa, have ex- 
 perienced frequent outbreaks. South-western Europe suffered severely 
 at the end of the eighteenth and beginning of the nineteenth century, 
 Gibraltar losing nearly 6000 persons, or more than one-third of its 
 total population, during an epidemic in 1804. Another severe 
 epidemic occurred there in 1828, and minor outbreaks in 1813 and 
 1 8 14. Since 1828 European outbreaks have been unfrequent, 
 and, wath the exception of an epidemic in Lisbon in 1856-57, 
 insignificant. They occurred at Brest, 1856; St. Nazaire, 1861; 
 Swansea, 1865; and Madrid, 1878. The Swansea outbreak caused 
 fifteen deaths, all of persons in direct or indirect communication 
 with an infected vessel from Cuba ; in the Madrid outbreak thirty- 
 five died, all in a locality where soldiers, recently returned from 
 Cuba, lived. 
 
 Seasonal prevalence. — In endemic areas north of the 
 equator seasonal activity commences in June, is at its height in 
 July, and continues with little diminution till December. The 
 disease is less active from January to May. In Rio these conditions 
 
144 MANUAL OF MEDICINE 
 
 are reversed. In epidemic zones, outbreaks usually last three 
 months, and are generally confined to periods of tropical heat, but 
 their duration varies and is influenced by other than seasonal 
 factors. 
 
 Influence of race, age, and sex. — No individual of any race 
 can claim immunity except by previous attack. Negroes, Moors, 
 Arabs, Chinamen, have all suffered on first coming into endemic or 
 epidemic areas. Negroes are apparently immune in the endemic 
 zone or where epidemics are frequent, but this is attributed to 
 attacks in childhood, probably unrecognised. On the other hand, 
 susceptibility to and severity of attack are much greater in white 
 than in coloured races, and in northern than in southern Europeans. 
 New arrivals in endemic areas are specially susceptible, but 
 susceptibility is not necessarily lessened by prolonged residence. 
 
 Age and sex influence severity, but not susceptibility, children 
 suffering mildly, and females less severely than males. 
 
 Bacteriology. — In 1897 Sanarelli obtained pure cultures of a 
 specific bacillus, bacillus icferoides, in the capillaries of the liver and 
 kidneys, never in the digestive tract, of persons dying in the 
 earlier stages of yellow fever. In later stages he found the body 
 invaded with intestinal and putrefactive microbes and the bacillus 
 icteroides incapable of detection. Outside the body, the growth of 
 this bacillus is specially active in the presence of moulds, of which 
 it appears to be a saprophyte, and it presents diagnostic growths on 
 culture media. Sterile cultures injected into men and animals had 
 steatogenous, emetic and hsematolytic effects, resembling attacks of 
 yellow fever. The conditions favourable for conservation of the 
 bacillus are humidity, warmth, darkness, and want of air. It lives 
 long in sea-water, resists drying, but is rapidly killed by solar rays. 
 Others have described specific microbes, but their conclusions have 
 been rejected. Sternberg failed, after careful investigation, to 
 detect a specific microbe, but notices the invasion of the body by 
 intestinal bacilli. The features of Sanarelli's bacillus explain, to 
 some extent, the fact that infection is specially liable to persist in 
 old wooden hulks and in dirty, dark, ill-ventilated ships and dwell- 
 ings of tropical sea-coast towns. Insanitary surroundings are 
 necessary for the propagation of the disease. Clean, well-paved, 
 well-drained cities suffer slightly ; those with reverse conditions 
 severely. Moist soil, polluted with faecal matter, forms the best 
 nidus, and a system of cess-pits in the endemic zone favours 
 endemicit}'. The mode of entrance of infective material into the 
 body is uncertain. Evidence of infection by the digestive tract is 
 
YELLOW FEVER 145 
 
 hegative. Air convection and inoculation by stinging or biting 
 insects are probable. Bedding, clothing and discharges from 
 patients, ship's cargoes, etc., are regarded as the media of convey- 
 ing, and polluted soil as the medium of propagating the disease, the 
 requirements for the development of an epidemic being: (i) the 
 introduction of infective material by sick persons, fomites, ships, 
 etc. ; (2) favourable conditions, such as polluted soil, warmth, and 
 moisture ; and (3) a community of susceptible persons. It is not 
 directly infectious from person to person, and one attack usually 
 confers immunity. 
 
 The minimum incubation period is one day, the maximum 
 five. Usually it is two to four days. An apparent ten days' 
 period has been noted, but records of longer periods are involved 
 in fallacies. 
 
 Clinical history and symptoms. — There may be malaise 
 before onset, but the attack is usually ushered in by sudden rigor 
 with rapid rise of temperature to 103° or 104° R, and of pulse to, 
 no or 120, and by severe orbital and lumbar pain. This febrile 
 paroxysm lasts two to five days, during which the temperature 
 shows no marked rise or fall, but the pulse-rate steadily declines. 
 The skin is usually dry, and there are anorexia, thirst, and restless- 
 ness. The patient feels and looks very ill. The face is turgid and 
 the eyes characteristically suffused. There is much epigastric 
 tenderness with vomiting, at first of the contents of the stomach, 
 but, later, of bile, gastric secretions, and mucus. On the third or 
 fourth day, seldom later, rapid defervescence sets in, the pains dis- 
 appear, the body becomes cool and moist, the pulse slows to 40 or 
 even less, and a stage of calm, with a sense of comfort and well- 
 being, ensues. This is deceptive both to patient and physician, 
 and requires careful management. In a few hours pathognomonic 
 symptoms develop, more or less rapidly, according to the severity 
 or otherwise of the attack. Yellowness of the conjunctivae, 
 gradually extending to face and body, diminished secretion of 
 urine, albuminuria, and an abnormally soft, slow pulse are in- 
 variably noticed early, along with discomfort in the epigastric 
 region. In mild cases no further symptoms may develop, and on 
 the fifth or sixth day they disappear and the patient rapidly 
 convalesces. In severer cases the icterus deepens and extends 
 rapidly, the urine becomes scanty, loaded with albumen and casts, 
 or totally suppressed, and active delirium, convulsions, and coma 
 may ensue, although in other cases the mind may remain clear 
 throughout. Lumbar pains return, abdominal discomfort increases, 
 VOL. I h 
 
146 MANUAL OF MEDICINE 
 
 vomiting becomes more frequent, at first of blood-stained or " coffee- 
 ground " matter, but eventually quantities of altered blood, 
 constituting "black vomit," may be ejected, and diarrhoea with 
 tarry stools may set in. The temperature rises or the body may 
 remain cold and clammy. Blood oozes from the lips and nostrils, 
 and occasionally from other mucous orifices. Sordes accumulate, 
 the pulse becomes feeble and slower, and a " typhoid state," with 
 peculiar cadaverous odour, ensues. Should recovery take place, 
 the symptoms gradually disappear about the tenth day, but con- 
 valescence may be complicated by boils, abscesses, parotitis and 
 hepatitis. In fatal cases death is most frequent on the fifth or 
 sixth day from anuria and coma, or from haemorrhage and 
 exhaustion, but it may occur early during the febrile paroxysm and 
 before pathognomonic symptoms are prominent. It rarely occurs 
 after the tenth day. Recurrence of the febrile paroxysm in the 
 stage of calm, or of the more severe symptoms during convalescence 
 from acts of indiscretion is not uncommon, especially in mild cases, 
 and such relapses are very fatal. 
 
 Diagnosis. — -The febrile paroxysm resembles the onset of small- 
 pox, dengue, or an attack of malarial fever. During an epidemic of 
 yellow fever the appearance of the face, the suffused eyes, epigastric 
 tenderness and severe lumbar pain should be sufficient for early 
 diagnosis, and absence of eruption or splenic enlargement and tender- 
 ness should positively exclude eruptive or malarial fevers. The 
 steady decline of pulse -rate from the first day, irrespective of a 
 stationary or rising temperature, the appearance of albuminuria 
 and icterus on the second or third day, are positive signs of yellow 
 fever. Later, anuria, epigastric discomfort and black vomit, tarry 
 stools and soft slow pulse form a group of symptoms which are un- 
 known in other diseases, and should render the diagnosis complete, 
 although in mild cases many of these symptoms are absent, and, 
 even in fatal cases, not necessarily present. Quinine checks 
 malarial but not yellow fever, and, although its use in diagnosis 
 is historical, it is deceptive, on account of the defervescence that 
 takes place naturally about the third day in the latter disease. 
 Serum diagnosis may prove valuable, recent experiments showing 
 that the serum of yellow fever patients causes agglutination in 
 cultures of the bacillus ideroides. 
 
 Prognosis, — An initial temperature of io6°, or even of io8" F., 
 has been noted occasionally, and is always fatal ; and the rule is 
 that the lower the initial temperature the milder will the case be. 
 In favourable cases the urine is scantiest on the third day, and 
 
YELLOW FEVER 147 
 
 then gradually increases; in unfavourable cases the reverse occurs, 
 and, if anuria sets in, death almost invariably ensues. Delirium 
 and coma, and, to a somewhat less extent, black- vomit are also 
 usually fatal symptoms. The influence of race, age and sex, and 
 also of relapses, has already been indicated. A previous history of 
 alcoholism is specially unfavourable, as is also a high degree of 
 albuminuria. An average case mortality is 30 per cent, but the 
 ratio varies widely in different epidemics. 
 
 Pathological anatomy. — The body is stained yellow, blood 
 trickles from and is caked about the mucous orifices, and there is 
 early discoloration from purpuric spots or hypostatic congestion. 
 The yellov^ staining is due to altered blood pigment and, unless 
 associated with biliary jrundice, is mottled rather than uniform, 
 and is specially marked on dependent parts and where there has 
 been pressure. Immediately after death a high temperature of 
 ioS° to 110° may be noticed. Cadaveric rigidity sets in early, 
 blood coagulability is diminished, and urine found in the bladder 
 is loaded with albumen. The liver, except in the earlier stages, 
 when it is engorged with blood, has a characteristic dry yellow or 
 yellowish-brown wash-leather appearance, due to fatty degeneration 
 of its cells, but is seldom contracted unless there is concurrent 
 cirrhosis from alcoholism. The stomach is generally full of dis- 
 integrated blood and its mucous membrane congested and ecchy- 
 mosed. The condition of the small intestine is similar, but the 
 large intestine frequently presents no abnormality. In the kidneys 
 hypersemia in the early stages and, later, haemorrhages beneath the 
 capsule and in the cortical substance are noted, and the tubules 
 present, microscopically, the appearances of acute desquamative 
 nephritis, with fatty degeneration of their epithelium. The serous 
 cavities usually contain some yellow-stained fluid and the other 
 organs hsemorrhagic infarctions or ecchymoses. No changes have 
 been noticed in the spleen. 
 
 Treatment. — No drug cure is known, and active medication 
 must be avoided. The treatment should be on general principles 
 and symptomatic. Sternberg recommends that three tablespoonfuls 
 of a mixture containing 150 grains of soda bicarbonate, and ^ 
 grain mercuric chloride in a quart of water should be given every 
 hour ice-cold, to lessen gastric irritability and acidity. The bowels 
 should be unloaded at the onse" by castor oil, though some prefer 
 calomel. Subsequently enemata only should be used. During the 
 febrile paroxysm simple diaphoretics and sponging are best ; but 
 lowering the vital powers by cold sponging at the time of defer- 
 
148 MANUAL OF MEDICINE 
 
 vescence must be guarded against, and, for the same reason, it is 
 best to avoid cold baths at any period. Hot applications to the 
 loins should be -applied early. Cold-water enemata and dry cup- 
 ping are also useful in relieving renal congestion. When scantiness 
 or suppression of urine is feared, pilocarpin hydrochlorate, |^ to ^^ 
 grain, may be injected hypodermically. After defervescence, 
 diffusible stimulants, especially champagne, are usually required, 
 but some prefer digitalis and strychnine, administered hypodermic- 
 ally. Good nursing and careful dieting are of paramount import- 
 ance. Absolute rest in bed, very little food by the stomach, and 
 that only in fluid form, given cold, and in small quantities, are 
 essential, especially in the stage of calm. Nutrient enemata should 
 then be employed and gastric discomfort relieved by sinapisms. 
 Opium must be avoided. Return to solid food must be very gradual. 
 
 Recently serum therapy has been employed by Sanarelli with 
 some success, both as curative and prophylactic. The serum 
 is obtained from horses or oxen prepared during a long period by 
 inoculations of bacillus icteroides cultures. It is supposed to be 
 bactericidal in action, but not a true antitoxin, and it is con- 
 sequently most successful in the early stages, and when injected 
 into veins. It is useless when anuria is present, but, in Sanarelli's 
 experience, always prevented h^emorrhagic symptoms. As a 
 prophylactic it had successful results when inoculated into persons 
 living in infected areas during an epidemic. 
 
 Other preventive treatment consists in attention to general 
 cleanliness, exposing dark corners to light and air, abatement of 
 overcrowding and removal of causes of soil pollution. Ship epidemics 
 may be stopped by sailing to cold latitudes ; troop epidemics by 
 moving from the infected locality. Disinfection of infected 
 clothing, bedding and discharges, as well as of habitations, should 
 be scrupulously and S5fstematically carried out. ^Vhere cremation 
 is not adopted, it is essential to fill the coffins and graves of those 
 who have died with strong disinfectants, such as chloride of lime. 
 Isolation of patients is practised as a matter of routine. In the war 
 between America and Spain in 1898 the rule was to keep prisoners 
 from infected localities isolated under observation for seven days, to 
 disinfect all their clothing and belongings, and to burn the surface 
 of polluted soil 
 
 W. G. Macpherson. 
 
WEIL'S DISEASE 149 
 
 WEIL'S DISEASE 
 
 In 1886 Weil {Deut. Archiv filr kiln. Med. xxxix.) described 
 four cases of an acute febrile disease associated with jaundice, 
 nephritis, and enlargement of the spleen. A number of cases with 
 similar clinical symptoms have since been recorded, especially in 
 Germany, and the name Weil's disease has been attached to the 
 malady. It appears to be a definite specific disease, and it is prob- 
 able that it was previously described under various designations. 
 
 Clinical characters. — The onset of the illness is generally 
 quite sudden, the patient being seized with headache, pains in the 
 calves, vomiting and diarrhcea, faintness, or rigors. The tempera- 
 ture quickly rises to between 102"" F. and 104° F., and continues 
 high throughout the attack, which is accompanied with the usual 
 symptoms of pyrexia — thirst, loss of appetite, rapid pulse, furred 
 tongue, etc. 
 
 In addition there are certain symptoms special to the disease. 
 Gastro-intestinal disturbances are sometimes prominent features, the 
 patient suffering from frequent vomiting and profuse diarrhoea. 
 Acute nephritis is an early and fairly constant symptom ; its presence 
 is indicated by the appearance of albumen, casts, and sometimes 
 blood in the urine. The splee7i is frequently enlarged, and hsemor- 
 rhages may appear in the skin and subcutaneous tissue. The 
 nervous system is often profoundly affected, as shown by headache, 
 restlessness, and delirium. Jmmdice is of constant occurrence ; it 
 comes on about the fourth or fifth day of the attack ; bile pigment 
 and occasionally crystals of tyrosin appear in the urine ; and the 
 stools are sometimes devoid of colour. The liver may become 
 enlarged and tender. 
 
 After the symptoms have lasted about ten days they usually 
 subside, the temperature gradually falls, and the jaundice and 
 nephritis clear up. Convalescence is always slow, and it is some 
 time before the patient has recovered his usual health. Relapses 
 are by no means uncommon during convalescence ; about a week 
 after the temperature has become normal, it rises again to 102° F. 
 or 104° F., and there may be a return of the jaundice and nephritis. 
 
 The attack does not always end in recovery ; Jaeger records 
 three deaths out of nineteen cases. 
 
 Post-mortem appearances, — The tissues arc bile-stained. 
 
ISO MANUAL OF MEDICINE 
 
 and haemorrhages may be found in the subcutaneous and sub- 
 pjritoneal tissue, and the endocardium. The s;jleen is either en- 
 larged or normal in size. The mucous membrane of the stomach 
 and intestines may be reddened and swollen, an infiltration of 
 small round cells being found on microscopical examination. The 
 principal changes are found in the liver and kidneys. The former 
 ,does not show much alteration to the naked eye, except perhaps 
 that it is a little enlarged ; but microscopically profound changes 
 are to be observed. The liver cells have undergone fatty degenera- 
 tion, and areas are found scattered throughout the organ in which 
 the structure of the lobules is lost and the cells are broken down 
 into a granular or fatty detritus. Areas of small round-celled in- 
 filtration are also found. The kidneys are swollen and sometimes 
 streaked with haemorrhages ; cloudy swelling and fatty changes are 
 found in the cells, and a small round-celled infiltration is present 
 between the tubules. 
 
 Pathology. — -From this short description it will be seen that 
 the disease resembles a septicaemia in which the effect of the virus 
 especially falls upon the liver and kidney ; the jaundice is due to 
 the degeneration of the liver cells, and the nephritis is set up by the 
 injury to the cells of the kidney. This view is further supported 
 by the researches of Jaeger, who found a bacillus belonging to the 
 Proteus group in the spleen, liver, and kidneys of two fatal cases, 
 and in the urine of several cases during life. This group of bacilli 
 contains several species. Some are well known as the cause of 
 putrefaction in animal and vegetable matter ; while one member — 
 the Proteus hominis capsulatus — is the cause of an acute septicaemia 
 occurring among rag-sorters in Italy, the virus being probably in- 
 haled with the dust from the rags. There is thus good reason to 
 believe that the protcus obtained by Jaeger (Zeitschrift filr IIygie?ie, 
 Bd. xii. 1892) is the cause of Weil's disease, and the frequent 
 occurrence of gastro-intestinal disturbances points to the mode of 
 infection being through the alimentary tract. The disease occurs 
 most frequently between June and September, when putrefactive 
 changes are at their height ; one of Jaeger's patients attributed his 
 attack to eating a bad sausage, several to bathing in foul w^ater ; 
 and it is significant that many of the sufferers from this disease 
 have been engaged in work at slaughter-houses and sewers. Jaeger 
 mentioned an epidemic among fowls due to a bacillus similar to 
 the one he found in the human cases, and he believed that the 
 water in which his patients had bathed was contaminated with the 
 excreta of infected fowls, 
 
WEIL'S DISEASE 151 
 
 Weil's disease bears a close resemblance to acute yellow atrophy 
 in clinical symptoms and in the changes found in the liver. In 
 both diseases a poison causes degeneration of the liver-cells ; in 
 Weil's disease the poison appears to be the proteus bacillus ; while 
 in acute yellow atrophy the nature of the poison is unknown. 
 
 Diagnosis. — Clinically Weil's disease has to be distinguished 
 from yellow fever, acute yellow atrophy, phosphorus poisoning, and 
 relapsing fever. The first named malady, which closely resembles 
 Weil's disease in the acuteness of onset, with rigors, pyrexia, and 
 other febrile symptoms and subsequent development of jaundice, is 
 to be recognised by a history of contagion, no enlargement of the 
 spleen, and later by the occurrence of black vomit. A fall in the 
 pulse-rate after the first day, notwithstanding a continued high 
 temperature, has also been said to be characteristic of yellow fever. 
 In acute yellow atrophy jaundice occurs for several days before 
 severe constitutional disturbances arise, while in Weil's disease 
 pyrexia and severe constitutional disturbances occur before the 
 jaundice sets in. The same remark applies to phosphorus poison- 
 ing, and in this disease the history or the presence of phosphorus 
 in the vomit will remove all doubt. Relapsing fever, especially 
 that form which is described as "bilious typhoid," is very similar 
 to Weil's disease, and the occurrence of a relapse in the latter 
 renders the resemblance more striking. The presence of the 
 characteristic spirilla in the blood in relapsing fever is the most 
 certain means of distinction. Various forms of febrile jaundice 
 may also be mistaken for Weil's disease. 
 
 The treatment of Weil's disease should be based on general 
 principles ; perhaps intestinal antiseptics, such as salol, are of 
 benefit. 
 
 J. W. Washbourn. 
 
152 MANUAL OF MEDICINE 
 
 ANTHRAX 
 
 Syn. Malignant Pustule, Woolsorters' Disease, Splenic 
 Fever, Charbon 
 
 Accounts of anthrax exist from the earliest time, and there have 
 been innumerable epidemics, destroying large numbers of herbivora, 
 both domestic and wild, and occasionally infecting men. Sheep, 
 horses, and oxen are especially liable to this disease, whilst carnivor- 
 ous animals are but slightly susceptible. In cattle, the disease may, 
 according to Bollinger, take three forms — (i) Respiratory. In this, 
 the animal may become unconscious, and convulsed with rapid 
 breathing, and die within a few hours. (2) An intestinal form, in 
 which blood passes with the fjeces ; there is marked pyrexia, and 
 sometimes convulsive movements. (3) Brawny inflammatory swell- 
 ings appear on the neck and body, which are very apt to slough. 
 
 The spleen, in all these forms, is greatly enlarged and softened, 
 hence the name " splenic fever," which, however, is less suitable for 
 the disease as it appears in man, owing to the usual absence of any 
 characteristic changes in the appearance of that organ. It is a 
 specific infective disease, which is most frequently conveyed to men 
 by handling or coming in contact with the hides, hair, or carcases 
 of infected animals. It is due to the introduction of the bacillus 
 anthracis, which multiplies rapidly at the seat of inoculation, and 
 only after an interval of some days is distributed throughout the 
 circulation. The rapid growth of the bacilli in the capillaries sets 
 up numerous haemorrhages ; the bacilli may be excreted by the 
 fceces, the bile, and the urine. 
 
 Bacteriology. — The bacilli are elongated cells 5 to 20 /* in 
 length, and rather less than 1.5 /x broad, straight or slightly concave, 
 and immobile (Plate 11. ). They multiply rapidly between the 
 temperatures of 30° C. and 40° C, in a neutral or alkaline medium, 
 and are Eerobic. When abundantly supplied with oxygen, they 
 form elongated threads and spore readily ; but in the living body, 
 owing to the insufficiency of oxygen, they develop but short rods, 
 and no spores. The latter are singularly resistant to heat, and 
 retain their vitality in the soil for long periods. When cultivated 
 on -gelatine, they liquefy the medium from above downwards, and 
 their appearance in stab culture is characteristic, 
 
ANTHRAX 153 
 
 Anthrax is met with in men as a Malignant Pustule or 
 cutaneous infection ; it occurs in those who handle hides and hair, 
 less often in knackers or butchers who deal with carcases, and but 
 seldom in farm labourers or shepherds who are in contact with the 
 living animals, and is still more rarely communicated directly from 
 one person to another. The disease is not common in England, 
 and in London most of the cases occur in the tanyards, which are 
 aggregated in the district of Bermondsey, and hence the great 
 majority of those affected are admitted to Guy's Hospital, where 
 eighty-three cases have been treated during the past twelve years, 
 of which thirteen proved fatal, while only twenty were observed 
 between 187 3-1 883. 
 
 Symptoms. — In almost every case the initial lesion is on an 
 exposed part, such as the face, neck, or occasionally the hands, due 
 to the inoculation of some scratch, pimple, or abrasion, which is very 
 often produced when carrying a bale of hides. A slight amount of 
 itching is noticed at first ; a papule forms, this soon passes on to a 
 vesicle, which is readily ruptured and soon dries up, the spot being 
 irritable and rather painful. About the third day there is an inflam- 
 matory swelling, and soon the characteristic appearances begin to 
 develop. They consist of a depressed black scar, surrounded by a 
 raised ring of small vesicles, while for some distance around there 
 is a firm oedema, which gradually becomes brawny, and spreads ex- 
 tensively in all directions. The adjacent lymphatic glands become 
 enlarged and tender. If the spot be on the face, it will quickly 
 lead to extensive oedema, sufficient to close the eyelids. The 
 nodule does not suppurate, hence the unfitness of the name 
 " pustule," but discharges only serous fluid, in which anthrax bacilli 
 may generally be found. The pain is chiefly due to the tension, 
 and is not severe. The temperature is raised. There are often 
 symptoms of great depression with rigors, followed by vomiting, 
 and not unfrequently delirium. Unless active local measures are 
 adopted, the toxaemia increases, and within about four days the 
 bacilli may become widely distributed through the system. The 
 disease is not necessarily fatal ; death may occur between the fifth 
 and eighth days, but some intercurrent trouble, such as oedema of 
 the larynx, which is not uncommon when the pustule is on the 
 neck, may cause death even earlier. 
 
 The cutaneous forms of the disease may be associated with one 
 or both of the following : — 
 
 WooLSORTERs' DISEASE. — This is the respiratory variety of the 
 affection. It was noticed in Bradford fifty years ago, after the 
 
154 MANUAL OF MEDICINE 
 
 introduction of alpaca and mohair, that there were occasionally 
 deaths with pulmonary symptoms amongst the men who handled 
 the hair, which were then inexplicable ; and it is chiefly in this 
 district that the majority of the cases of anthrax infection of the 
 lungs have been noticed in this country. 
 
 If the fleeces of animals which have had anthrax are slightly 
 damp, or if they are greasy owing to the natural fat or lanoline in 
 them, there is but little dust, and but little risk of pulmonary in- 
 fection. The infected hair of the camel, vicuna, llama, alpaca and 
 horse, which have no grease, are therefore the most dangerous. 
 
 Symptoms. — These are very obscure ; the patient may simply 
 feel chilly and ill, complain of oppressed breathing and be dead 
 within a few hours. In the less acute cases the patient may be 
 very ill, but there are generally no marked physical signs of disease 
 in the lungs beyond rales and rhonchi, and sputum which is blood- 
 stained. The temperature is raised several degrees, but, in con- 
 sequence of the collapse, tends to drop below normal, except in the 
 rectum. The pulse is small, rapid, and feeble. The prostration is 
 out of all proportion to the physical signs. Just before death 
 bacilli can be found in the blood, but it is generally impossible 
 to detect them at an early stage ; the sputum would probably be 
 found to contain bacilli much earlier in the disease. Those who 
 survive a week generally recover. 
 
 Intestinal Anthrax. — Infection has been stated to occur 
 from the meat or milk of diseased animals ; but is of very rare 
 occurrence. In this country it has only been observed associated 
 with the cutaneous or pulmonary varieties. Besides slight pyrexia, 
 prostration, and collapse, there will be vomiting, purging, and 
 abdominal pain, and the dejecta will contain blood. 
 
 In these internal forms of anthrax there may be delirium, or 
 convulsions in fatal cases, though sometimes the mental state is 
 unimpaired. 
 
 Diagnosis. — The absence of suppuration, of any sloughing 
 core or of severe pain, together with the presence of a central 
 eschar, with a surrounding ring of vesicles, and the brawny oedema 
 of the adjacent connective tissue are characteristic, and distinguish 
 anthrax from carbuncle. The lesion is a single one, which is not 
 the case in glanders. It is always desirable to take a drop of the 
 serum from a vesicle, or, if this be negative, also a drop from the 
 oedematous tissue ; stain it with methylene blue and examine for 
 the bacilli, which will generally be present ; though in a few cases 
 of undoubted malignant pustule they could not be found, 
 
ANTHRAX 155 
 
 In doubtful cases, especially when there is no skin lesion and a 
 history of exposure to the infection is uncertain, a mouse should be 
 inoculated with a drop of the patient's blood, which, if the disease 
 be anthrax, will prove fatal in two or three days, and the blood of 
 the animal will show the characteristic baciUi. 
 
 Prognosis. — The mortality of cases of malignant pustule on 
 the head or neck at Guy's Hospital is about 20 per cent, whereas 
 when the pustule is on the hand, not more than one in ten dies. 
 The onset of very extensive oedema in the neck adds gravely to the 
 risk ; when the pustule has been excised the oedema often subsides 
 considerably. Hurried respiration with cough, or severe diarrhoea 
 and vomiting are very suggestive of general infection. A very 
 rapid, feeble pulse is of evil import. At first the bacilli are limited 
 to within an inch or two of the seat of inoculation, but after four 
 days they tend to be widely distributed. Towards the end, in fatal 
 cases, the bacilli can be found in the urine, and not unfrequently in 
 the faeces and sputum, yet this does not necessarily indicate a fatal 
 issue, as several patients who passed bacilli in their urine for some 
 days, or even longer, ultimately recovered. When the meninges of 
 the brain are involved, delirium and coma with convulsions may 
 develop. The mortality of cases of malignant pustule occurring in 
 South America and in Africa is infinitely less than when workmen 
 in London are infected. It is difficult to explain this, except by 
 the large amount of meat which the former consume, and by their 
 physical vigour and open-air life. The degree of protection con- 
 ferred by an attack appears to be limited, as cases have been met 
 with where patients have had more than one attack of anthrax. 
 
 Post-morteni appearances. — Decomposition is rapid, the 
 skin is greatly discoloured, there is extensive cedema in the region 
 of the pustule, and very often in the connective tissue of the anterior 
 mediastinum. Numerous small extravasations of blood may be 
 seen in various parts of the body, and anthrax bacilli will be found 
 in such places. On examining small and inconspicuous haemor- 
 rhages on the mucous membrane of the alimentary canal, on the 
 meninges of the brain, and also on the pericardium, I seldom failed 
 to find bacilli. Occasionally extensive extravasations of blood may 
 take place, into or on the surface of the brain ; or into the intes- 
 tines. The serous cavities often contain fluid, in which the bacilli 
 will be found. 
 
 It is rare to find evidence of pneumonia, even in the pulmonary 
 cases, but microscopical sections will show extensive haemorrhages, 
 with innurnerable bacilli blocking up the capillaries. Souietimes 
 
156 MANUAL OF MEDICINE 
 
 portions of the mucous membrane of the alimentary canal will be 
 raised up by oedema, so as to form distinct swellings ; in places 
 there will be haemorrhages, and rarely a small central slough. The 
 condition of the spleen varies ; it is generally soft ; but often it is 
 not enlarged. The abdominal lymphatic glands are frequently 
 swollen. 
 
 Treatment. — The essential treatment for a pustule is to remove 
 it entirely, and, where indicated, incise the brawny tissue freely. The 
 wound is then generally packed with iodoform, and some surgeons 
 inject carbolic acid (5ss. of a 2 per cent solution several times 
 daily) into the adjacent tissue. A number of cases have also been 
 treated with ipecacuanha both locally and internally in large doses. 
 Although evidence has been adduced suggesting that this drug 
 might be of value, the result of experience at Guy's Hospital has 
 been to show that a series of cases so treated have not done better 
 than those where it had not been employed. Up to the present 
 time no efficient treatment by an antitoxin has been available. 
 
 Good feeding, of which meat in some form should constitute a 
 considerable proportion, and stimulants, with quinine, are essential ; 
 many of even the most unpromising cases ultimately recover. 
 
 G. Newton Pitt. 
 
 TETANUS 
 
 Tetanus is a specific infective disease, characterised by tonic 
 spasms, chiefly affecting the muscles of the face and trunk, usually 
 of traumatic origin, tending, with a somewhat acute course, towards a 
 fatal issue. 
 
 Bacteriology. — The disease is the result of infection by an 
 organism which was tirst obtained in pure cultivation in 1889. The 
 bacillus is extremely slender, with rounded ends, and varies in length 
 from 4 IX upwards. The threads, except when very short, are motile, 
 but after growing for about thirty hours at a temperature of 37° C. 
 spores begin to form, the threads segment, and motility ceases. 
 The spores which occur at the end of the segments distend them, and 
 hence the name " drum-stick " bacillus ; they are extremely difficult 
 to destroy (Plate II.). The organism is an obligate anaerobe, i.e. it 
 requires an atmosphere free from oxygen for its full development, 
 
TETANUS 157 
 
 otherwise the virulence of the poison produced is greatly diminished. 
 It grows freely between the temperatures of 14° C. and 42° C, 
 especially in a medium containing 2 per cent of grape sugar. In a 
 stab culture it liquefies gelatine. Owing to the resistent nature of the 
 spores a pure culture may be obtained by raising a mixed growth to 
 a temperature of 80° C. for an hour, which is sufficient to destroy the 
 other organisms. 
 
 The tetanus bacillus is abundant in garden earth, in dust, and in 
 excrement, especially in that of horses, but, fortunately, its virulence 
 is feeble where it has grown in the presence of air. 
 
 The conditions required to produce tetanus experimentally 
 are found to be somewhat complex. If an animal be inocu- 
 lated with tetanus bacilli, there is no local suppuration, and unless 
 the growth be an exceptionally virulent one, no further symptoms 
 may result, as the tissues appear to be capable of destroying the 
 organism. To produce tetanus, this protective mechanism must be 
 hindered, which may be done in several ways, either by introducing 
 at the same time some tetanus toxin ; by traumatic injury to the 
 tissue ; or by a mixed infection with pyogenic cocci, which, by 
 absorbing oxygen from the tissues, enhance the virulence of the 
 poison produced by the tetanus bacilli, and allow them to develop 
 more freely with less interference from the living tissues. 
 
 The bacilli remain localised at the seat of inoculation, and are 
 to be found neither in the blood nor in the other tissues. The 
 poison is produced very slowly, but it is one of the most virulent 
 which is known, as 3-^ minim of a filtered alkaline broth culture 
 of the microbes, three weeks old, is sufficient to kill a rabbit. 
 
 The poison can be obtained from the blood, spleen, liver, spinal 
 cord, urine, etc., of a patient with tetanus, by precipitation with 
 alcohol. The introduction of the toxin without any bacilli is capable 
 of producing all the symptoms of tetanus, and hence the removal of 
 the seat of infection so as to stop the production of the toxin has 
 been regarded as an important part of the treatment. It has been 
 shown that the poison has a definite affinity for the nerve cells, for 
 if a suitable portion of brain or spinal cord be rubbed up into an 
 emulsion with an otherwise fatal dose of tetanus toxin and injected 
 into an animal, no symptoms of tetanus will ensue, as the poison 
 appears to be fixed by the nerve elements. That the toxin is not 
 heutrahsed is shown by the fact that if the nerve tissue be only in- 
 jected close to the spot where the poison has been inserted, it does 
 not prevent the development of the symptoms. 
 
 When an animal has been successfully inoculated with tetanus, 
 
1S8 MANUAL OF MEDICINE 
 
 there is a short incubatory period, after which tonic spasms develop 
 in the muscles near the seat of infection. These are due to the 
 action of the poison, which appears to spread up to the spinal cord 
 by the nerves, and, acting on the adjacent cells of the anterior 
 horn, increases their irritability. Later on, the poison is diffused 
 through the body by means of the blood vessels, so that all the 
 nerve cells become subject to its influence. The spasms spread to 
 the muscles of the face, neck, and trunk, and soon become almost 
 universal. 
 
 Etiology. — Generally on examination a local injury can be 
 found, which may have been a severe one, such as a compound 
 fracture, or an operation such as ovariotomy ; but in many cases 
 there has been only some slight abrasion or a punctured wound, 
 commonly on the feet, hands, or face, particularly in persons liable 
 to come in contact with soil or garden mould. In some no definite 
 injury has been noticed ; these are called idiopathic, and have been 
 especially observed in time of war, where men have been exposed 
 to much wet and cold. Most of those cases which have been 
 observed after parturition have been reported from the tropics. 
 Some were premature deliveries, others at full time, but in several 
 the uterus had been plugged for haemorrhage. 
 
 Tetanus neonahirum occurs in new-born children in whom there 
 has been infection of the umbilical cord, and is very prevalent in 
 some islands, often as an epidemic. 
 
 Men are much more frequently affected than women in the 
 proportion of about six to one ; this is probably due to their in- 
 creased exposure to injuries. The disease may occur at any age, 
 more especially in the young and active ; but, excluding the cases 
 which occur within the week after birth, it is rare before the age of 
 five years. On the whole the disease is more prevalent in hot 
 climates. 
 
 Incubation period. — It is difficult to fix this, but in acute 
 cases, which run a rapid course, the symptoms appear within four 
 or five days after injury, and occasionally sooner ; the interval is 
 usually under two weeks. The interval varies with the amount of 
 the poison introduced. 
 
 Symptoms. — Tetanus commonly commences, a few days after 
 an injury, with symptoms of a stiff neck or of a sore throat, which are 
 at first considered to be trivial, or the patient finds that there is a 
 difficulty in opening his jaws owing to a tonic spasm of the mas- 
 seters, whence the name of lockjaw or "trismus." In other cases 
 the first indication is a set and aged expression, due to the contraction 
 
TETANUS 159 
 
 of the facial muscles, so that there is a fixed smile with a great 
 increase in the naso-labial folds, to which the term " risus sardonicus " 
 is applied. The forehead is wrinkled and the eyes but half opened, 
 owing to the contraction of the orbiculares oculorum. Shortly after 
 the advent of these symptoms the rigidity increases, and other 
 muscles, especially those of the trunk, become affected. The 
 abdomen becomes as rigid as a board, owing to the tonic con- 
 traction of the recti abdominis ; the trunk muscles become con- 
 tracted, and in severe cases a more or less marked condition of 
 opisthotonus develops, so that the patient is supported by his heels 
 and his head : sometimes also with a lateral curvature of the spine 
 during the paroxysms. It is a marked characteristic of the disease 
 that, although the proximal muscles of the limbs may be affected, 
 those of the hands and feet are neither rigid nor stiff, although 
 tenderness and a feeling of stiffness in the region of the seat of 
 infection may be noticed ; but local spasms are generally so slight 
 as only to be elicited by careful inquiry, the patient's first complaint 
 being usually of the condition of his head or neck. When the 
 initial lesion has been in the head the symptoms differ somewhat ; 
 there is some paralysis as well as rigidity of the facial muscles, and 
 not infrequently there is marked pharyngeal spasm ; such cases have 
 been termed " cephalic tetanus." 
 
 To the condition of tonic contraction are soon superadded 
 paroxysmal contractions, which are readily induced by the slightest 
 movement or even by a breath of wind. These recur with in- 
 creasing severity and frequency, and may be so violent as to lead to 
 rupture of muscular fibres. Exceptionally there may be only tonic 
 spasm or only paroxysmal contractions. 
 
 Pain is an early symptom, and in severe cases it is intense, similar 
 to that of cramp ; a very distressing pain behind the sternum is often 
 present, and is probably the result of spasm of the diaphragm. If 
 the patient can sleep the spasm relaxes, but in severe cases this is 
 often impossible. 
 
 The temperature varies ; in the extremely severe cases, with 
 frequently recurring convulsive attacks, it is raised and may run up 
 towards the end to 105° F. or higher. An analysis of the tempera- 
 tures in a series of cases shows that in the more moderate, when it 
 is only raised to 102° or 103°, there is generally sufficient local 
 suppuration to account for this ; and that when the initial seat of 
 infection is free from inflammation the temperature may nou be 
 raised. The pulse may be rapid and is often very small. 
 
 The urine is found to be free from albumen, but there is often 
 
i6o MANUAL OF MEDICINE 
 
 a difficulty in micturition owing to the spasms not only of the 
 abdominal muscles but probably also of those of the bladder. 
 Constipation is common. The amount of perspiration is variable, 
 sometimes it is excessive. 
 
 Prognosis. — The acute cases, 95 per cent of which are fatal, 
 seldom survive seven days, and death may occur in twenty-four to 
 thirty-six hours from the comniencement of the attack. The later 
 the onset of the symptoms the greater the probability of the case 
 running a subacute course. Exceptionally, however, patients have 
 died after five or six weeks, and one girl died five months after 
 running a nail into her foot, and four months after the onset of 
 symptoms, which throughout were never very violent. Very few 
 of the cases following parturition or occurring in new-born infants 
 recover. If the patient have survived ten days there is a fair 
 prospect of ultimate recovery. This is always a very gradual 
 process ; the spasmodic attacks become more infrequent and less 
 severe, but the tonic contraction of the muscles persists for a long 
 time, and only passes off very gradually. The mortality of so-called 
 idiopathic cases is about 50 per cent. 
 
 Modes of death. — In acute cases the patients may die from 
 asphyxia due to prolonged tonic spasm of the respiratory muscles, 
 which may remain absolutely fixed for more than a minute. If 
 such attacks recur, the patient is almost certain to die in one of 
 them, the pulse continuing after the respiration has ceased. In 
 other cases, the patient gradually dies from exhaustion or from 
 cardiac failure, the intelligence being preserved to the last. 
 
 Post-mortem appearances. — There are no constant lesions 
 to be found. In a few cases there has been evidence of inflamma- 
 tion spreading up along the nerves from the seat of injury, but in 
 many this is absent. Ecchymoses and cell-infiltration of the peri- 
 vascular spaces on the surface of the brain and in the spinal cord 
 have been noticed. Possibly with the modern methods of examina- 
 tion, changes may be found in the nerve cells of the spinal cord. 
 
 Diagnosis. — Tetanus has to be distinguished from the following : 
 
 Strychnine poisoni?ig. — Here the sjaiiptoms come on suddenly, 
 within a short period after taking the poison, and two hours after 
 the first spasm the patient is either dead or is recovering. There are 
 violent convulsive movements, which affect the whole body ; the 
 hands are clenched, but the jaws are affected late, if at all. The 
 muscles are completely relaxed between the spasms. The patient 
 may die within a few minutes of the onset of the spasms. 
 
 Hydrophobia, — In this malady the spasms are paroxysmal and 
 
TETANUS t6i 
 
 not tonic ; they mainly affect the muscles of deglutition and respira- 
 tion, and are induced by attempts to drink. Among other distin- 
 guishing features are the delusions and other mental disturbances 
 which are seldom or never met with in tetanus. 
 
 Cerebro-spinal meniiigitis. — Tonic spasms are readily induced 
 by movements ; but the pyrexia, the optic neuritis, the vomiting, 
 headache and stupor, suffice to distinguish. 
 
 Hysteria. — This may produce opisthotonus and trismus, but 
 the other associated symptoms indicate the diagnosis. If there is 
 only trismus, the onset is sudden and complete, and the neck is not 
 stiff. 
 
 Tetany. — The characteristic and tonic contraction of the fingers 
 at once differentiate this. 
 
 Local mfiammatioii., such as results from impaction of a wisdom 
 tooth, may prevent the jaws from being opened, but the masseters 
 are not contracted, nor are there contractions in other muscles. 
 
 Any suppurating centre should always be examined for tetanus 
 bacilli, but they are not always to be discovered, and in any case of 
 doubt cultivations should be made, and a drop of pus or fluid should 
 be inoculated into the root of the tail of a mouse, which, if infected, 
 will die within three or four days from tetanus. 
 
 Treatment. — Prophylactic treatment is of the greatest im- 
 portance. Since aseptic methods have come into use, tetanus has 
 become a much rarer disease than formerly. All wounds, especially 
 those which have been contaminated with garden soil or manure, 
 should be thoroughly cleaned, and suppuration should be prevented 
 when possible. In any case of tetanus any suspicious abrasion or 
 injury should be thoroughly scraped and examined under an 
 anaesthetic, any foreign body removed, and any inflamed or sup- 
 purating area excised when feasible. There is no justification, how- 
 ever, for the removal of a limb, solely on the ground that it would 
 remove a focus of infection, as this has not led to beneficial results. 
 It has been proposed that the wound should be dressed with a ten- 
 volume solution of peroxide of hydrogen, and frequently bathed in 
 it, but it is of even greater importance to keep the wound aseptic. 
 
 No more striking instance of the value of cleanliness and of the 
 use of antiseptics in the prevention of tetanus could be afforded 
 than that of its abolition in the year 1893 from the Island of St. 
 Kilda. Previously, 84 out of 125 children, or 67 per cent, had 
 died of tetanus, or, as it was called locally, of the "eight-day sick- 
 ness." 
 
 Antitoxin. — Tetanus was the first disease in which the curative 
 
 VOL. I M 
 
1 62 MANUAL OF MEDICINE 
 
 effects of the injection of the serum of animals which had been pre- 
 viously rendered immune to the poison of a disease was thoroughly 
 investigated. If such serum be injected at the same time, or soon 
 after, an animal is inoculated with tetanus, its prophylactic effect is 
 marked. When the subcutaneous injection of the antitoxin is delayed 
 until the onset of tonic spasm, it is quite unable, if the attack is 
 severe, to stay the progress of the disease. The serum is able to 
 protect nerve cells from afterwards becoming affected by the poison, 
 but it cannot counteract the poison if it have already injured the cells. 
 
 Within the past year, however, it has been shown by Roux and 
 Berrel that if the serum be injected directly into the brain substance, 
 even after the onset of symptoms, it is capable of terminating the 
 spasms and of inducing recovery. Clinical experience has also already 
 led to some remarkable recoveries following this method {Brit. Med. 
 Journal^ 1899, i. pp. 10, 895, and 1333). The procedure, how- 
 ever, is not free from danger, since one of these cases, when con- 
 valescence was apparently fully established and all symptoms of 
 tetanus had disappeared, died eight weeks after the last intra-cerebral 
 injection from cerebral abscess, although every care had been taken 
 to secure asepsis at the operation of drilling the skull and injecting 
 the serum {ib. ii. p. 9). 
 
 In a dubious case, before the onset of definite symptoms, the sub- 
 cutaneous injection of 10 cc. of antitoxic serum, repeating this once 
 or twice a day as necessary, will probably suffice to stay the disease. 
 Should the symptoms be fully developed, according to present experi- 
 ence, it is desirable also to trephine over each frontal eminence, and 
 with due aseptic precautions slowly to inject into the brain tissue on 
 each side 5 cc. of serum. The injections may require to be repeated. 
 This will prevent the cerebral cells from fixing the poison, while the 
 subcutaneous injections will neutralise the poison in the blood. Re- 
 covery takes place slowly after a prolonged illness. 
 
 The following means, though powerless to save a patient's life 
 if the attack is severe, are of considerable value in the milder cases 
 in alleviating the symptoms: — 
 
 It is most important that the patient be kept quiet in bed in a 
 darkened room, and carefully protected from every form of irritation. 
 
 Chloral, if used, must be given in large doses, and frequently 
 repeated, 20 to 30 grains being indicated, but much larger doses 
 have often been employed. Morphia, given subcutaneously and at 
 short intervals, affords great relief. One-sixth of a grain of morphia 
 was given every two hours for a fortnight to a boy under the writer's 
 charge, with very great amelioration of the symptoms, and with 
 
DIPHTHERIA 163 
 
 ultimate recovery. Preparations of physostigma in large doses, 
 bromides, and other sedatives frequently repeated, have been used 
 with some benefit. 
 
 Chloroform is required when the spasms are very severe, and 
 when the chest has been held fixed by a profound spasm. It may 
 advantageously be combined with artificial respiration, which is 
 preferable to tracheotomy should the respiration cease from spas- 
 modic fixation of the chest. 
 
 When there is a difficulty in feeding the patient, liquid food can 
 be introduced by a soft tube passed behind the teeth, or through the 
 nostrils, but the passage of a nasal tube into the oesophagus generally 
 brings on an attack of spasm, so that it may require to be introduced 
 under an anaesthetic, or rectal feeding may be resorted to. 
 
 G. Newton Pitt. 
 
 DIPHTHERIA 
 Syn. Membranous Croup 
 
 The disease is characterised by an exudative, or membranous 
 inflammation of the faucial, nasal, or respiratory mucous membranes, 
 more rarely of wound surfaces ; attended, in severe cases, with pro- 
 found constitutional depression, and degenerative changes in certain 
 tissues, notably the peripheral nervous system, cardiac muscle, and 
 renal parenchyma. These changes result from the absorption into 
 the circulation of toxic material elaborated by a specific bacillus 
 which is invariably present at the seat of exudation. The presence 
 of this bacillus, which was discovered by Klebs in 1883, and sub- 
 sequently confirmed by Loffler, is now held to be the only true 
 criterion of diphtheria ; although the teaching of Bretonneau, that 
 the presence of exudation was in itself distinctive, had until recent 
 years been almost universally accepted. ' 
 
 Etiology. — Though widely diffused, it is chiefly in temperate 
 and cold damp climates that diphtheria prevails. Damp, low-lying 
 districts, possessing a soil retentive of wet, and rich in decaying 
 organic matter, usually show a high fatality from diphtheria, especi- 
 ally if subject to the continued prevalence of cold winds, coupled 
 with a high rainfall. In this country the disease seems to have 
 
164 MANUAL OF MEDICINE 
 
 been on the whole more prevalent in those counties lying along the 
 east coast than elsewhere. Like enteric and scarlet fevers, the 
 greatest incidence of diphtheria falls in the late autumn and early 
 winter, the maximum usually being attained either in November or 
 December, when the case mortality, too, is often above the average. 
 The prevalence is usually at its lowest point during the summer 
 months. It is an interesting fact that in England, at any rate, 
 diphtheria, though formerly more frequent in rural districts, has 
 during the last twenty years shown a constantly increasing tendency 
 to affect the population of towns, though different outbursts are 
 characterised by considerable variation in severity. There are 
 good reasons for believing this to be mainly dependent upon con- 
 ditions associated with the extension of compulsory education. It 
 is now more or less endemic in most large towns. 
 
 Our views as to the part played by drainage defects in the 
 etiology of diphtheria have undergone considerable modification of 
 late. It is now very generally recognised that inadequate drainage 
 of the surface soil, deficient scavenging, and dampness of habitation, 
 are influences far more potent in the propagation of diphtheria than 
 the inhalation of sewer gas, which, until recently, was universally 
 regarded as a common source of direct infection. Now, although 
 sewer gas can hardly be regarded as a source of direct infection — 
 and it may be remarked that the diphtheria bacillus has never been 
 detected in it— there is no doubt but that the health of persons who 
 have been for some time living under its influence may become 
 injuriously affected. Their powers of resistance become lowered, 
 even if they do not suffer from a definite sore throat, and under 
 these circumstances they are prone to fall easy victims to a chance 
 infection, and contract the disease in an aggravated form. Another 
 important factor in the propagation of diphtheria is school attend- 
 ance. Not only does the herding together of a number of children 
 under one roof for several hours a day provide special opportunities 
 for the transmission of infection, but the potential victims are of an 
 age at which they are very liable to take diphtheria when exposed to 
 it, and one, moreover, at which they are very susceptible to the 
 noxious influence of overcrowding and inadequate ventilation. The 
 combination of the foregoing conditions, known collectively as 
 " school influence" has been shown by Sir Richard Thorne Thorne 
 to be competent to bring about a progressive increase of infectivity 
 in a consecutive series of throat attacks ; so that severe, or even 
 lethal attacks of diphtheria may result from what originally appeared 
 to be a trivial non-specific sore throat. 
 
DIPHTHERIA 165 
 
 Although the part played by faulty sanitation and school influence 
 in the diffusion of diphtheria is well recognised, the most important 
 agent is undoubtedly personal infection. The contagium of diphtheria 
 is readily transmissible by means of minute particles of mucus or 
 flecks of membrane, which may be ejected from the mouth or nose 
 by an act of coughing, sneezing, or even laughing in an explosive 
 manner. The infective material may either be transmitted directly 
 into the mouth or nose of another person, or indirectly, after com- 
 plete desiccation, by means of a current of air. Infection, too, may 
 result from the act of kissing, or from using the same pocket hand- 
 kerchief, cup, or spoon. Milk is a frequent channel of infection. 
 In some cases, no doubt, it becomes accidentally contaminated from 
 a human source. The bacillus grows well in milk ; in other cases, 
 according to Dr. Klein, the milk appears to derive its infective pro- 
 perties from the cow itself, in virtue of the animal being affected 
 with a disease the counterpart of human diphtheria. Cats are a 
 distinct source of danger, as they are hable to contract true 
 diphtheria, and thus transmit the disease. There is no reason to 
 think that diphtheria is ever spread by means of an infected water 
 supply. A person should be regarded as a possible source of 
 infection so long as any diphtheria bacilli can be detected in the 
 throat or secretions, nor, if practicable, should he be allowed to mix 
 with others until the discharge from any aff'ected surface has ceased. 
 
 Predisposition to diphtheria varies with age, sex, state of health, 
 and previous attack The influence of age and sex is shown by the 
 table given on next page, which is compiled from the total diphtheria 
 admissions into the hospitals of the Metropolitan Asylums Board 
 during the ten years ending 1897. 
 
 Approximately, three-fourths of the attacks were in children under 
 ten years of age. The same fact is apparent in respect to scarlet 
 fever ; but in that disease the incidence is greatest in the second 
 quinquennium of life, instead of the first. One-fifth more females 
 were attacked than males. Persons are very liable to contract 
 diphtheria who have been recently subject to any acute disorder, 
 especially if attended with any sore throat or nasal discharge, such as 
 tonsillitis, scarlet fever, or measles. In this connection the influence 
 of drainage defects and overcrowding has been already referred to. 
 The immunity conferred by an attack of diphtheria lasts but three 
 or four weeks in most persons, hence a relapse or definite second 
 attack is often met with. 
 
 The period of incubation is frequently dii^cult to determine, 
 because an exudation may have been present for several days before 
 
i66 
 
 MANUAL OF MEDICINE 
 
 
 
 Males. 
 
 
 Females. 
 
 
 Total. 
 
 
 AGES. 
 
 
 
 
 
 
 
 
 
 Admitted. 
 
 Died. 
 
 Mortality 
 
 
 Died. 
 
 Mortality 
 
 Admitted. 
 
 Died. 
 
 Mortality 
 
 
 
 
 per cent. 
 
 
 
 per cent. 
 
 
 
 
 Under i . . 
 
 239 
 
 "5 
 
 48.1 
 
 196 
 
 103 
 
 52.6 
 
 435 
 
 218 
 
 50.1 
 
 I to 2 
 
 
 819 
 
 411 
 
 50.2 
 
 729 
 
 368 
 
 50-5 
 
 1,548 
 
 779 
 
 50-3 
 
 2 „ 3 
 
 
 1,101 
 
 466 
 
 42.3 
 
 1,120 
 
 440 
 
 39-3 
 
 2,221 
 
 906 
 
 40.8 
 
 3 ,. 4 
 
 
 1,486 
 
 545 
 
 36.7 
 
 1,485 
 
 503 
 
 33-9 
 
 2,971 
 
 1,048 
 
 35-3 
 
 4 „ 5 • • 
 
 Totals under"! 
 5 years j 
 
 1,423 
 
 432 
 
 30-4 
 
 1,662 
 
 517 
 
 3I-I 
 
 3,085 
 
 949 
 
 30.8 
 
 5,068 
 
 1,969 
 
 38-9 
 
 5,192 
 
 1,931 
 
 37-2 
 
 10,260 
 
 3,900 
 
 38.0 
 
 5 to lo . . 
 
 3>978 
 
 850 
 
 21.4 
 
 4,720 
 
 1,094 
 
 23.2 
 
 8,698 
 
 1,944 
 
 22.3 
 
 lo ,, 15 
 
 
 1,205 
 
 no 
 
 8.7 
 
 1,695 
 
 144 
 
 8.5 
 
 2,960 
 
 254 
 
 8.6 
 
 15 ,, 20 
 
 
 497 
 
 26 
 
 5-2 
 
 817 
 
 34 
 
 4.2 
 
 1,314 
 
 60 
 
 4.6 
 
 20 ,,25 
 
 
 297 
 
 14 
 
 4-7 
 
 562 
 
 20 
 
 3-6 
 
 859 
 
 34 
 
 4.0 
 
 25 „ 30 
 
 
 182 
 
 12 
 
 6.6 
 
 405 
 
 13 
 
 3-2 
 
 5S7 
 
 25 
 
 4-3 
 
 30 „ 35 
 
 
 119 
 
 4 
 
 3-4 
 
 222 
 
 14 
 
 6.3 
 
 341 
 
 18 
 
 5-3 
 
 35 >> 40 
 
 
 67 
 
 4 
 
 6.0 
 
 118 
 
 5 
 
 4.2 
 
 185 
 
 9 
 
 4.9 
 
 40 ,, 45 
 
 
 37 
 
 3 
 
 X /■ 
 
 58 
 
 5 
 
 -12.3-' 
 
 95 
 
 8 
 
 ■ 13-3 
 
 45 » 50 
 
 
 19 
 
 I 
 
 
 34 
 
 4 
 
 53 
 
 5 
 
 50 „ 55 
 
 
 15 
 
 4 
 
 -15.0 J 
 
 14 
 
 2 
 
 29 
 
 6 
 
 55 ., 60 
 
 
 6 
 
 2 
 
 15 
 
 I 
 
 
 21 
 
 
 
 And upwards 
 
 3 
 
 2 
 
 9 
 
 4 
 
 V 
 
 12 
 
 6 
 
 J 
 
 Grand To 
 
 tals 
 
 ii>553 
 
 3,001 
 
 26.0 
 
 13,861 
 
 3,271 
 
 23.6 
 
 25,414 
 
 6,272 
 
 24.7 
 
 attention is called to the throat. Symptoms of invasion often appear 
 within thirty-six hours of infection, and though they are rarely delayed 
 more than four or five days, a quarantine of ten or twelve days 
 should be maintained. 
 
 For the purposes of clinical description, attacks of diphtheria 
 may be conveniently divided into the five following groups : — 
 
 I. Mild Fa ucial Form. — This class of case is most common 
 in adults, and, except for the presence of exudation, there is little to 
 distinguish it from an attack of simple tonsillitis. The exudation is 
 usually limited to the tonsils, which are more or less swollen, one 
 commonly more than the other ; but a patch may form on the con- 
 tiguous side of the uvula. The exudation usually takes the form of 
 a thin, fibrinous, or cheesy-looking pellicle, of a dead white or grayish 
 tint, lying on the surface of the tonsil, to which it is loosely adherent. 
 In other cases the exudation occurs in one or more depressed 
 
DIPHTHERIA 167 
 
 patches, with clearly-defined margin, resembling a shallow necrotic 
 ulceration of the tonsils, which, like the surrounding mucous mem- 
 brane, are red and angry-looking. The subjacent glandular swelling 
 corresponds to the extent to which the tonsil on that side is in- 
 volved. The pyrexia usually ranges from 101° to 103°, its degree 
 being proportionate to amount of faucial inflammation, and slight 
 albuminuria is common. After three or four days' appropriate treat- 
 ment the exudation commonly clears, and the patient is convalescent 
 by the end of a week or ten days. 
 
 11. Severe Faucial Form, tisually showing a tendency to 
 extension. — This is most common in young children, in whom the 
 mortality is very high. The disease affects the fauces primarily, and 
 from thence may spread to the pharynx, nares, or respiratory pas- 
 sages. The symptoms of invasion are in most cases pronounced ; 
 but in some patients the attack represents a progressive development 
 of one w^hich originally bid fair to run a mild course. For this 
 reason no attack of diphtheria in a young child, however mild, should 
 ever be lightly regarded. The onset is usually attended with shiver- 
 ing, pain in swallowing, and not infrequently vomiting, in addition 
 to the usual signs of febrile invasion. The tonsils are much swollen 
 at an early stage, and may almost meet in the mid-line so as to 
 partially obscure the uvula, which is usually oedematous. Their surface 
 is covered with thick white exudation, presenting either a glistening 
 or dead-white appearance like that of wash-leather, and the faucial 
 mucous membrane generally is usually of a pinkish rather than deep 
 red colour, and slippery-looking, owing to the presence of much 
 glairy mucus. The uvula is sometimes ensheathed with a coat of 
 membrane, like the finger of a glove, and patches of exudation are 
 often present on the soft palate and anterior pillars of the fauces. 
 There is usually considerable infiltration of the subjacent glands and 
 connective tissue, and a muco-purulent or thin straw-coloured dis- 
 charge may escape from the nostrils, in consequence of the nasal 
 fossse having become involved in the disease. The tongue is coated 
 with a pasty fur, and the temperature during the first three or four 
 days is raised, perhaps, to 103° or more ; but under the influence of 
 efficient local treatment, apart from the efi"ect of antitoxin, a rapid 
 fall commonly occurs, even before the condition of the fauces shows 
 a corresponding improvement. Diphtheria has no typical tempera- 
 ture curve, the worst cases often having a normal temperature almost 
 from the commencement. The patient's condition becomes one 
 of great distress, in consequence of the acute pain which constantly 
 attends the act of swallowing food and saliva. His distress is in- 
 
1 68 MANUAL OF MEDICINE 
 
 creased by reason of the nasal passages being more or less blocked ; 
 and should the disease extend to the larynx, the horrors of croup are 
 superadded. Epistaxis, or bleeding from the margin of the faucial 
 exudation, may occur at this stage, and the urine is usually albumin- 
 ous. As the case proceeds the exudation becomes discoloured, 
 owing to putrefactive changes, and is gradually thrown off, perhaps 
 to be replaced by a fresh deposit. If forcibly removed, a bleeding 
 and excoriated surface remains. 
 
 Should the patient survive, the general swelling of the parts 
 undergoes considerable abatement by the end of the week, or a few 
 days later, though the pulse at this stage may show distinct evidence 
 of weakness. A superficial ulceration remains after the membrane 
 has become detached. This soon heals, and the faucial discomfort 
 then disappears. 
 
 Now, it by no means follows that recovery will ensue, although 
 the patient may have progressed to the above extent. Nothing 
 could be more fallacious ; for the second week of diphtheria, 
 especially its latter half, is the time when the most fatal develop- 
 ment to which the patient is liable, viz. "cardiac failure," is most 
 likely to arise, though it may not appear until a week or two later. 
 The onset of cardiac failure is characterised by progressive enfeeble- 
 ment of the circulation, and often, though by no means necessarily, 
 there is marked dilatation of the left ventricle. The pulse becomes 
 unduly slow, or irregular, and, though in some cases its rapidity is 
 increased, its tension is always diminished. Incessant vomiting, 
 increasing pallor, combined with restlessness, and sighing, or irregular 
 respiration, are constant features. Acute pain in the epigastric or 
 precordial region is often present, and distressing cramps in the 
 muscles of the back and limbs are sometimes complained of. The 
 temperature becomes subnormal, much albumin appears in the 
 urine, which is scanty ; or it may be entirely suppressed for twenty- 
 four hours or more before death. Coldness of the extremities 
 gradually supervenes, the collapse becomes more profound, and life 
 slowly ebbs away, the patient usually retaining consciousness to the 
 end. The victim sometimes lingers on for several days, but a 
 sudden syncopic attack usually terminates the scene. 
 
 In the very worst, the so-called " malignant," attacks, the whole 
 of the faucial structures become rapidly covered with a thick sheet 
 of gelatinous membrane which often encroaches on the hard palate 
 and buccal surface of the cheek. The nares, too, are blocked, and 
 a thin blood-stained fluid exudes from the nostrils. There is much 
 swelling of the neck, and the patient, quite unable to swallow, dies 
 
DIPHTHERIA 169 
 
 from cardiac failure before the end of the week. The toxaemic 
 character of such an attack is evidenced by the waxy pallor of the 
 skin, which is early apparent, the cyanotic appearance of the lips, 
 the staining which is seen to follow the course of many of the 
 superficial veins, the lowness of the temperature, the cardiac de- 
 pression, and the liability to some form of hemorrhage. This 
 may occur from any of the mucous surfaces — fauces, nares, gums, 
 conjunctivae, stomach, intestines, genito-urinary passages, or into the 
 tissue of the skin. Bruising may result from the slightest pressure, 
 or the most insignificant contusion, and is well marked round the 
 site of a hypodermic injection. Hsemorrhagic attacks are seemingly 
 always fatal. Death usually occurs during the course of the second 
 week, but in the worst cases may take place earlier. 
 
 III. Laryngeal Form. — The air passages may be affected 
 primarily, sometimes exclusively ; but croup more often arises as a 
 complication of faucial diphtheria, which, if mild, may have pre- 
 viously escaped observation. The term " croup " denotes a condi- 
 tion of laryngeal obstruction, whether membranous, as in diphtheria, 
 or not. Its onset is characterised by the gradual development of 
 hoarseness, with an ineffectual, metallic cough, and ultimately com- 
 plete aphonia. After from twelve to thirty-six hours the laryngeal 
 affection usually becomes sufficiently pronounced to be a source of 
 actual dyspnoea. The breathing is stridulous, the child becomes 
 restless, and is in constant terror of suffocation. Marked recession 
 of the soft parts of the thoracic walls as well as of the lower ribs 
 and epigastrium on inspiration is then apparent ; expiration becomes 
 attended with distinct muscular effort ; cyanosis and drowsiness 
 gradually supervene, and the child dies suffocated, unless relieved 
 by operation. The membrane, meanwhile, usually spreads down 
 the trachea into the bronchial tubes, often to their smallest ramifi- 
 cations. In favourable cases the laryngeal swelling subsides in a 
 few days, more or less complete casts of the trachea and bronchi 
 being at times expelled, arid convalescence advances rapidly. 
 Diphtheria, when limited to the air passages, is rarely followed by 
 cardiac failure or paralysis. Primary laryngeal diphtheria is seldom 
 seen in adults, and although extension to the larynx occurs in them 
 occasionally, it rarely gives rise to obstructive dyspnoea. It may 
 prove fatal, however, by spreading to the smaller air passages. 
 
 IV. Nasal Form. — The nasal passages are frequently in- 
 volved in severe faucial attacks, consequently nasal diphtheria is 
 generally regarded as a grave condition. Pure nasal diphtheria, 
 however, is commonly a mild development, and occurs more often 
 
I70 MANUAL OF MEDICINE 
 
 than is usually supposed. Frequently, the only indications of its 
 presence are — a thin mucoid rhinorrhoea, containing numerous 
 diphtheria bacilli, slight soreness of the external nares, and some 
 tenderness of the superficial lymphatic glands beneath the jaw. 
 Occasionally shreds of membrane, or incomplete casts of the nasal 
 fossae are expelled. In rare instances the condition becomes more 
 or less chronic (rhinitis fibrinosa), and the patient continues to 
 expel casts, often of the inferior turbinated bone, every few days for 
 several weeks, or even months, though his general health remains 
 unaffected. The importance of the condition, however, from the 
 point of infectivity must not be overlooked. 
 
 V. Other Forms. — Diphtheritic exudation sometimes occurs 
 on the mucous membrane of other parts, viz. the cheeks, gums, 
 tongue, lips, conjunctivae, the external genitalia, especially in females, 
 and on the surface of open wounds. The condition is usually 
 associated with either faucial, nasal, or laryngeal diphtheria ; but in 
 the case of open wounds is, perhaps, more often primary. The 
 gravity of the condition is proportionate to the amount of surface 
 involved. Most cases of extensive wound diphtheria are fatal 
 through cardiac failure. 
 
 Of the complications liable to supervene, the following list 
 shows the percentage incidence amongst 16,360 attacks of diph- 
 theria : — 
 
 Albuminuria . 
 
 40.8 per cent 
 
 Paralysis 
 
 ■ 19-1 
 
 Broncho-pneumonia 
 
 2.2 
 
 Relapse 
 
 1.6 
 
 Nephritis 
 
 .88 „ 
 
 Albuminuria should be regarded as a symptom rather than a 
 complication of diphtheria. It is present in more than half the 
 number of severe attacks, and is often excessive. It usually arises 
 towards the end of the first week, or early in the second, and, as a 
 rule, disappears shortly after the throat is clear. Though some- 
 times persistent for several weeks, it does not imply any serious 
 lesion of the kidneys. 
 
 Paralysis of diphtheritic origin varies widely both in its distribu- 
 tion and degree. It is rarely complete, and is usually attended 
 with more or less sensory disturbance. It is far more common 
 after severe attacks than mild ones. Indeed, so true is this relation, 
 that the chance of subsequent paralysis may usually be gauged by 
 the character, extent, and persistence of the previous exudation. 
 
DIPHTHERIA 171 
 
 An exception, however, must be claimed in respect to larjmgeal, and 
 pure nasal diphtheria, which are rarely followed by definite, much 
 less extensive, paralysis ; and in rare instances a mild faucial 
 attack is followed by widespread palsy. The paralysis affects young 
 children more often than older patients, and most frequently arises 
 during the second, third, and, more rarely, the fourth week of illness, 
 though it may appear as late as the sixth or seventh week in 
 exceptional instances. The part most often, and, usually, earliest 
 affected is the palate. The velum is seen to lie motionless, and its 
 natural arch appears somewhat flattened. Its sensibility is im- 
 paired, and its reflex excitability lost. The voice, consequently, 
 assumes a nasal quality, and the act of swallowing results in the 
 passage of food into the nasal cavities. The ciliary muscle, next 
 to the palate, is most likely to suffer, resulting in failure of accom- 
 modation for near vision, and consequent inability to read. Oculo- 
 motor paralysis also occurs, though less often, causing diplopia and 
 strabismus, the external rectus being most often affected. It is 
 frequently bilateral. Complete ptosis is rare, but a partial weakness 
 of the levatores palpebrEe can often be detected, which gives the 
 patient a sleepy expression. Next to the palate and eyes, the legs 
 most frequently suffer. Sensory disturbance usually appears first 
 in the form of tingling, or " pins and needles " in the feet ; or a 
 sensation of cotton-wool under the soles, combined with numbness, 
 or actual anaesthesia. This may spread up the legs, even to the 
 thighs, and is almost invariably combined with loss of patellar 
 reflex. More or less muscular weakness in the legs is usually 
 present, but rarely complete paralysis. A loss of patellar reflex may 
 occur apart from any indication of paralysis or anEesthesia. 
 
 In exceptional cases the arms are affected, or the muscles of the 
 neck and trunk, the patient being then unable to sit up in bed or 
 support the weight of his head. The diaphragm, or the intercostal 
 muscles may become paralysed, both of which are a source of urgent 
 danger. In extreme cases anaesthesia of the tongue and buccal sur- 
 face may occur, and even blunting of the sense of smell and of 
 taste. The sphincters are unaffected throughout. Considerable 
 wasting of the affected muscles sometimes occurs, in degree pro- 
 portionate to the duration of the paralysis. Although in the large 
 proportion of cases recovery takes place in a few weeks, it may be 
 several months, or even several years, before complete restoration 
 to health is attained. 
 
 After severe attacks of diphtheria a group of paralytic symptoms 
 of far greater gravity than the foregoing is liable to arise. During 
 
172 MANUAL OF MEDICINE 
 
 early convalescence the paralysis of the palate may become attended 
 with paralysis of the pharyngeal constrictors, with the result that 
 deglutition is rendered impossible. The arytseno-epiglottidean 
 muscles, and the adductors of the larynx are usually affected as 
 well, and the larynx becomes anaesthetic. The patient is con- 
 sequently liable to be choked by the passage of food into the 
 trachea, or to be carried off by septic broncho-pneumonia. Vomit- 
 ing, cardiac depression or irregularity, and sudden albuminuria are 
 often superadded. These may be the result, no doubt, of cardiac 
 failure ; but their association with the above paralytic manifestations, 
 and the fact that recovery sometimes ensues, are strongly suggestive 
 that some temporary disturbance of the functions of the vagus 
 nerve, rather than myocardial degeneration, is responsible for their 
 production. 
 
 Broncho-p7ieumonia in some degree is probably more common 
 than the above record would seem to imply. Patches can almost 
 invariably be found in fatal cases of laryngeal diphtheria, though it 
 may have been impossible to detect them during life. 
 
 A relapse or recrudescence of the disease is liable to occur at 
 any time after the third week, especially in cases treated with anti- 
 toxin. It is almost invariably milder than the original attack. 
 
 Nephritis is very uncommon. Though renal casts are present 
 in all cases, hsematuria is rare. The attack otherwise presents no 
 special features and the patient usually recovers. 
 
 The susceptibility of the diphtheria patient to the infection of 
 scarlet fever must not be forgotten. 
 
 Prognosis. — The death-rate in different epidemics of diphtheria 
 is very variable. It is mainly influenced by the relative proportion 
 of young children amongst those attacked, and the hygienic con- 
 ditions under which they live. 
 
 The case mortality amongst the 25,414 cases tabulated on page 
 166 was 24.7 per cent, but under the influence of the antitoxin 
 treatment (commenced in December 1894) the fatality in the 
 hospitals of the Asylums Board has been reduced from over 30 per 
 cent to about 15. 
 
 The most important factors in prognosis are — 
 
 I. Character of attack. — In laryngeal cases the prognosis is always 
 grave, especially if secondary to previous faucial affection. In faucial 
 attacks important indications are yielded by the extent, persistence, 
 and character of the exudation. In proportion as the disease has 
 spread from the tonsils on to the palate, uvula, pharynx, or into 
 the nasal fossae, the gravity of the attack will be greater, because a 
 
DIPHTHERIA 173 
 
 larger surface is concerned in producing the toxin. So, too, if the 
 exudation be unduly persistent, more toxin is produced, and relatively 
 more absorbed. If an extensive membrane remain attached for five 
 or six days the case at once assumes a serious aspect ; if for two or 
 three days longer, the prognosis becomes exceedingly grave. The 
 prognostic significance of extent and persistence of membrane must 
 necessarily be relative. The most virulent type of membrane is 
 one which is thick and gelatinous, or sometimes distinctly fibrous 
 in appearance, and attended with marked cedema of the mucous 
 membrane. The least virulent is thin and friable, or of cheesy 
 consistence, with well-defined margin, and little, if at all, raised 
 above the surface. Between them all gradations occur. In thick 
 adherent membranes, putrefaction occurs ^>^ situ ; hence, fetor of 
 the breath is a bad sign. Extensive infiltration of the deep cervical 
 glands and connective tissue implies virulence of the local process. 
 A normal or subnormal temperature, coupled with a feeble or rapid 
 pulse, is indicative of toxaemia ; and waxy pallor of the complexion, 
 and the sudden onset of severe albuminuria is evidence in the same 
 direction. Haemorrhage from a mucous surface is usually a fatal 
 sign, and the writer has never seen a patient recover in whom pur- 
 puric spots were observed in the skin. 
 
 2. Age. — The enormous influence on fatality exerted by age is 
 well shown by the foregoing table (page 166). Age exerts a two- 
 fold influence. Not only are young children bad subjects for 
 diphtheria, but in them the disease shows a greater tendency to 
 assume the laryngeal and nasal forms. 
 
 3. Sex has less influence. The mortality amongst males in the 
 foregoing series was 26.0 per cent; whereas in females it was 23.6 
 per cent. 
 
 4. State of health. — Those who are subject to any wasting 
 disease, or who are cachectic in virtue of ill-nutrition or a tuberculous 
 dyscrasia are prone to severe attacks. So also are those who are 
 actually suff"ering from other acute infectious disease, particularly 
 measles, whooping-cough, and scarlet fever, as the malady then 
 usually affects the respiratory passages. The mortality of co-existent 
 measles and diphtheria in pre-antitoxin days was over 80 per cent. 
 
 5. Length of time before coining under treattnent. — The import- 
 ance of early treatment has always been recognised in respect to 
 local remedies, but it assumes a paramount importance in the case 
 of treatment by antitoxin. A procrastination of twenty-four hours 
 in one's determination to give antitoxin may make just the difference 
 between life and death in a young child. In laryngeal attacks the 
 
174 MANUAL OF MEDICINE 
 
 necessity for tracheotomy is often averted, and in faucial cases its 
 importance is nearly as great. 
 
 Bacteriology and pathology. — Tlie specific contagium of 
 diphtheria, the Klebs-Loffler bacillus, is always present in the exuda- 
 tion, and in the superficial layers of the affected mucous membrane. 
 Its local multiplication is attended with the formation of a specific 
 toxin, which is absorbed into the circulation, and, by its noxious 
 effects on certain tissues, is productive of the particular symptoms of 
 the disease. Diphtheria, then, like tetanus, is an intoxicative rather 
 than a truly infective disease, in which the blood becomes infested 
 with the micro-organisms themselves. Recent research, however, has 
 shown that this limitation of the bacilli to the local lesion is not 
 absolute ; for in severe attacks they have been found, not only in 
 the subjacent lymphatic glands, but in the tissue of the lungs, the 
 spleen, and more rarely the kidneys. The fact is, nevertheless, 
 beyond dispute that diphtheria is primarily, if not essentially, a 
 local infection. The toxin of a virulent culture of the bacillus 
 proves lethal to rabbits and guinea pigs injected with it, and tissue 
 changes are produced in them similar to those found in fatal cases 
 of human diphtheria. As to its chemical nature, it has been 
 variously held to be an enzyme, a toxalbumin, and an albumose. 
 
 The Klebs-Lofiler bacillus is polymorphic and varies in length 
 from 2 to 6 /A. It is not motile and does not form spores. It is 
 frequently somewhat curved, though more often straight, and 
 commonly shows a slight swelling of one or both ends (Plate I.). 
 It stains irregularly, and consequently often presents a beaded 
 appearance, or looks as if segmented. When alkaline methylene 
 blue is used, the irregularity of the staining is most apparent ; so 
 much so that a dark dot may usually be observed at each pole of the 
 bacillus, an appearance which is often well brought out by Gramm's 
 method. This efi"ect is commonly more pronounced in bacilli 
 taken from a culture than in those removed directly from the throat. 
 Two chief varieties of the bacillus are recognised, the long form and 
 the short. The former is much more distinctive than the latter, 
 the identification of which is sometimes very difficult. In old 
 cultures there is a tendency for the bacilli to become club-shaped 
 or pyriform, one end being much swollen, the other tapering off to 
 a fine point. Clubbing, however, is sometimes seen in newly- 
 formed colonies. Although considerable variation may be noted 
 in respect to the form and size of individual bacilli, their mutual 
 arrangement in the microscopic field is often very characteristic, 
 being frequently aggregated into small clusters, some of the members 
 
DIPHTHERIA 175 
 
 of which He parallel to each other, whilst others are disposed at 
 various angles ; the general appearance of the group thus resembling 
 that of a Chinese alphabetical character. 
 
 The colonies grow on blood-serum at 37° C, can be recognised by 
 the naked eye in twelve to sixteen hours as slightly raised, round, 
 grayish-white dots, and at the end of twenty-four hours are usually as 
 large as a fair-sized pin's head. On glycerine-agar at the same tem- 
 perature they grow somewhat less rapidly, and the colonies are slightly 
 grayer and more translucent at their periphery than in the centre. 
 On nutrient gelatine at room temperatures, the growth, though far 
 slower, is more characteristic. The colonies tend to become faintly 
 yellow in tint, their centres raised, and surrounded by concentric rings, 
 which give them a ripple-like appearance, though this is not very 
 obvious until after a week or ten days' growth. No liquefaction of the 
 gelatine takes place. When the bacillus is grown in broth the medium 
 soon becomes turbid, and deposits a white chalky sediment on the 
 bottom and sides of the tube. 
 
 Bacilli are frequently found in the throat, either alone or in 
 association with the true diphtheria bacillus, which, both morpho- 
 logically and in their cultural behaviour, are indistinguishable from 
 it, but differ in that they are quite devoid of virulence. Apart 
 from any difficulty in respect to the identification of these pseudo- 
 diphtheritic bacilli, there is considerable difference of opinion 
 amongst bacteriologists as to whether they are true diphtheria 
 bacilli which have become attenuated, or whether they should be 
 more properly regarded as members of an entirely distinct species. 
 This point is by no means conclusively settled. The local re- 
 action resulting from the multiplication of the bacillus of diph- 
 theria on the surface of a mucous membrane constitutes the lesion 
 which is so distinctive of the disease. It is essentially an inflam- 
 mation, characterised by hyperaemia, stasis, the accumulation of 
 leucocytes, proliferation, followed by necrosis, of the epithelial cells, 
 and the exudation between them, and on their surface, of more or 
 less fibrin. This either takes the form of a thin, loosely-coherent 
 pellicle, or, should the epithelial layers be involved to a greater 
 depth, of a thick tenacious membrane, in which distinct evidence of 
 lamination can be made out. In diphtheritic croup membrane 
 is found lining the trachea and bronchial tubes, in severe cases, 
 even to their smallest ramifications, where it becomes lost in a layer 
 of muco-pus. More or less broncho-pneumonia is always present, 
 usually of a truly diphtheritic nature, the alveoli being stuffed with 
 
176 MANUAL OF MEDICINE 
 
 fibrin, leucocytes, and bacilli ; or it may be of a septic order, due to 
 pyococcal infection. The common pyogenetic and putrefactive 
 organisms may be detected in the surface of the exudation in practi- 
 cally all cases of diphtheria ; but in some instances a definite septic 
 invasion takes place. These cases of " mixed infection " are almost 
 invariably severe. 
 
 Post-mortem appearances. — The appearances yielded by 
 the organs in fatal diphtheria are not very distinctive. In severe 
 faucial cases the spleen is often somewhat enlarged, and the same 
 is true of the kidneys, of which the cortex is broader and paler 
 than normal, while the epithelial cells lining the tubules usually 
 show considerable fatty change. The heart muscle is pale, and 
 its component fibres to a variable extent will be found to have 
 undergone fatty or granular degeneration, particularly, though not 
 necessarily, in cases fatal through sudden cardiac failure. The 
 change may be well marked as early as the fourth or fifth day of 
 the disease. The cardiac cavities, especially the left ventricle, 
 are often markedly dilated. It is on nerv-e tissue, however, 
 that the most distinctive effects of the diphtherial poison are seen. 
 Irregular foci of acute parenchymatous degeneration are found 
 scattered haphazard throughout the peripheral nerves, and, in less 
 characteristic degree, in the sympathetic. The change affects 
 certain fibres alone in a particular ner\-e, the others being spared ; 
 and since in a mixed nerve separate fibres to muscles, and points 
 in the skin to which the degenerated fibres run are alone affected, 
 not only does paresis of the muscle, rather than paralysis, result, 
 but the distribution of the wasting and ansesthesia is necessarily 
 irregular. 
 
 The differential diagnosis between diphtheria and certain 
 cases of non-specific inflammation of the faucial, nasal, and 
 laryngeal passages which simulate it is often extremely difficult, 
 especially in respect to follicular tonsillitis. It practically resolves 
 itself at the present day into whether or not the Klebs-Lofifler 
 bacillus can be detected in the exudation or discharges. The test, 
 however, valuable though it is, is unfortunately not infallible. In 
 most cases bacilli disappear in three or four weeks, but they may 
 persist for several months after the throat has recovered, and are 
 even occasionally found in the fauces and nasal discharge of per- 
 fectly healthy persons, especially those who have been in attendance 
 on patients suffering from the disease. Although, for this reason, 
 it is impracticable to strictly regulate the duration of a patient's 
 isolation by the fact of the presence or absence of the bacillus, its 
 
DIPHTHERIA 177 
 
 value as evidence as to the specific character of an inflamed throat 
 cannot be denied. 
 
 Treatment. — Although nothing can compare with the injection 
 of antitoxic serum in the treatment of diphtheria, representing, as it 
 does, a true specific for the disease, the simultaneous adojjtion of 
 efficient local treatment should not be omitted. This is best 
 effected by syringing out the pharynx, and, if necessary, the nasal 
 passages, every two, three, or four hours with some antiseptic and 
 astringent solution in the manner described in the treatment of 
 septic attacks of scarlet fever. By this means the local multiplica- 
 tion of the diphtheria bacillus, and other micro-organisms, is to 
 some extent inhibited, and offensive secretions are cleared away. 
 A solution of chlorine, or one of formalin (i in 200), or chinosol 
 (i in 600) is the best. The throat may be sprayed occasionally 
 with a weak solution of sulphurous acid, and one of borax and 
 bicarbonate of soda (of each 10 grains to the ounce) is sometimes 
 useful. Neither gargling or swabbing out the fauces are of much 
 practical value, and the same thing is true of the local application 
 of powdered sulphur, which used to be widely practised. 
 
 In early laryngeal obstruction a steam tent is indicated. For 
 its relief intubation is often successful in the hands of a skilled 
 operator. Tracheotomy, however, is preferable in most cases. 
 
 In cardiac failure drugs are of little value, but the hypodermic 
 injection of liquor strychninse (2 to 5 m.) every four hours, and 
 frequent small doses of alcohol should be tried. 
 
 A do6e of from 2000 to 8000 units of antitoxin, according to the 
 severity of the attack, should be given at the earliest possible 
 moment in every case when the patient is a young child. In the 
 mild form of attack in adults it may be withheld, but the case 
 must then be carefully watched. No regard need be paid to the 
 age of the patient in regulating the dosage. Should there be even 
 the faintest suggestion of croup, a full dose of 8000 units should 
 be given at once, as the necessity for tracheotomy will probably be 
 thereby averted. In all but the mildest attacks a half dose should 
 be repeated at least every twenty-four hours until the exudation has 
 definitely commenced to separate. It is of paramount importance 
 that the treatment should be commenced early. The serum can be of 
 no use after the tissues have been irreparably damaged by the toxin 
 already absorbed. The injection is preferably made under the skin 
 of the back or loins, with careful previous sterilisation of the syringe 
 and its needle. Under the influence of early treatment with 
 antitoxin, the development of the disease is checked, the faucir.l 
 
 VOL, I N 
 
178 MANUAL OF MEDICINE 
 
 swelling and rhinorrhoea abate, and the membrane separates 
 earlier, with the result that the patient's distress is greatly lessened, 
 laryngeal obstruction seldom supervenes, and the mortality is greatly 
 reduced, especially amongst the tracheotomy cases. The fact that 
 a rash, usually of a measly, or urticarial character, or a short period 
 of irregular pyrexia, or, though far more rarely, some pains in the 
 joints may arise a week or ten days after the antitoxin has been 
 given, is no reason against its employment, as they are never 
 attended with any permanent ill effect. 
 
 F. FooRD Caiger. 
 
 EPIDEMIC PNEUMONIA 
 
 The clinical features of croupous pneumonia, especially its 
 sudden onset, its definite course, and termination in a crisis, give it 
 a striking resemblance to such specific febrile diseases as typhus 
 fever or smallpox. Nor do the occasional occurrence of true 
 relapses diminish the resemblance. The apparent absence of in- 
 fectiveness in the vast majority of instances does not necessitate its 
 exclusion from the list of specific febrile diseases, as such maladies 
 present every degree of infectivity, the amount of this property 
 being determined in part by the accessibility of the infective material 
 to the surface of the body and in part by the environmental con- 
 ditions. The influence of environment is probably at its minimum 
 in anthrax and smallpox. It is very great in rheumatic fever and 
 in pneumonia, in which auxiliary factors are required besides the 
 " unconditioned microbe " to complete the causation of the disease. 
 The regular seasonal exacerbation of the disease (March to May), 
 and the fact that in certain years it is prevalent in such excessive 
 amount as to deserve the name of "epidemic," confirm the same 
 view. The official figures of the English Registrar-General, however, 
 do not lend themselves to a demonstration of the notion that in 
 certain years croupous pneumonia is epidemic ; because in them all 
 forms of pneumonia are necessarily reckoned together. Even if 
 an attempt were made to separate them, without universal autopsies 
 by skilled pathologists the results would require to be accepted with 
 caution. The following figures, contributed by MM. Montane and 
 Duponchel to the French Comite de Sante, are less open to objec- 
 
EPIDEMIC PNEUMONIA 
 
 179 
 
 tion. They give the morbidity rate from pneumonia in the 50th 
 Hne regiment of Perigueux among an adult population remaining fairly 
 constant througliout the period. The corresponding rates for 
 typhoid fever are given for comparison : — 
 
 
 Pneumonia. 
 
 Typhoid Fever. 
 
 
 Pneumonia. 
 
 Tj'phoid Fever. 
 
 1878- 
 
 83 
 
 Der 100 
 
 .00 per 100 
 
 1885 
 
 .50 per 
 
 106 
 
 1.36 per 180 
 
 IS79 
 
 36 
 
 
 .28 „ 
 
 1886 
 
 113 M 
 
 
 2-25 „ 
 
 IS80 
 
 57 
 
 
 •42 ,, 
 
 1887 
 
 2.16 ,, 
 
 
 1.85 ,> 
 
 I88I 
 
 00 
 
 
 .00 ,, 
 
 1888 
 
 3-32 „ 
 
 
 •52 „ 
 
 IS82 
 
 45 
 
 
 •35 „ 
 
 1889 
 
 3-37 „ 
 
 
 •52 „ 
 
 IS83 
 
 00 
 
 
 4-32 „ 
 
 1890 
 
 ■7?, „ 
 
 
 ■36 „ 
 
 1884 
 
 40 
 
 
 1.53 per 180 
 
 1891 
 
 1.85 „ 
 
 
 .16 „ 
 
 Thus the sickness rate from pneumonia was irregular until 1883, 
 then increased regularly until 1889, when the epidemic culmmated, 
 subsequently declining. 
 
 It may be argued that variations like the above may be caused 
 merely by climatic causes, such as excessively cold winters. The 
 facts do not confirm this view ; and it may be -added that the favour- 
 ing influence of climatic influences does not exclude the operation 
 of a specific micro-organism, which, although it cannot " uncon- 
 ditioned " cause pneumonia, is so far the essential cause that the 
 disease does not arise in its absence. Bacteriology, moreover, shows 
 the presence of micro-organisms in pneumonia (see Vol. IV.). 
 
 It may be that there is more than one disease under the name 
 croupous pneumonia, and that this may explain the difference between 
 sporadic cases, which nearly always occur singly, and epidemic cases, 
 occurring in small groups or in large epidemics. The relationship 
 between sporadic and epidemic pneumonia may resemble that between 
 an ordinary febrile catarrh and influenza, or between summer diarrhoea 
 and cholera, or between catarrhal jaundice and acute yellow atrophy 
 of the liver. It may, on the other hand, more closely resemble that 
 between ordinary ague and the pandemic ague, which has devastated 
 continents in the past, or between sporadic and epidemic cerebro-spinal 
 meningitis. Cerebro-spinal meningitis becomes epidemic under ex- 
 tremely insanitary local conditions. There is evidence of the same 
 kind for pneumonia. This is well instanced by an outbreak occur- 
 ring in 1883 at La Salpetriere. In the early part of the year the 
 sewers of this establishment were in process of reconstruction and 
 deep trenches dug, the work being executed in succession in three 
 chief courts or yards. The work was watched by a number of 
 hysterical and epileptic patients, and each portion of the work as it 
 was begun was followed by a new case of pneumonia. Four women 
 
i8o MANUAL OF MEDICINE 
 
 altogether were attacked, those who had not been outside close to 
 the trenches escaping. In 1874 Drs. Grimshaw and Moore noted 
 an increase of pneumonia in Dublin, during a prolonged drought, 
 which they attributed to diminished flushing of the sewers. A serious 
 epidemic of pneumonia raged in Florence in the winter of 1877-78, 
 which was ascribed by Bauti to foci of telluric infection, especially 
 to the stagnation of the River Arno, owing to the prolonged drought 
 of the preceding May to October. 
 
 It would appear also that foci of the disease may exist in dwell- 
 ings. Thus Mendelsohn (" Die Infect. Nat. der. Pneum.," Ztschr. f. 
 klin. Med. 1884, t. vii. p. 191) gives the instance of a coachman who 
 went to lodge on the 3rd of April 1883 in a very dirty house, the first 
 few days of his stay there being occupied in cleansing and sweeping. 
 On the 20th April his wife fell ill with pneumonia, next day a child 
 of five years old, a day later the baby, aged fifteen months ; the 
 third child, aged three years, escaped. On the 26th April the coach- 
 man himself began with the same disease. He was removed to the 
 hospital, returning to the same lodging convalescent at the end of 
 May, whence he had to return to hospital in June with a second 
 attack of pneumonia. It would be easy, did space permit, to give 
 numerous instances of epidemic pneumonia in connection with 
 prisons and barracks. 
 
 The evidence of direct contagion is feeble. It would appear to 
 be exceptional ; but Netter (" Contagion de la pneumonia," Arch, 
 gen. de med. 1888, 7" serie, t. xxi. p. 530) has collected a number of 
 scattered observations. The following case, reported by Schroeter, 
 may be instanced. A man aged twenty-four years had an attack of 
 rheumatism in October 1887. After six weeks, when he was 
 convalescent, his father was brought to the house with left- sided 
 pneumonia, and occupied the same bed as the son. On the eighth 
 day of the pneumonic attack, the son, who had not hitherto left his 
 room, began with typical right-sided pneumonia. Wynter Blyth has 
 narrated the case of a young woman who contracted pneumonia 
 while nursing her father for this disease, and who, after she had been 
 taken to her own home, communicated the same disease to her 
 husband. The following case is interesting, as the infection appears 
 to have clung to fomites {Lyon ?ned., 28th Avril 1889). -^ butcher's 
 child was convalescing from pneumonia, and about this time the 
 butcher's servant boy began with pneumonia (loth December). He 
 was removed to the hospital, and on the 15th December a second 
 boy took his place, sleeping on the same bed and in the same 
 clothes. Two days later he was seized with pneumonia. A third 
 
EPIDEMIC PNEUMONIA i8i 
 
 boy arrived on the i8th December; he slept \Yith the second boy 
 for two nights, and thirty hours later began with pneumonia. 
 
 The preceding observations raise a strong presumptive case for 
 the contagiousness of pneumonia, under exceptionally insanitary 
 conditions of soil or dwelling. It is not likely that the multiple 
 cases are explicable merely as coincidences. 
 
 Outbreaks of pneumonia have occurred in this country at 
 Middlesborough (682 cases and 143 deaths) and at Scotter. In the 
 former outbreak Klein was unable to discover either the micro- 
 coccus of Friedlander or the diplococcus of Frankel and Weich- 
 selbaum, but found instead a distinctive bacillus. This observation, 
 among others, renders it likely that in croupous pneumonia we 
 have to deal with several diseases, not yet differentiated. This fact, 
 if confirmed, may explain the varying infectivity of the disease. One 
 circumstance has to be borne in mind in connection with epidemics 
 of pneumonia. Some of them have coincided in time with the 
 prevalence of epidemic influenza. It may be, therefore, that the 
 pneumonia was but a local complication of this disease. This 
 explanation only, however, accounts for a small proportion of the 
 recorded epidemics of pneumonia. 
 
 Historically there are numerous accounts of epidemic pneumonia. 
 Some of these have spread over wide tracts of country, as for 
 instance those of 1564 in Italy, Switzerland, and Western Germany, 
 of 1779 in Italy, of 1783-85 in France, of 1863-75 in the United 
 States, and of 1857 in Bolivia, Peru, and Western Brazil (Hirsch). 
 We still lack, however, accounts of true epidemics of pneumonia 
 in which careful autopsies have been made of fatal cases, and in 
 which the exact cause of the infection has been traced and 
 described. 
 
 The clinical characters of the disease will be treated of else- 
 where. 
 
 Arthur Newsholme. 
 
MANUAL OF MEDICINE 
 
 INFECTIVE MENINGITIS 
 
 The pia-arachnoid membranes are not infrequently the seat of 
 inflammation consequent upon the invasion of several distinct 
 micro-organisms. Associated with the different varieties of causal 
 virus there is some difference in the clinical course and symptoms 
 of the resulting affections. The various forms at present recognised 
 are as follows : — 
 
 I. Epidemic cerebro- spinal meningitis. 2. Posterior basic 
 meningitis. 3. Suppurative meningitis. 4. Tuberculoas meningitis. 
 
 In the first and second forms, and also in the third, when the 
 disease is not secondary to pneumonia, erysipelas, middle ear 
 disease or injury, as it usually is, the anatomical lesions found post- 
 mortem are almost entirely confined to the meninges, and the 
 symptoms presented by the patient are as entirely referable to the 
 meningeal inflammation. For these reasons these maladies will be 
 described here ; the tuberculous variety, as well as the meningitis 
 associated with syphilis and new growths, will be treated of else- 
 where. 
 
 Epidemic Cerebro-spinal Meningitis 
 Syn. Cerebro-spinal Fever — Spotted Fever — Cerebral Typhus 
 
 An acute febrile disorder characterised by symptoms indicative 
 of special affection of the central nervous system, and very frequently 
 accompanied by a rash. 
 
 Since 1805 numerous epidemics on the Continent of Europe, in 
 Ireland, and in North America have been recorded. Great Britain 
 has been free from large outbreaks, though minor ones have not 
 been rare, and sporadic cases not at all infrequent. The malady 
 is most prevalent in temperate latitudes, but it also occurs in sub- 
 tropical climates. On a priori grounds it might be expected to 
 have a universal distribution, a view which receives confirmation 
 from its occurrence in India, and from the record of a few cases 
 in Australasia and the Fiji islands. 
 
 The epidemics have occurred mostly in winter and spring, and 
 among the predisposing causes may be enumerated ill or insufficient 
 nourishment, exhaustion, overcrowding, and unwholesome sur- 
 
INFECTIVE MENINGITIS 183 
 
 roundings. Notwithstanding the frequently recorded epidemics 
 among persons closely associated, such as are found in gaols, schools, 
 workhouses, asylums, and barracks, direct contagion is slight or 
 negative, and the exact method of communication is at present 
 undetermined. It is probably due to this circumstance that com- 
 paratively few individuals are attacked in any epidemic. 
 
 While children and young adults are especially liable, no age 
 is exempt, and though robust males in the prime of life are 
 frequently attacked, yet after thirty-five years of age the liability is 
 slight. The disease has been known to be transmitted from the 
 mother to the foetus iti iitero, as shown by identical post-mortem 
 appearances in both. 
 
 After an incubation period of unknown though probably 
 short duration, during which there may be vague or ill-pronounced 
 premonitory symptoms, the disease declares itself with remarkable 
 suddenness, the principal initial symptoms being intense occipital 
 headache, shivering, and vomiting. I'hese symptoms, accompanied 
 by prostration, rapidly increase in intensity ; the patient tosses rest- 
 lessly about, frequently becoming delirious ; the face is drawn and 
 pale ; an herpetic eruption appears on the face, and purpuric spots 
 on the legs and elsewhere. The skin is extremely sensitive. The 
 head is often retracted, and there is pain and tenderness in the 
 back and limbs, frequently severe. The pupils are small, the con- 
 junctivae injected, and frequently there is strabismus and sometimes 
 ptosis and facial spasms. The condition of the tongue is variable, 
 though in severe cases it is much furred. The abdomen is retracted 
 and the bowels constipated. By the third or fourth day the pulse 
 and respiration increase in frequency, the temperature ranging from 
 100° to 104°. The decubitus is lateral, with the legs drawn up. 
 The vomiting continues. The prostration and the spasm of the 
 muscles of the neck and back increase in severity. There is retention 
 or incontinence of urine, and the patient, who has been gradually 
 becoming deaf and drowsy with sighing respiration, lapses into 
 unconsciousness, and dies from pulmonary congestion and oedema. 
 
 Though the foregoing may be taken as the description of a 
 severe case, it is necessary to point out that the disease presents 
 more than one clinical picture. Four or five types are usually 
 described — malignant, severe, mild, and abortive, and considerable 
 variety of symptoms characterises different epidemics. 
 
 In the malignant form the patient may die in a comparatively few 
 hours in a condition of collapse and coma. It is in these cases that 
 petechiae and purpuric blotches are so well marked and of such fatal 
 
1 84 MANUAL OF MEDICINE 
 
 significance. In the milder forms all the symptoms are less violent, 
 and some, such as the petechicC, are absent. The abortive type is 
 usually recognised by the presence of headache, and some malaise 
 occurring during an epidemic. To these may be added the iiiter- 
 7nittetit variety, in which remissions and exacerbations of the symp- 
 toms occur, and the typhoid, wherein muttering delirium, dry, 
 brown-furred tongue, and other typhoid symptoms are prominent 
 phenomena. 
 
 Several symptoms and eomplieations, some of which have im- 
 portant sequelae, require to be specially noticed. Herpes of the face 
 and lips is present in the majority of cases, and may occur also on 
 other parts of the body. Though herpes is the most common, urti- 
 caria, pemphigoid bullae, and erythematous roseolar eruptions are 
 also described. In the severe and malignant types the skin is the 
 seat of hsemorrhagic petechiae and blotches, and these may be so 
 extensive and prominent as to warrant the term cutaneous hjemor- 
 rhages. Of late years, however, less note has been taken of rashes 
 or eruptions, with the exception of herpes. Coryza is occasionally 
 present, manifesting itself either before the outbreak or during the 
 attack. The chief interest of this symptom is that the nasal and 
 faucial mucosae may possibly be the portals of entry of the virus. 
 
 Of late attention has been drawn to Kernig's sign, by which is 
 meant the reflex contraction of the flexor muscles which occurs 
 when an attempt is made to extend the leg on the thigh, as in- 
 dicative of meningitis. To elicit this phenomenon the patient must 
 be placed in the sitting posture. The condition of the reflexes is 
 variable, that is, they may be normal, exaggerated, or absent. 
 
 The temperature mostly ranges between ioo° and 104°, though 
 in some cases, usually rapidly fatal, it may rise but little or not at 
 all ; while on the other hand it may ascend as high as 107°. There 
 is no special curve or type, and all that can be said is that it is 
 irregularly remittent. 
 
 The pulse is sometimes rapid, 100-120°, at any rate in children, 
 for in adults it may be quite slow, and quite out of relation to 
 the temperature. There is little to be said about the respiration, 
 except that it may be laboured and sighing ; still, pulmonary com- 
 plications must always be remembered. 
 
 One of the most frequent issues is eye trouble, such as palsy of 
 the ocular muscles, and conjunctivitis, which may become ulcerative. 
 Blindness has not infrequently resulted from suppuration of the 
 internal parts of the eye. Disease of the ear, resulting in per- 
 rnanent deafness or deaf- mutism in young children, is not at all 
 
INFECTIVE MENINGITIS 185 
 
 uncommon, and is decidedly more frequent than in posterior basic 
 meningitis. This sequela is due to direct extension of the inflam- 
 mation from the meninges to the labyrinth, and also to the affection 
 of the tympanum. Besides the eye and ear, the special senses of 
 taste and smell may also become impaired. 
 
 Other less constant and less common features are the presence 
 of albumen in the urine, heematuria, optic neuritis, and, in children, 
 convulsions. 
 
 Perhaps the most important sequela is chronic hydrocephalus. 
 This usually manifests itself during convalescence ; but its presence 
 may be suspected if the vomiting be protracted, and especially if 
 there be unaccountable rises of temperature and the headache be 
 persistent. 
 
 Other complications and sequelae which may be met with are, 
 suppurative and non- suppurative arthritis and periarthritis, pneu- 
 monia, broncho-pneumonia, pleurisy, peri- and endo-carditis, and 
 palsy of the limbs. The paralysis of the extremities may be 
 hemiplegic, paraplegic, or monoplegic in distribution. If mono- 
 plegic, the arm is the part most frequently affected. 
 
 Emaciation is a distinct feature of the disease ; sometimes it is 
 extremely marked and then is often associated with severe damage 
 to the central nervous system. 
 
 The principal and indeed the only essential morbid appear- 
 ance is a suppurative or fibrino-purulent leptomeningitis of the 
 brain and cord. The distribution of the exudation in the brain is 
 irregular, and affects both vertex and base. In amount and extent 
 it is extremely variable ; it may be considerable even in rapidly 
 fatal cases, though under these latter circumstances mere hyperEemia 
 only may be visible to the naked eye. In the spinal cord the 
 exudation is most marked on the posterior aspect and towards the 
 lower end. The cerebral ventricles are usually distended with 
 turbid fluid, and the lining membrane disintegrated. Though the 
 spleen 'may be much enlarged it is frequently but little or not at 
 all increased in size. Micro-sections show that the subarachnoid 
 exudation is principally cellular, and chiefly leucocytic, and the 
 presence of micro - organisms in the exudate has been demon- 
 strated. 
 
 In addition to the essential features there are often, as already 
 intimated, pneumonia, broncho-pneumonia, pleurisy, peri-, and endo- 
 carditis. 
 
 Special methods of investigation (e.^^. NissFs and Marchi's) have 
 deterrnined the existence of degenerative changes in the nerve cell§ 
 
1 86 MANUAL OF MEDICINE 
 
 and fibres of the central nervous system. The cells may be swollen, 
 granular, their shape disfigured and their chromatic bodies absent 
 (chromatolysis). The nucleus may be displaced or even lost. 
 
 Bacteriology. — The microbe to which the disease is due is 
 the diplococcus iiitracellularis meningitidis (\\"eichselbaum). This 
 organism has been discovered not only in the exudation, examined 
 post-mortem, but has also been obtained from the spinal fluid with- 
 drawn by lumbar puncture during life. 
 
 The diplococcus is very small, and occurs most often in groups 
 inside the cells of the exudation. Here and in cultures it is fre- 
 quently grouped in pairs, and for this reason has been described by 
 some observers as a tetracoccus. It stains with the ordinary aniline 
 dyes, but does not stain by Gram's method. One of its character- 
 istics, as described by Weichselbaum, is its very brief vitality, a 
 point in which it differs from the diplococcus of posterior basic 
 meningitis. There are other slight differences both on culture and 
 on inoculation between these two micro-organisms, but it is probable 
 that they are closely related. 
 
 From the pneumococcus the diplococcus intracellularis differs 
 in many respects, morphologically, in culture and on inoculation. 
 The diplococcus intracellularis is found not only in the epidemic, 
 but also in the sporadic cases of this disease. Some cases, how- 
 ever, which would in the past have been included under this head, 
 are now known to be due, some to the diplococcus of posterior 
 basic meningitis, some to the pneumococcus, which until recently 
 was regarded as responsible for the malady now under considera- 
 tion. 
 
 AVhether the pneumococcus does give rise to an epidemic form 
 of meningitis is uncertain ; but there are certain relationships 
 apparently existing between pneumonia and the epidemic cerebro- 
 spinal form of meningeal inflammation which are striking, such are 
 the same seasonal prevalence and frequent coexistence of the two 
 diseases, especially in crowded gaols and barracks, the sudden onset 
 and marked liability to the appearance of herpes. 
 
 Prognosis. — The mortality in this disease, especially in some 
 epidemics, is high, and has ranged from 20 to 80 per cent, so 
 that the average mortality may be assumed to be about 50 per 
 cent. In the more malignant cases death may take place in a 
 few hours to a few days (1-8). As a rule, convalescence is tardy. 
 Mild cases may get well in a week or two, while others, where the 
 symptoms have been only moderately severe, may last for five or 
 six weeks or longer. It is advisable to wait for ten to fourteen days 
 
INFECTIVE MENINGITIS 187 
 
 after the symptoms have subsided before stating that the patient is 
 to be regarded as safe. 
 
 Apart from special complications, such as hj'drocephalus, otitis, 
 endocarditis, and pneumonia, there is always grave danger from 
 asthenia and marasmus, conditions which may follow mild as well 
 as severe cases. When these conditions are marked the patient, 
 after lingering for months, usually dies from toxsemic cachexia. 
 The prognosis must depend chiefly on the severity of the symptoms, 
 though some assistance may be derived from the character of the 
 epidemic and the time it has lasted, for the cases are usually more 
 seveie at the beginning than at the end of the outbreak. When 
 the initial symptoms are severe, when coma supervenes, when 
 haemorrhagic blotches, especially if extensive, make their appear- 
 ance, the prognosis is extremely grave. 
 
 The diagnosis will depend in the first place on the recognition 
 of the more striking and salient symptoms, namely, headache, 
 vomiting, fever, pain in the back, retraction of the head and the 
 presence of herpes. Few disorders have such a sudden onset, and 
 are accompanied from the first by so much prostration. A positive 
 and early diagnosis might therefore seem a simple matter. Yet, 
 owing to the presence of headache, of constipation, and of the 
 absence of spots, enteric fever has been mistaken for cerebro-spinal 
 meningitis. With typhus fever it might more easily be confounded 
 owing to the presence of a petechial rash and of prostration. The rash, 
 however, appears more suddenly than that of typhus, from which it is 
 further distinguished by the greater intensity of the nervous symptoms. 
 Purpura hemorrhagica and hsemorrhagic variola have both been con- 
 fused with this disease. From tuberculous meningitis it is distinguished 
 by the gradual onset, the less severe symptoms and the absence of 
 rash in the latter ; from suppurative meningitis, by the absence of 
 some obvious exciting cause, such as traumatism or disease of the 
 ear ; from influenza, when severe, and when there is fever, headache, 
 pain in the back and prostration, by the absence of vomiting, of any 
 marked affection of the cranial nerves and retraction of the head. 
 
 Heart or lung complications, especially if early, might cause a 
 difficulty in coming to a conclusion, for the occurrence of cerebro- 
 spinal symptoms might lead to the suspicion that the affection of 
 the central nervous system was secondary and metastatic. 
 
 As may have been inferred from a consideration of the morbid 
 appearances, the line of treatment must be symptomatic and 
 palliative, and in a great measure expectant. Still there is a con- 
 sensus of opinion in favour of giving opium, or what seems to 
 
1 88 MANUAL OF MEDICINE 
 
 answer better, morphia, by hypodermic injection, in order to allay 
 the general irritability, to soothe the pain, to promote sleep, and in 
 some degree to restrain vomiting. 
 
 The abstraction of cerebro-spinal fluid by lumbar puncture has 
 been practised not unfrequently of later years, and cases of cerebro- 
 spinal meningitis are reported wherein this procedure has been 
 followed by recovery. Though, owing to the general character 
 of the disease and the parts principally affected, too much must not 
 be expected from the removal of cerebro-spinal fluid, the results 
 from lessening the tension are sufficiently encouraging to warrant its 
 adoption in this form of meningitis. 
 
 Subcutaneous injections of Liq. hydrarg. perchlor. have been 
 strongly advocated, improvements following, it is said, the second 
 or third injection. 
 
 The headache and spinal pain are sometimes alleviated by the 
 use of ice-bags, while blisters have been found unsatisfactory, and 
 their use is to be deprecated. 
 
 The results from general abstraction of blood are not en- 
 couraging, though local depletion by means of leeches may possibly 
 be found to afford some relief. 
 
 To check the vomiting, hydrocyanic acid with bicarbonate of 
 soda in simple draught or in effervescing mixture may be tried, 
 alone or in combination with one of the bromides as a sedative. 
 Though the foregoing and other drugs are sufficiently approved for 
 restraining retching and vomiting, their exhibition will depend on 
 the tolerance of the stomach to interference, and it may be found 
 advisable to adopt a cold liquid and scanty dietary until the main 
 symptoms are subsiding. 
 
 Constipation should be treated by enemata until convalescence 
 has set in and the alimentary canal is in a condition to bear 
 aperients. 
 
 During convalescence, which is frequently protracted and accom- 
 panied by general debility and emaciation, headache is not un- 
 common, and sometimes severe ; for this antipyrin or chloral and 
 bromides are indicated ; while as a general tonic a mixture of quinme 
 and iodides should be administered. 
 
 R. G. Hebb. 
 
INFECTIVE MENINGITIS 189 
 
 Posterior Basic Meningitis 
 
 The recognition of posterior basic meningitis as a specific disease 
 is of quite recent date. It had been observed for many years that 
 there occurred, chiefly in infants, a disease characterised by 
 prolonged and extreme retraction of the head, and it was with 
 reference to this striking symptom that the description of the 
 disease by Dr. Gee and Dr. Barlow in a paper on " The Cervical 
 Opisthotonos of Infants " appeared in 18 78. It was not, however, 
 until Dr. Carr in 1897, and shortly afterwards Dr. Barlow and Dr. 
 Lees, drew attention to the constancy of the symptoms, and the 
 general likeness to a specific disease, that its true position was 
 recognised, and its infective nature was finally confirmed by the 
 discovery of the micro-organism to which it is due. 
 
 The exact relationship of this disease to that known as 
 "Epidemic Cerebro- spinal ^Meningitis " has not yet been fully 
 ascertained, for although the bacteriological evdence shows them 
 to be very closely related, if not identical, there are slight differences 
 in the bacteriology, and more particularly in the clinical aspect of 
 the two conditions, which make it perhaps desirable, at any rate for 
 the present, to consider them separately. 
 
 Etiology. — Posterior basic meningitis, though it sometimes 
 occurs in later childhood, is most common during the first year of 
 life, and seldom occurs after the end of the second year. It is 
 frequently seen during the first six months of life, a period at which 
 tuberculous and epidemic cerebro -spinal meningitis are quite 
 uncommon. Girls and boys are affected with about equal frequency. 
 The disease shows a very marked seasonal variation ; it is much 
 commoner in winter and spring than in summer : fully two-thirds of 
 the cases have their onset between the beginning of January and 
 the end of May. 
 
 It would appear to be endemic in most large towns and cities, 
 and cases have been observed both on the Continent and in America, 
 so that although it is impossible yet to say anything definite as to 
 its geographical distribution, there can be little doubt that it is a 
 widely-spread disease, and is by no means limited to the British Isles. 
 
 In spite of the infective character of the disease no evidence 
 whatever of transmission from infant to infant has yet been observed. 
 The close resemblance to the sporadic cases of so-called epidemic 
 cerebro-spinal meningitis must, however, be borne in mind, for it 
 is at least possible that the posterior basic disease of infants is only 
 one sporadic manifestation of the epidemic disease. 
 
I90 MANUAL OF MEDICINE 
 
 In some cases a history of a fall or blow preceding the onset of 
 the illness is obtained ; in others some slight catarrhal symptoms, a 
 cough or "a cold" have occurred, but it seems very doubtful 
 whether these bear any causal relation to the disease. 
 
 Bacteriology. — The immediate cause of the meningitis is an 
 infection of the brain with a specific micro-organism, the diplococcus 
 of posterior basic meningitis, which shows only very slight differences 
 from the diplococcus intracellularis of epidemic cerebro- spinal 
 meningitis. It must not be confused with the pneumococcus, from 
 which it differs widely, and from which it can easily be distinguished 
 by culture and by inoculation. The diplococcus is very small ; its 
 average length, measured in the meningeal exudation, is 1.2 /x to 
 1.5 [jb. The two cocci of which it consists have their opposed 
 surfaces more or less flattened, and are separated by a narrow clear 
 space. It shows a marked tendency, especially in cultures, to 
 grouping in pairs side by side, so that an appearance like that of a 
 tetracoccus is produced. It is aerobic, and is easily cultivated at 
 a temperature of about 37° C. Its vitality is greater than that of 
 the pneumococcus or of the diplococcus intracellularis, while its 
 virulence on inoculation seems to be less. 
 
 The diplococci are found both free and in the cells of the 
 exudation, and in the cerebro-spinal fluid, during the acute stage of 
 the disease, but they disappear usually after a few weeks as the 
 inflammation subsides. 
 
 It is probable that, as in other forms of meningitis, a mixed 
 infection may occasionally occur, other micro-organisms gaining 
 access to the meninges either at the same time with the specific 
 micro-organism or at a later period ; but such an occurrence would 
 seem to be extremely rare. 
 
 The channel of infection in this disease has not yet been 
 ascertained. There is no evidence to show that infection occurs 
 through the ear. 
 
 Symptoms. — The onset of the disease is sudden : an ap- 
 parently healthy infant is seized with vomiting, becomes feverish, 
 and perhaps screams without apparent cause. Convulsions may 
 occur at this stage, but more commonly begin later. 
 
 Within a few hours, or at most within a few days, of the onset 
 the head is noticed to be drawn back ; sometimes indeed this is the 
 first symptom noticed. Of all the symptoms of posterior basic 
 meningitis the head retraction is by far the most constant and the 
 most characteristic. It appears very early in the disease, and lasts 
 usually for several weeks or even months. The retraction varies in 
 
INFECTIVE MENINGITIS 191 
 
 degree in different cases, and may vnry from day to day ; it may be 
 so slight as to be only just noticeable, but in the majority of cases 
 is quite obvious, and in some is so extreme that the occiput almost 
 touches the buttocks. Where this happens there is extreme 
 opisthotonos of the dorsal spine as well as of the cervical ; more 
 often, however, the opisthotonos is limited to the cervical region, the 
 head being thrown backwards, so that there is barely room for two 
 fingers between the occiput and the upper dorsal spine, while the 
 dorsal spine itself is rather in a position of kyphosis. 
 
 Clonic convulsions may occur at any period of the disease, but 
 they are not a marked feature, and are sometimes absent throughout. 
 A commoner condition is one of tonic rigidity, and as the disease 
 becomes advanced the infant often lies on its side with head thrown 
 back and limbs rigidly extended, the forearms at the same time 
 being fully pronated, so that the palms of the clenched hands look 
 outwards, while the shoulders are drawn back, and the legs tend to 
 cross owing to some adductor spasm of the thighs. 
 
 Champing movements of the jaw and grinding of the teeth are 
 curiously common in this disease, although not peculiar to it ; either 
 of them may continue sometimes for hours. 
 
 With the head retraction there is often a staring appearance of 
 the eyes, due apparently to a spasmodic raising of the upper lid, so 
 that the palpebral fissure is widely open ; and this staring appearance 
 becomes even more noticeable when there is added to it the vacant 
 look of blindness. 
 
 Blindness is present in about one-third of the cases of posterior 
 basic meningitis, and appears to be quite independent of any gross 
 changes in the eye : there can be little doubt that it is entirely 
 central in origin. In most cases, even with complete blindness, 
 there is no optic neuritis, and in the rare cases where inflammatory 
 changes are present in the disc they are usually very slight. 
 Paralysis of the ocular muscles is seldom a marked symptom ; in 
 nearly half the cases strabismus is absent altogether, and when 
 present it is often slight and transitory ; paralysis of other cranial 
 nerves is extremely rare. Slight nystagmus is not uncommon. 
 Deafness has occurred in a few cases, but is quite exceptional. 
 
 Sensation appears to be normal ; there is evident pain wben any 
 attempt is made to push the head forward into its natural position, 
 but otherwise the infant lies quietly on its side, apparently free from 
 pain, and only giving a sudden start when disturbed. 
 
 The superficial reflexes are unaltered ; the tendon jerks, 
 especially the knee jerks, are usually over-active, especially in the 
 
192 MANUAL OF MEDICINE 
 
 chronic stage of the disease, when there is sometimes ankle-clonus. 
 The " tache cerebrale " is a less marked feature in this disease than 
 in tuberculous meningitis. 
 
 Vomiting is one of the most constant of the early symptoms, and 
 is usually more or less persistent throughout the disease. The 
 bowels show less tendency to costiveness than in tuberculous 
 meningitis, and diarrhoea is a common complication, especially 
 towards the end of the illness. The urine shows nothing abnormal. 
 
 The pulse is usually more rapid than normal throughout, and 
 if irregularity occurs it is slight and transitory ; the marked slowness 
 and irregularity of the pulse which occurs in tuberculous meningitis 
 is not observed at any period of the posterior basic disease. 
 
 The respiration, especially in the later stage, frequently shows 
 some periodic irregularity, long pauses alternating with a series of 
 rather rapid respirations, but without the rhythmic increase and 
 decrease in depth which characterises the Cheyne-Stokes' type of 
 breathing. 
 
 The temperature at the onset is raised to 102° or 103°, and 
 there is irregular pyrexia usually for the first two or three weeks. 
 The temperature then gradually falls, and may remain normal for 
 the rest of the illness, or may become subnormal where there is 
 much vomiting and exhaustion. Sudden hyperpyrexia may occur 
 just before death. In some cases, and these usually the more 
 severe, there is persistent and considerable pyrexia of a remittent or 
 intermittent type throughout the illness. 
 
 In most cases where the disease is prolonged beyond a few 
 weeks- wasting is a marked feature ; the emaciation may be 
 extreme. 
 
 Rashes, especially the herpes and purpura, which are so common 
 in the epidemic form of meningitis, are almost invariably absent in 
 the posterior basic disease of infants, but too much stress must not 
 be laid on this as a distinguishing feature, for very rarely a labial 
 herpes has occurred at the onset, and at a later period a generalised 
 blotchy erythema has been seen. 
 
 Complications. — The most important, because the most 
 frequent, and the most fatal is hydrocephalus. In most cases where 
 the disease lasts longer than a few weeks the head is noticed to be 
 increasing in size, the fontanelle becomes bulged, and the eyes are 
 turned downwards by increasing intracranial pressure, and even where 
 death occurs earlier, and the only symptom of hydrocephalus during 
 life has been fulness of the fontanelle, there is generally found after 
 death to be some dilatation of the ventricles, the almost inevitable 
 
INFECTIVE MENINGITIS 193 
 
 result of the adhesive inflammation between the medulla and 
 cerebellum. 
 
 Another complication, which was observed four times in forty 
 consecutive cases, is an inflammation about the joints, giving rise to 
 swelling and dusky redness. The process appears to be more often 
 a periarthritis than a true arthritis ; the exudation occurs about the 
 neighbouring tendon-sheaths outside the capsule of the joint. It 
 has recently been shown that this periarthritis is produced by a local 
 infection with the same diplococcus as that found in the meningeal 
 exudation. 
 
 Other accidental complications, such as diarrhoea and broncho- 
 pneumonia, are apt to occur towards the end of the illness, when 
 emaciation and exhaustion are extreme. "With these occasional 
 exceptions the thoracic and abdominal viscera are singularly free from 
 obvious disease. 
 
 Prognosis. — The prognosis in this disease is much more hopeful 
 than in tuberculous or in suppurative meningitis, pneumococcal or 
 otherwise. While it may be doubted whether recovery ever occurs 
 in these latter forms of meningitis, there is no doubt that quite an 
 appreciable proportion, probably quite 10 per cent, of the cases of 
 posterior basic meningitis recover. There may be complete recovery, 
 but often there remains some permanent damage to the brain, 
 resulting in some cases in chronic stationar}- hydrocephalus, in 
 others in idiocy or imbecility, with or without hydrocephalus. 
 
 It is noteworthy that in cases of recovery the blindness of 
 posterior basic meningitis has disappeared completely after some 
 months' duration. The periarthritis and arthritis also tend to 
 recover spontaneously. 
 
 The disease in many cases proves fatal about five weeks after 
 the onset, but often the fatal result does not occur until the end of 
 the third or fourth month of the illness, and in some cases, as 
 already mentioned, the symptoms slowly subside and the child 
 recovers. 
 
 The prognosis in any individual case depends mainly on the age 
 of the patient — the younger the child the less is the chance of 
 recover}- — and the severity of the symptoms; long-continued pyrexia, 
 extreme head retraction and much rigidity of limbs are all bad 
 signs ] but the gravest of all symptoms is the rapid supervention of 
 hydrocephalus. In cases that seem to have recovered except for 
 the presence of hydrocephalus, prognosis must be guarded, for 
 although the hydrocephalus may appear to be stationary, such cases 
 are apt to die suddenly and quite unexpectedly. 
 
 vo'.. I o 
 
194 MANUAL OF MEDICINE 
 
 Diagnosis. — The disease with which posterior basic meningitis 
 is most likely to be confused is tuberculous meningitis. The most 
 important point of distinction is the presence of head retraction. 
 There is often some stiffness of the neck in tuberculous meningitis, 
 but anything like the definite and often extreme head retraction 
 which characterises the posterior basic disease is very rare in 
 tuberculous, and indeed in any other form of meningitis. At the 
 beginning the diagnosis may be difficult, but the earlier age, the 
 more sudden onset, the screaming, the absence of irregularity of the 
 pulse, and the absence of paralysis of cranial nerves are points in 
 favour of posterior basic meningitis. Later on the much slower 
 course, the persistence of vomiting, contrasting with its more inter- 
 mittent character in the tuberculous disease, in which vomiting 
 often occurs only at the beginning and at the end of the illness, the 
 absence of slow and irregular pulse, and of optic neuritis, the 
 presence of blindness, and above all the persistent head retraction, 
 usually make the diagnosis easy. Signs of tuberculosis in other 
 parts of the body would of course favour the diagnosis of tuberculous 
 meningitis. 
 
 From suppurative meningitis, whether due, as most commonly 
 happens, to the pneumococcus or to other micro-organisms, the 
 posterior basic form can generally be distinguished clinically by the 
 absence of a primary focus of infection. In suppurative meningitis 
 an obvious source of infection is almost invariably present, by far the 
 commonest in children being pneumonia or empyema, or it may be 
 otitis media or some other infective disease, such as erysipelas ; the 
 presence of such a source, together with the far more rapid course of 
 the disease, which seldom lasts more than a few days, and the absence 
 of head retraction would point to suppurative meningitis. Between 
 epidemic cerebro-spinal meningitis and posterior basic meningitis the 
 clinical differences are but slight. The limitation of this particular 
 group of symptoms almost to early infancy, the more chronic course, 
 the absence of the rash, especially of the herpes which has charac- 
 terised some epidemics, the greater prominence of the head retrac- 
 tion, the absence usually of deafness, of conjunctivitis, of hyperses- 
 thesia, these are the clinical points which, together with the slight 
 differences of bacteriology and morbid anatomy, have been thought 
 to separate the posterior basic from the epidemic disease. Head 
 retraction, it must be remembered, is not always a symptom of 
 meningitis ; reflex irritation, sometimes from ear disease, sometimes 
 from the teeth, may cause distinct head retraction for several days ; in 
 infants also with pulmonary and other disease, associated with much 
 
INFECTIVE MENINGITIS 195 
 
 dyspnoea, the head is sometimes considerably retracted, probably for 
 the better use of the extraordinary muscles of respiration. 
 
 Morbid anatomy. — The essential feature of the disease is an 
 exudation of lymph in the pia-arachnoid at the base of the brain and 
 on the spinal cord. The exudation extends forward usually to the 
 optic chiasma and sometimes slightly along the Sylvian fissures, but 
 there is very rarely any trace of it on the vertex, which appears quite 
 normal except for some flattening of the convolutions from the fluid 
 distension of the ventricles, which is almost always present. 
 
 The most constant site of the inflammation at the base is the 
 reflection of the arachnoid between the medulla and cerebellum ; it 
 is the inflammation here which determines some of the clinical 
 features of the disease, especially the occurrence of hydrocephalus 
 from obstruction of the foramina of Majendie and of Luschka, first 
 by inflammatory exudation, and later by adhesions. The head retrac- 
 tion also is probably due to the inflammation in this region, which 
 acts as a direct stimulus to the upper cervical nerves, and so produces 
 spasm of the muscles which they supply. But this is not the whole 
 explanation of this symptom, for, as already pointed out, it occurs 
 also with ear disease without meningitis ; in such cases, and probably 
 to some extent in posterior basic meningitis, it is to be regarded as 
 a reflex phenomenon. 
 
 In cases where the illness has lasted three or four months, all 
 lymph exudation has disappeared, leaving only thickening and 
 adhesions of the pia-arachnoid. 
 
 An important feature in the morbid anatomy of posterior basic 
 meningitis is the absence of any obvious source of infection. The 
 rest of the body is healthy except for such accidental complications 
 as may happen towards the end of any chronic disease. Herein, 
 as already pointed out, it contrasts markedly with ordinary suppura- 
 tive meningitis. 
 
 Treatment, — No drug can be said to have any special influence 
 over this disease. It has been thought that occasionally mercury 
 has had some beneficial effect ; some of the cases that have recovered 
 have been treated with mercury, and it is certainly worthy of trial 
 either by inunction or by internal administration. Potassium 
 iodide has also been recommended, and may possibly hasten 
 absorption of the lymph exudation. 
 
 The application of ice to the head or the nape of the neck, with 
 due precautions against collapse, seems to check the vomiting in 
 some cases, and may have some beneficial influence on the inflamma- 
 tion. Counter-irritants, if used at all, must be used with the utmost 
 
ig6 MANUAL OF MEDICINE 
 
 caution ; the risk of producing troublesome sores on the delicate skin 
 of an infant is hardly compensated by the doubtful value of this 
 method of treatment. 
 
 Persistent vomiting may be very difficult to check ; dilute hydro- 
 cyanic acid in minute doses, a quarter to half a minim for an infant 
 of nine months, may be tried, but as a rule no drugs will check it. 
 Nasal feeding, which sooner or later almost always becomes necessary, 
 owing to the obstinate refusal to take nourishment, may have some 
 beneficial effect on the vomiting. 
 
 Every effort must be made to maintain nutrition ; rectal feeding 
 must be used if necessary, and the diet must be carefully planned. 
 Cod-liver oil and malt are useful, especially during the slow process 
 of recovery. 
 
 Recently operative treatment has been attempted, chiefly with a 
 view to establishing drainage of the ventricles, and so preventing the 
 tendency to progressive and fatal hydrocephalus. The results 
 hitherto have been disappointing ; in most cases death has followed 
 shortly after the operation, sometimes with sudden hyperpyrexia ; in 
 at least one case, however, the operation has been successful. 
 
 Puncture of the membrana tympani on both sides is advisable 
 in doubtful cases, where there is any suspicion that the symptoms 
 may be reflex in origin or due to the secondary meningitis of ear 
 disease. 
 
 The arthritis and periarthritis tend to disappear spontaneously ; 
 they should be treated by simple warm applications. 
 
 G. F. Still. 
 
 Suppurative Meningitis 
 
 Suppurative meningitis, by which is meant a purulent exudation 
 in the pia-arachnoid of the brain and spinal cord, occurs under two 
 conditions — the first, and by far the commonest, as a complication of 
 some other infective disease ; the second, very rare, as a primary 
 disease. The advance of bacteriology has made it evident that 
 many, perhaps most of the cases of supposed primary suppurative 
 meningitis, should be regarded as sporadic instances of so-called 
 epidemic cerebro- spinal meningitis, being due to the specific 
 micro-organism of that disease, namely the diplococcus intracellularis. 
 There still remain, however, rare cases in which an apparently 
 primary infection is produced by other micro-organisms. 
 
 Some confusion has been introduced into this subject by the 
 
INFECTIVE MENINGITIS 197 
 
 attempt to classify cases of acute meningitis according to their 
 anatomical distribution ; in this way suppurative meningitis has been 
 distinguished as " vertical," and the epidemic disease has been 
 called " cerebro- spinal " ; but it must be clearly understood that 
 any form of meningitis may be, and often is, cerebro-spinal in dis- 
 tribution, and suppurative meningitis, though it tends to affect the 
 vertex first and chiefly, may nevertheless be limited to the base and 
 spinal cord. 
 
 The ideal basis of classification is the bacteriological, but in the 
 present state of our knowledge no complete cUnical differentiation 
 on the same fines is possible, so that for practical purposes it is 
 convenient to group together under the head of suppurative men- 
 ingitis those cases of acute leptomeningitis which, although infective 
 in character, do not fall into clinical groups corresponding with 
 their bacteriological differences, as happens in the epidemic, the 
 posterior basic, and the tuberculous forms. 
 
 Etiology. — Suppurative meningitis is most common in infancy, 
 but it occurs at all ages. There is no marked difference in the 
 frequency with which the two sexes are affected. No particular 
 seasonal variation has been observed, except in so far as the 
 meningitis follows the seasonal curve of the infective conditions 
 with which it is associated ; the pneumococcal cases for this reason 
 are commoner in winter and spring than at other times. 
 
 Suppurative meningitis occurs most often as a complication of 
 pneumonia or empyema. The next most frequent cause is bone 
 disease in connection with the ear. It occurs also as a complication 
 of several infective diseases, especially erysipelas and pyaemia, includ- 
 ing under the latter head malignant endocarditis ; rarely it com- 
 plicates smallpox, scarlatina, typhoid, and influenza, and still more 
 rarely it has been seen in cases of nephritis ; but in all these 
 conditions it may be rather a sequela than a complication, and it is 
 certain that sometimes at least in such cases the meningitis is not 
 due to the same virus as the primary disease, but is pneumococcal 
 or streptococcal in character, and is secondary to some pneumococcal 
 or streptococcal lesion elsewhere, to w^hich the primary disease 
 predisposed. It may be due also to injury ; sometimes it results 
 from disease of the nasal cavities ; and in infants a not very rare 
 cause is sloughing of the skin over a spina bifida. 
 
 Bacteriology. — The micro-organism most commonly found in 
 the meningeal exudation is tht pneufnococais. In children fully two- 
 thirds of the cases are due to the pneumococcus. This micro- 
 organism also would seem to be the usual cause of the meningitis in 
 
198 MANUAL OF MEDICINE 
 
 the very rare cases where this disease is primary. Where meningitis 
 occurs as a complication of erysipelas or pyoemia the streptococcus is 
 often found in the exudation, while in cases secondary to disease of 
 the petrous bone a mixed infection is usually found, streptococcus 
 pyogenes, and staphylococcus aureus or albus being present sometimes 
 with bacillus coli cot?i/nums and sometimes with the pneumococcus 
 also. In some cases, even where the primary source of infection is 
 pneumococcal, and cultures from the meningeal exudation show an 
 almost pure growth of the pneumococcus, the streptococcus pyogenes, 
 or staphylococcus albus or aureus is found to be present also, mixed 
 infection having occurred. Cases have been reported in which the 
 influenza bacillus or the typhoid bacillus have been found in the 
 meningeal exudation, where meningitis occurred as a complication 
 of influenza or of typhoid fever. 
 
 Symptoms. — In many cases, especially in infants, when the 
 patient is already severely ill with the primary disease, the onset of 
 suppurative meningitis is obscured by the previous symptoms, and 
 this complication may even be entirely unsuspected until post- 
 mortem examination reveals its presence. 
 
 More often, however, vomiting and convulsions occur at the 
 onset, and in older children and adults delirium may be a marked 
 feature. Sometimes from the beginning there is stupor, which 
 gradually deepens into coma after a few days. 
 
 Headache is severe, and even when the patient is semicomatose 
 the fades, with its anxious expression and knitting of the eyebrows, 
 often suggests the continuance of pain. Retraction of the head is 
 occasionally present, but is much less marked than in posterior basic 
 meningitis. 
 
 Bulging of the anterior fontanelle is an early symptom in infants. 
 
 A fine tremor of the limbs, especially on movement, is often 
 noticed quite early in the disease ; paralysis of one or more limbs is 
 sometimes present, and towards the end of the disease there is often 
 rigidity. 
 
 Paralysis of cranial nerves is more common than in the posterior 
 basic disease ; squint is usually present. Slight nystagmus is some- 
 times seen, but much less often than in posterior basic meningitis. 
 Optic neuritis is often associated with suppurative meningitis, but by 
 no means always. 
 
 Vomiting is generally frequent throughout; the bowels are costive. 
 The pulse and respiration are rapid and often irregular ; the latter 
 may be of Cheyne-Stokes' character. The temperature is usually 
 highj but sometimes becomes subnormal towards the end. 
 
INFECTIVE MENINGITIS 199 
 
 Diagnosis. — It will be seen that in many of its symptoms 
 suppurative meningitis resembles other forms of meningitis, and 
 sometimes indeed the diagnosis is extremely difficult. There are, 
 however, two points which ser\-e to differentiate the suppurative form, 
 both from the posterior basic disease and from tuberculous 
 meningitis : first, its rapid course ; suppurative meningitis is a 
 disease of a few days, the onset of symptoms is sudden, their course 
 is rapid : secondly, the presence of a source of infection, whether it 
 be some local disease, such as empyema or ear disease, or some 
 general disease, such as pyaemia. Where symptoms of meningitis 
 are associated with such a source of infection, and prove fatal in less 
 than a week, the diagnosis of suppurative meningitis is almost 
 certain. From sporadic cases of the epidemic cerebro-^pinal disease, 
 suppurative meningitis is usually distinguished by the presence of 
 some obvious source of infection, but in the rare cases of primary 
 suppurative meningitis, where this point of distinction is lacking, the 
 diagnosis may be impossible. Perhaps the presence of herpes or of 
 a purpuric rash may point to the " epidemic " disease ; certainly the 
 prolongation of the illness beyond the tenth or eleventh day would 
 be strongly against suppurative meningitis, but in most cases the 
 only possible method of diagnosis is a bacteriological examination, 
 and it may therefore be advisable in rare cases to make use of 
 lumbar puncture. 
 
 In connection with ear disease there is often some difficulty of 
 diagnosis, for, on the one hand, cerebral abscess may closely simulate 
 suppurative meningitis, and on the other hand the meningitis which 
 complicates ear disease is by no means always suppurative ; in many 
 cases it is tubercular. Cerebral abscess may be distinguished by 
 its slower course, a normal or subnormal temperature, unilateral 
 paralysis, sometimes aphasia, and in rare cases localised tenderness, 
 but even such symptoms may be deceptive, for it sometimes 
 happens, especially with ear disease, that suppurative meningitis 
 remains for some time quite a localised process and may thus give 
 rise to hemiplegic symptoms. 
 
 In tuberculous meningitis the onset is more gradual ; the course 
 is much slower; the temperature is generally lower than in the 
 suppurative form ; tache cerebrale, retraction of the abdomen, and 
 slowness of the pulse, with irregularity, are more marked symptoms. 
 
 Prognosis. — In suppurative meningitis, whether secondary or 
 primary, the prognosis is very bad. There is reason to believe 
 that some cases of localised suppurative leptomeningitis in con- 
 nection with ear disease have recovered where early operation has 
 
200 MANUAL OF MEDICINE 
 
 been performed, but with this exception it is doubtful whether re- 
 covery ever occurs. It must be understood that no reference is made 
 here to those sporadic cases of cerebro-spinal meningitis in which 
 the diplococcus intracellularis is found ; these are included under 
 the head of epidemic cerebro-spinal meningitis and have a much 
 more favourable prognosis. Suppurative meningitis is usually fatal 
 in less than a week. The fatal result is very rarely delayed beyond 
 the tenth day. 
 
 Morbid anatomy. — In very acute cases, where death has 
 occurred within a day or two of the onset of the meningitis, the 
 only abnormal appearance on the brain may be some excess of 
 almost clear fluid in the pia-arachnoid, giving it a watery oedema- 
 tous appeara'^ce, while at the same time there is some undue 
 vascularity of the meninges, and perhaps a trace of grayish opacity 
 along the vessels in the sulci. To this condition some observers 
 have given the name of " serous meningitis." It differs only in 
 degree from the later stages, in which the grayish opacity along the 
 vessels becomes first yellowish exudation, then definitely purulent, 
 until, in the most advanced cases a continuous sheet of greenish- 
 yellow pus in the pia-arachnoid covers the whole surface of the 
 brain. In many cases the exudation is most marked over the 
 anterior two-thirds of the vertex, but it is seldom limited to the 
 vertex. In most cases the base also is affected. Sometimes only 
 a patch of purulent exudation is seen on the inferior surface of 
 each temporo-sphenoidal lobe, but often the whole base is covered 
 almost as thickly as the vertex. The spinal cord seldom escapes ; 
 the posterior surface, especially in the lumbar region, is affected 
 earliest; later the whole cord is covered with exudation. 
 
 Although the mflammation is mainly in the meninges, it must 
 not be forgotten that there is certainly in many cases, if not in all, 
 some extension of the inflammadon to the brain substance beneath, 
 and in some cases this can even be appreciated by the naked eye 
 as undue redness and vascularity of the superficial brain substance, 
 which may show minute ecchymoses or even minute points of pus 
 on section. 
 
 Rarely the meningitis is the only discoverable lesion, but in 
 most cases, as already pointed out, some primary lesion is found 
 elsewhere. In children this is usually empyema or thick l3^mph 
 on the pleura, and it is not uncommon to find associated with the 
 meningitis, in addition to the pleurisy, a purulent or sero-purulent 
 pericarditis, and sometimes also peritonitis. 
 
 Treatment. — The only cases in which treatment is likely to 
 
INFECTIVE MENINGITIS 201 
 
 be of much avail are those in which meningitis is secondary to ear 
 disease. Early surgical treatment in such cases has been success- 
 ful, but it seems likely that where such a favourable result has 
 occurred only a limited area of the pia-arachnoid has been affected. 
 Operation is probably useless where the meningitis has already 
 become generalised. 
 
 There can, however, be little doubt that much may be done in 
 the way of prophylaxis. Careful antisepsis and timely operative 
 measures in the treatment of otitis media would do much to reduce 
 the mortality from suppurative meningitis. In empyema also, and 
 suppurative pericarditis, any delay in operation probably increases 
 the risk of meningitis. So long as pus or thick lymph is pent up 
 in the pleural or the pericardial cavity there is a virulent culture 
 of pneumococcus or other micro-organisms, which may at any 
 moment give rise to a secondary infection of the meninges. It is 
 important also to remember that even where an empyema has 
 been already opened a separate collection of pus, perhaps only a 
 drachm or two, may remain shut off by pleural adhesions, or en- 
 closed in the mediastinal connective tissue, and such small collec- 
 tions may serve as the focus of infection from which a suppurative 
 meningitis may result. 
 
 The treatment of suppurative meningitis in those cases which 
 appear to be primar}-, or are not amenable to surgical treatment, 
 resolves itself mainly into the treatment of symptoms, particularly 
 the alleviation of pain. For this purpose the application of an 
 ice-bag to the head or of leeches behind the ears may be tried ; if 
 these fail morphia should be administered. Nasal or rectal feeding 
 will probably be necessarj'. In cases where there is great collapse 
 and prostration early in the disease, as sometimes happens, stimu- 
 lants, such as strychnine or alcohol, may be required, and hot-water 
 bottles may be placed in the bed ; but in this, as in other forms of 
 meningitis, the patients often show a curious tendency to blister- 
 wi:h the application of a degree of heat which would be quite 
 innocuous in other diseases. 
 
 The use of antitoxic serum, either anti-pneumococcic or anti- 
 streptococcic, according to the probable nature of the infection, is 
 worthy of trial, but there is not at present sufficient experience to 
 show how far such treatment may be of value. 
 
 G. F. Still. 
 
MANUAL OF MEDICINE 
 
 INFLUENZA 
 
 Few diseases manifest themselves under guises so varied as 
 influenza. Hardly an organ or system of the body that may not 
 be its victim ; hardly a symptom or subjective sensation it has not 
 awakened. This almost infinite variety of manifestations not only 
 makes diagnosis difficult, but leads to many obscure conditions 
 being ascribed, without adequate evidence, to influenza, which has, 
 so to speak, become the last resource of the baffled diagnostician. 
 There are certain broad types of the disease which may be thus 
 described : — 
 
 I. The simple type. — Here with suddenness occur the chilli- 
 ness of fever, severe pains in the head, back, and limbs, rapidly 
 followed by great nervous prostration. The face is flushed and the 
 conjunctivae suff'used ; the tongue is tremulous, indented, moist, and 
 covered by a dirty white fur ; the breath is foetid. On examining the 
 throat, the posterior pharyngeal wall is found red, injected, and often 
 dry, the tonsils red and angry-looking, but not appreciably swollen ; 
 less often they are enlarged and their follicles plugged, as in a case 
 of scarlet fever or tonsillitis. The pulse beats 90 or 100 to the 
 minute — an acceleration moderate in proportion to the symptoms, 
 and is soft and compressible, and liable to become dicrotic. The 
 respiration is but slightly increased. There is either no cough or 
 one that is dry and irritable, and having its origin in the throat and 
 trachea. There are no abnormal physical signs in chest or abdomen. 
 The skin is hot and dry to begin with, but later there is often 
 profuse sweating. The urine is febrile. The pain in the head is 
 severe, and on any attempt at movement is well-nigh unbearable ; 
 the eyeballs ache. The pains in the limbs are more marked in the 
 legs than in the arms ; the muscles and tendons are often ex- 
 cessively tender on manipulation, and the skin hypersesthetic. The 
 joints are neither swollen nor more tender than the condition of 
 the periarticular structures will account for. The patient aches 
 everywhere as if bruised, and in no position can comfort be 
 obtained. He is restless and unable to sleep, except fitfully, and at 
 times there is delirium. Further there is added an indescribable 
 misery and depression, the whole constituting a feeling of illness 
 which life could not endure, but for a brief space. The character 
 of such an attack extends usually from two to five days, then the 
 
INFLUENZA 203 
 
 temperature, which has varied from 100 to 103, or higher, falls to 
 normal, or below it. 
 
 2. In the PULMONARY TYPE the disease is ushered in with the 
 same symptoms of chilliness, fever, pains and prostration, but cough 
 and embarrassed breathing early become prominent features. The 
 cough is dry, especially troublesome at night, and exceedingly 
 harassing — no cough more so ; it will sometimes last almost 
 continuously for an hour or more at a time, draining the patient's 
 strength to the point of utter exhaustion. It may persist for weeks 
 after the acute symptoms have subsided. The sputum is very scanty 
 and tenacious, or may at first be quite absent. As the case 
 progresses it will become rather more plentiful and change from the 
 mucoid and translucent to the muco-purulent and opaque, but it 
 often remains extremely sticky and tenacious, despite all efforts of 
 treatment to loosen it. 
 
 The physical signs are slight in proportion to the severity of the 
 symptoms and depend on the distribution and extent of the lung 
 trouble. If the mischief is bronchial and confined to the larger and 
 medium -sized tubes, the symptoms are milder than when it is 
 broncho-pneumonic with the smaller tubes and alveoli involved. 
 The more severe pneumonic condition is denoted by more rapid 
 breathing, a weak rapid pulse of 120 or more, duskiness of the face, 
 greater prostration. The physical signs of this influenzal broncho- 
 pneumonia are peculiar and ill-defined, and in their absence of 
 clearness and distinctness stand out in contrast with the definite 
 signs of lobar pneumonia. The first feature to claim attention is 
 a marked diminution of breath sounds, especially over the backs of 
 the lungs, and a short, highly pitched, sticky rale, which is character- 
 istic and conveys the same idea to the sense of hearing that the 
 glutinous sputum does to the sense of sight. These special rales 
 may often be brought out after coughing, over spots where the only 
 sign before was diminished or absent breath sounds. There is a 
 general impairment of resonance, more marked in some places than 
 others, but no clearly defined area of dulness. Vocal resonance and 
 tactile vocal fremitus are modified in no very helpful or constant 
 way, but are diminished more often than increased. There may be 
 here and there a patch of bronchial breathing, but it does not 
 stand out as a usual or prominent sign. The next strikingly 
 characteristic feature of these phenomena is the way in which they 
 extend and change their distribution. Manifesting themselves 
 more prominently at the bases, they creep from one part of the 
 chest to another ; perhaps one area will improve only for another 
 
2 04 MANUAL OF MEDICINE 
 
 to be affected, or if one lung shows signs of improvement the 
 other shows those of deeper involvement. It is this uncertainty as 
 to the length of the illness, with its constant strain on the patient's 
 strength, that makes this form of influenza so discouraging and 
 anxious. If the case is tending towards a fatal issue the above 
 signs extend over wider and wider areas of lung, but do not alter 
 their features. At the same time the breathing becomes more 
 rapid and shallow, the patient more distressed, and it may be 
 delirious, the fever increases, the face appears more dusky, a semi- 
 comatose condition supervenes, and, quickly following it, the end. 
 
 3. The abdominal type. — This form of influenza has been 
 prominent in many less severe epidemics and is present in most. 
 
 The fever is moderate — often not above 100° F. The attack 
 is characterised by the same suddenness of onset, and the same 
 depression and prostration as in the former. Acute abdominal pain 
 usually begins the illness and is followed by vomiting, and in some 
 cases by diarrhoea as well. Anorexia is complete. Such an attack 
 is often at first difficult to distinguish from other causes of acute 
 abdominal pain, such as intestinal colic, gall-stone colic, gastralgia, 
 and even peritonitis, but head or back pains, a sore throat or a 
 cough make the true nature of the illness evident. 
 
 Course. — In no disease is the course of an attack so difficult to 
 foresee. Fortunately a goodly proportion of the cases are moderate 
 in severity and simple in type, and after three or four days of fever, 
 headache, etc., the temperature will fall to subnormal, and the 
 patient, feeling bruised and shattered, will slowly recover strength. 
 No doubt, as with other specific diseases, there are slight, almost 
 abortive, attacks, which run an even shorter course. Frequently 
 symptoms will continue after the temperature has subsided, and this 
 disproportion between the degree of pyrexia and the state of the 
 patient is a characteristic feature. Or the temperature may keep 
 up for two, three, or even more weeks, and, although the acute 
 pains may go, the feehng and evidences of " illness " remain, 
 perhaps creating doubt as to whether the case is not one of 
 typhoid fever. Or what may begin with a simple attack will pass 
 on into influenzal bronchitis or broncho-pneumonia, either directly, 
 or in the form of relapse after a brief interlude of normal tempera- 
 ture ; and, as already stated, this form of pneumonia is- often 
 very long-abiding. The clinical forms of the disease as described 
 are not always sharply demarcated, but may follow or accompany 
 each other. 
 
 Special symptoms, complications, and sequelsa—Jlfod/^^ 
 
INFLUENZA 205 
 
 (ations of the iemperaiure. — All varieties of curve may be met v, itb. 
 Frequently highest at the onset, the acme may not be reached for 
 several days. For some time the fever may be of a regularly inter- 
 mittent type, accompanied by shivering or rigors, and followed by 
 sweating — presenting a malariform character ; or the greatest variety 
 may be exhibited from day to day, occasionally the highest point 
 being reached in the early hours. Now and then cases run their 
 course with no rise of temperature — an apyrexial influenza. In such 
 there is great prostration and depression, a subnormal temperature 
 of 96-97° F., no acute pains, but a feeling of great illness and a 
 sensation of sinking through the bed, a misery that defies descrip- 
 tion, and an utter inability to even hope or try to get better 
 constituting a form of the disease perplexing to recognise, and one 
 that recovers slowly and with difficulty. This occasional absence of 
 fever recalls a similar and more frequent feature of diphtheria. 
 Or, on the other hand, hyperpyrexia may set in, and this has 
 been more particularly noticed in cases marked by severe cerebral 
 complications. 
 
 Pulmonary complications. — Whilst the incidence of the disease 
 specially tends to the respiratory passages, some part or other of 
 which rarely escapes, — though the most prominent symptoms may be 
 connected with other organs, — the greatest variety exists in the extent 
 to which the several regions of the tract may be involved. The 
 general nature of the affection is, primarily at least, that of a dry 
 catarrh, often of very partial and limited distribution, with ill-defined 
 physical signs. 
 
 The soil of the influenzal bacillus is congenial to that of the 
 pneumococcus, and lobar pneumonia will often supervene in a case 
 of influenza ; pleurisy and empyema, the latter due to secondary 
 streptococcal infection, are also met with. Influenza may awaken or 
 reawaken phthisis. Gangrene, fibrosis of lung, bronchiectasis, all 
 may have their origin in an attack of influenza. 
 
 Cardio-vascularco?nplications. — Influenzal, like diphtheritic cardiac 
 affections, for the most part have their origin in some vice of the 
 controlling nerve mechanism which is due to the influenzal toxines ; 
 thus tachycardia and irregularity of rhythm are both late effects of 
 influenza, and may last for very many months ; or the pulse may be 
 markedly slowed in the later stages. Acute dilatation of the heart 
 may develop during, or at what is apparently the end of, an attack ; 
 it manifests itself subjectively by faintness and extreme weakness, 
 and objectively by pallor, displacement of the apex beat, a rapid, 
 irregular, and feeble heart action and pulse. It is always a grave. 
 
2o6 MANUAL OF MEDICINE 
 
 though fortunately rare, occurrence, and, as in acute rheumatism, 
 may be attributed to the direct effect of the toxin on the myocardium. 
 Pericarditis is sometimes met with. There are grounds for think- 
 ing that influenza, although not a cause of endocarditis, yet favours 
 in some way the development of ulcerative endocarditis. 
 
 Phlebitis and thrombosis of veins. — In the cases met with, 
 the lower extremities are most often the seat, and the usual 
 manifestations of pain, tenderness along the affected vein, and 
 swelling are present, with the same obstinate slowness of recovery. 
 Thrombosis of arteries, especially the popliteal, with subsequent 
 gangrene of the limb, has been recorded. 
 
 Epistaxis, melsena, haematemesis, hcematuria, and menorrhagia 
 are examples of bleeding from mucous surfaces, and purpura has 
 been frequently observed, either alone or in conjunction with other 
 rashes. It may be noted that these bleedings are sometimes 
 severe. 
 
 (Edema, general or confined to the lower extremities, not owing 
 its origin to the condition of the heart or kidneys or to thrombosis, 
 is occasionally a late effect. It varies considerably in degree from 
 time to time, and may last many months. Its pathology is obscure, 
 but is apparently toxic in origin. 
 
 Digestive disturbances. — Although clinically it is convenient to 
 refer to an abdominal type of the disease, there are rarely, if ever, to 
 be met with structural changes comparable to those found in the 
 respiratory organs. The usual phenomena met with are anorexia, 
 furred tongue, foul breath, constipation, or oftener diarrhoea, and 
 not unfrequently vomiting. If the gastro-intestinal symptoms be 
 severe, and especially if certain of the nervous complications develop, 
 the resemblance to typhoid fever may be marked. Parotitis is of 
 occasional occurrence. Jaundice, varying from the slightest tinting 
 of the conjunctivae to a general definite staining of the skin, has 
 been noticed, with urobilinuria. 
 
 Spleen and lymphatic glands. — An enlargement of the spleen is 
 sometimes noticed. 
 
 Besides the tonsillar glands, which are usually swollen and tender 
 when the throat is involved, it is not unfrequent to find a more 
 general enlargement of the glands of the neck, and even rarely of 
 other parts of the body. 
 
 Nervous systetn. — The headache, frontal or general, and pain in 
 the back, which characterise the onset of the disease in most cases, 
 may attain an extreme degree. Insomnia also is frequent and dis- 
 tressing, and may persist long after other symptoms have subsided, 
 
INFLUENZA 207 
 
 whilst delirium is not uncommon during the febrile stage. Vertigo 
 is a feature of some cases. Loss of taste and smell are sometimes 
 complained ot. 
 
 Neuralgia is often severe and lasting. It is widely distributed, 
 and only occasionally localised to the courses of particular nerves. 
 Myalgia, particularly of the thighs and calves, is frequent. These 
 pains are in large measure due to the condition of the nerve 
 centres, degrees of peripheral irritation, which in health would pass 
 unheeded, being brought up into consciousness and producing 
 pain. 
 
 Neural troubles resembling organic disease either of the peripheral 
 nerves, or of the spinal or cerebral centres, are common. Nervous 
 symptoms, which at their inception perhaps suggest neuritis or 
 myelitis, often prove to be caused by a functional toxic poisoning. 
 At the same time neuritis, either multiple or local, does occur in the 
 course of influenza, as in that of diphtheria, typhoid, and other 
 microbic diseases. It is not selective, and shows no special bias 
 for any particular group of muscles, like the diphtheritic form for 
 the palate, and the alcoholic and lead varieties for the extensor 
 muscles of the wrist and ankle. 
 
 Meningitis and myelitis, either local or diffused, are also among 
 the rare effects, but may be due to a mixed infection. 
 
 Beyond these more easily defined effects, influenza will leave the 
 nervous system bankrupt and exhausted. Weariness of the body 
 and mind make all effort irksome and difficult ; memory is bad, 
 ability to think enfeebled, and there is an absence of that initiative 
 and spontaneous desire to be up and doing which is so strong a 
 feature of health. The enforced idleness brings with it no sense of 
 ease or repose, and the patient feels gloomy and depressed. It is 
 common to meet examples of people who, without having any illness 
 that can be labelled, have for ever been ailing since an attack of 
 influenza. Their power to stand up against the wear and tear of 
 life seems gone, and they threaten to become a burden to themselves 
 and to others. Passing to certifiable insanity, melancholia, with or 
 without delusions, is by far the most common, and next to this 
 is mania. 
 
 Otitis media. — This may appear with but slight warning. A 
 sore throat is followed by intense ear-ache, which is often not 
 relieved till the membrana tympani bursts, and pus is discharged. 
 The condition will slowly improve, or may pass into a chronic 
 condition. 
 
 Numerous affections of the eye may com.plicate influenza; amonn; 
 
2o8 MANUAL OF MEDICINE 
 
 those of more frequent occurrence are conjunctivitis, keratitis, and 
 various ocular neuroses. 
 
 Skin affections. — Erythematous, urticarial, herpetic, purpuric, 
 and rarely bullous eruptions, will make their appearance during the 
 height of an attack, or during early convalescence. The erythematous 
 rashes are the most common, and may be difficult to distinguish 
 from those of scarlet fever or measles. 
 
 Renal complications. — A trace of albumen in the urine is not un- 
 common. A large quantity of albumen, with or without hccmaturia, 
 may be present ; sometimes it is accompanied by oedema and 
 denotes nephritis, but more often it does not. Glycosuria is of 
 occasional occurrence. 
 
 Orchitis sometimes arises, and it is said to do so in conjunction 
 with parotitis. 
 
 Arthritic affections are rare, but met with. Influenza predisposes 
 to rheumatoid arthritis. 
 
 The exceedingly wide range of manifestation here set forth 
 confers the multiform character on the disease. How far all these 
 phenomena are to be regarded as essentials of the malady, and 
 directly attributable to the causal microbe is doubtful and the 
 possibility of mixed infection should not be lost sight of. 
 
 Diagnosis. — Owing to its many-sidedness, influenza often pre- 
 sents difficulties in diagnosis. At its inception the high temperature 
 and the onset might well suggest measles, scarlet fever, or pneumonia, 
 or other specific fevers. 
 
 Where the characteristic rash and throat of scarlet fever appear 
 on the second day all doubt is usually at an end, but we have to 
 remember that these signs may both be present in influenza, and 
 then the difficulties may be great. The points to consider are 
 these, the rash of influenza is not punctiform, does not begin on 
 the chest and extend like scarlet fever, is patchy in distribution, 
 and fades and intensifies alternately, even from hour to hour. 
 Further, it is sometimes polymorphic, The difference between an 
 influenzal and scarlatinal throat is of great importance. The former 
 is chiefly pharyngeal, while the latter chiefly shows itself in redness, 
 enlargement, and plugging of the tonsils and redness of the soft 
 palate. But when it is remembered that the tonsils are sometimes 
 swollen and plugged in influenza, it will be seen how very difficult 
 it may be to differentiate between the two diseases. The history of 
 a previous attack diminishes the probability of scarlet fever. 
 
 From measles the difficulty of diagnosis arises during the first 
 four days. The more marked caiarrh of the nose and eyes of 
 
INFLUENZA 209 
 
 measles on the one hand, and the definite pains of influenza on 
 the other, will aid in the forming of a judgment. When the 
 time for the appearance of a measles rash arrives, the difficulty is 
 usually at an end, but it has to be borne in mind that a morbilli- 
 form rash may accompany influenza. 
 
 Diphtheria. — In so far as the diagnosis depends on the local con- 
 dition, it is the same as that between tonsillitis and diphtheria. In 
 the latter a cultivation from the throat will reveal the Loefiler bacillus. 
 
 Pneumonia. — The sudden onset, the hot dry skin, are features 
 common to the two diseases. But in pneumonia, if there is pain, 
 it is in the side, not in the head and back, the breathing is rapid, 
 and there may be herpes of the lips. Further, signs of extensive 
 lobar consolidation — dulness, marked tubular breathing, increased 
 voice sounds — would be convincing evidence of croupous pneumonia, 
 although the absence of these signs must not lead to a contrary 
 opinion from the fact that the appearance of physical signs in 
 pneumonia is often delayed several days. It must be remembered, 
 too, that pneumonia is an early complication of influenza. The 
 distinctions between influenzal and pneumococcal pneumonia are 
 well defined. In the latter the distribution is lobar and clearly 
 circumscribed ; in the former it is lobular and ill-defined ; in the 
 latter there are tubular breathing and increased voice and breath 
 sounds over an area of distinct dulness ; in the former there are 
 no such signs, but diminished breath sounds and sticky crepitations 
 over ill-defined areas, slightly, but not distinctly, dull. An examina- 
 tion of the sputum for bacillus influenzae should be made in cases 
 of doubt. 
 
 When a case hitherto thought to be influenza develops 
 shivering, rigors, hectic temperature and sweating, doubts may 
 occur, and the possible existence of deep-seated suppuration, of 
 pyaemia, or of malaria, be thought of. But the fact that influenza 
 may develop malarial characters, and the early history of the 
 attack, or the absence of primary or secondary foci of suppuration 
 should lead to a right judgment. 
 
 Enteric fever. — This question arises at two stages of the illness — 
 during the first few days when the evidences of influenza are perhaps 
 ill-marked, and again when the fever extends into the second or 
 third week. In the former case, doubt is felt at the commence- 
 ment of the iUness, and is usually set at rest by the faU of tempera- 
 ture and amelioration of the symptoms on the third or fourth day ; 
 while in the latter case doubt develops later in the physician's 
 mind, and a diagnosis of influenza which he at first adopted with 
 
 VOL. I P 
 
2 13 MANUAL OF MEDICINE 
 
 certainty, becomes, as the days roll by, more and more open to 
 question. Since influenza and typhoid are both diseases whose 
 positive evidences are sometimes lacking, it will be readily under- 
 stood that a confident diagnosis may at times be impossible. The 
 points of distinction to attend to are these. The pain of typhoid 
 is chiefly confined to the head, while that of influenza is as marked 
 in the back and legs ; the tongue of typhoid during the first week or 
 ten days resembles that of influenza, but, unlike influenza, changes 
 to a dry, glazed, cracked appearance towards the end of the 
 second week ; in typhoid, a distended elastic abdomen and a 
 palpable spleen are common, while in influenza they are un- 
 common. The presence of the typical diarrhoea is in favour of 
 typhoid, but it is important to bear in mind that its absence is not 
 evidence to the contrary, for constipation is as frequently met with 
 in that disease. The same holds good with regard to rose-coloured 
 spots — their appearance goes far to determine a diagnosis of 
 typhoid, but their absence does not point strongly to influenza, 
 considering that they may be long delayed, or even absent alto- 
 gether. By the middle of the second week the general condition 
 of a typhoid patient, as evidenced by the appearance and wasting, 
 mental dulness and apathy, is distinctive, and becomes more 
 accentuated with the lapse of each subsequent day. On the other 
 hand, with influenza, unless aggravated by some grave complication, 
 there is, although great weakness, no such marked wasting, and the 
 patient continues to take notice of his surroundings. And, lastly, 
 Widal's serum test should be employed, remembering that, though 
 evidence of importance which should contribute to the forming of 
 a judgment, it is not infallible. 
 
 Gastro-enteric influenza is Hable to be confused with other 
 causes of sudden diarrhoea and vomiting, such as poisoning, either 
 ptomaine or metallic. In poisoning the subnormal or normal 
 temperature, the marked and early collapse, and the history lead 
 to a right diagnosis. But sudden pain and vomiting may be the 
 only symptoms, and then this form of influenza has to be distin- 
 guished from other causes of acute abdominal pain, such as the 
 various forms of colic, and even peritonitis. 
 
 In many of its features influenza resembles dengue ; the sudden 
 onset, severe pain in head and back, nervous prostration and high 
 temperature, are alike in both. But in the latter affection the 
 joint pains are more constant and tend to last longer, and a 
 roseolar exanthem starting in the hands and spreading to the trunk, 
 followed by desquamation, is usually to be seen. 
 
INFLUENZA ^ 2 1 1 
 
 Morbid anatomy. — Characteristic changes are few, and are 
 almost entirely confined to the pulmonary type of the disease. 
 The trachea and bronchi are red, injected, and contain tenacious 
 mucus. The lungs show the changes of a broncho-pneumonia ; 
 they are imperfectly serated, and on squeezing them a thick muco- 
 pus exudes from the bronchioles. Disseminated patches of con- 
 solidation of varying density are seen. They are smooth and of 
 darker hue. and interspersed amongst them are areas of aerated and 
 collapsed lung tissue. Or through coalescence of the lobular areas 
 the lung may present some resemblance to lobar pneumonia, but 
 its section has not the homogeneous granulated appearance of that 
 condition. Under the microscope the changes seen are those of 
 broncho-pneumonia. There have also been described small areas 
 of purulent infiltration, the centres of which are packed with round 
 cells. Pleurisy is sometimes found in conjunction with the above 
 changes. As in other acute infections, the spleen is frequently 
 somewhat enlarged and soft. 
 
 Etiology. — Influenza is a communicable disease propagated 
 from person to person. The critical study by Dr. Parsons of the 
 1 889-1 892 epidemics pointed strongly to the conclusion that the 
 spread of the disease was conditioned by human intercourse and 
 was not dependent upon air-borne infection. The rate, and still 
 more the mode of extension strongly supported this view, and, as 
 will be seen below, what we know of the bacteriology of the disease 
 leads to a like conclusion. Several distinguished physicians of the 
 eighteenth century taught that the disease was contagious, but until 
 the investigations which sprang from our recent visitations, the 
 teaching of the nineteenth century has favoured an air-borne 
 theory of infection. This view owed much of its strength to the 
 lightning-like rapidity with which the disease struck down large 
 numbers of people within a very short space of time. This feature, 
 in common with some others, is the combined effect of a short 
 incubation period, an early infectiousness, a widespread suscepti- 
 bility and early unrecognised cases. The incubation period is 
 two to six days, and perhaps at times the limits are wider. In- 
 fectiousness commences very early, often within the first twenty- 
 four hours, and it may be before the character of the disease has 
 declared itself. It persists as long as the acute symptoms, and in 
 the pulmonary form as long as the catarrh lasts, and, judging by the 
 presence of Pfeiffer's bacillus, even longer. The widespread sus- 
 ceptibility is due to the very imperfect and transient immunity con- 
 ferred by a previous attack. Indeed, with some people one attack 
 
212 , MANUAL OF MEDICINE 
 
 predisposes to, rather than protects from, another. Granting, for 
 the sake of illustration, an incubation period of two days, a power 
 of infection commencing at the end of the first day's illness, and 
 that each case each day infects two or three people, a simple calcu- 
 lation will show that a single case will have become converted into 
 many hundreds after a very short time. 
 
 Bacteriology. — The bacillus infiuenzcB was discovered by R. 
 Pfeiffer in 1892. It occurs singly or in clumps as very minute 
 rods 1.2 /J, X 0.4 /x, devoid of capsules. The bacilli are found abund- 
 antly in the respiratory tract, often existing in pure culture in the 
 sputum either in or among the leucocytes. In the nose, mouth, 
 and pharynx, they are present, but admixed with other microbes. 
 They have been obtained from the discharge in cases of otitis 
 media, and from five or six cases of fatal meningitis. In the blood 
 it is the exception to find them, and it is probable that when present 
 they do not survive long. They are found in no other disease. 
 
 To search for the bacilli in the sputum, select for choice the small 
 greenish-yellow masses in the latter, make cover-glass preparations, dry 
 and stain for a quarter of an hour in Ziehl-Neelsen's carbol fuchsine 
 (i in 12 of water), afterwards wash, dry and mount in Canada balsam. 
 The poles of the bacilli stain, while the middle portions do not; so that 
 at first sight they show a resemblance to diplococci if isolated, or to 
 streptococci if several are placed end on. 
 
 Artificial cultures are not easy to make or preserve. The best 
 medium is blood agar, and, if a streak cultivation with sputum be made, 
 after twenty-four hours at the body temperature colonies will appear 
 consisting of minute transparent dots like drops of dew. These colonies 
 will not live long, and if it is desired to preserve the strain, subcultures 
 have to be made every second day. 
 
 The vitality of the bacillus is low, its maximum temperature is 
 42° C, and its minimum is 25° C, while it thrives best at the normal 
 temperature of the human body. It will not live beyond two days, 
 either in the dry state {e.g. dried sputum) or in water, but in moist 
 sputum its vitality extends to two or three weeks. 
 
 Animals are for the most part immune, and numerous attempts 
 to reproduce the disease in them have yielded negative results. 
 Although this is a weak link in the chain of evidence, there is 
 little doubt that the bacillus influenzae holds a causal relationship 
 with the disease. The bacilli do not circulate in the blood, but 
 find their home in the respiratory tract and other places congenial 
 to their growth. Here the toxines are produced, and, entering the 
 
INFLUENZA 213 
 
 circulation, work havoc in different tissues, but especially in nerve- 
 cells and fibres, thus resembling diphtheria. 
 
 The mode of propagation of influenza, the low resisting power 
 of the bacilli, the small range of temperature within which they 
 flourish, their inability to live but a short time in a dry condition 
 or in water, and the immunity of animals, all lead to the conclusion 
 that the disease is mainly spread from person to person, either 
 directly or mediately by means of fomites. It now can be under- 
 stood why it is that such factors as climate, soil, altitude, occupation 
 and sanitary surroundings have little or no bearing on the incidence 
 of the disease. 
 
 There are, however, many problems connected with the spread 
 of influenza as yet unsolved. Why, for instance, should the disease 
 spring up simultaneously in epidemic form in widely separated 
 regions of the earth's surface? Thus the 1891 epidemic began 
 simultaneously in the month of March in Yorkshire, Wales, and the 
 United States. Why, again, are the visitations intermittent ? There 
 must be external conditions of the nature of which we are ignorant, 
 acting over wide areas, that either increase the life activity and 
 virulence of the microbe, or the vulnerability of the human beings 
 exposed to its action. 
 
 Prognosis. — The severity of the disease and therefore its 
 mortality vary grea'dy in different epidemics. At all times a large 
 proportion of the deaths is due either to influenzal broncho- 
 pneumonia or supervening pulmonary complications. With the 
 simpler forms of the disease, which constitute the majority of the 
 cases, given previous good health and eflicient treatment recovery 
 is to be expected. Amongst the aged and those who are weakly 
 even the milder forms of the disease afford cause for anxiety, and 
 recovery, if such results, is often incomplete. As regards the late 
 effects of influenza, although they may linger — it may be for months 
 or even years — with a most discouraging persistence, yet, if there 
 is no organic lesion and the patient was previously of sound con- 
 stitution and is not old, ultimate restoration to health is the rule. 
 
 Prophylaxis. — It is most important for the fact to be recog- 
 nised that influenza is an infectious disease whose spread can be 
 checked by isolation. In institutions like workhouses, whose 
 normal relations with the outside world are restricted, and in which 
 strict isolation of first cases is carried out, it is possible to protect 
 the inmates from infection even when the disease is raging in their 
 immediate neighbourhood. When, however, on the one hand, 
 the peculiar features of the disease, and on the other hand the 
 
214 MANUAL OF MEDICINE 
 
 conditions of social life are considered, it must be admitted that 
 isolation has its limitations and can only mitigate but not entirely 
 prevent an epidemic. The question then arises — What measures 
 that are practicable can be taken by a community to check the 
 spread of the disease ? 
 
 (i) As far as possible prevent the contact of the uninfected 
 with the infected. Thus, people who are down with the disease 
 should remain indoors, not only for their own sakes, but for the 
 sake of others. It might be desirable to close schools ; and large 
 assemblages of people, as in theatres and churches, should be 
 avoided. (2) Good ventilation and cleanliness of street, house, 
 and person are important. (3) The sputum should be kept moist. 
 (4) The room and clothing of a patient should, when practicable, 
 be disinfected at the end of the attack. In schools isolation should 
 be continued for at least a week after the subsidence of symptoms. 
 
 Treatment. — The underlying aim of treatment should be " to 
 help him to bear it." There is not only the crushing effect of the 
 original onslaught to be dealt with, but it is impossible to tell what 
 the duration of the illness will be, or what complications will 
 supervene. What begins as an apparently mild, develops into a 
 severe attack, and some complications are as prone to follow mild 
 as severe invasions. What has to be done is to save the nervous 
 system the wear and tear — the devitalising effects of pain and distress, 
 and this may be achieved by measures that make for comfort, and 
 therefore for strength, and measures that relieve discomfort. 
 
 Bed is the only place for the victims of influenza, and it cannot 
 be too strongly insisted that the need for bed in a mild case of 
 this disease is as urgent as in a mild case of diphtheria. Many 
 fatal results have followed the neglect of this precaution. 
 
 Food.—\x\ the early stages, milk and meat-fluids are all that the 
 patient wants, or that it is useful to give him. As soon as the 
 more urgent symptoms of illness subside, it is well to try and 
 cautiously extend the dietary by tempting morsels of easily-digested 
 food, such as custards, jellies, oysters, white fish, boiled chicken, 
 sweetbread. And here it may with advantage be mentioned that a 
 remnant of fever and a persistence of fur on the tongue need not 
 be a bar to solid food. Indeed, their disappearance is often pro- 
 moted by the change from liquid diet, partly perhaps because of 
 the encouragement the patient feels on returning to a food more 
 resembling that of health. 
 
 Free action of the bowels should be secured, but severe purga- 
 tion avjjded, 
 
INFLUENZA 2 1 5 
 
 To diminish the pains. — Phenacetin, methylacetanilide, phena- 
 zone and allied drugs are of great use. The first is, as a rule, 
 the best, and is given in powder, gr. 8 to 10 for an adult every 
 three or four hours, according to the severity of the symptoms. 
 If the circulation is depressed, or the patient weakly, it is well 
 to combine caffeine gr. 2 with each dose of phenacetin. Methyl- 
 acetanilide is conveniently administered in mixture — 4 grains 
 for a dose, put up with tinct. aurantii to dissolve and flavour 
 it. Salicin and salicylates are sometimes employed with the 
 same objects as the foregoing, but in efficiency they are inferior. 
 Sometimes a saline diuretic and diaphoretic mixture affords most 
 relief. 
 
 In a disease productive of so much weariness and distress, it is 
 of the highest importance to give the body some rest and the mind 
 some forgetfulness. Sleep should be secured by the exhibition of 
 hypnotics alone, or in combination with anodynes. Of these 
 trional and sulphonal are the most suitable ; they have not the 
 depressing effects of chloral nor the persistently unpleasant taste of 
 paraldeheyde. Trional has an advantage over sulphonal in that its 
 latent period is shorter. Where there is acute pain, a hypnotic will 
 not alone secure sleep, but needs the assistance of the anodyne 
 effect of opium. A good combination is 10 to 15 grains of Dover's 
 powder with 20 grains of trional administered in a cachet. Or 
 the opium may be given as a morphia injection and the trional or 
 sulphonal by the mouth. In one acute form only of influenza 
 must the use of morphia be avoided or employed with great 
 caution, namely, in the broncho - pneumonic. There the great 
 tenacity of the sputum and the diffuse distribution of the inflam- 
 mation render its use hazardous. 
 
 Stimula?tts. — These are not required if the form of the disease 
 is simple and the subjects are robust. But if the attack is pro- 
 longed or of a severe type, and if the patient is either old or of 
 weakly constitution, alcohol is both necessary and desirable. Where 
 there is evidence of cardiac and respiratory failure ammonia and 
 ether, or better, perhaps, hypodermic injections of strychnine (gr, 
 -gij- to -^^\ or caffeine (gr. 2), should be prescribed even to several 
 times in the twenty-four hours. 
 
 The dryness and soreness of the throat usually require relief ; an 
 inhalation of carbolic acid partially secures this — R Acidi carbolici 
 liq. Aq. aa 5ij. Misce. One drachm to the pint of hot water. 
 Inhalations of pumiline and Tinct. Benzoin co : may also be 
 employed. Carbolic acid may also be used as a gargle. R Acid 
 
2i6 MANUAL OF MEDICINE 
 
 carbol. liq. 3i., Glycerine 31., Inf. Rosae acid : ad 511]. Mix and 
 dilute with equal parts of hot water. 
 
 It is a great comfort to the patient to have the furred tongue 
 and the mouth cleaned. This is best done by means of cotton wool 
 held by dressing forceps and dipped in the following solution — 
 R Acid carbolici liq. 3ss., Hydrogen peroxidi sij., Glycerini boracis 
 31., aquam ad 5vi. Misce. Used as it is, or diluted with a little 
 warm water. This preparation may also be used as a gargle or 
 spray. 
 
 Where the pahis in, or more often round, the joints are severe 
 and persistent, relief may be given by glycerine of belladonna and 
 moist heat locally. 
 
 Influenzal broncho-pneumonia is exceedingly resistant to treat- 
 ment. Its irritable cough and its sticky sputum often seem but 
 little affected by such expectorant remedies as ipecacuanha, potassium 
 iodide, ammonia, squills, etc. Turpentine, 5 to 10 minims for a 
 dose, in gelatine capsules every four hours, sometimes does good, 
 but when giving this drug the urine must be carefully watched. 
 The necessity for caution in the use of opium in this condition has 
 already been referred to. External applications in the shape of 
 poultices not only afford comfort but help to loosen the sputum. 
 
 For the gastro-intestinal symptoms nourishment should be restricted 
 to milk, with soda or barley water given in small quantities frequently. 
 If there is vomiting a blister to the epigastrium will often stop it, 
 and hot applications will allay abdominal pain. For drugs, sodium 
 bicarbonate, sal volatile, and spirits of chloroform, with t?ie addition 
 of morphia to check the pain and diarrhoea. If vomiting is a 
 persistent feature acid hydrocyanic: dil: or the agreeable tinctura 
 pruni Virginians, may be added to the above. Bismuth is also 
 employed, but is of less use than in simple gastro-intestinal 
 irritation. 
 
 The malarial type yields well to quinine given in 3 to 5 grain 
 doses three or four times daily. 
 
 During convalescefice the patient should not be allowed to get up 
 till the temperature has been down for some days, and then only 
 with caution, always bearing in mind the liability to relapse. The 
 diet should be generous and the appetite encouraged, and a little 
 wine with the food should be allowed. Quinine is now the drug 
 most generally useful, alone or in combination with strychnine. As 
 recovery is approached iron should be added. Where possible a 
 change of air should always be advised, and after severe attacks 
 should be strongly insisted upon. It is only in this way that 
 
GLANDERS 217 
 
 recovery is consolidated and the long and varying train of sequelae 
 avoided. The treatments of the late effects of the disease do not 
 call for detailed description. A word of warning, however, is 
 needed concerning the insomnia, the various neuralgias and distress- 
 ful feelings that sometimes tarry so long and wearily. On no 
 account must opium be employed for their relief. This drug is as 
 bad at this stage as it is often good in the first and acute stage. 
 Hypnotics, too, like trional and sulphonal, must be given cautiously. 
 
 Bertrand Dawson. 
 
 GLANDERS 
 
 Syn. Farcy, Equinia, Malleus 
 
 An infectious disorder peculiar to the horse and ass, though 
 transmissible to other animals, and also to man. 
 
 In the majority of cases of human glanders the patient acquires 
 the disorder directly, by inoculating a sore or wound of the skin or 
 mucous membrane. In other instances the contagium seems to 
 gain entrance through the respiratory mucosa, the tonsils, or the 
 alimentary canal. 
 
 Nearly all the recorded cases have occurred in males, and in 
 those who are closely associated with horses, such as stablemen, 
 grooms, knackers, etc. ; but occasionally the infection has been 
 transferred from man to man, and the malady has been acquired in 
 the laboratory. 
 
 Bacteriology. — The actual exciting cause is a schizomycete, 
 bacillus mallei, a microbe about the same size as, but rather thicker 
 than the tubercle bacillus. Though an aerobe, B. mallei is also a 
 potential auccrobe. Its cultural appearances in glycerin-agar and 
 blood-serum are sufficiently distinctive, but on potato the growth is 
 quite characteristic. On this medium at incubation temperature the 
 growth is at first honey or amber yellow in hue, afterwards darken- 
 ing to brown. The microbe is best stained with phenol-fuchsin or 
 with phenol-methylene blue. It does not stain by Gram's method. 
 From veal broth cultures, its specific metabolic product, mallein, is 
 obtained by filtration. This is used for diagnostic purposes, and 
 when injected into glandered animals it excites a marked local and 
 
2i8 MANUAL OF MEDICIXE 
 
 general reaction. Another experimental test is afforded by injecting 
 pure cultures into guinea-pigs, whereby a glanderous caseation of 
 the testicles is almost invariably determined. 
 
 The average incubation period is from three to five days, but it 
 may be shorter, and incubations of fifteen to twenty days are known. 
 
 Symptoms. — ^The onset of the disease is usually marked by a 
 rigor or frequent shiverings, malaise, headache, pyrexia, hot, dry 
 skin, by general pains, especially marked in the joints and muscles, 
 and by prostration. 
 
 The febrile symptoms are followed by an eruption which rapidly 
 appears when the infection is the result of direct inoculation, but 
 may be delayed when there is no definite local origin. The inocu- 
 lation site swells, pustules form, and thereafter, breaking down, dis- 
 charge a foetid ichorous pus. Swellings which rapidly suppurate 
 may appear in other parts of the body, chiefly on the skin, muscles, 
 mucosa of the nose, and in the lymphatics and lymphatic glands. 
 In many cases there is a specific pneumonia, a purulent arthritis, 
 and in very severe cases an erysipelatoid tumefaction of the face. 
 Such acute cases last for about a fortnight. Chronic cases continue 
 for weeks, and may drag on for months. In these the febrile 
 phenomena are less severe, and the anatomical lesions less frequent 
 and often indolent. Yet these chronic cases may terminate in acute 
 glanders. 
 
 The clinical pictures presented by glanders vary much as to 
 the duration of the disease and the extent and distribution of the 
 anatomical lesions. For descriptive purposes the disease has been 
 subdivided into acute and chronic glanders, and acute and chronic 
 farcy. The distinction made between glanders and farcy refers to 
 the greater extent to which the respiratory system is affected in the 
 former and the prominent position taken by the skin in the latter, 
 the so-ca.lled farcy buds being nothing more than either the swollen 
 lymphatic glands or the morbid collections in the cutaneous lymph- 
 atic vessels. A perusal of recorded cases will, however, show that 
 no distinct line can be drawn between the two even clinically, and 
 will convey the notion that glanders is a specific disorder on pyjemic 
 lines, characterised by more or less febrile phenomena and by 
 caseating, suppurating or ulcerative lesions in skin, mucous mem- 
 brane, muscles, lungs, etc. 
 
 In many instances the naso-phar}'ngeal mucosa is little if at all 
 implicated. But should the mucosa of the nasal passages be affected 
 by continuity or by metastasis, a discharge, at first mucoid, rapidly 
 becoming purulent or saniopurulent, flows from the anterior and 
 
GLANDERS 219 
 
 posterior nares. This glanderous ozaena may infect the lungs and 
 alimentary canal. The inflammation of the lungs is indicated by 
 dyspnoea and by saniopurulent expectoration, the physical signs of 
 pulmonary consolidation beiiig frequently absent. Infection of the 
 intestine is indicated by diarrhcea and offensive stools. 
 
 In chronic cases the original infection site may present the 
 aspect of an intractable chronic ulcer from which proceed the 
 thickened lymphatics and their swollen glands. In the majority of 
 the recorded cases the virus has been inoculated on a sore or wound, 
 but there are many instances where no such local infection has been 
 demonstrable. In these the incubation period seems to have been 
 longer, and after the general febrile symptoms have declared them- 
 selves the disease has become diagnosable by the advent of a 
 vesicular eruption rapidly suppurating, by the occurrence of intra- 
 muscular abscesses, by a foetid ozaena, or by the specific pneumonitis. 
 
 The character of the pyrexia is variable ; it may be continuous 
 or of the remittent type ; it may be slight or severe (104° or higher). 
 
 A positive diagnosis of glanders is at first often difficult. 
 Considerable assistance will, of course, be received from a know- 
 ledge of the patient's occupation and a possibility of contact with 
 the virus. In chronic cases one of the most prominent features is 
 old-standing ulcerations of the skin, and such sores have more than 
 once been mistaken for those of tertiary syphihs. The induration 
 and thickening of the lymphatic glands and vessels in connection 
 with the sore may help to guard against this error. 
 
 When the disease is suspected a diagnosis may be made by 
 bacterioscopic examination of the contents of the pustules, of the 
 abscesses or of the discharges ; by the characteristic cultural ap- 
 pearances of the bacillus, especially on potato ; by inoculation of 
 the peritoneal sac of guinea-pigs with pure cultures ; by means of 
 the serum test or by the reaction to mallein which consists of the 
 chemical products derived from the artificial culture of the bacillus 
 mallei, subcutaneous injection of which causes a reaction similar to 
 that produced by tuberculin in persons suffering from tuberculosis. 
 
 The prognosis is always bad. Nearly all the acute cases are 
 fatal, and of the chronic ones many terminate as acute glanders. 
 
 Of the chronic cases about 50 per cent are stated to recover, 
 and the issue is the more favourable according as the symptoms are 
 slow and indolent and the course of the malady protracted. Yet 
 when they do recover a permanent condition of debility, general or 
 local, may remain. 
 
 The general treatment of glanders resolves itself into maintain- 
 
2 20 MANUAL OF MEDICINE 
 
 ing the strength of the patient by means of suitable and nourishing 
 diet and by stimulants. Drugs are of little avail. Mercury has 
 been exhibited both internally and by inunction, but quinine and 
 iron have more repute. 
 
 The most effective part of the treatment of glanders is surgical 
 and antiseptic. The pustules, sores, and abscesses should receive 
 constant and energetic attention, the results being the more satisfac- 
 tory according as the cases are less acute and more chronic. 
 
 It is hardly necessary to point out that the dressings, soiled 
 clothes, etc., should be carefully disinfected, or, what is better, 
 burned. 
 
 R. G. Hebb. 
 
 TUBERCULOSIS 
 
 Tuberculosis is a specific infective disease set up by the action of 
 a special virus, this last being a micro-organism now well recognised 
 and distinguished as the tubercle bacillus. This bacillus, either 
 directly, or by means of chemical products due to its presence, causes 
 a special form of inflammation of the tissues, resulting in the forma- 
 tion of what is known as acute miliary tubercle or tuberculous 
 nodules. 
 
 The present article deals with tuberculosis generally, its modes 
 of invasion, its methods of local increase and extension to other 
 organs, and its distribution throughout the body. For its effects 
 upon the separate organs, and the symptoms resulting from them, 
 reference must be made to the articles dealing with the diseases 
 special to those organs. 
 
 Bacteriology. — The tubercle hacillus can be readily demon- 
 strated in the sputa of tuberculous subjects, and is commonly found 
 in the urine, pus, and other secretions from parts affected with the 
 disease. It can also be shown in sections cut from the affected 
 tissues. The bacillus is a motionless rod with rounded ends, about 
 one-half the diameter of a blood corpuscle in length, and about one- 
 sixth of its own length in thickness (Plate II.). The bacillus is chiefly 
 recognised from its behaviour with certain aniline dyes. When a pre- 
 paration containing it is stained with carbol-fuchsine and afterwards 
 treated with dilute mineral acids, these last remove the colouring 
 matter from all but the bacilli themselves, which then sometimes 
 show a beaded structure with alternate coloured and uncoloured 
 
TUBERCULOSIS 221 
 
 portions. Whether this beading is due to spore formation or not 
 is as yet undetermined. The leprosy bacillus is the only other 
 pathogenetic organism at present known with a similar property of 
 retaining its colour when treated in this way. (The caseous secre- 
 tions of the glands of the vulva and glans penis frequently contain 
 a bacillus which closely corresponds to the organism of tubercle 
 and leprosy in its behaviour to carbol-fuchsine and acids, though it 
 is stated that alcohol discharges the stain sooner in the former. 
 This fact should be remembered when examining urine for the 
 tubercle bacillus.) The ordinary method of showing the presence 
 of the tubercle bacillus is to first stain the suspected preparation 
 with carbol-fuchsine, then to decolorise with a dilute mineral acid, 
 and finally to stain again with methylene blue, when the bacilli 
 retain the red colour of the fuchsine and contrast strongly with the 
 blue of the rest of the preparation. The bacilli can be cultivated 
 on several special media at temperatures between 98.5° F. and 
 102° F., but in every case the growth is essentially a slow one. 
 Except when grown in this way, the bacilli have no power of extra- 
 corporeal increase. They can, however, even when dried up, retain 
 their vitality for a long period of time. 
 
 Histology. — In whatever way the virus may have gained an 
 entrance, the initial lesion is a miliary tubercle, and the successive 
 formation of such miliary tubercles is the essential and constant 
 feature of the complaint. Under the microscope this tubercle is 
 found to be made up of three separate zones or layers. The inner- 
 most zone consists of one or more large many-nucleated cells, with 
 prominent branching processes — the so-called giant cells. Surround- 
 ing the inner zone is a layer of epithelioid cells. Outermost of all 
 is a layer of smaller lymphoid cells. These three layers of cells are 
 not always present, and a tubercle may be composed of two only of 
 them, or even of lymphoid cells alone. 
 
 A single tubercle proper, such as that just described, is hardly 
 perceptible by the naked eye. Commonly, however, several of them 
 are aggregated together, and it is such collections of them that give 
 the characteristic visible features of the complaint, and to which the 
 term tubercle is ordinarily applied. Before undergoing any retro- 
 gressive change, these collections of tubercles tend to form little 
 tumours of a definite size, this size varying somewhat in the different 
 tissues of the body ; and it will be convenient to follow the usual 
 custom and speak of such collections as tubercles simply. A tubercle, 
 in this sense, is usually a small globular body, about one-twelfth of 
 an inch in diameter, pearly gray or yellowish in colour, and some- 
 
222 MANUAL OF MEDICINE 
 
 what translucent in appearance (gray granulation). It is strictly 
 extra-vascular, and capillaries can be traced up to its very margin, 
 but never into its substance. Sooner or later the presence of 
 tubercles is accompanied by inflammation of the tissues containing 
 them, both in their immediate neighbourhood and in distant parts. 
 
 After reaching maturity, tubercles are liable to two forms of 
 degenerative change — the caseous and the fibrous. Both processes 
 are usually combined to some extent, although the amount of the one 
 generally predominates over the other. 
 
 (a) Caseous degeneration is a form of dry necrosis which, owing 
 probably to its non-vascularity, starts primarily in the tubercle itself, 
 but afterwards involves the surrounding inflammatory products as 
 well. The resulting formation is a homogeneous yellowish mass, 
 somewhat of the consistence and appearance of soft cheese, which 
 was formerly known as "yellow tubercle." Under the microscope 
 the degenerated mass is found to consist of shrivelled corpuscles 
 intermixed with granular debris and fat. By the coalescence of the 
 separate tubercles caseous masses of considerable size may be formed, 
 more especially in situations having no connection with the free 
 surfaces of the body. In active cases the caseous masses may be 
 surrounded by recent miliary tubercles. Further changes may bring 
 about the softening of the caseous material with the formation of an 
 ulcer or an abscess, according as the tubercle occurs on a free sur- 
 face or in a closed cavity. When the caseous masses do not soften, 
 and remain obsolescent, they are apt to take up lime salts from the 
 blood, and so become transformed into cretaceous material. 
 
 (V) The other form of tuberculous degeneration, the fibroid, is a 
 frequent feature in tuberculosis of the pleura and peritoneum, and 
 not very uncommon in the lungs. Here the inflammatory products 
 surrounding the tubercles, instead of undergoing caseous degenera- 
 tion, are transformed into fibrous tissue, which is often of con- 
 siderable thickness and extent. The fibroid change is in the 
 direction of the cure of the complaint, for the fibrous tissue resulting 
 from it may interpose an effective barrier against the spread of the 
 virus. In such a change the actual tubercles themselves generally 
 persist as fibrous nodules, or as small cretaceous masses. 
 
 Tuberculosis in its clinical aspects presents itself in two forms : 
 a chronic one, in which the complaint is mainly confined to one 
 or two organs or set of tissues, spreading mainly by direct extension 
 or by means of the lymphatics ; and a more or less acute one, 
 general tuberculosis, in which many organs are simultaneously 
 attacked j in this variety it is evident that the virus must have 
 
TUBERCULOSIS 223 
 
 been carried by means of the general blood stream. It is this 
 generalised form which is most frequent in infancy and early child- 
 hood. 
 
 Invasion and distribution. — Of the modes of entrance of 
 the bacilli into the human body only three need be considered — 
 inoculation through a breach of the skin, inhalation through the air 
 passages, and introduction into the alimentary canal along with 
 food. 
 
 The first mode, moculatiofi through a breach of the skin, is 
 extremely rare : examples of it being the occasional occurrence of 
 warts on the hands of those making post-mortem examinations on 
 tuberculous subjects. 
 
 The second mode, through the agency of the air passages, is by 
 far the most frequent one by which the disease is contracted. It is 
 by means of the virus inspired with the air, and, but less frequently, 
 through the agency of food, that the glands in the neck, the lungs, 
 and the bronchial glands are usually infected, and it is in few cases 
 of tuberculosis that one or more of these structures is not involved. 
 
 The glands in the neck are infected by the bacilli gaining en- 
 trance to them from the parts about the mouth, more especially 
 the lymphoid tissue of the tonsils, and the pharynx. That the 
 organisms can gain an entrance to the glands when the parts 
 inside the mouth are in a healthy state is perhaps true, but that 
 an inflammatory condition of such parts assists their entrance is 
 more than probable. Once in the glands the bacilli may multiply 
 with the resulting formation of miliary tubercles, followed in due 
 course by inflammation, necrosis, and caseation. Such is the origin 
 of the familiar and well-known " strumous " or " scrofulous "' glands 
 in the neck. (Since it is now proved that the condition expressed 
 by these terms is due to the tubercle bacillus, their retention is only 
 justifiable on the ground of clinical expediency and not on that of 
 pathological distinction.) Here the process may stop, and the 
 tuberculous glands may persist for many years as chronic indolent 
 swellings. Often the inflammation goes beyond this point, and a 
 tuberculous abscess forms in the neck. In other cases the necrotic 
 process in the glands involves the walls of the blood vessels, 
 generally a small vein, with the result that the bacilli gain an 
 entrance into the general blood stream. Once m the veins the 
 bacilli are carried along by the venous current towards the lungs, 
 and either find a lodgment in the pulmonary tissues or pass through 
 the capillaries of the lungs to infect distant organs. It may be 
 remarked here that it is almost certain that the bacilli, whilst in 
 
2 24 MANUAL OF MEDICINE 
 
 motion with the blood stream, have no power of multiplying, and 
 only in rare instances have they been discovered in the blood itself. 
 For their increase a condition of rest is probably an essential. 
 Another consequence of tuberculosis of the glands is that the in- 
 flammatory process sometimes leads to rupture of their capsules, 
 wkh the result that the bacilli gain an entrance into the lymph 
 current and thus infect other glands, or pass into the general blood 
 stream by way of the thoracic duct. Amongst these other glands 
 those at the root of the neck surrounding the apices of the lungs, 
 and the tracheo-bronchial glands, are of prime importance, as their 
 infection may lead by direct extension to disease of the lungs 
 themselves. 
 
 From the pharynx the bacilli may gain an entrance into the 
 tympanicm by way of the Eustachian tube, and tuberculous disease 
 of the ear is frequent in children and especially in infants. The 
 usual result of the presence of the organisms is suppuration in the 
 tympanic cavity, which may be followed by caries or necrosis of 
 the petrous portion of the temporal bone and tuberculosis of the 
 brain or its membranes. Much more rarely tuberculous meningitis 
 is due to disease of the bones at the base of the skull ; the bacilli 
 having reached them by the route of the nasal passages. 
 
 In the bmgs the bacilli gain an entrance with the inspired air, 
 and their first effects are exercised upon the finest bronchial tubes. 
 The apices of the lungs are the parts most often attacked, owing 
 doubtless to the fact that they are the least expansile portions, and 
 that the bacilli are most likely to attain a footing where the air is 
 more or less stagnant. From primary foci in the finer bronchial 
 tubes the disease has a tendency to spread in one of two directions, 
 or in both simultaneously, viz. along the bronchi to the alveoli of 
 the lungs, or else from the bronchi into the surrounding tissue and 
 thence by direct continuity into the general connective tissue of the 
 organ. In both cases there is progressive formation of tubercles 
 and inflammation corresponding to the nature of the structures in- 
 vaded. Besides spreading by direct extension in these directions, 
 the complaint may attack more distant parts through the agency of 
 the blood vessels and lymphatics. By the implication of the walls 
 of the former, the bacilli may enter the blood stream, and develop 
 fresh miliary tubercles in the general connective tissue of the lungs, 
 corresponding closely to the ramifications of the terminal branches 
 of the pulmonary artery. Fresh foci of infection, too, can often 
 be traced in the lung tissue along the course of the lymphatic 
 vessels on their way to the bronchial glands. These last are invari- 
 
TUBERCULOSIS §25 
 
 ably affected as well as the lungs, and it is only in exceptional 
 instances that any tuberculous disease of these glands is not accom- 
 panied by demonstrable affection of the lungs as well. The effect 
 of the disease in the bronchial glands is the same as in that of 
 the glands of the neck, and the affection of the bronchial glands 
 may be the means of spreading the disease to the lungs or to more 
 distant parts, either directly by means of the blood vessels, or in- 
 directly by the route of the thoracic duct. In exceptional instances, 
 too, an affected gland may ulcerate into a bronchus, and the released 
 bacilli may set up fresh foci of the complaint in many parts of the 
 lung corresponding to the terminations of the finer bronchi. In 
 other cases the disease spreads to the pulmonary tissues from the 
 glands surrounding the bronchi in their passage to the lungs, and 
 some authorities state that this mode of infection of the lungs is 
 the commonest one in infants and young children. 
 
 The pleura interposes a barrier, more or less effective, against 
 the spread of the disease into its cavity, and there may be extensive 
 disease of the lungs with entire freedom of the pleura. As there 
 is in fact no direct communication between the lymphatics of the 
 pleura and those of the lungs, the pleura can only be infected by a 
 breach of its surface through necrosis or other means. A secondary, 
 non-tuberculous, pleurisy usually, however, complicates pulmonary 
 tuberculosis of any great extent. In general tuberculosis gray 
 miliary tubercles are frequently found on both the visceral and 
 parietal pleural surfaces. Not infrequently, too, the first clinical 
 manifestations of tuberculosis are exhibited in the pleurae. It is 
 now almost universally admitted that simple, primary, serous 
 pleurisies are generally tuberculous in origin. However rapidly 
 and apparently completely the victims of such pleurisies recover, 
 statistics prove that the majority of them die before three years are 
 over with undoubted tuberculous disease of the lungs and other 
 organs. 
 
 Tuberculosis of the pericardiutn is seldom found except as the 
 result of the general disease when many organs are involved. 
 
 Tuberculous disease of the larynx is nearly always secondary to 
 disease of the lungs, and is probably due to infected sputa becoming 
 lodged in the folds of the larynx. 
 
 In the third mode of entrance into the body, by way of the 
 alimentary canal, the bacilli can readily reach the stomach and in- 
 testines by being swallowed with the saliva or sputum, or by the use 
 of infected food. Modern research has proved beyond question 
 the extreme frequency of the presence of the bacilli in ordinary 
 VOT. I n 
 
2 26 MANUAL OF MEDICINE 
 
 household milk and butcher's meat. It might be expected, then, 
 from this fact that primary tuberculosis of the stomach and intes- 
 tines would be of frequent occurrence. Fortunately this is far 
 from the case, and primary tuberculosis of the intestinal mucous 
 membrane is a rare event. Too much stress, then, has possibly 
 been laid upon the frequency of infection through the agency of 
 food by some recent authorities in their laudable attempts at con- 
 trolling the disease. There can be no doubt, too, that cases of 
 tabes mesenterica, i.e. tuberculosis of the mesenteric glands, are 
 vastly exaggerated in frequency in the death returns. The com- 
 parative freedom of the intestinal tract from infection due to food is 
 no doubt due to some destructive action of the gastric and intestinal 
 secretions on the bacilli. Rare as a primary disease, tuberculosis of 
 the intestines is far from uncommon as secondary to tuberculosis 
 of other parts, most frequently that of the lungs. There is every 
 reason for believing that in this case infection is incurred by the 
 swallowing of tuberculous sputa. It is possible that in this instance 
 the bacilli are protected from the destructive influence of the gastric 
 and intestinal secretions by the mucus in which they are imbedded. 
 Tuberculosis of the stomach is rare, although not quite so un- 
 common as some authorities have asserted. In every case it is 
 accompanied by tuberculosis of the intestines. The parts of the 
 bowels most frequently affected are the lower end of the ileum 
 and the large intestine. In the ileum the disease begins in the 
 Peyer's patches and the solitary glands. Gray miliary tubercles 
 form in the lymph follicles, and these turn yellow and soften 
 from necrotic change. The mucous membrane over and ad- 
 jacent to the follicles sloughs, and thus an ulcer is formed which 
 enlarges by the additional formation of fresh tubercles round its 
 margins and on its base. The ulcers thus spread beyond the areas 
 of the Peyer's patches, generally in the direction of the blood 
 vessels, and may extend around the whole circumference of the 
 bowel. By the progressive destruction of the deeper parts, nothing 
 of the bowel structure may be left beyond the peritoneal coat and 
 perforation may result, but more often inflammatory adhesions are 
 formed with neighbouring coils of intestines. Tuberculous ulcers 
 of the ileum are not unfrequently somewhat like in appearance to 
 typhoid lesions in the same situations. They are to be distin- 
 guished from these last by their more irregular shape, their tendency 
 to spread across the bowel, the hardness of their base, and from 
 the fact that very often separate tubercles can be discerned in them 
 and on the peritoneal surface. 
 
TUBERCULOSIS 227 
 
 Similar ulcerations, commencing in the solitary glands, also occur 
 in the lar^e i?itcstine. They form rather deep, excavated ulcers, often 
 with a small circular opening on the mucous surface of the bowel. 
 
 The corresponding Mesenteric glands are invariably affected 
 along with the intestines. In some instances these glands are 
 found in a state of caseation where there are no discoverable signs 
 of any present or previous affection of the intestines. It is said 
 that the disease may spread by means of the lymphatics from the 
 mesenteric glands to those at the root of the lungs, and that thus 
 the latter organs may be infected from a source arising from tuber- 
 culous food. 
 
 With regard to the primary infection of the glands of the neck, 
 of the ears, the lungs, and the intestines, there is no difficulty in 
 surmising as to the mode of access of the bacilli from the outside. 
 Very often, however, tubercles, seemingly primary in character, are 
 found in parts of the body remote from those last named. It 
 may then be far from an easy matter to settle as to the manner of 
 entrance of the organism into the body. In the vast majority of 
 such cases careful search generally reveals an older focus of in- 
 fection, most often a caseous gland. In rare instances no such 
 source of infection is found, and in such the affection of the distant 
 parts must be regarded as primary in character. The bacilli have 
 here, possibly, found their way into the system from surfaces that 
 are unaltered, as occasionally happens with small particles of foreign 
 substances. 
 
 Tuberculosis of the meninges in the majority of cases is either 
 only a part of the generalised complaint, or is secondary to disease 
 of the ear. In a few instances it is due to a direct extension to the 
 meninges of tuberculous disease of the brain or cerebellum. Not 
 infrequently, however, it is apparently primary in character, no 
 tuberculosis being found elsewhere in the body. The attending 
 meningitis is most marked at the base of the brain, but here the 
 resulting fibrinous effusion, matting the parts together, may be so 
 dense as to mask the tuberculous nature of the disease. The 
 tubercles are found in the greatest numbers in the fissure of Sylvius, 
 vary greatly in size, and when very minute are perhaps more easily 
 felt than seen. They apparently begin in the perivascular spaces 
 surrounding the smaller arteries, and accompany the arterioles into 
 the meninges and the brain substance. Along with the meningitis 
 there is always a varying amount of cerebritis as well. In the 
 greater number of cases of tuberculous meningitis, tubercles are 
 present also in the choroid plexus of the ventricles. 
 
2 2^ MANUAL OF MEDICINE 
 
 Tuberculosis of the brain substance may result in the formation 
 of caseous masses varying in size from that of a pea to that of a 
 walnut. In the brain the' individual tubercles and the masses they 
 form are larger than in any other part of the body. In recent cases 
 the caseous masses are apt to be surrounded at their circumferences 
 by a layer of gray miliary tubercles. The tuberculous tumours are 
 almost invariably multiple in number, and are most frequent in the 
 cortices of the cerebral hemispheres, the cerebellum, and the pons, 
 in the order given. In some cases they give rise to no symptoms 
 at all, and are only revealed by post-mortem examination. In 
 other cases they produce all the symptoms of cerebral and cerebellar 
 tumours, and tubercle accounts for the larger number of growths 
 found in these situations. In inf:ints and young children tuber- 
 culous masses in the cerebral hemispheres are a frequent cause of a 
 permanent hemiplegia. 
 
 Tuberculosis of the peritoneum may occur from the direct per- 
 foration of an ulcer of the intestine into its cavity, or as only a part 
 in the widespread disease. Not unfrequently, however, usually in 
 childhood, it is apparently primary in character. In its acute forms 
 the peritoneal surfaces, both visceral and abdominal, are studded 
 with very numerous gray miliary tubercles, and the cavity is rapidly 
 distended with the out-poured fluid. In more chronic cases the 
 peritoneum is greatly thickened, the intestines are densely matted 
 together, and there is a tendency to obliteration of the peritoneal 
 cavity. 
 
 In acute general tuberculosis the spleen is invariably affected, 
 and in a large proportion of cases of the more chronic infection it 
 is the seat of tubercle. Beyond enlargement of the organ, never of 
 any great extent, there are no symptoms or physical signs attending 
 tuberculous disease of the spleen. 
 
 The liver is affected under the same conditions and in the same 
 proportion of cases as the spleen, and in addition tubercles on 
 the peritoneal surface may penetrate into the substance of the 
 organ. Tuberculosis of the intestines, too, may lead to that of 
 the liver, owing to the virus being carried to the last by means of 
 the mesenteric veins. In this case the distribution of the tubercles 
 may correspond closely with that of the portal vessels. As a rule, 
 tuberculosis of the liver is only clinically manifested by enlargement 
 of the viscus. Tuberculosis of the portal canals, however, may give 
 rise to an overgrowth of connective tissue, and cause one of the 
 forms of hj'pertrophic cirrhosis of the liver. 
 
 Tuberculosis of the kidney occurs in two distinct forms. In 
 
TUBERCULOSIS 229 
 
 the general complaint gray miliary tubercles, or small caseous 
 masses, are scattered throughout the kidneys, more especially in the 
 cortical portions, to which the capsules are generally adherent. In 
 the other form the lining membrane of the hilum is the seat of 
 varying degrees of ulceration and caseation (tuberculous pyelitis), 
 which lead on gradually to the destruction of the kidney. From 
 the kidney the disease spreads to the ureter, which may be lined 
 with caseous material throughout its whole course, and from the 
 ureter the disease may spead by continuity to the bladder. The 
 kidney is more or less enlarged in a large majority of cases of 
 tuberculous pyelitis, and when the ureter is blocked by the caseation 
 there may be a condition of pyo-nephrosis. Only one kidney may 
 be affected, and when both are attacked one is generally much more 
 affected than the other. 
 
 Tuberculosis of the bladder is extremely rare as a primary 
 manifestation, and is generally secondary to tuberculosis of the 
 testicle or the kidney. 
 
 Tuberculosis of the testis^ apparently primary in origin, is far 
 from uncommon. Here it attacks the epididymis, and an indolent 
 tumour is formed which almost completely surrounds the testicle. 
 In adults and older children the disease has a great tendency to 
 extend by means of the spermatic channels to the vesiculas seminales, 
 the prostate, the bladder, and even up to the kidneys. In children 
 under the age of seven the disease usually confines its ravages to 
 the epididymis itself, and a chronic abscess often forms which bursts 
 through the scrotal walls. 
 
 Next to the lymphatic glands, the bones and joints are the most 
 frequent sites of the localised complaint in childhood. The spongy 
 portions of the bones are the parts chiefly affected, and in the 
 long bones it is the epiphyses entering into the formation of the 
 joints that are mainly involved, leading to necrosis of the cartilages 
 and infection of the lining membranes, along with destructive 
 changes in the joints of a greater or less severity. In the spinal 
 column the contiguous surfaces of adjacent vertebrae are commonly 
 affected, and it would seem as if the disease had started in the inter- 
 vertebral cartihiginous discs, but owing to the non-vascularity of the 
 latter such an origin is unlikely. In the joints the complaint may 
 start in the membranes instead of being an extension from diseases 
 of the bones. Cases commencing in disease of the membranes are 
 usually more chronic in their course than those beginning in disease 
 of the bones. 
 
 It is not uncommon for cases that have for a lona; tmie been 
 
230 MANUAL OF MEDICINE 
 
 essentially of the chronic and localised form to suddenly take on 
 an acute and generalised character, owing to the entrance of the 
 virus into the general blood stream. Such an occurrence is usually 
 marked by an access of fever and bodily distress, apart from any 
 symptoms arising from the implication of fresh organs in the com- 
 plaint. The generalised form may even follow upon such purely 
 local conditions as tuberculous disease of the bones. 
 
 The distribution of |ubercle in the different organs in the general- 
 ised disease is one of scientific interest rather than one of practical 
 importance. Many published lists differ widely in their estimation 
 of the frequency with which the different organs are involved, and 
 this is bound to be the case where so much depends upon the indi- 
 vidual care and upon accuracy of observation. All statistics, however, 
 agree upon the rarity with which the lungs escape. This is doubtless 
 owing to the fact that in extension from most parts of the body, 
 whether directly by the blood vessels or indirectly by means of the 
 thoracic duct, the bacilli have to pass ultimately through the capil- 
 laries of the lungs. Out of sixty-three cases of general tuberculosis, 
 tabulated by Dr. Shardlow at the East London Children's Hospital, 
 in only five were the lungs recorded as free, and in two of these five 
 the bronchial glands were caseous. Of the remaining three, in one 
 the tubercles were almost confined to the pleura, pericardium, peri- 
 toneum, and meninges ; in one the peritoneum and meninges were 
 chiefly affected ; and in one there was ulceration of the intestines, 
 with caseation of the mesenteric glands. It is noteworthy that, in 
 all the sixty-three cases, in one only the disease seemed to have its 
 primary origin in the intestinal membranes. In the same cases the 
 liver was recorded as tuberculous in thirty-one instances, or about 
 fifty per cent. This possibly understates the percentage of cases of 
 involvement of the liver, as in that organ the tubercies are often so 
 microscopic in size that they are overlooked. The frequency of 
 tuberculosis of the liver is no doubt due to the virus being carried to 
 it from the other abdominal organs by the portal vein. 
 
 Influence of age and sex. — General tuberculosis is infinitely 
 more common during the first two years of life, and there is a 
 lessening tendency to it wnth each year of life up to the age of 
 puberty, after which it is comparatively rare. Tuberculosis of the 
 bones and joints, the lymphatic glands, and to a less degree the 
 testicles, is most frequent in childhood, but is far from uncommon 
 in adult age. Chronic pulmonary tuberculosis is uncommon under 
 the age of seven, but the tendency to it increases with every year 
 up to the age of puberty. It is most frequent between this last 
 
TUBERCULOSIS 231 
 
 and the age of twenty, and after this decreases with each decade of 
 life, until it becomes comparatively rare after the age of forty as a 
 primary complaint, and extremely so after that of sixty. Tuberculous 
 meningitis is rare under the age of six months, and is most common 
 between this age and that of puberty ; but it is much more common 
 in adults than is generally supposed. As a whole it may be taken 
 that tuberculosis is commonest in childhood and early adult life, 
 but there is hardly a single phase of it that may not occur in 
 extreme old age. 
 
 There are no reliable statistics showing that there is any marked 
 tendency to tuberculosis in the one sex over the other. It is the 
 general experience that the progress of tuberculosis is frequently 
 arrested during pregnancy, to develop with increased virulence after 
 parturition. 
 
 Contagiousness. — There is no certain proof that tuberculosis 
 is contagious in the ordinary sense of the term ; but that one person 
 can indirectly contract the disease from another is incontestable. 
 From the wide prevalence of tubercle bacilli, both in the air and 
 articles of food, it would appear that less importance should be 
 attached to its mere presence, and more to the element of predis- 
 position to the disease. That the members of certain families are 
 specially prone to the disease is indubitable, but this is due, not to 
 the direct transmission of the virus, but to a hereditary susceptibility 
 to contract the complaint, or, more strictly speaking, to a lessened 
 resistance to its attack. This susceptibility may not only be inherited, 
 but acquired. It is principally acquired by those persons in whom 
 the general health is reduced, and especially by those in whom the 
 respiratory functions are placed at a disadvantage. Thus tuberculosis 
 is most common amongst the inhabitants of over-crowded dwellings, 
 in those breathing the vitiated air of factories, and in those exposed 
 to the inhalation of finely divided dust. Chronic alcoholic excess 
 is also an important predisposing cause. There is not only a pre- 
 disposition on the part of certain individuals to acquire the complaint, 
 but in some of these the vulnerability to the disease may rest only 
 in particular tissues of the body. It is only by the conception that 
 the vulnerability is restricted to certain tissues that an explanation 
 can be found of the simultaneous affection of several of the serous 
 membranes in the same individual, in whom the rest of the tissues 
 escape. Again, it is not uncommon for many of the bones of the 
 body to suffer from tuberculosis, either simultaneously or after long 
 intervals of time, with no evidence of the disease in other parts. 
 This susceptibility on the part of particular tissues may be inherited, 
 
232 MANUAL OF MEDICINE 
 
 and it is not unusual for the members of certain families to die 
 mainly from the effects of the complaint on the cerebral meninges, 
 whilst in other families the chief stress always falls on the lungs or 
 abdominal organs. 
 
 Curability. — Acute general tuberculosis is invariably fatal. 
 The same fatal prognosis attaches to tuberculous meningitis, as 
 cases of recovery are too exceptional to afford any reasonable 
 grounds for hope when the disease is well marked and unmistak- 
 able. The majority of cases, indeed, of reported recovery from 
 tuberculous meningitis, as Henoch has pointed out, have probably 
 been examples of croupous pneumonia with cerebral symptoms 
 where the diagnosis has been at fault ; or of pneumococcal menin- 
 gitis secondary to the lung affection. Cases of the more chronic 
 form of general tuberculosis, even where there is evidence of many 
 organs being involved, may undoubtedly recover temporarily, but 
 only too often the disease recurs with a fatal termination. Still, 
 there is no proof that all such cases relapse, and the fact that 
 temporary recovery is possible affords reason for belief that in 
 exceptional instances recovery may even be permanent and complete. 
 In most other cases, except perhaps when the disease is far advanced 
 in the lungs or intestines, tuberculosis is far from necessarily fatal, 
 and complete recover}' may occur. Yer)' often post-mortem examina- 
 tions reveal the presence. of unexpected tuberculous lesions which 
 had long been recovered from and become obsolete, and in many 
 such cases there is no history of the patient having at any time 
 suffered from tuberculosis. In numerous instances, too, tuberculous 
 disease is apparently recovered from, but only to recur again shortly 
 after the onset of more acute disease, such as one of the exanthe- 
 mata. Measles, in particular, is frequently responsible for relighting 
 up quiescent tuberculosis, and this in a manner beyond its mere 
 power of setting up a catarrhal state in numerous regions. Some 
 authorities, too, state that surgical operations often convert a localised 
 tuberculosis into one of the generalised form, but the alleged fre- 
 quency of this occurrence is not, perhaps, in accord with general 
 experience. 
 
 Clinical symptoins. — In every case where there is any wide 
 distribution of tuberculous disease fever is a marked feature of the 
 complaint. The fever, too, is specially characterised by its irregular 
 nature. In some cases the temperature is high in the mornings with 
 evening remissions, and in others it is heightened in the evenings 
 with remissions nearly to the normal in the mornings. These two 
 types of temperature, again, may be present in the same case at 
 
TUBERCULOSIS 233 
 
 different stages of the disease. Death may ensue from the general 
 condition, apart from any disease special to the organs involved ; and 
 here the heightened temperature may be the only prominent symptom 
 during life. In the majority of cases, however, the fever is accom- 
 panied by profound pallor, and rapid wasting from no obvious cause. 
 
 Where death is delayed, in addition to fever and wasting, there 
 are often symptoms arising from the implication of special organs in 
 the complaint. Of these last, the lungs undoubtedly most often 
 furnish evidence of being attacked. It must not be forgotten, how- 
 ever, that the lungs may be extensively riddled with tubercles where 
 the physical signs are healthy both to auscultation and percussion. 
 In other cases the only evidence of extensive involvement of the 
 lungs may be high-pitched, somewhat metallic rales audible generally 
 over the chest. Where the disease is of longer standing, there may 
 be the physical signs of more or less extensive consolidation of the 
 lungs j and it is noteworthy that such consolidation is most frequent 
 at the bases instead of at the apices, as it is in the chronic and 
 localised forms of the complaint. In exceptional instances signs of 
 softening and cavitation may follow upon those of consolidation in 
 the affected lungs. 
 
 Next to the lungs the nervous system most frequently shows 
 signs of special implication in the disease, and many patients with 
 general tuberculosis die with head-retraction, vomiting, and pro- 
 gressive coma, the results of meningitis, as the only prominent 
 evidences of the widespread complaint. 
 
 In a minority of cases the chief stress of a general tuberculosis 
 falls upon the abdominal organs, and the victims may die apparently 
 from the effects of a protracted and incurable diarrhoea. In rare in- 
 stances rose spots, indistinguishable from those of enteric fever, may 
 occur upon the abdominal walls, and it has been asserted, but on no 
 reliable grounds, that such spots in tuberculous subjects are in- 
 variably associated with disease of the intestines. The spleen is 
 generally enlarged, and this splenic enlargement is often the earliest 
 physical sign of general tuberculosis. In young infants, who are 
 much wasted, hsemorrhagic staining is common upon the abdominal 
 walls and elsewhere, but such staining may occur in wasting from 
 other complaints besides tuberculosis, although it is, perhaps, most 
 marked in the last. 
 
 In many cases the resemblance of the symptoms of acute 
 general tuberculosis to those of enteric fever may be very marked, 
 and in the early stages of the two complaints it may be extremely 
 difficult, if not impossible, to distinguish between them. In tuber- 
 
234 MANUAL OF MEDICINE 
 
 culosis, however, the temperature seldom assumes the regular rise 
 and daily variations characteristic of enteric fever ; the tongue, as a 
 rule, is less furred ; if diarrhoea be present the stools very seldom 
 present the typical appearance of those that occur in enteric fever ; 
 wasting takes place earlier and is more rapid ; and there is a greater 
 tendency to early and progressive coma. All these distinctive signs, 
 however, may fail us ; and then valuable assistance may be derived 
 from the serum test. 
 
 It must be remembered that the presence of tubercle favours 
 invasion by staphylococci, streptococci, and other organisms, and 
 that such mixed infection is frequently met with, contributing its 
 own symptoms to the general morbid manifestations. 
 
 Duration. — In cases of acute general tuberculosis death is 
 seldom protracted beyond the limits of three weeks or a month. 
 The same time may be fixed as the limit of the course of cases of 
 tuberculous meningitis. The duration of the less acute cases of 
 general tuberculosis is usually to be reckoned by months rather than 
 by years. In most other phases of the complaint the duration is 
 dependent on so many factors that no possible general rule can be 
 adduced. When the disease is restricted to non-vital parts death 
 may be indefinitely postponed, and, when it occurs, is usually due 
 to the supervention of acute tuberculosis or to the lessened resist- 
 ance to other complaints induced by the original disease. 
 
 Treatment. — In the light of our present knowledge the 
 prognosis of general tuberculosis is hopeless, and treatment is 
 practically unavailing. The utmost that can be done in this last is 
 to control temperature, to check convulsions and diarrhoea, and to 
 relieve pain. The hopes founded on tuberculin a few years back 
 proved a failure, and its use in many cases was a source of danger, 
 if not of positive harm. A small minority of cases, however, im- 
 proved temporarily under this agent in the most striking manner. 
 It is, perhaps, in the direction of the discovery of a more perfect 
 tuberculin, or some serum remedy, then, that hopes should rest 
 in the future treatment of the established disease. If at present 
 nothing can be done in the way of cure, much can be done in the 
 way of prevention. Improved hygiene, especially the ensurance of 
 abundance of fresh air, and the non-exposure of the predisposed to 
 sources of infection, would guard many a one from the disease. 
 The services of the surgeon, too, might be more often employed 
 in the removal of scrofulous glands than is the present custom, to 
 prevent the spread of the virus to more vital parts. 
 
 . . J. A. COUTTS. 
 
LEPROSY 235 
 
 LEPROSY 
 
 A chronic specific disease tending to a fatal issue, the result of 
 infection by the bacillus leprce. ; characterised by the formation of 
 granulomatous infiltrations of the skin and of certain nerves and 
 viscera, which induce functional irregularities and trophic changes 
 in the parts affected. 
 
 The names "elephantiasis grsecorum " and "lepra," which have 
 been applied to the malady, are liable to lead to confusion. The 
 former is apt to be confounded with the filarial disease elephantiasis 
 arabum, or true elephantiasis, and the latter is a term employed by 
 Willan to designate a disease having nothing in common with leprosy 
 except a cutaneous resemblance. Leucoderma, a common condition 
 more particularly amongst the yellow races, has, owing to the Biblical 
 phrase, " a leper as white as snow," come to be viewed with suspicion 
 without any reason. 
 
 History. — Leprosy seems to have existed among all the ancient 
 peoples of the earth who have recorded their histories, whether 
 Egyptians, Jews and their neighbours, Hindoos or Chinese. It may 
 fairly be assumed also to have existed amongst many other less 
 literary races of the earth, from what we know of them at the 
 present day. Although leprosy is chronic in nature, but slightly 
 contagious, and but slowly infectious, it would seem that the tide of 
 its intensity flows and ebbs, and that waves of the disease pass 
 over portions of the world at long intervals. In ancient and medi- 
 aeval times we find countries at one time free from leprosy being 
 invaded and again purged of the disease. Greece, previously free, 
 seems to have been attacked about 400 B.C., as intercourse with 
 Egypt increased, and the Crusaders appear to have been responsible 
 for leprosy reaching Western Europe, where, after establishing itself 
 for some 300 or 400 years, it subsequently receded, until at the 
 present day it is all but extinct. On the other hand, in modern 
 times, we find leprosy reaching countries never before visited ; of 
 these the Hawaiian group of islands is the most marked example. 
 Some fifty years ago the disease was unknown in these remote 
 Pacific Islands, but now it is the most grievously affected part in 
 the world. 
 
 Geographical distribution. — At the present day lepers are met 
 with in increasing numbers as the equator is approached, and its 
 
236 MANUAL OF MEDICINE 
 
 presence is in inverse ratio to sanitary advance. There is perhaps 
 no country in Europe, Asia, or Africa quite free from the malady. 
 Of European countries the British Isles contain perhaps the fewest, 
 and Norway, in proportion to population, perhaps the greatest 
 number of lepers. In Asia two great leprous centres exist, viz. 
 Northern India and Southern China. Siberia, Japan, the Malay 
 Peninsula, Cochin China, Arabia, Syria, the great islands of Java 
 and Sumatra, and many, but by no means all, of the islands of the 
 Eastern Archipelago are tainted. Australia has lepers within its 
 seas, but they are for the most part Chinese, as are the majority of 
 lepers in the Pacific Archipelago. 
 
 Africa, North, South and Central, has lepers amongst its varied 
 peoples. In the best known parts they are fairly numerous, as 
 Egypt in the north and as Robin Island off Cape Colony with its 
 leper settlement testify. In the western hemisphere the same law 
 holds good, namely, that as the equator is approached the number 
 of lepers increases, and in tropical America and the West Indian 
 Islands the disease is prevalent. 
 
 Etiology. — The bacillus leprce is the one pathological factor in 
 leprosy which requires to be discussed. Before its discovery in 
 187 1 the supposed causes of leprosy were multitudinous. Amongst 
 these, want of salt, malaria, unwholesome food, scrofula and tuber- 
 culosis, syphilis, scurvy, anaemia, etc., each had its advocates. Mr. 
 Hutchinson's theory that the consumption of uncooked fish is the 
 vehicle of contamination in leprosy has been neither proved nor 
 disproved, and many arguments for and against the idea may be 
 adduced. Heredity finds believers and disbelievers. Against the 
 transmission of leprosy from parent to child is the fact that no child 
 is born leprous, and that the suckling of a leprous mother does not 
 exhibit signs of leprosy. It is seldom before the third year that a 
 child so brought up becomes leprous, and the appearance of the 
 symptoms may be delayed until the period of puberty. All clinical 
 evidence points to prolonged and intimate contact as being the real 
 channel of transmission. From husband to wife, or vice versa ; from 
 one member of a family to another, more especially when sleeping 
 together ; from mother to child, especially if the child is breast fed ; 
 from the native leper to the healthy European, if occupying the same 
 bed for a time ; and by sexual intercourse, are some of the more 
 direct means of conveying the contagium from one person to another. 
 And yet intimate contact is not certainly provocative. The writer 
 saw a woman, married to three leper husbands in succession, and 
 living among lepers, in the leper village in Canton, who was perfectly 
 
LEPROSY 237 
 
 free from any leprous taint or mark. A number of such cases are 
 on record, showing that leprosy is by no means highly contagious or 
 infectious : in fact, many deny the propagation of leprosy by contagion 
 at all. It would appear that leprosy is on a level, in this point, as 
 in many others, with tuberculosis, and just as tubercle is occasionally 
 conveyed from one person to another, so it would seem leprosy is 
 transmissible. 
 
 Bacteriology. — The microbes of tuberculosis and leprosy are 
 closely allied in their microscopic appearance and in their reactions 
 to staining fluids. Specimens of the bacillus leprae can be readily 
 obtained during life from a leprous nodule or anaesthetic patch 
 which has been rendered bloodless by being slowly compressed 
 between the blades of a clamp or forceps. When the pale surface 
 is pricked by a needle in several places, a clear lymph-like fluid 
 freely exudes from the punctures. Specimens of the bacillus can 
 be obtained in pus issuing from an ulcer, in the sputum when the 
 disease affects the mouth or larynx, and Horder {Jourtial of Trap. 
 Medicine, Oct. 1899, p. 68) has shown that the microbe is also 
 found in the blood, where it occurs chiefly in the leucocytes but 
 now and again in the plasma. 
 
 Post - mortem specimens of the leprosy bacillus are readily 
 obtained from any leprous granulomatous tissue. The skin, the 
 nerve sheaths, the lymphatic glands, the liver and spleen, are richly 
 endowed ; but in lesser luxuriance it is also present in the ganglia of 
 the spinal cord, in the endothelium of the blood vessels, and in the 
 liquor sanguinis or leucocytes of the blood. The bacillus has not 
 been proved to exist in bone, muscle, cartilage, the tissues of the 
 brain, the walls of the alimentary canal, the kidneys or urine. 
 
 The following method of staining the bacillus in the blood, recom- 
 mended by Horder, gives excellent results : — After making cover-glass 
 preparation, dry, float the specimens in cold carbol-fuchsine solution for 
 twenty-four hours, wash, pass through 2 5 per cent sulphuric acid, wash 
 again, dry and counter-stain with methylene blue. 
 
 The bacillus of tubercle and leprosy are so similar that their 
 descriptions are well-nigh identical (see p. 220, and Plate II.). In 
 one or two points only are they to be differentiated. {a) The 
 bacillus leprae when stained is decolorised less readily by acids ; {b) 
 the microbe in leprosy occurs almost wholly within the tissue cells, 
 in marked contrast to the extra-cellular disposition of the tubercle 
 bacillus ; {c) the bacilli in leprosy tend to become aggregated in 
 colonies. 
 
238 MANUAL OF MEDICINE 
 
 The microscopic appearance of the bacilli in leprosy is typically 
 a straight rod, but, just as in tubercle, club-shaped and branched 
 forms are found. Until the present year no positive evidence of 
 the sustained cultivation of the leprous bacillus has been known. 
 Dr. Bevan-Rake and the writer both reported having obtained 
 single cultivations on agar-agar in 1893, but Dr. Carrasquilla of 
 Bogota asserts that he has successfully cultivated the bacillus 
 leprae in solidified human serum and on beef bouillon prepared 
 according to the method of Thouiot and Masselin {^British Medical 
 Joiirn. July 1899). Dr. Carrasquilla cultivated the bacillus from 
 serum to serum and bouillon to bouillon, pure cultures always 
 being obtained. The same observer says that he noticed the 
 ba'illus to be mobile in two stages of its development \ one form 
 consists of long, slender bacilli moving in an undulatory manner ; 
 and the other form occurs as short, coarse, almost elliptic bodies 
 moving in a straight line. Further, Dr. Carrasquilla believes he 
 observed flagella proceeding from the shorter bacillus. Professor 
 Campagna of Rome states that he has also cultivated the bacillus 
 leprae. 
 
 So far it has been found impossible to produce the signs of 
 leprosy in any lower animal by inoculation. 
 
 Period, of incubation. — This appears to be most variable. 
 Symptoms would seem to have first manifested themselves in a few 
 weeks, or it may be many years, after exposure to infection. 
 
 Symptoms. — For months or even years before leprosy declares 
 itself the patients may suffer from general debility, febrile attacks, 
 exhaustion after exertion, rheumatic pains in the muscles, neuralgia 
 in certain nerve areas, epistaxis, sweatings, and marked mental 
 depression. Occasionally there is complete absence of all pre- 
 monitory symptoms. 
 
 The division of leprosy into "nodular" and " ansesthetic " is a 
 mere clinical convenience, since in all cases of nodular leprosy there 
 is an accompanying affection of the nerves and attendant anaesthesia. 
 The attempt to multiply names by giving prominence to a mere sign 
 or symptom is neither scientific nor useful; such names as "nerve 
 leprosy, "macular leprosy," "lepra Isevis," etc., are of this nature 
 and do not assist our knowledge of the disease. For clinical con- 
 venience, however, the division into " maculo-anassthetic " and 
 "nodular" aids description, although these forms are liable to 
 overlap. 
 
 I. Lepra maculo- an-Esthetica. — The first characteristic 
 symptom which appears is an erythematous or pigmented eruption 
 
LEPROSY 239 
 
 on the skin. The spots develop gradually or suddenly, accom- 
 panied by marked fever. All the spots become in time pale and 
 anaesthetic in the centre, and possess a zone of red and blue 
 vessels at the circumference, which is somewhat elevated. The 
 spots vary in size from a diameter of a quarter of an inch to that 
 of a crown piece, but after a time they may coalesce and embrace 
 a large irregular area, the margins of which continue to extend 
 until, it may be, the whole circumference of the limb is involved. 
 Frequently the eruption is symmetrical, remarkably so, but this is 
 by no means a constant feature. In the very early stages the 
 centres of the affected areas become hypersesthetic. The eruption 
 may be seen first on the chest, but the limbs and face are 
 very soon involved. The nerves along their trunks and in the 
 area of their distribution show signs of implication in the patho- 
 logical lesion. Neuritis increases as the disease advances, and 
 in such palpable nerves as the ulnar and peroneal, where they 
 cross the bones, they are to be felt thickened and are painful to 
 pressure. In consequence of the neuritis, neuralgia supervenes, 
 succeeded by anaesthesia and trophic changes in the part. Bul- 
 bous eruptions appear on the skin, the hair falls, the sweat glands 
 become functionless, the nails become brittle, the joints of the 
 fingers especially become swollen and tender, the tendons of the 
 fingers and toes contract, and the muscles of the forearm, hand, 
 legs and feet, atrophy and become paralysed. Facial paralysis may 
 render shutting the mouth and eyelids impossible. The muscular 
 paralysis is in no sense ataxic, as lepers can use even their damaged 
 hands for fine work, and their power of walking, although weakened, 
 is not affected when their eyes are closed. In time ulcers appear on 
 the parts of the sole of the foot subjected to most pressure ; the 
 ulcers may be shallow, or may penetrate to the bones causing 
 necrosis. In the hands also a similar condition obtains, and nothing 
 is more common than to find a leper severely scalded in consequence 
 of his putting his anaesthetic hand into very hot fluids. In the hands 
 and feet the bones may atrophy, necrose, and exfoliate, so that mere 
 stumps are left at the wrist or ankle. In this condition the patient 
 is a piteous object, and the forlorn aspect is added to by the 
 expressionless face, by the drooping eyelids and lower lip, the 
 epiphora consequent upon the everted puncta, and it may be the 
 loss of an eye from ulceration and giving way of the cornea owing 
 to exposure of the eyeball. Towards the end smell and taste may 
 be lost, gastric catarrh and diarrhoea are common, albuminuria may 
 supervene, or pulmonary tuberculosis may carry off the patient. 
 
240 MANUAL OF MEDICINE 
 
 II. Lepra tuberosa. — The exact period at which tubercular 
 or nodular leprosy comuiences in any single individual is well-nigh 
 impossible to ascertain. A few scattered nodules may exist for 
 years, and the patient may either conceal them or be unaware of 
 their significance. After a time, however, a fresh crop of nodules 
 appears, and the process is repeated at longer or shorter intervals. 
 Accompanying each eruption the patient is attacked by rigors and 
 fever, which may reach 103° or 105° F., and last a day or two. 
 With each fresh eruption the old nodules soften and may com- 
 pletely disappear. 
 
 This disappearance of old nodules with the formation of new, 
 accompanied in every case by fever, suggests that during the process 
 the bacilli leprae are absorbed and re-deposited, giving rise to auto- 
 infection. There are several arguments in favour of this assump- 
 tion as to the manner of the spread of the leper bacillus or its 
 products in the body. Leprous nodules vary in size from a grain 
 of rice to a chestnut, or even half a fair-sized orange. They feel 
 hard and inelastic, and attain a yellowish tint when of some 
 standing. They are usually met with in the exposed parts of the 
 body, viz. the face, back of hands and wrist, and the fronts of the 
 legs, but afterwards they may appear anywhere except on the glans 
 penis, the palms of the hands, the soles of the feet, and the scalp. 
 The eyebrows, forehead and cheeks, early present signs of infiltra- 
 tion, but every part of the face may be so thickened and reddened 
 that a " leonine " aspect ensues. The ears become thickened and 
 discoloured ; the eyelids become nodular ; the eyes suffer from 
 keratitis or iridocyclitis, resulting in loss of sight. The mucous 
 membrane of the nose is infiltrated and leads to destruction of that 
 part of the nose supported by cartilage. The mucous membranes 
 of the cheek, tongue, gums, pharynx and larynx become infiltrated 
 and nodular, leading to ulceration and possibly partial paresis of 
 the laryngeal muscles. 
 
 The lymphatic glands in anatomical relation with the affected 
 parts in both nodular and maculo-angesthetic leprosy are always 
 somewhat enlarged, although they never suppurate. The nerves in 
 nodular leprosy, as in the maculo-ansesthetic, are subject to infil- 
 tration and neuritis, with consequent neuralgia, but this lesion 
 develops later in the former than in the latter disease. The testicle, 
 liver, and spleen, are always the seat of leprous infiltration in the 
 nodular variety; the testicular tissue becoming wholly atrophied, 
 and supplanted by fibrous material. As the disease advances nodules 
 come and go, but the actual number increases with each attack of 
 
LEPROSY 241 
 
 fever. These eruptions and attacks of fever may supervene every 
 few years, then every year, or several attacks may occur yearly. 
 The nodules may, however, become stationary and ultimately burst, 
 ulcerate, and then heal, leaving a scar. In the course of time 
 ulceration often leads to lardaceous degeneration, or tuberculosis 
 ensues, and is finally fatal after some eight or ten years. 
 
 The nodules of leprosy, when cut into, appear white and homo- 
 geneous, and the tissue beneath the microscope is seen to consist 
 of round, epithelioid and spindle-shaped cells, and scattered amongst 
 the cellular elements, connective tissue and a few blood vessels. 
 
 Diagnosis. — The nodular variety of leprosy is usually so pro- 
 nounced in character that there is but little chance of any mistake 
 arising. Large nodules, however, when few in number, are some- 
 times mistaken for Keloid growths, or, again, the nodules may be so 
 small that only by microscopic examination and finding the bacillus 
 can a decided opinion be given. The maculo-ansesthetic form of 
 the disease in the commencing stages is more difficult to diagnose, 
 but the early anaesthesia and the lymphatic gland enlargement are 
 usually sufficient to determine its character. Charcot mentions and 
 differentiates between the lesions of syringo-myelia and leprosy. 
 As in the former there are neither maculae, thickened nerve trunks, 
 nor enlarged glands ; there is no occasion for confusion to the 
 careful observer. Tertiary syphilis perhaps exhibits lesions which 
 resemble some leprous conditions more closely than any other 
 disease. The means of diagnosis, however, is always at hand, 
 namely, the demonstration of the lepra bacillus. 
 
 The leper is subject to many skin affections which may obscure 
 the real disease. Scabies is a common accompaniment, but eczema, 
 lichen, psoriasis, etc., are often met with. 
 
 Prognosis. — Leprosy is essentially a chronic disease, but 
 occasionally, owing to rapid exhaustion of strength, some fatal 
 intercurrent affection supervenes within a year or two. Nodular 
 leprosy is much more acute than the maculo-anaesthetic variety ; the 
 average lifetime of the leper afflicted with the former, after the 
 malady declares itself, is eight to ten years. But in the case of the 
 latter, Jife may be prolonged for a period of fifteen to twenty or 
 even forty years. 
 
 The patient succumbs usually to phthisis, pneumonia, nephritis, 
 or amyloid degeneration of the viscera. So-called spontaneous 
 cure is recorded, but it would seem to be merely a cessation of 
 infection, the nodules disappearing to be succeeded by a scarred 
 anaesthetic patch. " In the maculo-anaesthetic form the cure of the 
 
 VOL. I R 
 
242 MANUAL OF MEDICINE 
 
 leprosy is almost invariably the result " (Hausen and Looft). On 
 excellent authority it would seem that leprosy may disappear and 
 leave a healthy man, but the rule is that a maimed and mutilated 
 being is left to continue a miserable existence. 
 
 Treatment. — There is no specific treatment for leprosy ; many 
 drugs have been announced as such, but a temporary reputation is 
 all that any one of them has attained. The destruction of the 
 bacillus, either by medicinal or hygienic treatment, is what has to 
 be aimed it. With this intention Unna introduced pyro-gallol and 
 chrysarobin and Dr. Danielssen the salicylates. The ointment 
 employed by Unna for application to the body consists of: — 
 chrysarobin, 5 per cent ; salicylic acid, 2 per cent ; ichthyol, 5 per 
 cent; lard to 100. When the ointment is for the face Unna re- 
 commends pyrogallic acid, 6 parts ; salicylic acid, 2 parts; ichthyol, 
 5 parts; lard to 100 parts. The administration of 10 drops of 
 acid hydrochloric dil., twice or thrice daily, counteracts the 
 deleterious action of the pyrogallic acid. The writer had very 
 gratifying results in numbers of cases of leprosy treated in this 
 manner. Chaulmoogra oil has attained a considerable reputation ; 
 10 drops and upwards are given in milk twice daily ; and externally 
 it is applied with olive oil (i in 16) as an embrocation, which is 
 allowed to remain on the skin for some hours and then washed off 
 with soap and water. Gurjon oil has been employed in a similar 
 manner. 
 
 Dr. Danielssen's treatment is perhaps the most satisfactory. 
 The general health of the patient is first improved by good food, 
 and the administration of cod-liver oil, iron and quinine. When 
 the general condition is fairly good 15 grains of salicylate of soda 
 is administered three or four times a day. The dose may be 
 gradually increased, and its use continued for six or twelve months. 
 
 The writer has employed almost every drug recommended for 
 leprosy by the Chinese, but with no marked benefit ; and besides 
 these creasote, phosphorus, arsenic, mercury, aristol, naphthol, 
 and salol, etc., with similar unsatisfactory effects. 
 
 Koch's tuberculin was first tried by the writer on an extensive 
 scale, as many as fifteen lepers being under treatment at a time. 
 A certain number responded to the treatment, but in a few no effect 
 was produced. In some the effect was most marked, almost all 
 cutaneous signs of leprosy disappearing after the initial fever had 
 subsided. In several cases coolies who suffered from leprosy, and 
 who had been driven off by their fellow-labourers from working 
 alongside of them were, after treatment by tuberculin, received back 
 
MYCOSES 243 
 
 amongst them as "cured." Unfortunately the beneficial effects 
 were transitory. 
 
 A curative serum has been prepared and employed, but, so far, 
 with dubious results. 
 
 Surgically the leper may require : — to have tracheotomy per- 
 formed ; operations for ectropion, iridectomy, etc. • removal of dead 
 bone when the bones of the hands and feet necrose ; nerve stretching 
 in cases of anaesthesia, etc. When the nerve trunk supplying a 
 paralysed area is stretched and incised longitudinally, the sensation 
 may return and the muscular power reappear for a time. 
 
 Prophylaxis. — Complete segregation of lepers with separation of 
 the sexes is the only known system whereby the spread of leprosy 
 may be held in check. 
 
 James Cantlie, 
 
 MYCOSES 
 
 In addition to animal and bacterial parasites the human body 
 is liable to be attacked by a number of vegetable parasites, and 
 more especially by certain fungi ; and although, strictly speaking, 
 bacteria belong to the vegetable- kingdom, it is convenient to dis- 
 tinguish the diseases due to bacterial invasion from those dependent 
 on the parasitic activity of fungi and other similar organisms. 
 
 The number of fungi that are found either associated with or 
 actually causative of pathological lesions in man is daily increasing. 
 It has long been known that certain skin diseases are dependent on 
 the presence of these organisms, but it is only comparatively recently 
 that other diseases have been found to be associated with or de- 
 pendent on the presence of such vegetable parasites as the fungi. 
 
 The most important of these maladies are those known as 
 actinomycosis and aspergillar mycosis, but it is convenient to give 
 the name of mycosis to the entire group, including under this such 
 diverse affections as various forms of dermatitis, otitis media, and 
 possibly certain tumours. 
 
 Various species of Blastomycetes (saccharomyces) have been found 
 associated with a number of inflammatory states usually chronic in 
 character, such as otitis, less often running a definite pyemic course. 
 Further, these fungi have been found in other conditions besides 
 inflammation. Thus a cystic growth of the tibia has been recorded 
 
244 MANUAL OF MEDICINE 
 
 where the broken-down material in the cyst contained a large 
 number of saccharomyces, and in this case a general pya^mic 
 infection occurred and the metastatic foci contamed the same 
 organism. 
 
 Several observers have described the presence of yeast -like 
 organisms (blastomycetes) in malignant growths, both sarcomatous 
 and carcinomatous. In many of the cases of inflammatory lesions, 
 and perhaps in some of the malignant cases, the presence of the 
 fungus may be due to accidental causes and to secondary infection, 
 the fungus being a saprophyte and not the cause of the lesion. In 
 others, however, it is apparently definitely parasitic and pathogenetic, 
 since the inoculation of animals with a culture of the fungus has 
 led to the formation of similar lesions to those occurring in the 
 human subject. In addition to various species of blastomycetes, 
 Mucor, Penicillmm, Aspergillus, and other fungi have been found 
 associated with a variety of pathological states, both in the human 
 subject and in warm-blooded animals. The spores of Penicillin m, 
 when injected experimentally into animals, cause not only emboli, 
 but a mycelium is under certain circumstances produced, which 
 extends inside the vessels and passes through their walls into the 
 adjacent tissues, and its presence here is asserted to cause a fatty 
 and granular degeneration of the tissues, and death may result. 
 
 The infection caused by some of these fungi, and more especially 
 that produced by actinomyces and aspergillus, is characterised by 
 the formation of granulomata which resemble superficially those 
 produced by the virus of syphilis, or tubercle, or glanders ; the last 
 two disorders at any rate are definitely proved to be of microbic 
 origin, and thus the lesion produced by the fungi resembles that 
 produced by certain microbes ; but whereas the microbes produce, 
 in addition to granulomata, toxins which often exe:t a poisonous 
 effect on the body at large, the fungi apparently produce all their 
 pathological effects either mechanically or by interfering with the 
 oxidation of the tissues, and there is no evidence either in the case 
 of actinomycosis or of aspergillar mycosis of the production of any 
 toxin. 
 
 The most important mycoses clinically are actinomycosis, madura 
 foot and aspergillar mycosis. 
 
 Actinomycosis 
 
 Actinomycosis is an infectious malady characterised by the 
 formation of granulomata, affecting man and many domestic 
 
MYCOSES 245 
 
 animals, and is dependent on the growth of an organism belonging 
 to the genus Oospora according to some authors, but it is more 
 usually described as a species of Streptothrix. The disease is more 
 especially prevalent in cattle, the jaws and tongue being the parts 
 most frequently affected, but it is also found widely disseminated 
 in the internal organs. It is rare in horses and donkeys, and occurs 
 occasionally in the pig and sheep. In some herds of cattle it has 
 been observed to the extent of 8 per cent, and it is said to be 
 especially prevalent in the fen country. 
 
 In the human subject from 50 to 80 per cent of the cases 
 attack primarily the cervico-facial region, including the mouth. The 
 abdomen and chest are next most frequently affected, and the skin 
 and limbs are the least often involved. 
 
 Histology. — The actinomyces occur in the form of yellowish- 
 green grains, the largest of which are the size of a pin's head, and 
 of rather irregular oval or reniform outline. These are found in the 
 depths of the tissue affected and also in the pus. Each grain con- 
 sists of a central portion composed of a mycelium, and at the 
 periphery are found the characteristic clubs arranged more or less 
 irregularly. In addition to these, spores of i to 2 /a are scattered 
 through both the central and peripheral portions of the granules, 
 but most abundantly in the former situation. The most constant 
 structure in the actinomycotic granule is the mycelium (Plate I.). 
 This consists of threads of from i to 2 /x in breadth, and varying 
 from 3 to 100 ^ in length. The growth of the organism occurs by 
 ^the formation of spores, and these spores are developed from certain 
 filaments which are rather thicker and more differentiated than the 
 neighbouring ones. It was formerly thought that the clubs were also 
 concerned in the process of reproduction, but more recently it has 
 been demonstrated that the club formation depends on hyaline 
 degeneration of the peripheral portion of the filament constituting a 
 kind of sheath. The cultivation of actinomyces is difficult, but it 
 can be grown in peptonised broth and on agar, and it develops 
 readily on the moist surfaces of cereals at a temperature of 35° to 
 37° C. Inoculated into animals it grows with.facility in the peritoneal 
 cavity of the rabbit, but it is difficult to obtain virulent cultures. 
 
 Mode of infection. — The malady has been communicated to 
 man by contact with animals affected, but this is rare, and it is 
 seldom one infected animal conveys the disease to another. It is 
 more usual for the human subject to become infected through 
 barley and rye, both of which are frequently affected with the fungus. 
 Infection is probably caused by chewing the fresh grains, which have 
 
246 MANUAL OF MEDICINE 
 
 been actually found in the seat of the lesion. The presence of 
 carious teeth is undoubtedly an important predisposing cause. 
 Cereals are not the only materials by which the disease is com- 
 municated, and numerous instances have occurred where the disease 
 has developed as the sequel to a wound produced by a splinter of 
 wood, but the infecting agent usually enters the body either through 
 the digestive tube or the respiratory tract. 
 
 Course and symptoms. — Clinically the disease presents itself 
 in two forms. In the one the lesion simulates to a greater or less 
 extent a new growth ; in the other it is more definitely inflam- 
 matory, and leads to suppuration, but even in the latter case the 
 abscesses formed are characteristic in being surrounded by extensive 
 chronic inflammation and induration, so that they have exceedingly 
 thick walls. The likeness to a new growth is owing to the fact that 
 the actinomycotic tumours are granulomata, and the resemblance 
 is especially great when the face and jaws are attacked and the 
 malady has existed for some time. The differential diagnosis from 
 malignant disease is difficult in the early stages. After a time, 
 however, portions of the growth break down into pus, and this 
 ultimately reaches the surface through long fistulous channels. A 
 very characteristic appearance is for one side of the face and neck 
 to be occupied by a tense brawny swelling, covered with livid and 
 congested skin, in which are several ulcerated sinuses discharging 
 pus. The association of the mass with a purulent discharge is very 
 characteristic. Similar tumours not uncommonly involve the jaws, 
 the floor of the mouth or the tongue, and in all cases they have the 
 characteristics described above. It is probably impossible to 
 diagnose the disease until a certain amount of breaking down has 
 occurred. The pus, usually inodorous, often contains the yellowish- 
 green grains characteristic of actinomyces, which somewhat resemble 
 particles of iodoform, and are easily visible to the naked eye. In 
 the abdomen the liver is most frequently the seat of the deposit of 
 actinomyces, and the appearance produced here is also very 
 characteristic. The organ may be greatly enlarged and contain a 
 mass the size of a foetal head or even bigger. On section the tumour 
 is yellow or greenish yellow in colour, and has frequently a peculiar 
 arborescent appearance, especially in the more peripheral portion of 
 the growth, the structure consisting of a dense fibrous framework, the 
 meshes of which are occupied by softer purulent material, which 
 can be washed away. Occasionally there are multiple foci and 
 still more frequently the disease spreads from the liver through the 
 diaphragm into the lung, as the mode of growth is almost always by 
 
MYCOSES 247 
 
 continuity. Actinomycotic tumours thus resemble aneurism in their 
 mode of extension, involving and destroying all the tissues without 
 any regard to anatomical limitations. Sometimes the growth spreads 
 so as to involve the abdominal and costal parietes, and ultimately 
 reaches the surface, a long fistulous and sinuous track surrounded 
 by dense fibrous tissue, discharging externally the pus which may be 
 formed at a great depth in the liver, lung, or other viscus. It is 
 probable that in all cases of apparent primary actinomycosis of the 
 liver that the real primary seat of the mischief has been in the 
 appendix, or some other portion of the alimentary canal. Actinomy- 
 cotic deposits in the right iliac fossa in connection with the appendix 
 are not uncommon, undoubtedly occurring more frequently than is 
 supposed, inasmuch as the diagnosis is difficult, unless the pus is 
 examined microscopically. Occasionally cases have been recognised 
 by the miicroscopical examination of the faeces, the characteristic 
 grains have been found, and have at once cleared up the nature of 
 the hard dense tumour-like mass occupying the iliac fossa. In these 
 cases of actinomycotic appendicitis there is usually great induration, 
 so that the pus may only be reached by incising a mass of fibrous 
 tissue perhaps an inch thick, and it is for this reason that the lesion 
 in this neighbourhood is peculiarly apt to be mistaken for malignant 
 disease. 
 
 Actinomycosis of the lung may be primary, in which case the 
 causal organism is supposed to have been inhaled, or it may extend 
 from some neighbouring part, as the oesophagus or liver or even the 
 root of the neck ; or the lung may contain numerous metastatic 
 deposits reaching it through the blood from some primary mass 
 elsewhere. Some cases have been described where the lungs were 
 studded with minute nodules simulating those of tubercle ; more 
 frequently, however, the disease in the lung leads to the formation 
 of a tumour-like mass, in which a cavity or cavities containing 
 pultaceous puriform material are found ; these are surrounded by 
 dense fibrous tissue which spreads irregularly through the lung, and 
 so produces an appearance verj' similar to that seen in some forms 
 of malignant growth. The bases are more liable to be affected than 
 the apices. It may lead to the production of pleurisy or of empyema, 
 or may even spread and involve the chest wall and discharge ex- 
 ternally much in the same way as in hepatic actinomycosis. 
 
 In the case of the skin, growths simulating sarcomata in their 
 softness and their general appearance are produced, but very soon 
 ulceration of the integument occurs with the formation of crater-like 
 ulcers discharging the characteristic pus. 
 
2 48 MANUAL OF MEDICINE 
 
 Lymphatic glands are not commonl)- affected in actinomycosis, 
 the virus being disseminated more usually through the blood stream, 
 and even when the disease has produced a large mass breaking down 
 and ulcerating in places, it is exceptional to detect clinically any 
 marked glandular enlargement. 
 
 The general symptoms include more especially fever and wasting. 
 Mechanical effects dependent upon the anatomical position of the 
 lesion are necessarily present in many cases. Cough, in the 
 pulmonary form of the disease, is a prominent symptom, more 
 especially in the " bronchitic " type of the malady. The fever is, 
 as a rule, moderate in its intensity, rarely exceeding 103", and more 
 usually not rising above 101°. The course of the fever is very 
 similar to that seen in chronic suppuration. The disease is usually 
 chronic. It may, however, run an acute course, more especially 
 when complicated by secondar)- affections. 
 
 Diagnosis. — \Mien a tumour is produced which can be felt the 
 principal error that is made is to confound it with a mahgnant 
 growth such as a sarcoma. '\^Tien the growth has caused ulcera- 
 tion, as, for instance, in the neck or in the tongue, it is liable to be 
 confounded %vith epithelioma. The occupation of the patient 
 rendering him liable to infection, and more especially the examina- 
 tion of the pus, will throw light on the nature of these cases, which 
 are, however, always obscure. 
 
 In visceral actinomycosis the diagnosis is still more difificult, 
 unless a sinus has formed, owing to the disease having spread to 
 the surface of the body; usually the case will only be recognised 
 during an operation, unless the characteristic grains have been 
 found in a discharge or in the faeces. The case will probably be 
 looked upon as one of malignant disease, or perhaps as one of 
 abscess. 
 
 In the case of pulmonar}^ actinomycosis it is most apt to be 
 confounded with tuberculosis, since it so frequently produces a 
 persistent bronchitis and recurrent pleurisy and effusion, and here 
 also the diagnosis can only be made in the earlier stages by a 
 microscopic examination of the expectoration. In the fully estab- 
 lished and later stages of the disease the characteristic involvement 
 of the chest waU and the formation of sinuses wiU reveal the nature 
 of the case. 
 
 Treatment. — Some forms of actinomycosis, as for instance the 
 cervdco-facial, the buccal, and actinomycotic appendicitis, are fairly 
 amenable to surgical interference ; this is more difificult, but not im- 
 possible, where the malady is deep-seated in the lungs or liver. The 
 
MYCOSES 249 
 
 hEemorrhage from scraping actinomycotic sinuses is, however, some- 
 times very excessive. 
 
 Pulmonary and visceral actinomycosis are often beyond the 
 reach of surgery, and are most suitably treated by the administra^ 
 tion of iodide of potassium, which has a very great influence on the 
 malady both in man and in animals. Large doses, 20 to 30 grains 
 three times a day, are necessary, and this drug is also of consider- 
 able value in the treatment of the other forms of the disease involving 
 the face, skin, neck, and tongue. Different observers estimate the 
 value of this drug differently, but it seems certain that only a small 
 proportion of cases are really cured by its administration even in 
 large doses. Tonics and a liberal diet are necessary to counteract 
 the general weakness. 
 
 When the disease involves the skin and subcutaneous tissues the 
 local treatment should consist in the applicaLion of some antiseptic 
 ointment or dressing, such as boracic ointment, cyanide gauze, or 
 boracic lint, preceded by thorough scraping, and sometimes with 
 advantage chloride of zinc may also be used. Iodoform should not 
 be employed. 
 
 Mycetoma or madura foot is an affection of the subcutaneous 
 structures of the foot, very similar to that produced by actinomyces, 
 and the resemblance between the lesions seen in the cervico-facial 
 form of actinomyces and Madura foot is very close. The same 
 brawny sweUing with fistulous sinuses and projecting fungoid granu- 
 lation tissue are seen in both conditions. The tissues of the foot 
 are infiltrated with a mycelium which is now recognised as the 
 cause of the disease. The myceUum of Madura foot resembles 
 that of actinomyces, but the spores seen in the latter have not 
 been detected as yet in the former. Two varieties of the disease 
 are recognised, one where the infiltrated tissues are pigmented, the 
 so-called melanoid form ; the other where the lesion is colourless. 
 The black pigmentation is usually regarded as dependent upon 
 degeneration of the fungus. Some observers have thought that two 
 distinct varieties of fungus, one black and one white, exist. The 
 disease is more especially prevalent in India, and is probably 
 dependent upon direct infection of the naked foot. 
 
 ASPERGILLAR MyCOSIS 
 
 The aspergillus has been found in a considerable number of 
 different lesions ; most frequently the association of this organism 
 
250 MANUAL OF MEDICINE 
 
 with the disease is accidental, but in some cases it is undoubtedly 
 pathogenic and the actual cause of the conditions found after death. 
 Aspergillus fufuigatus is the species that is most often parasitic in 
 addition to being saprophytic, and this is apparently dependent 
 upon the fact that the spores of this species develop readily at the 
 body temperature of most warm - blooded animals. Aspergillus 
 fumigatus and A. flavescens develop readily at a temperature of 
 37° C. According to Lichtheim, aspergillus fumigatus has a special 
 affinity for the membranous labyrinth, but the characteristic lesions 
 produced by this fungus are also found in such internal organs as 
 the kidneys, lungs, Peyer's patches, glands, etc., when the spores are 
 injected into the circulation of animals. Primary aspe.rgillar mycosis 
 in internal organs removed from direct access of the air is, according 
 to De Bar)', of doubtful occurrence. 
 
 In the human subject aspergillar mycosis is most often found 
 associated with otitis media, with a mycosis involving the nails, and 
 in an interesting form involving the lungs, and known as pneumo- 
 mycosis, usually as a purely secondary phenomenon and not as the 
 cause of the lesions. The aspergillar infection may occur in any 
 case of chronic otitis and frequently gives rise to no symptoms. 
 Occasionally the fungus growth occurs primarily on the cornea or 
 conjunctiva, and here the resulting lesion is usually of traumatic 
 origin; thus one case is quoted where the growth followed a blow 
 on the eye from a falling pear, and in another case from a piece of 
 straw injuring the cornea. An ulcer of the cornea may be produced 
 in this way in the human subject, and experimentally similar ulcers 
 have been produced in rabbits by inoculations of the cornea with 
 aspergillus fumigatus. It has also been found in the nasal fossae and 
 in the antrum. In the lungs the parasite is usually saprophytic, 
 forming a felt-like membrane in cavities that owe their origin to 
 other causes, such as tuberculosis or bronchiectasis, but exceptionally 
 it is found in lungs presenting no such lesions, and in one remark- 
 able case no other lesion was found except extreme emphysema. 
 In this case, which occurred in a young agricultural labourer aged 
 twenty-two and was fatal, there was reason to believe that the asper- 
 gillar growth might have produced such alterations in the lungs as to 
 destroy their elasticity and to cause the emphysema. Clinically the 
 case was remarkable owing to attacks of suffocative dyspnoea. Chante- 
 messe and others have described a malady seen in France amongst 
 those rearing and feeding pigeons which resembles chronic phthisis 
 and is no doubt confounded with it ; the prognosis, however, of the 
 aspergillar infection is not so serioiis as that of the tuberculous. It 
 
MYCOSES 251 
 
 is known that recovery is not uncommon in the experimental 
 pneumomycosis that can be produced by the injection of the spores 
 of aspergillus fumigatus, and it is probable that similar recoveries are 
 not uncommon in the human subject. 
 
 The diagnosis in the human subject of aspergillar pneumo- 
 mycosis can only be arrived at by considering (i) the occupation of 
 the patient, the infection usually being dependent upon the habit of 
 chewing grain, and such grain may be infected with the aspergillus ; 
 (2) the detection in the sputum of the mycelium, hyphae and spores ; 
 the spores can only be identified by their cultivation and by the 
 results seen to follow their injection into animals. The pigeon is an 
 animal very susceptible to aspergillar mycosis and usually dies some 
 three to four days after the injection ; the rabbit usually survives 
 longer, the average duration of life being six to eight days. In the 
 case of the pigeon the characteristic lesions are found in the lungs 
 and respiratory tract, also in the air sacs and in the hollow bones in 
 connection with the bronchi. Aspergillus (especially when injected 
 into the circulation) forms little white nodules resembling those seen 
 in tuberculosis, and this has led some pathologists to describe the 
 lesions under the general name of pseudo - tuberculosis. In the 
 nodules the mycelial filaments are arranged more or less radially ; 
 sometimes they assume a fan-like form. The mycelium is sur- 
 rounded by macrophages and each nodule lies embedded in a necrotic 
 area that merges into an inflammatory zone. These are well seen 
 when the nodules are present in the lungs. The vessels are throm- 
 bosed, and, as mentioned above, the mycehum may be found in the 
 lumen of the vessels. 
 
 For examining specimens histologically for the presence of this 
 fungus, logwood is, according to Boyce, the most useful stain. 
 
 John Rose Bradford. 
 
252 MANUAL OF MEDICINE 
 
 TYPHUS FEVER 
 
 A highly contagious fever, usually lasting about a fortnight, and 
 terminating by crisis. It is characterised by sudden onset, often 
 severe nervous symptoms, as delirium and stupor, and the presence 
 of a mottled measly rash appearing between the fourth and seventh 
 days, which often becomes petechial. 
 
 The bacteriology of typhus requires further investigation, and 
 the specific microbe of the disease has not yet been certainly 
 determined. Dubief describes a diplococcus which he terms 
 the Diplococcus exanthematicus. Lewaschew, a microccus which 
 in one stage of its development is flagellated, and also forms 
 free filaments or spirochsetas : to this organism he gives the 
 name Spiroch(zta exa?tihematica. Other microbes have also been 
 described. 
 
 Etiology. — Typhus is a fever which spreads by direct con- 
 tagion from the sick to the healthy, and by means of fomites, i.e. 
 articles which have been in contact with the patient and to which 
 the poison adheres. The poison appears to be given off in the 
 breath and exhaled from the body, and where many patients are 
 crowded together in ill-ventilated rooms it acquires intense viru- 
 lence, but free ventilation renders it inert, and in a well-ventilated 
 room very close contact is necessary to contract the disease. The 
 corpse retains infective powers till decomposition has set in, and 
 the disease has often been communicated to persons making post- 
 mortem examinations or dissections. It is a disease of temperate 
 climates, and is most prevalent during the cold season. 
 
 The predisposing causes are especially overcrowding and desti- 
 tution. It invades the overcrowded districts of large towns, prisons, 
 barracks, camps, ships, besieged cities, and is especially prevalent 
 in times of war and famine. In the last century it was often 
 termed jail fever, and so late as 1893 an outbreak took place in 
 overcrowded prisons in France. 
 
 In this country it has for many years past shown a steady de- 
 cline, and the same is the case in Ireland, where it used to cause 
 great ravages. In London it is now rarely present, but it still 
 lingers in some of the large northern towns. 
 
 Typhus is seldom seen except among the poor and miserable, 
 and those persons whose avocations bring them into close contact 
 
TYPHUS FEVER 253 
 
 with them. In this respect it offers a marked contrast to typhoid 
 fever. 
 
 It attacks persons of all ages, but is much less severe and fatal 
 in the young. Under twenty the rate of mortality is very low, not 
 above three or four per cent. Above middle age more than half 
 the persons attacked die. It occurs equally in both sexes. One 
 attack protects against a second, but not invariably. 
 
 Morbid anatomy. — Typhus does not cause any distinctive 
 lesions, so that from a post-mortem examination alone it would 
 often be impossible to diagnose the disease. 
 
 The rigor mortis is of short duration. The skin presents 
 livid patches and petechial spots. The blood is dark and co- 
 agulates imperfectly. The muscles show Zenker's degeneration, as 
 in typhoid. The spleen is usually, but not always, enlarged and 
 softened. The heart is often softened, and the muscular fibres 
 granular. There is cloudy swelling of the liver, kidneys, and other 
 glandular organs. Sometimes there is catarrhal or even mem- 
 branous laryngitis. The lungs are usually in a state of hypostatic 
 congestion. There are no characteristic lesions of the intestinal 
 canal, or of the central nervous system. 
 
 Incubation period. — The usual incubation period of typhus 
 is about twelve days, but much shorter periods, especially when 
 the poison has been very concentrated, have been observed, even 
 a few hours, and it may be as long as twenty-one days. 
 
 Symptoms and course. ^ — The onset of typhus is generally 
 sudden. There are rigors or repeated attacks of chilliness, frontal 
 headache, which is often very severe, pains in the back and limbs, 
 particularly in the thighs. Feelings of weariness and prostration ; 
 sometimes, especially in children, there is vomiting. There is 
 complete loss of appetite and much thirst. The tongue is large, 
 pale, coated with a white fur, which soon becomes yellowish-brown. 
 The face is flushed and dusky. The countenance dull and heavy. 
 The sclerotics injected, eyes watery, pupils small. Pulse accelerated, 
 full and soft. There are noises in the ears, sleep is disturbed by 
 bad dreams. After three or four days there is often slight delirium 
 on waking. There is rapidly increasing muscular debility, tremors, 
 tottering gait, so that the patient usually takes to his bed on the 
 second or third day of his illness. The temperature rises rapidly, 
 and may attain 104 the first night. It usually reaches its maximum 
 by the fourth night, when it may be 106 ; it is of a less remittent 
 type than in typhoid, the difference between the morning and 
 evening not exceeding one to half a degree. The bowels are 
 
254 
 
 MANUAL OF MEDICINE 
 
 generally constipated, the urine scanty, high coloured, of high 
 specific gravity, the urea and uric acid in excess, and the chlorides 
 diminished ; in the later stages albumin is often present. 
 
 Between the fourth and seventh days, usually on the fourth or 
 fifth, the characteristic eruption of typhus makes its appearance. It 
 consists of two elements — a diffused dusky sub-cuticular mottling, 
 and maculae. These consist at first of slightly elevated spots of 
 irregular shape and size of a rose or dusky pink colour, which soon 
 gets darker, and in the later stages of the fever they often become 
 the seats of haemorrhage, and are converted into petechise. The 
 
 Temperature Curve in a Case of Typhus Fever. 
 
 F. 
 
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 18 
 
 
 combination of mottling and maculae gives the raph a measly 
 appearance. The spots usually come out first on the anterior fold 
 of the axilla, and on the sides of the chest and abdomen, thence 
 they spread over the trunk and limbs, but seldom appear on the 
 face. Sometimes they are first observed on the backs of the hands, 
 where they are commonly very abundant. At first they disappear 
 on pressure, later they are permanent, and persist till the crisis, and 
 do not, as in typhoid, come out in successive crops. The rash is 
 always present, except perhaps in the very mild cases, and its 
 amount is some indication of the severity of the attack. It is 
 usually much slighter and more evanescent in children. 
 
 About the end of the first week the headache usually subsides ; 
 and now, in severe cases, delirium becomes a prominent symptom. 
 
TYPHUS FEVER 255 
 
 Sometimes it is noisy and violent ; the patient shouts and struggles, 
 -will get out of bed and rush about, and may even jump out of the 
 window. This violent deUrium is usually followed by great depres- 
 sion. More often the delirium is of a quieter character, and consists 
 in an incoherent muttering. Both forms are attended by sleepless- 
 ness. The prostration increases, the tongue becomes dry and brown, 
 the teeth are covered by sordes, an unpleasant effluvium is emitted 
 from the body, and in the breath. The eruption becomes darker, 
 and about the eighth or tenth day petechije begin to appear. The 
 temperature, except in very severe cases, usually falls somewhat 
 about the eighth day, and has a lower range during the second than 
 during the first week. Towards the middle of the second week the 
 symptoms of excitement are followed by nervous depression and 
 stupor. The prostration becomes extreme ; the patient lies on his 
 back with a tendency to sink down in the bed ; he is deaf, takes no 
 notice of anj-thing, and can with difficulty be roused ; but he is not 
 asleep, the eyes remaining half open, and he often mutters incoher- 
 ently ; this state, when well marked, is often termed coma-vigil ; 
 frequently there is subsultus tendinum or floccitatio. The pulse may 
 vary from 100 to 130, and is weak and undulating; the heart's 
 impulse is feeble, and the first sound diminished in intensity. The 
 breathing is accelerated and shallow, and crepitant rales are audible 
 over the back. The urine is often passed in the bed, or may be 
 retained ; it frequently contains albumin. Bed-sores are liable to 
 form. The patient may pass several hours or days in this state ; 
 then if he survives, usually on the fourteenth day — sometimes a day 
 or two earlier or later — a sudden improvement manifests itself. The 
 temperature rapidly falls, often 4 to 6 degrees in the course of a 
 single night ; he falls asleep and awakes free from delirium and 
 stupor, with his tongue moist, his skin perspiring, and an inclination 
 for food, though he is still in a state of great prostration, from which 
 he now rapidly recovers. Sometimes, though the crisis takes place, 
 and the temperature falls, the patient does not rally, but sinks into 
 a state of profound collapse, and so dies, the temperature rising again 
 before death. In other cases the patient dies in a state of coma 
 about the fourteenth or fifteenth day, the temperature often rising to 
 a great height— 106 or more — before death. In mild cases, where 
 the nervous symptoms are but slightly marked, the crisis often takes 
 place on the twelfth day, or earlier. If the fever continues after the 
 twenty-first day, it is always due to the presence of some complication. 
 Varieties of typhiis.— Typhus differs greatly in its severity, 
 and extreme forms have been classed as varieties. In severe 
 
256 MANUAL OF MEDICINE 
 
 epidemics, especially in times of war, in camps and besieged cities, 
 the disease may be fatal in the course of one or two days. This 
 has been termed typhus sideraas, or blasting typhus. Very mild 
 cases are often termed febricula. Sometimes the disease takes a 
 hcemorrhagic form. 
 
 Complications and sequelae. — Bronchitis, hypostatic conges- 
 tion of the lungs, and lobular pneumonia, are frequently present. 
 Sometimes there are embolic infarcts from thrombi in the heart or 
 veins ; these may soften down, or even cause gangrene. Thrombosis 
 of the veins in the lower extremities is very common. Sometimes 
 there is a tendency to gangrene of the extremities, probably due to 
 arterial occlusion, either by thrombosis or embolism. Gangrenous 
 bed-sores are liable to form. Suppurative parotitis is more common 
 than in typhoid. Secondary abscesses are liable to form in other 
 parts. 
 
 Meningitis is a rare complication, but sometimes occurs : and 
 typhus may be followed by hemiplegia or other forms of paralysis, 
 probably the result of embolism or thrombosis. Mania, melancholia, 
 and dementia occasionally supervene, as in typhoid. 
 
 In pregnancy, miscarriage often takes place, but by no means 
 invariably ; if near the full time, the child is usually born alive, 
 and is healthy. 
 
 Relapse in typhus, though not unknown, is of great rarity. 
 
 Diagnosis. — Typhus usually occurs in epidemics, and then 
 can generally be diagnosed without much difficulty, but sporadic 
 cases, and the earlier cases of an outbreak often escape recognition. 
 The only characteristic symptom is the eruption, but this may be 
 simulated by other conditions, or may be only slightly marked. 
 
 From typhoid the main points of distinction are the more 
 sudden onset, the higher range of temperature during the first few- 
 days, its less remittent type, the dull heavy aspect, the injected 
 sclerotics, the contracted pupils, the paler tongue, the absence of 
 abdominal distension and diarrhoea, the greater tendency to delirium 
 and stupor. The rash differs in its earlier appearance and the 
 accompanying general mottling ; the more extensive distribution, the 
 darker colour and irregular size of the maculae, their persistence, 
 and their conversion into petechise. But nevertheless, acute forms 
 of typhoid with a very abundant rash may be very difficult at first 
 to distinguish from typhus. Widal's serum reaction does not seem 
 to be a decisive criterion, as the serum in typhus appears to have 
 some power in causing clumping of typhoid bacilli, though it acts 
 more slowly. 
 
TYPHUS FEVER 257 
 
 The purpuric spots which sometimes occur in ulcerative endo- 
 carditis have been mistaken for the typhus rash. Rheumatic 
 purpura may cause difficulty, the severe pains in the limbs often 
 present in typhus may likewise simulate rheumatism, but they are 
 muscular rather than arthritic. 
 
 The rash of measles has some resemblance to that of typhus, 
 but the spots are larger, more raised, appear first on the face, and 
 the other symptoms are different. Drug rashes, as copaiba, are 
 hardly likely to cause much difficulty if care be taken. 
 
 More perplexing are sometimes cases where tramps and vagrants 
 are attacked by some acute febrile disease as pneumonia ; their skin 
 is often discoloured by dirt and neglect, irritated by lice, and 
 studded with petechia due to flea bites. These, however, are 
 -smaller than the typhus petechise, and the minute puncture can 
 usually be distinguished. 
 
 Other febrile diseases accompanied by delirium, stupor, and 
 prostration may be confounded with typhus. Asthenic forms of 
 pneumonia and broncho -pneumonia have often given rise to 
 confusion in both directions, the earlier causes of an outbreak 
 having on more than one occasion been regarded as bronchitis and 
 broncho-pneumonia. The presence of the rash and the physical 
 signs must be the criteria. 
 
 During epidemics, meningitis, delirium tremens, and uraemia are 
 liable to be regarded as typhus. Besides the absence of the rash 
 which is the most important distinction, the headache of meningitis is 
 -more intense, of a more darting character, accompanied by great 
 intolerance of light and sound (while in typhus the senses are 
 usually obtuse), vomiting is more frequent, spasmodic and paralytic 
 affections of the cerebral nerves are more likely to take place, and 
 the pulse is often slow. In delirium tremens the tongue is usually 
 moist, the skin often perspiring, there have been no rigors or severe 
 headache, and unless there be some complication as pneumonia the 
 temperature is not much raised. Uraemia may closely resemble 
 typhus, the dry brown tongue, the stupor, the muttering delirium, 
 the albuminuria are common to both, but in uraemia there is no 
 rash, and the temperature is seldom much raised. 
 
 Treatment. — Preventive treatment requires the clearing out 
 and disinfection of overcrowded houses, and the removal of the 
 sick to well-ventilated rooms. All fomites should be disinfected by 
 baking, fumigation, or steeping in disinfecting solutions. No one but 
 the necessary attendants should be allowed access to the patients. 
 The nurses should, if possible, be selected from those who are 
 
 VOL. I S 
 
258 MANUAL OF MEDICINE 
 
 rendered immune by a previous attack; where this is impracticable 
 they should be as young as possible, as the disease is much milder 
 in the young. The medical attendant should wear a special coat 
 or overwrap when visiting the cases. He should never stoop 
 down and put his ear to the patient's chest, but use a long binaural 
 stethescope, and should avoid inhaling the air evolved when the 
 bed-clothes are turned back. 
 
 It is of the utmost importance that the room should be 
 cool and thoroughly well ventilated, not only for the sake of the 
 attendants, but also for the patient's own. In a recent outbreak of 
 typhus in a prison in Paris the earlier cases all died, the remainder 
 were transferred to the garden and treated in the open air, and all 
 recovered. 
 
 The general regimen and diet must be the same as that re- 
 commended for t}'phoid, but as there are no intestinal lesions the 
 restrictions need be less severe, and solid food may be given 
 as soon as the appetite returns. Alcoholic stimulants are 
 seldom required under the age of twenty, in older patients they 
 must be freely administered when signs of nervous or cardiac 
 prostration appear. The temperature should be kept down by 
 tepid bathing, sponging, cold packing, the application of cold to 
 the head. These measures will tend to prevent or relieve the 
 delirium and stupor. If there is great sleeplessness, some hypnotic 
 is indicated. It is safer not to give chloral in the later stages of 
 the fever when the heart is weakened. Opium may be given alone, 
 or combined with digitalis ; Graves strongly recommended a com- 
 bination of opium and antimony ; tinct. opii 3i- ant. tart. gr. iv. aq. 
 camph. ad. 5 viii., a tablespoonful every two hours till sleep is 
 induced. Where opium is contra-indicated, as where there is much 
 hypostatic congestion of the lungs, belladonna may be given, or a 
 hypodermic injection of hyoscin, gr. 2-^. 
 
 When there is much subsultus tendinum, and floccitatio, and 
 other signs of great nervous prostration, camphor gr. iv. and musk 
 gr. X. used formerly to be given, and apparently with much benefit. 
 In collapse, ether 5ss. and liq. strychn i to 3 minims may be injected 
 hypodermically. Hypostatic congestion of the lungs and lobular 
 pneumonia require free stimulation, and ol. terebinth, m. x. com- 
 bined with ether and ammonia may be administered. Counter- 
 irritation in the form of mustard poultices or turpentine stupes may 
 be used, but the skin must never be blistered. 
 
 The state of the bladder must be carefully attended to ; bed 
 sores must be prevented by cleanliness, the skin may be washed 
 
MEASLES 259 
 
 with a spirit lotion, if any redness appears it may be painted with 
 flexile collodion. A water pillow or water mattress may be 
 employed. Secondary suppurations and gangrene must be treated 
 in accordance with the rules of surgery. 
 
 When the patient is convalescent he should not be allowed to 
 mix with other people in the clothes he was wearing when attacked, 
 without their having been thoroughly disinfected, though it is best 
 to have them destroyed ; and he is to be regarded as capable of 
 communicating the disease to others for a period of four weeks from 
 the commencement of his illness. He himself should have several 
 disinfecting baths. Neglect of these precautions has often spread 
 the disease. 
 
 W. Cayley. 
 
 MEASLES 
 
 Syn. Morbilli 
 
 Measles is a specific infectious fever, characterised by catarrhal 
 inflammation of the nasal and respiratory mucous membranes, and 
 the presence of a distinctive red eruption. 
 
 Etiology. — The disease is met with pretty well all over the 
 world, and is apparently independent of climate, being found to 
 prevail under opposite extremes of temperature. Having once ob- 
 tained a footing in a country, it never seems to entirely die out, though 
 its prevalence shows considerable seasonal fluctuation. In Great 
 Britain the seasonal prevalence of measles is peculiar, inasmuch as 
 "the monthly curve shows a double rise, one occurring in the spring 
 and early summer, and the other in the winter, the maxima being 
 reached in June and December respectively. Periods characterised 
 by increased prevalence of measles have been noticed to recur 
 every eighteen months or two years, and, according to Whitelegge, 
 there are indications of what may be regarded as a major curve, 
 the maxima of which are separated by intervals of about ten years. 
 
 Although the large majority of attacks are mild, the disease 
 is liable to take a severe form in young children, especially under 
 the influence of poverty and a defective hj-giene, but no outbreak 
 of measles comparable in severity with the form recognised in the 
 past by the name " Black Measles " is ever met with in this country 
 at the present day. 
 
266 MANUAL OF MEDICINE 
 
 Infection in measles is usually derived from personal contact 
 with a previous case. Indirect infection through the agency of 
 clothes, books, toys, etc., no doubt occurs sometimes, but the 
 activity of the contagium is rapidly destroyed by free exposure to 
 air and light. The disease is infectious from a very early stage, 
 even before the initial symptoms are sufficiently pronounced to 
 lead to its recognition ; hence it is that isolation of the patient, 
 even when practised early in the attack, is so often ineffectual in 
 checking the spread of the disease. A patient should be regarded 
 as probably infectious for at least a fortnight after the appearance 
 of the rash, and should not be allowed to mix with other children 
 even then, should any sign of catarrh or desquamation be detected. 
 School attendance is without doubt the most potent factor in the 
 propagation of the disease. 
 
 A distinct predisposition is conferred by the presence of any 
 catarrhal condition of the respiratory passages, so 'that rickety 
 children, and those of a tuberculous constitution, are very liable to 
 attack ; and pre-eminently those who at the time are suffering from 
 chronic bronchitis, whooping-cough, broncho-pneumonia, or actual 
 phthisis, or who have recently had an attack of scarlet fever or 
 diphtheria. In countries not previously invaded by the disease no 
 special liability is apparent in respect to either age or sex. Second 
 attacks of measles occur not unfrequently, but a true relapse is 
 extremely rare. 
 
 The incubation stage in most cases of measles is about ten 
 days ; in other words, the eruption is very likely to declare itself 
 on the fourteenth day after infection has been received. In some 
 instances the latent period appears to be two or three days longer, 
 and it may be shortened to the same extent Sixteen days should 
 elapse after a child has been exposed to infection before it can be 
 regarded as free from the suspicion of having taken measles, dis- 
 infection having been carried out at the commencement of the 
 quarantine. 
 
 Syoiptoms. — The invasion is characterised by the sudden 
 access of fever and more or less catarrh. The temperature may 
 reach 103° F. by the evening of the first day, and there is usually 
 loss of appetite, coating of the tongue, frontal headache, and some- 
 times nausea, though rarely actual vomiting. The conjunctivas 
 become injected and watery, and the eyelids probably red and 
 swollen. Cough, often of a croupy character, hoarseness, and 
 sneezing occur, together with a variable amount of nasal discharge. 
 Diarrhoea is liable to arise at this stage, and is sometimes very 
 
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262 MANUAL OF MEDICINE 
 
 intractable, while epistaxis is not uncommon. Lachrymation and 
 photophobia may be very pronounced, the latter a source of con- 
 siderable discomfort, and the face not unfrequently presents a 
 blotchy or " measly " appearance, best marked in the region around 
 the mouth and nose. The aspect of a child during the early 
 stage of measles is frequently very characteristic ; he looks, as 
 indeed he feels, the embodiment of human misery. 
 
 Now, the condition described above may persist throughout 
 the pre-eruptive stage, but more often in benign attacks a distinct 
 improvement sets in within forty-eight hours of invasion, characterised 
 by a partial remission of temperature, and a lessening in the 
 severity of the coryza and other catarrhal symptoms. 
 
 The improvement, however, is but temporary, for during the 
 course of the third or fourth day, usually, in some cases a few 
 hours earlier, the characteristic measles eruption begins to show 
 itself, and its development is attended with an aggravation of both 
 the febrile and catarrhal symptoms. The temperature rises rapidly 
 as the eruption comes out, registering, perhaps, 104° F. or more 
 within twelve hours. The cough, sneezing, and lachrymation 
 become more pronounced ; rhonchi may be heard over both lungs, 
 and often moist rales in addition ; the respiratory rhythm is 
 accelerated. A sero-purulent discharge runs from the eyes, and 
 the rhinorrhoea becomes thicker and more profuse. Diarrhoea is 
 apt to recur, or it may now appear for the first time, and there is 
 sometimes frequent desire to pass water, due, no doubt, to slight 
 urethral irritation. There is always some enlargement of the 
 lymphatic glands in the sub-maxillary, sub-mastoid, and cervical 
 regions, but the swelling is rarely very great, or attended with much 
 tenderness. These symptoms commonly reach their full de\^elop- 
 ment coincidently with the eruption, and the patient will in all 
 probability be at his worst on the fifth or sixth day of the disease. 
 
 In most cases speedy improvement then sets in, the temperature 
 being rarely sustained for much more than thirty-six hours after 
 the first appearance of the rash. As a rule it falls rapidly, the 
 normal being reached in favourable attacks at some time during 
 the sixth day, or by the seventh morning at the latest. The drop 
 of temperature is, however, often incomplete, but if delayed for 
 more than a few hours, it usually indicates the supervention of 
 pulmonary mischief. 
 
 The eruption presents the following characters : — It appears 
 in the form of small red spots, usually first seen on the sides of 
 the forehead and head at the margin of the hairy scalp, and on the 
 
MEASLES 263 
 
 upper part of the neck behind the ears. The spots soon spread 
 over the face, neck, trunk, and arms, for the most part in a down- 
 ward direction, and lastly invade the legs and feet, the lower 
 extremities being affected from twelve to twenty-four hours later 
 than the face. As the rash develops, the individual spots become 
 larger and distinctly papular. They coalesce with neighbouring 
 ones in variable degree, and, as a result of their confluence, 
 irregular raised tracts of red injected skin are presented, the in- 
 tervening areas remaining pale and unaffected. The spots are 
 often said to show a crescentic grouping, and this, no doubt, is 
 as common an arrangement as any other which the imagination 
 may suggest. The extent to which the face is involved varies a 
 good deal ; in some cases the spots are mainly confined to the 
 forehead and chin. The circumoral region frequently presents a 
 blotchy appearance, and is more often than not definitely invaded 
 by the eruption. Both the flexor and extensor aspects of the 
 limbs are affected promiscuously, and the rash is usually repre- 
 sented on the palms and the soles by a simple vivid flush. It 
 may, however, in these situations, be of a spotted character, but is 
 never distinctly raised. 
 
 The rash fades in the order in which it appeared, and rarely 
 remains fully out for more than twenty-four hours at any particular 
 spot. It will consequently have nearly disappeared on the face by 
 the time it is reaching its full development on the legs. The 
 actual eruption will usually have faded by the end of the week, but 
 a brown or purplish mottled staining can usually be detected on 
 the trunk and legs for several days, even a week or more, after the 
 hypertemia has disappeared. A fine scurfy peeling usually follows. 
 This is rarely extensive, sometimes confined to the trunk ; in other 
 cases limited to the face and limbs, but it is never seen on the 
 palms or soles. The peeling is usually completed within ten days 
 after the rash has faded. It is sometimes stated that numerous 
 small red points or spots with bluish-white centres may be detected 
 on the palate or the inside of the cheek and lips for some hours, 
 even three days (Koplik), before the eruption appears on the skin. 
 They can be detected in some cases, but far more frequently 
 they cannot, and usually nothing more can be made out than a 
 catarrhal redness of the entire faucial and buccal mucous mem- 
 brane, which has existed since the beginning of the illness. 
 
 In some attacks of measles the eruption is very transient and 
 indistinct ; indeed, it may be absent altogether. 
 
 Of the severe forms of measles two well-recognised varieties are 
 
264 MANUAL OF MEDICINE 
 
 met with, \\z. pulmonary and toxic. In the former, grave pulmonary 
 implication is present from the outset ; the breathing becomes 
 extremely rapid, and the surface dusky. The temperature runs at 
 a high level, and the pulse is very frequent. Fine crepitation can 
 be detected all over the lungs without obvious dulness, dependent 
 on widespread catarrh of the bronchioles, and general pulmonary 
 congestion. The rash is often patchy, or it may be almost entirely 
 suppressed. Cyanosis, drowsiness, and coma supervene, and death 
 occurs before the week is out, in young children often preceded by 
 convulsions. 
 
 In the toxic form, a typhoid condition rapidly supervenes. The 
 temperature is sometimes as high as 106° F. ; the pulse becon.es 
 extremely feeble, often reaching 180 or 200, and the tongue dry 
 and brown. The rash is intense, and soon becomes petechial ; 
 epistaxis is common, and muscular tremor pronounced. Delirium 
 is present early, and soon passes into stupor, and the patient dies 
 comatose on the fourth or fifth day. The variety known to the 
 older writers as "black measles," if not hsemorrhagic smallpox, 
 must undoubtedly have represented an extreme development of 
 the toxic form of the disease. 
 
 Measles arising shortly after an attack of scarlet fever is often 
 characterised by a higher mortality and a shortening of the pre- 
 emptive stage. The rash often appears on the first, and rarely 
 later than the second, day of illness. When measles attacks a 
 person who is just recovering from diphtheria, the condition is very 
 serious, as there is great danger of the latter reappearing in the 
 laryngeal form. Membrane rapidly spreads down into the smaller 
 bronchi, and the case usually proves fatal ; broncho-pneumonia in 
 some degree being rarely, if ever, absent. 
 
 The complications of measles for the most part represent an 
 exaggeration, in some cases an extension, of the catarrhal condition 
 which is a normal feature of the attack. The most important are 
 undoubtedly certain inflammatory affections of the respiratory 
 organs, viz. — aci/te lar\-ngitis, capillar}' bronchitis, and broncho-pneu- 
 ?no?iia, the symptoms of which in no way differ from those of the 
 independent disorders. The laryngitis, however, may be membran- 
 ous, in which case marked stridor develops. In some cases it is 
 undoubtedly diphtheritic, while in others it is said to be due to the 
 agency of pyogenetic micro-organisms. 
 
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 of shallow ulcers on the gums and adjacent side of the tongue or 
 cheeks. In ill-nourished, or strumous children, though usually at a 
 
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266 MANUAL OF MEDICINE 
 
 later date, severe gangrenous, or sloughing stomatitis, known as 
 canciiin oris or noma, may arise and lead to a fatal issue^ perhaps 
 a;;tended with necrosis of the alveolar process, or even perforation 
 of the tissues of the cheek ; and the same condition may affect the 
 vulva in female children. The nasal catarrh of measles may give 
 rise to a chronic ?tnico-puruktit rhmorrhcca. Extension along the 
 Eustachian tube frequently leads to catarrh of the middle ear, 
 characterised by deafness, tinnitus, and otalgia. This often be- 
 comes purulent, hence chrotiic otitis media, perforation of the drum, 
 and troublesome otorrhoea are common. The conjunctival catarrh 
 sometimes leads lo phlyctenular cotijunctivitis, or it may develop into 
 severe muco-purulent ophthalmia, attended with intense chemosis. 
 Keratitis, or ulceration of the cornea, is liable to supervene, sometimes 
 leading to hypopyon, and even, in rare instances, to panophthalmitis. 
 Diarrhcea may become excessive, and even prove fatal through 
 intensity of catarrhal enteritis. Certain affections of the nervous 
 system are occasionally observed to follow measles in children, of 
 which chorea and muscular atrophy of limited distribution, suggesting 
 anterior poliomyelitis, are perhaps the most common; while both 
 diffuse myelitis and hemiplci^ia of doubtful origin have been known 
 to arise during the course of the attack. A peculiar form of bliftd- 
 ness, unattended with any obvious lesion of the fundus or transparent 
 media, has sometimes been observed in adults. Phthisis, suppuration 
 of the 7nastoid cells, and caries of the petrous bone with its consequences, 
 are all conditions for which an original attack of measles must often 
 be held responsible. 
 
 Bacteriology. — The specific infecting agent in measles is 
 doubtless a living microbe, but its identity has so far not been con- 
 clusively demonstrated. Canon and Pielicke in 1892 discovered a 
 small bacillus in the blood and sputum of measles which they 
 succeeded in cultivating. Their observations, however, lack con- 
 firmation, and it has been supposed by some that the bacillus was 
 in reality that of influenza. Secondary invasion by septic and 
 pyogenetic micro-organisms, however, is common, and to their 
 presence most of the fatal complications of the disease must be 
 ascribed. Moreover, both diphtheria and tubercle are liable to 
 supervene during early or late convalescence, in each case showing 
 characteristic lesions. 
 
 The post-niortem appearances, apart from its complications, 
 are inconclusive in measles. 
 
 Prognosis. — The death-rate in different epidemics of measles 
 is very variable. It varies from two or three to over fifty per cent 
 
MEASLES 
 
 267 
 
 in proportion to the number of young children amongst those 
 attacked, their social status and general physique, and the coldness 
 of the season. 
 
 The influence of age is well shown by the following figures, 
 quoted by Dr. Theodore Thomson, as representing the fatality of 
 an epidemic affecting an urban population of 35,000 persons, 
 amongst whom the compulsory notification of measles was in force. 
 
 Age in Years. 
 
 Percentage Incidence. 
 
 Percentage Fatality. 
 
 O-I 
 
 7.2] 
 
 
 9.6) 
 
 1-2 
 
 II. 9 
 
 
 19.7 
 
 
 2-3 
 
 17.2 
 
 [13.7 \ 
 
 10.2 
 
 8.5^ 
 
 3-4 
 
 16.2 
 
 
 4.9 
 
 
 4-5 
 
 17 J 
 
 ^2.8 
 
 i-SJ 
 
 16.1 
 
 S-io .... 
 
 6.2 
 
 
 I.I 
 
 10 and over 
 
 .07) 
 
 0. J 
 
 Measles is most fatal during the latter half of the first, and the 
 second years of life ; after this the fatality rapidly declines until the 
 fifth year is reached, when it almost ceases to exist. A rachitic, 
 tuberculous, or syphilitic dyscrasia, or the presence of whooping- 
 cough, diphtheria, or chronic lung disease, implies a high fatality. 
 
 Special symptoms which point to an unfavourable prognosis are, 
 early high temperature without remission, early rapidity of breath- 
 ing, cyanosis, rapid and feeble pulse, dry brown tongue, petechial 
 eruption, severe diarrhoea, muscular tremor, stupor, and convulsions ; 
 while the supervention of any complication, such as membranous 
 laryngitis, capillary bronchitis, broncho-pneumonia, or noma, is 
 equally serious. 
 
 Diagnosis. — Measles, if unattended with a rash, may be 
 difficult to distinguish from a simple cold in the head and chest, 
 but such peculiarity of the attack is by no means common. The 
 pyrexia of measles is usually more pronounced, and it may be 
 possible to establish a connection with an undoubted attack. Only 
 three of the eruptive fevers are likely to be mistaken for measles, 
 viz. — rotheln, scarlet fever, and early smallpox. 
 
 From rotheln the distinction may be very difficult. Apart from 
 any connection with a previous case, the following points are of 
 value : — In rotheln, the degree of pyrexia and the severity of the 
 catarrhal signs are less. There is an absence of pre-eruptive ill- 
 
268 MANUAL OF MEDICINE 
 
 ness, the rash being usually the first sign, though tenderness of the 
 cervical glands may have been complained of previously. The 
 rotheln eruption is more transient, and presents features which are 
 discussed more fully in the article devoted to the description of 
 that disease (see p. 272). 
 
 In scarlet fever, vomiting is more likely to be present at the out- 
 set, and the rash appears within twenty-four hours of invasion. 
 Coryza and respiratory catarrh are absent ; the fauces are definitely 
 inflamed, and perhaps actually ulcerated ; while the glands under 
 the jaw are usually enlarged and tender. The eruption is re- 
 presented on the face by a simple vivid flush, the circumoral region 
 remaining pale and unaffected. It never presents a spotted 
 character on the palms or soles. The individual papules of the 
 eruption are smaller and more closely aggregated, and though the 
 papular element in parts may be well developed, the general surface 
 of the skin presents a well-marked flush, which, as it fades, leaves 
 behind a uniform staining rather than an appearance of mottling. 
 The temperature shows a gradual decline as the eruption fades, 
 instead of falling suddenly when the rash has reached its full 
 development, as is the rule in measles. The peeling of the tongue 
 is more complete, and the desquamation characteristic ; moreover, 
 the subsequent appearance of either adenitis, arthritis, albuminuria, 
 or nephritis, are confirmatory of scarlatina. 
 
 Smallpox in its early stage is sometimes mistaken for measles, 
 but the occurrence of a rigor, vomiting, and severe lumbar pain at 
 the outset, the absence of catarrh, the appearance of the rash on 
 the third day, attended with an immediate fall of temperature and 
 a general improvement, are most distinctive. Moreover, in small 
 pox the eruption can be felt in the skin before it is clearly visible, 
 whereas in measles the spots are always macular before they be- 
 come raised above the surface. Collie aptly compared the feel of 
 the measles rash to that of velvet, in contrast to the sensation im- 
 parted by that of smallpox, which he likened to corduroy. 
 
 The treatment of measles is for the most part cornprised in 
 the endeavour to ward off its complications. The patient should 
 be isolated as soon as possible, and placed in a room of fair 
 capacity and easy of ventilation. He should be protected from 
 draught, and the light should be subdued in view of the photo- 
 phobia, which is often distressing. The temperature of the room 
 should not be allowed to fall below 60° F., or rise above 70° ; the 
 atmosphere should be moistened with steam from a bronchiis 
 kettle, and the patient lightly, but warmly, covered. If there be 
 
ROTHELN 269 
 
 much laryngeal irritation, a steam tent will prove most soothing, and 
 a hot fomentation, or sponge wrung out of hot water, may be 
 frequently applied over the larynx. In young children, if there be 
 much bronchial affection, it is a good plan to encase the chest for 
 the first few days in a light jacket-poultice, which should be changed 
 every four hours. Many a young child's life has been saved by this 
 means, and the benefit is often very striking. 
 
 In toxic attacks but little can be done beyond alleviating 
 symptoms. Attempts to reduce the temperature by means of cold 
 applications, though a source of comfort to the patient by reason of 
 their sedative effect, have usually failed to cure. No drug has been 
 proved to have any influence on the course of the disease. Rest- 
 lessness, insomnia, and delirium, are indications for a ner\-e sedative, 
 and either trional, chloralamide, or the wet pack may be used. 
 Stimulants in small but frequent doses should be given in all really 
 severe attacks, and whenever a patient is taking his nourishment 
 badly. The treatment of the ordinary complications of measles 
 calls for no special mention here. 
 
 F. FooRD Caiger. 
 
 ROTHELN 
 
 Syn Rubeola, Rubella, German Measles, Epidemic 
 Roseola 
 
 Rotheln is 'a specific, infectious, and often febrile disorder, 
 attended with a morbiUiform eruption, enlargement of the lymphatic 
 glands in the mastoid and posterior cervical regions, and occasionally 
 slight catarrh of the ocular, nasal, and faucial mucosa. 
 
 It is almost invariably a mild affection, and seems to be 
 unattended with any recognised complications or sequelae. It 
 occurs for the most part in temperate climates, and appears to be 
 more common in Europe and North America than elsewhere. In 
 our own country it is most prevalent in the spring and early summer, 
 especially the months of April, May, and June. The disease in this 
 country rarely shows the widespread epidemic prevalence which is 
 so characteristic of measles, but commonly occurs in localised 
 outbreaks, for the most part confined to the members of small 
 communities, who are thrown into intimate association by reason 
 
2 70 MANUAL OF MEDICINE 
 
 of various educational, trade, or administrative necessities. Tliis 
 probably depends upon the fact that the activity of the contagium 
 is easily destroyed, and that close personal contact, under favourable 
 conditions, is essential to effective extension. 
 
 Apparently no special susceptibility attaches to early youth ; 
 hence it is that outbreaks are no more common in schools than 
 they are amongst the adult employes of Government departments, 
 business houses, banks, workshops, clubs, and hotels, many of whom 
 probably have never previously suffered from the disease. The 
 presence of, or recent convalescence from, any acute disorder, such 
 as scarlet fever, measles, or diphtheria, undoubtedly favours success- 
 ful infection, whereas the fact of having once suffered from rotheln 
 will almost surely protect from subsequent attack. 
 
 Much uncertainty has existed in the past as to the nature of 
 rotheln. It has been variously held to be a modified form of 
 measles, of scarlet fever — a hybrid of both — and a separate and 
 specific infection. No other view but the latter is now tenable, 
 and further discussion is uncalled for. It is unfortunate that greater 
 unanimity has not prevailed in the past amongst those to whom we 
 are indebted for its clinical description. It is evident that the 
 descriptions given by Patterson in 1840, and the older German 
 writers, apply, not to rotheln as we know it to-day, but apparently 
 to a severe form of measles. Its features, however, are now pretty 
 generally recognised. 
 
 The incubation stage may vary from seven or eight days to 
 fourteen or fifteen, and, it is stated, even to twenty-two. In the 
 writer's experience it has been most often ten days or a little over. 
 In schools a quarantine of at least twenty days after removal of the 
 last case is commonly insisted on. 
 
 Symptoms. — The attack usually commences with a feeling of 
 malaise, and perhaps slight febrilicy, followed in a few hours by the 
 appearance of the eruption. The rash, however, is often the first 
 sign. The conjunctivae are usually injected, and this may be the 
 only evidence of catarrh ; but more often the patient experiences 
 the sensation of having a cold in the head, which at the same time 
 may ache, and there may be slight cough, and more or less faucial 
 discomfort. On examination of the throat, it is usually seen to be 
 somewhat reddened and injected, and the tongue moderately 
 coated. The glands beneath the jaw are rarely much enlarged, 
 but those in the posterior cervical region, and the one lying over 
 the mastoid bone, are both swollen and tender. In some attacks 
 . tenderness of the concatenate glands is complained of for several 
 
ROTHELN 271 
 
 days before the rash comes out, and, in rare instances, those in the 
 axillae and groins are also involved. The temperature at the out- 
 set may rise to loi'', or even a degree or two higher. It soon 
 reaches its climax, and falls to normal again within forty-eight 
 hours. In exceptional cases, particularly when there is much 
 glandular affection, pyrexia of greater degree and persistence may 
 be observed. Frequently, however, the temperature remains 
 normal throughout the attack ; and this occurs more often than is 
 usually credited. 
 
 The eruption commonly appears first on the face in the form of 
 small round or oval pinkish-red spots, and from thence spreads 
 rapidly over the trunk and limbs, and finally invades the legs. 
 The spots are but slightly raised, and soon coalesce ; so that a 
 uniform redness closely simulating the rash of scarlet fever is 
 frequently to be seen on the lower part of the trunk, forearms, and 
 Lgs. An occasional result of their coalescence is that irregular 
 erythematous patches of variable extent and well-defined margin 
 are presented. On the face the spots fade rapidly, as a rule, with- 
 out previous coalescence ; they are rarely very distinct for more than 
 twenty-four hours, and the circumoral pallor may not have been 
 encroached upon. In some instances the rash first appears on the 
 trunk or limbs, in which case the face probably escapes altogether. 
 The rash commonly fades within three, or at the most four days, 
 leaving little or no staining behind, though definite peeling often 
 follows. It is usually of a powdery or furfuraceous character, but 
 "pinhole " peeling, indistinguishable from that of scarlet fever, some- 
 times, though very rarely, follows an undoubted attack of rotheln. 
 The illness may be regarded as at an end when the rash has faded, 
 and in many cases the patient cannot be said to have been ill at 
 all. According to Forchheimer, a number of rose-red spots may 
 often be seen coincidently with the appearance of the skin 
 eruption on the mucous membrane of the uvula and soft palate. 
 They are said to be about the size of a large pin's head, very little 
 raised above the surface, devoid of crescentic grouping, and not to 
 remain visible longer than twenty-four hours. 
 
 Pathology. — As to the nature of rotheln infection we know 
 nothing, but infer that it is dependent upon the activity of some 
 specific micro-organism. It is doubtful whether the disease is ever 
 directly fatal ; nor are any morbid changes in the blood, tissues, or 
 internal organs recognised. The patient should be regarded as 
 probably infectious for at least ten days after the appearance of the 
 rash, and even longer, should any peeling remain. The occurrence 
 
272 MANUAL OF MEDICINE 
 
 of a definite relapse has been occasionally recorded ; but this, like 
 a second attack, must be very uncommon. 
 
 The diagnosis of rotheln is often confused by reason of its 
 likeness to mild attacks both of scarlet fever and measles. 
 
 It resembles mild scarlet fever in that slight faucial affection is 
 often present ; that the rash appears early in the attack, and is 
 usually followed by distinct desquamation. The resemblance is 
 most marked at that stage when the rash has faded from the face, 
 and is present as a continuous flush on the trunk and limbs, with 
 perhaps a distinct remnant of papulation. It differs from scarlet 
 fever in that prodromal vomiting is rarely, if ever, present ; faucial 
 injection is less constant, and early cleaning of the tongue, much 
 less a raw tongue, is wanting. The rash occurs on the face in the 
 form of slightly raised spots, instead of being represented by a 
 continuous vivid flush, which in scarlet fever neither presents a 
 macular appearance, nor invades the oral circle. If seen at an 
 early stage, the morbilUform character of the rotheln eruption will 
 be apparent on the trunk. A complaint from the patient of tender- 
 ness, or pain in connection with the posterior cervical glands is 
 most characteristic of rotheln ; while the absence of " pin-hole " 
 peeling, arthritis, nephritis, and adenitis during subsequent con- 
 valescence is confirmatory as far as it goes. 
 
 The resemblance between a case of rotheln and a mild attack 
 of measles may be so close as to make a confident diagnosis in an 
 isolated case impossible. This is especially true when the patient 
 has recently had scarlet fever, as under these circumstances the 
 pre-eruptive stage of measles is frequently curtailed, and con- 
 sequently a valuable distinction is lost. The differences between 
 measles and rotheln are of degree rather than of kind ; hence the 
 difificulty which may be encountered in their diagnosis. In rotheln, 
 the interval between exposure to infection and the appearance of 
 the rash is more often nearer ten days than fourteen, and the 
 eruption appears on the first or second day of invasion, rather than 
 the third or fourth. The individual spots of the eruption are 
 usually smaller, pinker, more discrete (while still raised), less con- 
 stant on the face, less persistent, and less staining, though liable to 
 be followed by considerably more peeling. 
 
 The catarrhal symptoms, moreover, are less prominent, if not 
 entirely absent ; while distinct tenderness of the posterior cervical 
 glands is the rule rather than the exception. 
 
 An attack of rotheln calls for no special treatment. The 
 patient, if a child, should be kept indoors, and not allowed to mix 
 
ROTHELN 273 
 
 with others until at least a week or ten days has elapsed since 
 the eruption faded. The desquamation may be hastened by the 
 employment of warm baths and vigorous friction. 
 
 Although the vast majority of attacks are exceedingly mild, the 
 possibility of rotheln taking a severe form must not be lost sight of. 
 An outbreak, occurring in 1879, has been reported by Dr. Cheadle, 
 the earlier cases of which were characterised by a severity surpass- 
 ing that of ordinary measles. The attacks were mainly distin- 
 guished by severe affection of the broncho-laryngeal tract, giving 
 rise to incessant croupy cough of a painful and harrassing nature, 
 and by dusky red infiltrations of the faucial structures. Coryza, 
 lachrymation, and intestinal irritation were practically absent, but 
 excepting that the pre-eruptive stage was unduly short, the attacks 
 bore in other respects more resemblance to severe measles. The 
 writer met with similar cases in the year 1888, the diagnosis of 
 which was most confusing. They occurred amongst a number of 
 children convalescent from scarlet fever, and in some instances the 
 attack proved fatal. 
 
 The term " epidemic," or "infective roseola," is applied by the 
 Council of the ]\Iedical Officers of Schools Association to certain 
 cases which they regard as entirely distinct from rotheln, though 
 commonly confused with it. The cases occur in groups, usually 
 in the summer time, and are characterised by absence of any pro- 
 dromal symptoms, and of definite evidence of catarrh. The rash 
 appears suddenly on the neck, limbs and trunk, the face usually 
 escaping altogether. It consists of large rounded areas of bright 
 red, closely aggregated spots, scarcely raised above the surface of 
 the flushed skin. There is an absence of glandular swelUng, little 
 or no pyrexia, and the general health is hardly, if at all, interfered 
 with. Whatever view may be taken as to the nature of these cases, 
 they certainly sometimes occur in association with undoubted 
 attacks of rotheln. 
 
 F. FooRD Caiger. 
 
 VOL. I 
 
2 74 MANUAL OF MEDICINE 
 
 SCARLET FEVER 
 
 Syn. Scarlatina 
 
 Scarlet fever is an infectious febrile disease, of which the most 
 prominent features are inflammation of the faucial structures, a red 
 punctiform rash, followed by characteristic desquamation, and a 
 subsequent tendency to inflammatory affections of the middle ear, 
 glands in the neck, joints, and kidneys. 
 
 Though showing a wide geographical distribution, the disease 
 occurs but little in tropical regions. It is a good deal more 
 prevalent in Europe, especially its north-western portion, and in 
 America, than other parts of the world. Scarlet fever is rarely 
 altogether absent from the larger towns of Western Europe, though 
 periods characterised by its wider extension throughout the country 
 at large tend to recur at irregular intervals ; and in many of the 
 large towns of Great Britain something approaching a local cycle is 
 often apparent, the periods of greater incidence recurring every 
 five or six years. In this country scarlet fever is most prevalent 
 during the autumn and early winter months, the maximum occur- 
 ring towards the end of October or beginning of November. It is 
 least so during the spring and summer, the minimum usually being 
 reached in either March or April. The fatality has shown a • pro- 
 gressive diminution, at any rate in London, during the last fifteen 
 years. 
 
 Etiology. — Infection is always derived from a previous case, 
 either directly from the patient, or indirectly through some article 
 of clothing or furniture, or perhaps a book or toy which has become 
 contaminated with a minute particle of mucus, or of cuticle derived 
 from his person. The degree of infectivity attaching to the faucial 
 mucus, and particularly to any discharge from the nose or ear 
 which has been present during the scarlatinal attack, is probably 
 much greater than that of the desquamating cuticle, excepting, 
 perhaps, that shed during the early period of convalesence. The 
 epidermis, which separates during the later weeks, is apparently 
 little, if at all, infectious, though the popular belief is to the 
 contrary. Scarlet fever is sometimes conveyed by milk, many 
 localised outbreaks having been definitely traced to a particular 
 dairy. In no case has it been satisfactorily estabUshed that scarlet 
 
SCARLET FEVER 
 
 275 
 
 fever has been propagated by means of defective drainage or an 
 infected water supply. Infection is not very active before the rash 
 is well out. The patient is probably most infectious at the height 
 of the attack, and during the defervescence. Infectivity rapidly 
 diminishes as convalescence proceeds, but the time at which a 
 person actually ceases to be infectious is unknown. He should, 
 however, be regarded as a probable source of danger so long as any 
 discharge from a mucous surface remains, and as a possible source 
 until his peeling is completed. The Medical Officers of Schools 
 Association advise that isolation should be maintained for " not less 
 than six weeks from the date of the appearance of the rash, provided 
 convalescence is completed and desquamation has ceased, and 
 there is no sore throat, discharge from ear, suppurating glands, or 
 eczematous patches." 
 
 The following table comprises 81,605 consecutive cases of 
 scarlet fever admitted into the hospitals of the Metropolitan Asylums 
 Board during the six years ending 1897 : — 
 
 Ages. 
 
 Males. 
 
 Females 
 
 
 
 T.,TAL. 
 
 Admitted. 
 
 Died. 
 
 Mortality 
 per cent. 
 
 Admitted. 
 
 Died. 
 
 Mortality 
 per cent. 
 
 .•Admitted. 
 
 T^- , Mortality 
 
 1 
 
 Under i . . 
 
 443 
 
 no 
 
 24.8 
 
 362 
 
 98 
 
 27.1 
 
 805 
 
 208 
 
 25.8 
 
 I to 2 
 
 
 1,456 
 
 298 
 
 20.5 
 
 1,371 
 
 280 
 
 20.4 
 
 2,827 
 
 578 
 
 20.4 
 
 2 „ 3 
 
 
 2,631 
 
 406 
 
 15.4 
 
 2,553 
 
 3«3 
 
 15.0 
 
 5,184 
 
 789 
 
 15.2 
 
 3 „ 4 
 
 
 3,599 
 
 404 
 
 II. 2 
 
 3,688 
 
 417 
 
 II-3 
 
 7,287 
 
 821 
 
 "•3 
 
 4 „ 5 
 
 
 3,862 
 
 314 
 
 8.1 
 
 4,140 
 
 281 
 
 6.8 
 
 8,002 
 
 595 
 
 7-4 
 
 i Totals under) 
 S years / 
 
 
 
 
 
 
 
 
 1 
 
 11,991 
 
 1.532 
 
 12.8 
 
 12,114 
 
 1,459 
 
 12.0 
 
 24,105 
 
 2,991 
 
 12.4 
 
 5 to 10 . . 
 
 iS>79i 
 
 495 
 
 3-1 
 
 17,592 
 
 523 
 
 3-0 
 
 33,383 
 
 1,018 
 
 3-0 
 
 10 ,, 15 
 
 
 7,359 
 
 97 
 
 1-3 
 
 7,862 
 
 «5 
 
 I.I 
 
 15,221 
 
 182 
 
 1.2 
 
 15 ,, 20 
 
 
 2,366 
 
 36 
 
 1-5 
 
 2,368 
 
 35 
 
 r-S 
 
 4,734 
 
 71 
 
 1-5 
 
 20 ,, 25 
 
 
 926 
 
 II 
 
 1.2 
 
 1,149 
 
 20 
 
 1-7 
 
 2,075 
 
 31 
 
 1-5 
 
 25 ,> 30 
 
 
 420 
 
 5 
 
 1.2 
 
 657 
 
 7 
 
 I.I 
 
 1,077 
 
 12 
 
 I.I 
 
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 215 
 
 6 
 
 2.8 
 
 343 
 
 6 
 
 1-7 
 
 558 
 
 12 
 
 2.2 
 
 35 „ 40 
 
 
 91 
 
 2 
 
 2.2 
 
 140 
 
 3 
 
 2.1 
 
 231 
 
 5 
 
 2.2 
 
 40 „ 45 
 
 
 45 
 
 4 
 
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 80 
 
 3 
 
 
 125 
 
 7 
 
 
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 26 
 
 2 
 
 
 23 
 
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 49 
 
 3 
 
 
 50 „ 55 
 
 
 17 
 
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 5 
 
 
 
 4 
 
 
 
 9 
 
 
 
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 I 
 
 
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 3 
 
 
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 4 
 
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 Grand Totals 
 
 39,253 
 
 2,191 
 
 5.6 
 
 42,352 
 
 2,142 
 
 5-1 
 
 81,605 
 
 4>333 5-3 
 
2 76 MANUAL OF MEDICINE 
 
 The varying liability in respect to age is apparent. The largest 
 number of attacks occurred in the second quinquennium of life, the 
 first coming next, and then the third. After fifteen years of age 
 the attacks were relatively few. All statistical records tend to show 
 that the highest susceptibility to scarlet fever occurs during the fifth 
 year of life. 
 
 The table further shows that females were attacked more often 
 than males in the proportion of about fourteen to thirteen. 
 
 A definite second attack is occasionally met with, as is an un- 
 doubted relapse ; but in most persons one attack of scarlet fever is 
 sufficient to protect for life. 
 
 The period of incubation is usually three days, or a little less. 
 It is said that it may be as short as twenty-four hours, and it is 
 occasionally as long as six days. The Medical Officers of Schools 
 Association recommends a quarantine of ten days subsequent to 
 removal of the source of infection. 
 
 Clinical description. — From the clinical standpoint three 
 varieties of scarlet fever are recognised, viz. the simple, the septic, 
 and the toxic. 
 
 I. Simple form, or scarlati.ya benign a. — The invasion is 
 commonly more or less sudden. The patient complains of head- 
 ache, shivering, and aching pains in the back and limbs ; the throat 
 feels sore, and the act of swallowing is uncomfortable, if not actually 
 painful ; the tongue becomes coated and the appetite lost, and in 
 most cases is attended with troublesome nausea, if not with actual 
 vomiting. The association of headache, vomiting, and sore throat 
 is most distinctive of the early stage of scarlet fever. On examina- 
 tion, the whole of the faucial mucous membrane is seen to be red 
 and tumid, and the tonsils swollen — perhaps considerably. The 
 temperature often registers 102° F. by the end of the first day, and 
 the pulse is very rapid. The glands beneath the jaw are slightly 
 enlarged, and probably somewhat tender. The rash usually appears 
 within twenty-four hours of invasion, and is rarely delayed more 
 than thirty- six. It comes out first on the chest, neck, and upper 
 arms ; and from thence spreads all over the surface in the course of 
 the next twenty-four hours, for the most part in a downward 
 direction. By this time the sides and tip of the tongue will have 
 become red and raw-looking as the result of incipient denudation. 
 Delirium of a quiet kind is not unfrequently met with in children, 
 and is always associated with a high temperature. Together with 
 the development of the eruption, both the faucial and glandular 
 swelling and the general febrile signs increase, and the climax of 
 
SCARLET FEVER 277 
 
 the attack is reached usually on the third or fourth night of 
 illness. 
 
 A gradual improvement in all respects then sets in. The 
 temperature slowly declines, the faucial tension abates, swallowing 
 becomes less painful, the rash fades, and commencing desquamation 
 becomes apparent. The duration of the febrile stage of simple 
 scarlet fever, then, is about a week, though often a day or two less. 
 The appetite is quickly regained as the throat improves, and con- 
 valescence proceeds rapidly. 
 
 In some undoubted attacks of scarlet fever there is practically 
 no throat affection whatever, though the eruption may be extremely 
 well developed ; the temperature is but little raised, and the whole 
 attack may be over within three days. This is characteristic of 
 the cases often spoken of as "Surgical Scarlet Fever," which, 
 though very mild, are certainly infectious. 
 
 The scarlatinal rash is of a bright brick-red colour, and consists 
 of two distinct elements, viz. an erythematous flush and a number 
 of minute, closely-set, injected papules, which, to a large extent, 
 though by no means necessarily, correspond with the points of 
 emergence of the hairs. The rash, consequently, has a distinctly 
 punctate appearance. This will be more apparent in proportion as 
 the erythematous element is wanting, and as the latter fades before 
 the papular injection subsides, the punctiform character of the rash 
 is usually best marked during the later stage. The eruption appears 
 first on the chest, neck, and upper arms, and, spreading downwards, 
 reaches the legs some hours later. It attains its full development 
 in about two days, — that is, about the third evening of the disease, — 
 from which time, or a day later, it begins to decline, and, fading in 
 the order in which it came, is usually gone by the end of the 
 week. 
 
 After the rash has disappeared a uniform greenish-yellow stain- 
 ing of the skin is left, best marked on the abdomen. This is in 
 no sense a mottling. Where the skin is normally harsh, as on the 
 outer side of the legs and upper arms, a number of coarse injected 
 papules commonly remain for several days after the general eruption 
 has faded. Occasionally some of the papules on the trunk and arms 
 become distinctly vesicular, especially if the rash be intense and 
 the patient have been sweating. 
 
 On the palms and soles nothing but a vivid flush is seen, 
 punctation being exceedingly rare. Nor does punctation occur on 
 the face ; there the rash is represented by a red flush, which, 
 though present to a slight extent on the forehead, nose, and chin, 
 
2 78 MANUAL OF MEDICINE 
 
 is most intense on the cheeks. It never invades the region around 
 the mouth, which ahvays remains pale and uninjected. This 
 "circumoral pallor," which is strictly limited by the naso-labial 
 folds, stands out in striking contrast to the vividly injected cheeks. 
 It is an appearance seen in other febrile conditions besides the 
 early stage of scarlet fever, notably in pneumonia ; but at a later 
 stage, viz. the second or third day of the rash, a fine powdering 
 becomes apparent on the flushed surface, imparting a curious 
 " powder and rouge " appearance to the complexion which is most 
 distinctive of scarlet fever. In children of delicate complexion it 
 closely resembles the bloom on a ripe peach, and is most becoming. 
 The powdering is in reality the expression of incipient desquamation. 
 
 More or less peeling of the skin probably always occurs in cases 
 which have been attended with a definite rash, its amount being 
 generally proportionate to the intensity and persistence of the 
 latter. In infants in whom the skin is velvety and contains a good 
 deal of fat, peeling is usually slight and transient, and in adults is 
 sometimes so insignificant as to be practically limited to the hands 
 and feet. This is especially true of persons whose skin is naturally 
 greasy, as in the subjects of acne punctata. 
 
 The character of the desquamation varies in different parts of 
 the body. On the face, ears, and inner side of the upper arms, at 
 any rate at an early stage, it is represented by a simple powdering 
 of the surface. On the neck, trunk, and limbs it takes the form of 
 delicate flakes or scales of variable size, preceded by a pin-hole or 
 worm-eaten appearance of the cuticle which is very distinctive. 
 Each " pin-hole " is caused by the mechanical rupture of the 
 delicate epidermal covering of one of the papules comprising the 
 eruption. From each of these centres peeUng extends centrifugally, 
 until, by fusion of their peripheries, any such ring-like arrangement 
 becomes unrecognisable. From the palms and soles, where it is 
 normally thick, the cuticle is shed in large patches or shreds, which 
 may be continuous with that covering the fingers or toes, and so 
 lead to the separation of an incomplete glove or golosh. On the 
 palms and soles before actual separation occurs the surface becomes 
 yellowish, dry, and wrinkled, suggesting in its appearance and feel 
 a piece of old parchment. In some cases a dry chalky condition 
 of the palms and soles is all that can be found to represent 
 desquamation. 
 
 Desquamation is rarely completed until six or eight weeks from 
 the date of the eruption, and occasionally not until the expiration 
 of three or four months. The earliest sign of peelmg, viz. the 
 
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2 So MANUAL OF MEDICINE 
 
 powdering on the face, can usually be detected by the second or 
 third day of the rash. By the end of the first week peeling will be 
 well marked on the face, neck, and upper part of chest. By the 
 end of the second it will have become general. By the end of the 
 fourth it is often complete, with the exception of the palms and 
 soles, which, especially the latter, often require two or three weeks 
 longer. 
 
 The tefiiperature in simple scarlet fever rises rather rapidly, and 
 usually reaches a climax on the third or fourth night. Defervescence 
 then occurs gradually by lysis, and the normal is reached in most 
 cases on the sixth or seventh day. The temperature shows a daily 
 range of from one to two degrees, and the highest record is rarely 
 above 105'. 
 
 The scarlatinal pulse is characterised by undue rapidity in 
 proportion to the degree of pyrexia. This, however, is only 
 observed during the early stage of the attack. A pulse-rate of 144 
 to 160 in a child during the first two days of scarlet fever is in 
 itself no cause for alarm. 
 
 In some attacks there is hardly any actual swelling of the ionsils, 
 although they are usually somewhat red and tumid. In other cases the 
 swelling is considerable, and if the inflammation be ver}' acute their 
 surface may become coated with granular fibrinous deposit, which is 
 often mistaken for a diphtheritic exudation. Tonsillitis must, there- 
 fore, be regarded as a contingent, rather than a necessary factor in 
 simple scarlet fever, though an essential feature in the septic form 
 of the disease. 
 
 The appearance of the toftgue in scarlet fever is most distinctive. 
 It rapidly becomes coated with a thick white fur, through which 
 some of the fungiform papillae may usually be seen protruding. 
 Denudation of the surface then begins, starting from the tip and 
 edges, which are usually clean by the end of the second day, and, 
 proceeding centripetally, the whole surface of the tongue becomes 
 stripped of fur by the third or fourth day of attack. The tongue 
 thus comes to present the raw denuded appearance w-hich has been 
 aptly compared to that of a ripe strawberr5\ Early in the course 
 of the second week a renewal of its normal epithelium takes 
 place, and the tongue resumes its usual aspect. The complete- 
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 mouth and fauces, just in the same way as the amount of peeling 
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282 MANUAL OF MEDICINE 
 
 II. Septic form, or scarlatina ulcerosa. — In this variety 
 the ordinary symptoms of scarlet fever are aggravated by the 
 presence of faucial ulceration, which, in addition to being a serious 
 lesion in itself, provides a focus from which septic material is 
 absorbed into the system. The temperature, instead of declining 
 during the latter half of the week, remains elevated and takes on an 
 irregularly remittent character. The rash may be intense, and is 
 often patchy, and delirium, combined with restlessness, is usually 
 present. 
 
 The most characteristic signs, however, are swelling, ulceration, 
 or even necrosis of the tonsils, inflammatory infiltration of the 
 subjacent glands and connective tissue, and a profuse muco-purulent 
 or thin straw-coloured rhinorrhoea, the irritant quality of which often 
 leads to excoriation of the external nares. 
 
 The tongue peels as in the simple form of attack, but a few 
 days later becomes re-coated with a dirty white fur, which assists in 
 imparting an offensive odour to the breath, while patches of super- 
 ficial ulceration may develop on the sides of the tongue or at the 
 angles of the mouth. At this stage there is often albuminuria, and 
 diarrhoea is not uncommon. 
 
 Should recovery ensue, a gradual improvement in all respects 
 sets in towards the end of the second week, or a few days later, 
 attended with subsidence of the faucial and lymphatic engorgement, 
 delirium, and pyrexia. The ulceration of the tonsils heals, and the 
 patient is again able to swallow without distress and obtain the 
 benefit of sleep. The severity of the tax he has undergone is re- 
 vealed by the degree of weakness, loss of flesh, and aneemia which 
 is present at the commencement of convalescence. This in some 
 cases may not take place until the expiration of more than three 
 weeks from the date of invasion. 
 
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 character, attended with enormous infiltration of the tissues of the 
 neck; so much, indeed, that the space between the upper border of the 
 clavicle and the lower jaw becomes occupied by a collar of brawny 
 induration. Or, again, the ulceration may spread, and thus involve 
 the pillars of fauces, uvula, and soft palate, which, in some cases, 
 becomes perforated, or, extending downwards, may cause extensive 
 destruction of the tissues forming the upper opening of the larynx. 
 The mechanism of the parts becomes interfered with in consequence, 
 and any attempt at swallowing results in the passage of food into 
 the nares, or through the laryngeal aperture. Nor is the patient 
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284 MANUAL OF MEDICINE 
 
 awakened, half choked, by the passage of irritant secretions into the 
 larynx, or by the dropping back of the base of the tongue and 
 epiglottis, with consequent obstruction to the breathing, since the 
 nasal passages are blocked up with swelling and secretion. For its 
 relief tracheotomy may be required. The exhaustion entailed by 
 this constant distress, coupled with the severity of the disease, soon 
 becomes extreme, and the patient rapidly sinks, death often occurring 
 between the tenth and fourteenth days. 
 
 In cases which linger on, the septicgemic character of the attack 
 becomes more pronounced ; profuse sweats, diarrhoea, and great 
 emaciation, albuminuria, pulmonary congestion, or septic broncho- 
 pneumonia commonly arise before death, which may not take place 
 until the end of the third week. Occasionally a pyjemic condition 
 supervenes, characterised by the appearance of secondary abscesses 
 in the glands, connective tissue, joints, or pleurae. Moreover, a 
 septic rash may develop during the latter half of the second week. 
 It is sometimes erythematous, and more often morbilliform in 
 character, and limited to the cheeks, buttocks, and extensor surface 
 of the joints. About five out of every six cases attended with a 
 septic rash are fatal. 
 
 III. Toxic form, or scarlatina maligna. — In this variety 
 the gravity of the condition is out of all proportion to the throat 
 affection, being dependent on the toxic intensity of the strictly 
 scarlatinal poison. Cases deserving of the term "malignant," in 
 which the patient is struck down and dies, perhaps, within forty-eight 
 hours, before the typical symptoms of the disease have had time to 
 develop, are extremely rare in this country at the present day ; but 
 we occasionally meet with attacks to which the term " semi-malig- 
 nant " may be fairly applied. They are characterised by great 
 severity, and usually prove fatal on the fourth, fifth, or sixth day of 
 the disease. 
 
 The symptoms of invasion are unduly severe, especially the 
 vomiting, which may be incessant, and usually persists to the end. 
 The rash is very intense, with a tendency to become petechial as the 
 case proceeds. The temperature is very high, and shows but very 
 slight remission; it is often above 105°, rarely falling below 104°, 
 and before death may rise to over 106^. The pulse is extremely 
 rapid, in children often registering 180 on the first day of attack. 
 The fauces are red, and vividly injected ; but there may be very 
 little swelling of the tonsils, while ulceration or marked infiltration 
 of the subjacent lymphatic glands is exceptional. The patient is 
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2 86 MANUAL OF MEDICINE 
 
 with pronounced muscular tremor. In adults the delirium is apt to 
 be violent, and there is always great prostration. In most cases 
 coma supervenes, and the case soon proves fatal. Cadaveric lividity 
 sets in rapidly, often before life is extinct ; it and the petechial 
 character of the eruption are expressive of the intense toxic disinte- 
 gration which has taken place in the blood. 
 
 Of the complications likely to arise in connection with scarlet 
 fever, the following list enumerates their percentage incidence, 
 among 30,417 consecutive attacks: — 
 
 Otitis media . 
 Simple albuminuria 
 Cervical adenitis . 
 Arthritis 
 Acute nephritis 
 
 14.74 I Abscess . . . 2.58 
 
 8.26 ' Tonsillitis (secondar}') . 2.36 
 
 5.66 Ulcerative stomatitis . 2.12 
 
 3.75 Broncho-pneumonia . 1.33 
 
 3.12 Bronchitis . . . 1.2 1 
 
 With the exception of certain other infectious diseases to which the 
 scarlatinal convalescent is very liable, viz. diphtheria, chicken-pox, 
 measles, and whooping-cough, no other affection showed an incidence 
 as high as i per cent. 
 
 Otitis ??iedia, like ulcerative stomatitis and broncho-pneumonia, 
 is essentially a disease of young children, rarely arising after ten 
 years of age. It is more frequent after severe attacks than mild 
 ones, and, though the invasion may be acute, in many cases otorrhcea 
 is the first and, indeed, the only symptom. The otorrhcea, if 
 continued, may lead to suppuration of the mastoid cells ; and 
 ultimately, if neglected, be followed by thrombosis of the lateral 
 sinus, pyjemia, abscess of the brain, or meningitis 
 
 Albuminuria, like acute nephritis, which is the expression of the 
 same, though more severe, lesion of the kidney, is as common after 
 a mild attack of undoubted scarlet fever as after a severe one. They 
 most often arise during the latter half of the second and the third 
 week, but occasionally somewhat later. Cold, in itself, seems to 
 have but little influence ; but in raw, damp, or even " muggy " 
 weather the Hability is greater. Acute nephritis associated with 
 scarlet fever is noteworthy, in that h^ematuria is constant, and a 
 relatively prominent symptom, whereas dropsy of any degree is 
 rare, and complete recovery the rule under early and appropriate 
 treatment. 
 
 The cei^ical adenitis referred to arises during convalescence, 
 usually during the third and fourth weeks of illness, and is attended 
 with a fresh rise of temperature. It is often associated with nephritis, 
 and suppuration is not uncommon. 
 
SCARLET FEVER .287 
 
 ■ Arthritis^ like secondary tonsillitis, usually affects adults and 
 older children, especially females. Its time of onset is remarkably 
 constant, viz. the fifth, sixth, or seventh day of attack, just when the 
 temperature is falling to normal. The arm is more often affected 
 than the leg, the smaller joints than the large, and the wrists and 
 metacarpal joints most of all ; the heart and pericardium are very 
 rarely affected, and recovery is usually rapid. 
 
 An abscess may occur in any situation, especially after a septic 
 attack. Its most frequent seat is in the glands of the neck and 
 over the mastoid bone, in the latter case usually preceded by otor- 
 rhoea. Suppurative arthritis and empyema occur sometimes. 
 
 Ulcerative stomatitis is usually a mild affection ; but in delicate 
 children, though fortunately rarely, it may assume a sloughing 
 character, and lead to alveolar necrosis or perforation of the cheek. 
 Noma vulvae is occasionally seen. 
 
 Broncho-pneumonia is prone to arise in the course of a septic 
 attack in a young child, and is frequently fatal. 
 
 Chorea has been sometimes observed to follow scarlet fever. It 
 is, however, an extremely rare sequela, and it is very doubtful 
 whether the association can be regarded as more than accidental. 
 
 Bacteriology. — Scarlet fever is, no doubt, due to the specific 
 activity of some micro-organism which multiplies within the system. 
 So far, however, its identity has not been conclusively established, 
 though Klein has demonstrated the presence in the blood and fauces, 
 in certain cases of scarlet fever, of a streptococcus which he regards 
 as distinctive. Its presence has been confirmed by other observers, 
 but it is usually regarded as dependent upon the septic element 
 which is present in most severe attacks. 
 
 There is reason to beheve that the scarlatinal virus undergoes 
 multiplication in the blood rather than in the throat or skin, though 
 infection is doubtless transmissible through these channels. 
 
 The post-mortem appearances observed in the organs are 
 not very distinctive of scarlatina, but are for the most part common 
 to the febrile state. In the intestines, however, a distinct enlarge- 
 ment of the lymphatic foUicles is noticeable, — perhaps more often 
 than not, — and in rare instances ulceration. The kidneys present 
 no constant appearance in scarlatina; but should any evidence of 
 renal involvement have been apparent during life, signs of glomerular 
 nephritis, with or without marked interstitial change, will be present, 
 according as the case was fatal at an early or late stage of the 
 disease. 
 
 The general mortality of an outbreak of scarlet fever, like 
 
288 MANUAL OF MEDICINE 
 
 that of diphtheria, is mainly regulated by the comparative number 
 of young children amongst those attacked, and the degree of 
 poverty in which they exist. The fatality of scarlet fever at the 
 present time in London at large is about 4 per cent. The case 
 mortality of 81,605 cases treated in the hospitals of the Metro- 
 politan Asylums Board during the years 1892-97 was 5.3 per cent 
 (see table on p. 275). 
 
 The prognosis in an individual attack is influenced by certain 
 personal factors, viz. age, sex, and state of health, apart from any 
 inference to be drawn from the type of attack. 
 
 The case mortality progressively falls with each year of life until 
 the time of puberty, from whence until about the thirtieth year it is at 
 its lowest. Afterwards a slight rise occurs. In the series referred 
 to above, the mortality for the first three quinquennia was 12.4, 3, 
 and 1.2 per cent respectively. 
 
 The influence of sex is not very great, but the fatality amongst 
 males is the higher. 
 
 Scarlet fever is very prone to take a bad form in ill-fed, 
 strumous, and tuberculous subjects. Pulmonary tuberculosis, pre- 
 viously latent, is apt to be lighted up, and hurried to a fatal issue. 
 During the puerperium there is a great tendency for scarlet fever 
 to develop into fatal septicaemia. In persons suffering from chronic 
 renal disease an attack of scarlet fever usually sets up fresh 
 nephritis, which is very likely to prove fatal. 
 
 Severity of faucial swelling and ulceration, especially if attended 
 with much adeno-cellular infiltration and a high temperature, is a 
 bad sign, as indicating a septic attack ; while extreme restlessness 
 and persistent vomiting, with a petechial rash, high temperature, 
 early mental impairment, and muscular tremor, point towards toxic 
 intensity, and consequently danger to life. DeUrium in an adult 
 implies a severe attack, while convulsions in a young child, arising 
 subsequent to the stage of invasion, are practically always fatal. 
 
 The differential diagnosis of scarlet fever from measles and 
 rotheln is discussed in the articles relating to those diseases. 
 Simple tonsillitis rarely affects young children, but in an adult may 
 lead to confusion, especially if attended with a rash. The absence, 
 however, of distinct punctation, vomiting, peeling of the tongue, 
 and desquamation will usually decide its nature, while the appear- 
 ance of arthritis towards the end of the week, or of albuminuria or 
 nephritis during convalescence, point strongly to scarlet fever. 
 
 In the treatment of scarlet fever a specific virtue has been 
 claimed for many drugs. None of them, however, have yet been 
 
SCARLET FEVER 289 
 
 shown capable of exerting the least influence over the course of 
 the disease. Happily, the large proportion of attacks are mild, 
 and no active treatment is called for. It is usually sufficient to 
 isolate the patient in a well-ventilated room, maintained at a 
 temperature of from 56' to 60' F., to sponge the surface of the body 
 over at least once a day with tepid water, and see that he is suit- 
 ably fed and warmly, though not too heavily, covered. 
 
 Should the throat feel sore and the fauces be red and tumid, a 
 mild astringent gargle or spray of boric, tannic, or weak sulphurous 
 acid may be used every few hours. The constant sucking of pieces 
 of ice, or the frequent sipping of an iced lemonade, containing a 
 drachm of bitartarate and chlorate of potash to the pint, will prove 
 distinctly comforting. A linseed-meal poultice or hot fomentation, 
 renewed frequently, may be applied to the neck should tenderness 
 of the glands be complained of, and the bowels should be 
 regulated by means of a gentle aperient. The diet during the 
 febrile stage should mainly consist of milk and beef-tea or broth, • 
 with the addition of jelly and grapes or oranges if desired ; and a 
 light solid diet containing fish, milk-pudding, bread and butter, and 
 eggs may be allowed as soon as the temperature is normal and the 
 patient is inchned to swallow it. From this time onwards a warm 
 bath may be given every night with advantage. If the attack 
 has been mild the patient may be allowed to get up at the end of 
 ten days or a fortnight, and go out of doors a day or two later in 
 fine weather. Care should be taken that he is warmly clad and 
 does not get wet or sit about on a damp day. 
 
 In cases, however, in which the fauces are much inflamed, and 
 especially if the tonsils are at all ulcerated, or even if they threaten 
 to become so, energetic local treatment should be at once adopted 
 with the object of preventing the development of a septic focus 
 from which absorption would necessarily follow. To this end, 
 nothing is better, or indeed so good, as the irrigation of the fauces 
 and, if necessary, the nasal passages every two, three, or four hours 
 with the acid solution of chlorate of potash, containing free chlorine, 
 which is so useful in faucial diphtheria. It is made in the follow- 
 ing proportions : — -5 minims of strong hydrochloric acid poured on 
 to 9 grains of powdered chlorate of potash, to which is gradually 
 added, with frequent shaking, i ounce of water. Mixed with an 
 equal volume of hot water, about half a pint of the solution is used 
 on each occasion in the following manner : — 
 
 The patient sits up in bed with his head inclined forwards over 
 a basin which he supports on his knees. Into his open mouth the 
 VOL. I U 
 
290 MANUAL OF MEDICINE 
 
 nurse, standing on the right side of the bed, with her left hand 
 supporting his head, passes in a backward direction the nozzle of a 
 four-ounce rubber enema bottle charged with the solution, which 
 she then injects with moderate force so as to thoroughly wash out 
 the faucial passage. The liquid runs out of the mouth and is 
 caught in the basin underneath. Care should be taken to pause 
 between each squeeze of the syringe, in order to allow the patient 
 an opportunity of taking a breath. The irrigation is to be con- 
 tinued until the solution is used up ; and, should there be any 
 rhinorrhoea, the nasal passages must be treated in the same way, 
 though more gently, and the patient directed to keep his mouth 
 open in order to facilitate the return of the solution through the 
 other nostril, rather than allow it to run down the throat and set 
 up coughing through entering the larynx. By thus thoroughly 
 flushing out the fauces, pharynx, and nasal fossae at frequent 
 intervals with an astringent antiseptic solution, all offensive secre- 
 tions are cleared away, and the parts kept in a clean and whole- 
 some condition ; a result which cannot be attained by means of 
 any gargle, spray, or swab. Should the chlorine cause vomiting, a 
 half per cent solution of formalin with equal parts of water, or one 
 of boric acid, may be employed ; but neither are so efficacious. 
 
 The inflammatory infiltration of the glands and cellular tissue 
 in the neck, which is frequently present in a septic attack, may 
 necessitate incision. In such cases it is better not to wait for 
 definite evidence of suppuration, but the brawny swelling should 
 be incised in several places and tension thus relieved. Afterwards 
 hot boric acid fomentations should be applied. 
 
 In young children it is sometimes necessary to feed by nasal 
 tube or enema, in consequence of the difficulty in getting them to 
 swallow, and in all septic attacks a little brandy should be given at 
 frequent intervals. 
 
 In toxic attacks but little can be done beyond supporting the 
 strength as far as possible by means of stimulants and concen- 
 trated nourishment. Unfortunately, the persistent vomiting so 
 often precludes satisfactory oral feeding. The high temperature 
 usually proves refractory alike to the influence of cold applications 
 and of antipyretic drugs, but the cold pack is not without value as 
 a sedative. The complications which are liable to super^^ene 
 during convalescence from scarlet fever demand the same treat- 
 ment as when arising independently. 
 
 F. FooRD Caiger 
 
ACUTE AND SUBACUTE RHEUMATISM 291 
 
 ACUTE AND SUBACUTE RHEUMATISM 
 Syn. Rheumatic Fever 
 
 To understand the disease known as "acute rheumatism" it 
 must be studied, first and chiefly, in the child. For in childhood 
 it is more frequent, more varied, and more virulent than in the 
 adult. The earliest period of life is, indeed, almost exempt, for 
 rheumatic symptoms are hardly ever seen before two years of age. 
 But if the frequency of rheumatism were represented by a curve, the 
 vertical height of which indicated the number of cases at each 
 successive year of Ufe, it would be found that the maximum height 
 of the curve would be at or about ten years. The rise to this height 
 would be rather rapid, the fall much more gradual. At the age of 
 forty the curve would nearly have reached the base-line. The 
 manifestations of the disease are more varied in the child than in 
 the adult ; some of the phenomena fairly common in the former 
 are rarely seen in the latter. It is also more virulent ; an acute 
 attack rarely proves fatal in an adult, but this is much less un- 
 common in children. 
 
 Clinical characters. — The invasion is moderately abrupt, 
 sometimes preceded or accompanied by slight sore-throat. In a 
 day or two the temperature rises to about 102°, vague pains are 
 complained of, and the child loses appetite. There may be slight 
 effusion, with pain and tenderness, in one joint, perhaps even in 
 two or three, but the arthritic phenomena are often very sHght, and 
 may easily be overlooked altogether. 
 
 Yet even in the slightest cases the heart may be affected. An 
 acute dilatation seems to be almost invariable. If the " deep " 
 cardiac dulness be carefully delimited by fight percussion, it will 
 almost always be found to be larger than normal. In the healthy 
 child this dufi area extends from one finger-breadth (or rather less) 
 to the right of the right border of the sternum in the fourth inter- 
 costal space to just within, or in children under seven quite up to, 
 the left nipple -line. In the child suffering from rheumatism the 
 heart will be found, on careful examination, to extend to the left of 
 the nipple-line from a half to one finger-breadth, but the right fimit 
 is usually, in a first attack, imaltered. This indicates a definite 
 dilatation of the left ventricle. The first sound at the apex is 
 
292 MANUAL OF MEDICINE 
 
 altered in quality ; it is less loud and clear than normal and usually 
 shorter, though it may be prolonged into a systolic murmur. At 
 the base the pulmonary second sound is too loud. The cardiac 
 impulse is diminished in strength, and felt over too large an area ; 
 the maximum is in the nipple-line, or even slightly to the left of it. 
 These phenomena may easily escape notice, but they are of great 
 importance. They show that the affection of the heart in rheumatism 
 is in no sense a " complication " ; it is a characteristic, and the most 
 important, part of the disease. 
 
 Greater severity of rheumatic attack in a child manifests itself 
 less by increase of arthritis than by a fiercer assault upon the heart. 
 Several (or even many) joints may be affected, but in children the 
 arthritis is usually less severe and more transient than in the adult. 
 The heart often sustains grievous damage, the effects of which are 
 permanent. The acute dilatation is more marked than in the 
 slighter cases, and is probably due to definite myocarditis, in 
 addition to the toxic action on the cardiac muscle which seems to 
 be the cause of the minor degrees of acute dilatation. Endocarditis 
 is common, the mitral being almost invariably the valve first 
 affected, causing a systolic apex murmur which tends to be con- 
 ducted towards the axilla. This must not be confounded with the 
 systolic murmur over the right ventricle, which is not uncommon in 
 healthy children. A systolic murmur at the apex in a rheumatic 
 attack may perhaps sometimes be due to ansemia, but endocarditis 
 should always be suspected. After a time it may be observed in many 
 cases that the systolic murmur is followed by a double second sound 
 heard only at the apex. The first element of this double second sound 
 is probably the normal second sound of the heart ; the second element 
 is probably produced by tension of a slightly thickened and stiffened 
 mitral flap, resulting from the active ventricular dilatation which 
 normally occurs at the commencement of diastole. The first 
 element of this double second sound never changes its character as 
 long as it is audible at all. But in many cases the second element 
 becomes altered from the sharp sound of tension into a short blow- 
 ing murmur, the effect of vibration of the stiffened mitral caused by 
 the commencing inrush of blood from the auricle into the ventricle. 
 Sometimes, and especially on auscultation a little more internally, 
 this murmur in the early part of the diastolic period is found to be 
 replaced by a similar short blowing murmur of presystolic time. 
 This is no doubt produced by vibration of the stiffened mitral 
 caused by the greater force of the blood current during the auricular 
 systole, but it must not be taken to mean any definite narrowing of 
 
ACUTE AND SUBACUTE RHEUMATISM 293 
 
 the mitral orifice. After a while the doubling of the second sound 
 at the apex disappears. This perhaps means that slight shortening 
 has occurred in the valve or its chordae, the result of contraction of 
 the new fibrous tissue, so that its tension occurs earlier and again 
 coincides with the normal second sound, or that the early diastolic 
 murmur, growing more definite, commences at the earliest instant of 
 the diastolic expansion and obliterates the second sound. 
 
 Pericarditis may occur even in a first attack. It is a symptom 
 of danger, for it is usually associated with great increase of the 
 cardiac dilatation, indicating probably a profound affection of the 
 heart-muscle. The first evidence of pericarditis may be vomiting, 
 or subjective distress, or a disturbance of the cardiac rhythm (so 
 that it becomes triple or confused) ; or else an audible rub, heard 
 over some part of the cardiac area, usually first at the base and 
 later over the right ventricle, sometimes even at the apex and to 
 the right of the sternum. The quality of the friction-sound is' 
 usually rough, often so rough as to resemble scratching or tearing, 
 but at the base it may at first be so soft as to simulate a double 
 aortic murmur. The cardiac dulness is almost always enlarged 
 before the rub is heard, and it soon becomes further increased. 
 It is possible that this increase may to some extent be caused by 
 effusion of fluid into the pericardial sac, but post-mortem evidence 
 shows that, though the whole heart may be covered with plastic 
 lymph, there is rarely any great increase in the pericardial fluid, 
 and that sometimes none at all is found even where the increase in 
 the dulness is most extensive. On the other hand, marked dilata- 
 tion is found to be very common, and extreme dilatation is not rare.^ 
 The outline of the precordial dulness affords very little assistance 
 in determining whether fluid pericardial effusion is present in 
 addition to the cardiac dilatation, but decided extension of dul- 
 ness to the left of the sternum in the second and third inter- 
 costal spaces is in favour of some effusion, for this usually is most 
 abundant at first about the great vessels. 
 
 Cases of rheumatism in which pericarditis and great dilatation 
 of the heart are present often exhibit symptoms of grave cardiac 
 failure^ due no doubt to the damaged state of the cardiac muscle. 
 Dyspncea is marked, and may be extreme, even in the absence of 
 any lung complication. It is probably the exaggeration of a normal 
 reflex from the right ventricle to the respiratory centre, by which an 
 overstrained right ventricle is automatically relieved.^ The failure of 
 the left ventricle is shown by the feebleness and frequency of the 
 
 ^ Vide Med. -Chi. Trans. 1898, p. 447. ^ Lancet, 1893, vol. ii. p. 1050, 
 
294 MANUAL OF MEDICINE 
 
 pulse. Vomiting and delirium may also occur, the former probably 
 of reflex origin, the latter analogous to the delirium sometimes seen 
 at the end of a case of chronic heart disease. Fortunately, peri- 
 carditis does not often produce much pain, though it causes local 
 tenderness. Coexisting pleurisy may cause pain. It is revealed by 
 a pleural rub in one or both axillae, or along the left border of the 
 heart ; in the latter position the rub, though of pleural origin, may 
 be of cardiac rhythm. Rheumatic pleurisy rarely leads to much 
 effusion of fluid, being in this respect similar to rheumatic pericar- 
 ditis. Pneumonia is a somewhat rare complication ; it adds greatly 
 to the danger. Both the pleurisy and the pneumonia of rheuma- 
 tism prefer the left side. 
 
 These affections of the thoracic organs are the points on which 
 the attention of the physician ought to be primarily fixed when 
 called to see a child suffering from even the mildest attack of 
 rheumatism. The more external manifestations of the disease in 
 skin, joints, and fibrous tissues, are not of vital importance. But 
 they are often of much use in diagnosis, and some description of 
 them is necessary to complete the clinical picture. 
 
 The affected joints are usually only slightly swollen. They are 
 distinctly tender and painful, but neither swelling, tenderness, nor 
 pain is equal to what is often observed in the same disease at a 
 later period of life. There may be hyperaemic patches of skin over 
 these joints, but they usually soon disappear. There may also be 
 some pain and tenderness in the adjacent tendons, especially behind 
 the knees. Pain and tenderness in the cervical spinal articulations 
 or in the tendinous insertions of the cervical muscles may cause 
 stiffness and immobility of the neck, simulating caries of the 
 cervical spine. 
 
 In the neighbourhood of the joints, and in fibrous tissues 
 elsewhere, children often manifest a form of rheumatic affection 
 which is rarely seen in adults. Small, firm, sUghtly movable sub- 
 cutaneous nodules^ not painful, but sometimes slightly tender, are 
 found over prominent bony points, especially over the ends of the 
 long bones, the vertebral spinous processes, and the iliac crests ; also 
 in tendinous structures, such as the pericranium, the sternal apo- 
 neuroses, and the flexor and extensor tendons of the fingers and 
 toes. They exist in about one-fourth of the cases of rheumatism in 
 children. Sometimes only a single nodule may be discoverable, in 
 other instances only two or three, but there are often many, and 
 more than fifty may be present at the same time. The smaller 
 nodules are of the size of a pin's head ; the largest commonly met 
 
ACUTE AND SUBACUTE RHEUMATISM 295 
 
 with are about equal to a pea, though still larger ones are occasionally 
 seen. There may be a simultaneous outburst of many nodules, 
 followed by their gradual disappearance, and a subsequent appear- 
 ance of a fresh crop. Some may vanish in a few days, others 
 remain for many months or even for more than a year. The 
 existence of many or of large nodules is certainly one of the 
 indications of an intense rheumatic process, and makes it prob- 
 able that serious progressive morbid change is occurring in the 
 heart. 
 
 These nodules were carefully described, and their histological 
 structure investigated, by Prof. Hirschsprung of Copenhagen in 
 1879, also by Dr. Barlow and Dr. Warner in 1881. They were 
 found to consist mainly of fibrous tissue with some cells (round or 
 spindle-shaped), dilated vessels, and a certain amount of nearly 
 homogeneous, more or less fibrillated "ground-substance." Recently 
 Dr. Poynton and Dr. Still have brought forward evidence to show 
 that this homogeneous substance is in reality a fibrinous exudation, 
 and therefore probably the manifestation of a local rheumatic in- 
 flammation. They thus confirm the suggestion of Drs. Barlow and 
 Warner that these nodules are homologous with the inflammatory 
 exudation which forms the base of a " vegetation " on a cardiac 
 valve, and also with that found on the pericardium in rheumatic 
 pericarditis. Occasionally quite unmistakable nodules have been 
 seen both on the pericardium and on the mitral valve. 
 
 Rheufnatic manifestations in the skin are not uncommon. Excess 
 of sweating is sometimes observed, but is seldom profuse in children. 
 A definite rheumatic eruption shows itself in not a few cases. It 
 is usually an erythema ; — papular spots, or small circular areas with 
 slightly raised hypersemic margins and paler centres, or larger areas 
 with irregular outline formed by coalescence \ it is perhaps most 
 frequent about the joints, though it may occur on the trunk. In 
 rare cases the erythema becomes vesicular or purpuric, or there 
 may be numerous petechiee, especially on the legs and feet. But 
 erythema nodosum is probably not a manifestation of rheumatism, 
 though it may occasionally be found in a rheumatic subject ; it 
 appears to be an independent exanthem, with a pyrexial course 
 of definite length and a characteristic eruption. 
 
 In the micscles vague pains may be felt, and some distinct atrophy 
 is occasionally observed after a rheumatic attack. When there 
 is also slight numbness and some defect of cutaneous sensibility, 
 there is reason to suspect a local neuritis. 
 
 Tonsillitis, sometimes of the "follicular" variety, may precede or 
 
296 MANUAL OF MEDICINE 
 
 accompany rheumatic symptoms, or there may be a generalised 
 pharyngitis. 
 
 Anmnia is often a prominent feature of a rheumatic attack ; it 
 may be rapidly produced or intensified. 
 
 Chorea is frequently associated with rheumatism in childhood. 
 The relationship between the two affections needs further elucidation, 
 but the more carefully they are studied, the more intimate it is found 
 to be. Choreic symptoms of slight intensity are common in children 
 suffering from acute or subacute rheumatism, and when there is no 
 definite chorea there may sometimes be seen the tendency to 
 emotional disturbance, the causeless and transient fits of crying, 
 which are so often observed in chorea. The onset of a severe 
 chorea frequently follows two or three weeks after the occurrence of 
 symptoms which, though slight, were definitely rheumatic. During 
 an attack of chorea undoubted symptoms of rheumatism may 
 manifest themselves. Many cases of chorea which have apparently, 
 at the time, no connection with rheumatism, suffer from an attack 
 of that disease a year or two later. After making allowance for 
 possible coincidences, the conclusion is irresistible that there is 
 some very close connection between the two diseases, and that in 
 many cases chorea must be looked upon as a definitely rheumatic 
 symptom. 
 
 A rheumatic attack which has been inadequately treated, or in 
 which the treatment has been suspended too soon, is very apt to 
 relapse. Symptoms which had almost or altogether subsided may 
 return, or fresh rheumatic symptoms may show themselves. This 
 is a fact of the greatest importance and one to be constantly 
 remembered in the treatment of even the mildest cases. In some 
 patients this tendency to relapse is specially strong, and can be 
 overcome only by regular and persistent treatment carried on for a 
 long time. Even after health has apparently been restored and all 
 rheumatic symptoms have entirely subsided, there is in children a 
 very strong tendency to recurrence of the disease a few months 
 later, or after a year or two. Many have three, four, or more 
 attacks. If rheumatism were simply an arthritis, this would perhaps 
 be of little consequence. But the fact that in almost every attack 
 the heart is more or less affected makes such recurrences a serious 
 calamity. Too often the dilatation of the heart produced by the 
 first attack has not subsided when a second attack dilates it further, 
 even if no definite endocarditis or pericarditis is produced. 
 Enormous dilatation may thus be brought about ; the heart may 
 extend nearly to the right nipple fine and beyond the left anterior 
 
ACUTE AND SUBACUTE RHEUMATISM 297 
 
 axillary line, the left border rising two or even three finger-breadths 
 above the left nipple. These dimensions can easily be demonstrated 
 by careful percussion, and they are confirmed by autopsy. 
 
 In a secojzd or siibseqimit attack of rheumatism, in addition to 
 increased cardiac dilatation, there is often distinct evidence of 
 permanent damage to the mitral valve, and reason to suspect fresh 
 endocarditis. The systolic murmur is louder and conducted to the 
 angle of the scapula ; it is often accompanied by a much shorter 
 blowing murmur of early-diastolic or of presystolic time. In some 
 cases an aortic regurgitant murmur becomes audible, but this is 
 much less common. At a later period the early-diastolic apex 
 murmur tends to disappear, and the presystolic murmur becomes 
 slightly vibratile, the vibrations becoming coarser as the years go by. 
 But it is very rare to find in children under ten a churning murmur 
 at all Hke that which is characteristic of the mitral stenosis of 
 young adults. The narrowing of the orifice is a slow process and 
 requires several years for its development. 
 
 Pericarditis is less frequent than dilatation and endocarditis, but 
 it is the mark of a specially acute rheuniatic attack, and it greatly 
 increases the danger. It is usually accompanied by marked increase 
 of the dilatation, and symptoms of cardiac failure are not far off. It 
 rarely leads to any great amount of fluid effusion into the peri- 
 cardium, in spite of the current teaching on this subject, which is 
 founded on the erroneous assumption that the increase of the pre- 
 cordial dulness is entirely caused by effusion of fluid into the peri- 
 cardial sac, and that it is an accurate indication of the amount of 
 such effusion. Plastic lymph, more or less organised, is found in 
 a fatal case, and often much thickening of the pericardium, but 
 seldom much fluid, and sometimes hardly any at all. More or less 
 pericarditis, old or recent, is found in about three-fourths of the 
 fatal cases ; in about one-half the pericardial surfaces are found to 
 be entirely adherent. 
 
 Extensive venous thrombosis has been met with shortly before 
 death in a few cases ; Dr. Poynton has recently drawn attention to 
 this. 
 
 Below the age of ten years, girls and boys are equally liable to 
 suffer from rheumatism. But from ten to fifteen years of age, girls 
 are twice as liable as boys to rheumatism, and three times as liable 
 to chorea. This may possibly be in some way connected with the 
 more rapid development of girls than of boys during these years, 
 the girls gaining both in height and weight more rapidly than the^ 
 boys. The greater liability of girls between ten and fifteen to 
 
298 MANUAL OF MEDICINE 
 
 rheumatism and to chorea goes a long way to explain why mitral 
 stenosis is so much more frequent in women than in men. 
 
 In adolescents, from fifteen to eighteen years of age, rheuma- 
 tism is less common, for many of the most susceptible subjects 
 have been already eliminated. It is also on the whole less virulent. 
 Pericarditis is now less commonly fatal, but it often produces 
 permanent crippling of the heart. Dilatation is almost invariable. 
 Endocarditis is common. The evidence of former heart disease is 
 often marked ; it takes two forms. One is that of a dilated heart, 
 wdth or without evidence of pericardial adhesions, with a loud, 
 long systolic murmur at the apex. The other is that of a definite 
 mitral stenosis, the presystolic murmur beginning now to assume 
 its typical character. The two types may be combined. Nodules 
 are less common than at an earlier age ; arthritis somewhat more 
 common. 
 
 In adults, arthritis is usually the most prominent symptom, and 
 often causes much suffering. Many joints may be affected, one or 
 two leading the way, and others becoming involved in rapid 
 succession. The distribution of the arthritis is fairly, but not 
 accurately, symmetrical. The larger joints, especially the knees, are 
 most affected, but the smaller joints have no immunity. The synovial 
 sacs, where the structure of the joint allows it, become distended 
 with fluid ; this is most marked in the knees, where it lifts the 
 patella from the condyles and distends the suprapatellar sac, the 
 normal outline of the joint being lost in a rounded swelling. The 
 skin over the joint is generally pale, though it may be slightly 
 hyperaemic. The tendon sheaths near the joint may also be 
 affected. Movement of the affected joints is very painful. In 
 slighter cases, the inflammation may leave the joint or joints first 
 affected and appear in others. 
 
 Sweating may be general and profuse ; it often causes a peculiar 
 odour, especially when the patient is allowed to remain in an 
 unchanged flannel night-dress. Sudamina and miliaria are fre- 
 quently caused by the sweating. Erythema is occasionally seen ; 
 urticarial and purpuric forms of eruption are rare ^ ; chorea is seldom 
 met with in adults, nodules still more rarely. 
 
 The urine in acute rheumatism is scanty and of high specific 
 gravity, soon becoming turbid with urates, and occasionally containing 
 
 ^ A case of very extensive bullous purpuric erythema, with pericarditis and fatal 
 myocarditis, in a girl of seventeen under the care of the author, is reported (with an 
 ■account of the autopsy and of the microscopical examination of the cardiac muscle) 
 by Dr. Poynton in the Lancet, Oct. 28, 1899. 
 
ACUTE AND SUBACUTE RHEUMATISM 299 
 
 a trace of albumin. The tongue is often furred. Anemia is 
 rapidly produced by rheumatism, and is often a marked feature of 
 the disease. 
 
 The predominance of the arthritis in adults has brought it 
 about that acute rheumatism has been classed among diseases of the 
 joints, and that the far more important cardiac affections have been 
 considered as " complications." How essentially erroneous this 
 view is a careful examination of the heart in almost any case of acute 
 or subacute rheumatism will show. Even in a subacute case, in 
 which there is very slight arthritis and hardly any pyrexia, deter- 
 mination of the so-called " deep " cardiac dulness by careful light 
 percussion will almost always reveal an increase in size of the heart, 
 which usually diminishes more or less when the attack is over, and 
 sometimes returns to the normal. Accompanying this evidence of 
 dilatation there is generally some alteration in the quality of the 
 first sound, and the cardiac impulse is diffused and feeble.^ 
 
 These facts prove that the arthritis of rheumatism is but one 
 manifestation of a toxaemia, in which the central organ of the circu- 
 lation is almost always more or less seriously affected. The physician 
 must beware of being satisfied with the absence of murmur ; the 
 quality of the first sound must be observed, and a most careful 
 examination of the heart, by percussion and palpation as well as 
 by auscultation, must be made in every case. An acute dilatation, 
 whether merely toxic or due to definite myocarditis, is a serious 
 matter, and calls for prolonged rest and careful treatment. 
 
 Often the evidence of disease of the heart is obtrusive, even on 
 the most superficial examination ; but it is by no means easy to 
 decide in all cases whether, or how far, the carditis is recent or of 
 old standing. This is especially true with regard to dilatation and 
 systolic murmurs. An increase of dilatation and a fresh endocarditis 
 may very probably be part of the present attack. Fresh pericarditis 
 is not ver}^ common in adults, and in them it is usually much less 
 serious than in children, but an adherent pericardium is not 
 uncommon. It cannot, however, be diagnosed unless there are also 
 external adhesions fixing heart and pericardium to sternum, pleurae, 
 and lungs. It is probable that the greater part of the embarrassment 
 of the heart usually assigned to adherent pericardium is due to 
 myocarditis, old or recent, and increasing dilatation. 
 
 The results of chronic heart disease produced by previous attacks 
 of rheumatism often add enormously to the danger of a later attack, 
 and ver)' greatly increase the difficulty of treatment. When chronic 
 
 ^ Vide Med. -Chi. Trans. 1898, pp. 401-417. 
 
300 MANUAL OF MEDICINE 
 
 dilatation, mitral stenosis, or aortic regurgitation has existed for some 
 years, compensation is apt to break down readily on the occurrence 
 of even a slight fresh rheumatism, and congestion of the bases of the 
 lungs, with indications of bronchitis or oedema, dilatation of the right 
 heart, enlargement of the liver, sometimes dropsical effusion into 
 the serous cavities or into the subcutaneous tissue of the lower limbs 
 and of the loins, may manifest themselves. 
 
 The lungs and their serous covering suffer much less in rheuma- 
 tism than the heart and pericardium. Pleuritic friction sometimes 
 occurs, and is painful ; but there is rarely much fluid effusion. 
 Pneumonic consolidation of lung is met with in a few cases. 
 
 The temperature in rheumatism is variable. In a large propor- 
 tion of cases it is comparatively low, not exceeding 102° F., often 
 not over 100°, and it rapidly falls to normal under treatment. But 
 even with this very moderate pyrexia acute cardiac dilatation is 
 usually present, and severe pericarditis may exist. The temperature 
 chart in this disease furnishes no trustworthy indication of the extent 
 of the damage to the heart which is being produced. Yet there is 
 one very important reason why it should be closely watched ; in 
 some cases the temperature rapidly rises, and it may run up in a few 
 hours to 107°, 108°, 109°, or even 110° F. Death may quickly 
 follow, unless some method of cooling the patient is used immedi- 
 ately. As hyperpyrexia comes on there is usually a tendency to 
 delirium, and often a marked subsidence of the arthritis. A warning 
 of the onset of this grave complication is frequently to be found 
 in the cessation of perspiration, the skin becoming hot and dry in 
 a patient who had been previously sweating profusely. Headache, 
 sleeplessness, and restlessness should also be considered as warning 
 symptoms. Rheumatic hyperpyrexia hardly ever occurs in a 
 child, which is remarkable, for a terminal hyperpyrexia is by no 
 means uncommon in some cerebral affections in infancy and early 
 childhood. Occasionally, however, a case of chorea may end in 
 hyperpyrexia, sometimes preceded by distinct rheumatic symptoms, 
 sometimes alone. 
 
 Symptoms strongly suggestive of meningitis, such as strabismus, 
 opisthotonos, muscular spasm, and final coma may occur in 
 rheumatic hyperpyrexia, and even when the temperature does not 
 exceed 104°, but actual inflammation of the cerebral membranes 
 is very seldom found post-mortem. 
 
 The arthritis of acute or subacute rheumatism usually subsides 
 completely when the attack comes to an end, which may occur 
 spontaneously, as was shown in the cases "treated" with mint- 
 
ACUTE AND SUBACUTE RHEUMATISM 301 
 
 water in the presalicylic days. But this spontaneous recovery was 
 often very slow, as indicated by the well-known story of the 
 physician who was asked what was good for rheumatism, and 
 replied " six weeks." Those who remember how rheumatism 
 behaved before the introduction of salicylates will acknowledge 
 that this was no great exaggeration. The shortening of the dura- 
 tion of a rheumatic attack by the use of the salicylates is marked 
 and unquestionable. 
 
 But it must be added that the subsidence of a rheumatic 
 arthritis, treated or untreated, is not always complete. Occasionally, 
 in what seems to be a subacute rheumatism affecting several joints, 
 one joint remains swollen and painful long after all the others have 
 recovered, and it may show indications of structural changes. 
 Some cases of this kind are not truly rheumatic, but are a gonor- 
 rhoea! arthritis ; others are the initial stage of the disease known 
 as "chronic rheumatoid arthritis." ^Mienever "rheumatism" 
 settles down into a chronic arthritis of a single joint, one or other 
 of the above-named diseases should be suspected. The relation- 
 ship of true rheumatism to " chronic rheumatism " affecting many 
 joints and crippling them with fibroid thickenings of ligaments 
 and tendons, and also to the chronic myalgias of later life, is a 
 subject with regard to which further precise investigation is needed. 
 
 Until recently acute rheumatism was regarded as essentially 
 an arthritis, and the painful, tender, swollen joints, the acid sweats, 
 the furred tongue, the scanty urine loaded with urates, and the 
 pyrexia, were thought to be the essentials of the disease. Pericarditis 
 and endocarditis were looked upon as "complications." But when the 
 malady was carefully studied in hospitals for children, it became 
 evident that this view was far too narrow, that in early life arthritis 
 is a comparatively insignificant part of the disease, and that the 
 damage to the heart is more frequent and severe than in adults, 
 ^lore recently it has been shown that the rheumatic state manifests 
 itself not only by arthritic and cardiac lesions, but also by various 
 other clinical phenomena formerly regarded as complications, or as 
 of merely accidental occurrence. In opening the discussion on 
 "Rheumatism, and its i\.llies in Childhood," at the meeting of the 
 British Medical Association in 1883, Dr. Barlow, in an exhaustive 
 paper, showed that erythema (and occasionally urticaria and pur- 
 pura), stiff neck, slight pains referred to the muscles, tonsillitis, 
 subcutaneous nodules, and chorea are frequent and characteristic 
 evidences of rheumatism in childhood. Dr. Cheadle summed up 
 the results of his long experience at the Hospital for Sick Children 
 
302 MANUAL OF MEDICINE 
 
 in lectures on " Heart Disease in Children," published in the 
 Lancet in 1885, and again in his Harveian lectures (1888) "On 
 the Various Manifestations of the Rheumatic State, as exemplified 
 in Childhood and Early Life," in both of which he emphasised the 
 importance of these non-articular evidences of rheumatism in child- 
 hood, and showed how the various members of the "rheumatic 
 series " may occur in varying sequence and combination. He 
 also insisted on the frequency and importance of an inherited 
 predisposition to rheumatic disease, and pointed out that evidence 
 of such inheritance, combined with the presence of some of the 
 non-articular manifestations of rheumatism, is sufficient to prove 
 the rheumatic origin of many cases of heart disease in which no 
 history of arthritis can be obtained. The late Dr. Sturges, in his 
 Lumleian lectures in 1894, laid great stress on the cardiac inflam- 
 mation caused by rheumatism in children, and on the high mortality 
 thence resulting. When it was observed that in rheumatism there 
 is usually, if not invariably, an acute dilatation of the heart, even in 
 subacute cases with trifling pyrexia and slight symptoms, it became 
 evident that the most important part of this malady is its toxic 
 action on the heart, and the resulting inflammatory condition of 
 this organ. 
 
 Pathology. — The true nature and origin of this disease are still 
 unknown ; but the facts already stated make it certain that no 
 neurotic theory and no theory of perverted metabolism can fully 
 account for the phenomena : these strongly suggest a microbic infec- 
 tion. The greater frequency and greater virulence of rheumatism 
 in childhood remind the physician of the infectious fevers, and the 
 occasional occurrence of sore throat and of a characteristic eruption, 
 with the pyrexia, are other points of resemblance. In its ill-defined 
 course it resembles tuberculosis. In its tendency to produce acute 
 dilatation of the heart it resembles influenza. The arthritis of 
 rheumatism is very closely simulated by the arthritis produced by 
 the gonococcus. No microbe has yet been proved to be the 
 cause of rheumatism ; but the same is true of such undoubtedly 
 microbic diseases as measles, scarlet fever, whooping-cough, and 
 syphilis. The strongly-marked hereditary predisposition to rheuma- 
 tism causes no difficulty, for the same fact is observed in tuberculosis. 
 That exposure to cold and wet is often a factor in the causation of 
 a rheumatic attack is analogous to what is often observed in 
 pneumonia. 
 
 Rheumatism has a certain relation to season, the maximum 
 number of cases in London occurring in October and November. 
 
ACUTE AND SUBACUTE RHEUMATISM 303 
 
 It is also more prevalent in some years than in others. For an 
 elaborate analysis of the available statistics on this subject reference 
 may be made to Dr. Newsholme's " Milroy Lectures." ^ The times 
 of greater prevalence are probably times when the conditions of 
 temperature and moisture of the soil are specially favourable to 
 the development of certain microbes. 
 
 It seems not unlikely that rheumatism may be a house disease, 
 the germs being endemic in damp, ill-drained dwellings, extending 
 upwards along damp walls, or being carried by air-currents from the 
 soil. It would be interesting to inquire whether the disease ever 
 occurs in houses with impermeable basement. 
 
 Recurrences of rheumatism may be fresh infections, or they may 
 be caused by renewed activity of germs lying dormant in some part 
 of the human organism, as occurs with regard to tubercle. As the 
 pneumococcus may be found in the saliva of many persons who have 
 suffered from pneumonia, so the rheumatic microbe may be lurking 
 somewhere in the patient who has had rheumatic fever. As a man 
 who has been infected with syphilis is always syphilitic, so a patient 
 who has once suffered from rheumatism may be permanently 
 rheumatic, and the temporary diminution of his power of resistance 
 by a chill may suffice to produce a second attack. 
 
 It should be noted that rheumatism does not excite suppuration ; 
 the inflammatory effusions which it causes are all of the fibro-serous 
 type. If suppuration occurs in a joint believed to be affected with 
 rheumatic inflammation, either the diagnosis is erroneous or a mixed 
 infection has taken place. 
 
 It has long been known that rheumatism produces a disastrous 
 effect on the heart, and that endocarditis and pericarditis are 
 frequent results ; but far too little attention has been paid to the 
 condition of the cardiac muscle, and a careful investigation of this, 
 by the most recent histological methods, is greatly needed. In four 
 recent fatal cases Dr. Poynton found (along with plastic pericarditis) 
 very definite myocarditis ; loss of striation with much fatty degener- 
 ation of the cardiac muscular fibres, and dilated capillaries with 
 numerous foci of small cells in the interstitial tissue, not merely near 
 the pericardium, but also throughout the entire thickness of the cardiac 
 wall. These observations suggest that rheumatic myocarditis is 
 not due simply to extension from an inflamed pericardium or 
 endocardium, but is a primary lesion. If this be so, it is a fact of 
 the greatest importance. It seems probable that the damage to 
 the muscular substance of the heart is the true explanation of the 
 
 ^ Lancet, 1895. 
 
304 MANUAL OF MEDICINE 
 
 destructive action of rheumatism. It is easy to understand how the 
 injury to the cardiac muscular wall reveals itself clinically in an acute 
 dilatation, a condition which often remains as a permanent chronic 
 dilatation, and becomes the most important element in the cardiac 
 failure of chronic heart disease. It is, however, by no means certain 
 that an actual myocarditis is present in the cases which recover, and 
 especially in those of slight intensity. The dilatation observed in 
 subacute cases may possibly be due to a minor degree of toxic 
 action on the muscle without myocarditis. In an investigation 
 published in the third volvLxne^ o{ \.\\q Physiological /ourtial {iZ?>o), 
 Dr. Gaskell found that a dilute solution of lactic acid (i in 10,000) 
 produced marked dilatation in the frog's ventricle, and also in its 
 arterioles, while a dilute solution of sodium hydrate caused contrac- 
 tion of both. He found that some drugs acted like lactic acid, 
 others like sodium. 
 
 It has long been suspected, though on insufficient grounds, that 
 lactic acid is the poisonous element in rheumatism, and Dr. Gaskell's 
 observations indicate that it would produce the acute dilatation 
 which actually occurs. But it seems more probable that the poison 
 is a toxine produced by a microbe, and that the poisoning of the 
 tissues in rheumatism is a selective action of this toxine, analogous 
 to the selective action of the toxines of diphtheria and of tetanus. 
 
 Since endocarditis and dilatation are so characteristic of the 
 rheumatic heart, great doubt must be felt as to the rheumatic 
 origin of cases in which the pericardium is found to be entirely 
 adherent and greatly thickened, with extensive mediastinal ad- 
 hesions, but where the valves are normal, and the heart is small. 
 One case of this kind recently examined post-mortem at the Hospital 
 for Sick Children was found to be of tuberculous nature. 
 
 Prognosis. — A rheumatic attack in a child is much more serious 
 than in an adult. In early life the mortality from cardiac rheuma- 
 tism is very considerable. The prognosis as to life or death in such 
 an attack must be mainly founded on a careful examination of the 
 heart, especially with regard to its size and strength. The important 
 points are: (i) The amount of cardiac dilatation ; (2) the strength 
 and localisation, or the feebleness and diffusion of the impulse ; and 
 (3) the presence or absence of pericarditis. Endocarditis has but 
 little bearing on the immediate prognosis, unless it be of the malig- 
 nant variety, which is rare at this age. Mitral stenosis and aortic 
 regurgitation are seldom so advanced in a child that they can to any 
 great extent influence the prognosis as to recovery. 
 
 The condition of the heart when acute rheumatism has subsided 
 
ACUTE AND SUBACUTE RHEUMATISM 305 
 
 is of great Importance as the basis of an opinion as to the limitation 
 of life or of capacity for active exertion which will result. But the 
 most careful estimate is only too likely to be falsified by the occur- 
 rence of another attack of rheumatism, involving increased injury to 
 the heart. It must, therefore, be constantly borne in mind that 
 evidence of an active rheumatic toxaemia is of the greatest importance 
 from the point of view of prognosis, and that such evidence is by 
 no means limited to the question of arthritis, but that it may be 
 manifested by sore throat, erythema, rheumatic nodules, chorea, 
 pleurisy, pericarditis, endocarditis, and especially by acute dilatation 
 of the heart.^ After two or three such attacks, very great dilatation 
 may be produced, and pericarditis, then supervening, may rapidly 
 cause death. 
 
 In adolescents there is less likelihood of a fatal result from a 
 rheumatic attack ; but the presence of valvular disease (mitral 
 regurgitation, mitral stenosis, less commonly aortic regurgitation) 
 makes the prognosis more serious. Marked cardiac dilatation, and 
 adhesion of the pericardium, both to the heart and to the sternum, 
 pleurae, and lungs, increase greatly its gravity. The least hopeful 
 cases are those in which there is much dilatation, with a loud 
 systolic apex murmur, and evidence of external pericardial adhesions: 
 such patients rarely survive to adult life. The most hopeful are 
 those in which dilatation is slight, external pericardial adhesions 
 absent, and a mitral systolic the only murmur : such cases may 
 have permanent compensation and live for many years, some even 
 to old age. Mitral stenosis of high degree is of evil prognosis, 
 especially if the right heart is more dilated than hypertrophied, 
 and the liver has become enlarged. Mitral stenosis of low degree 
 with efficient compensation may permit the patient to live to forty 
 years, in a few instances even longer. The great majority of the 
 cases of mitral stenosis in which no history of rheumatism or 
 chorea can be obtained are almost certainly the result of a slight, 
 perhaps relapsing, rheumatic endocarditis which escaped observation 
 because pain and arthritis were absent or so slight as to have been 
 entirely forgotten. Mitral stenosis is probably never of congenital 
 origin ; it would be safe to assert that no one has ever heard a 
 presystolic murmur in a baby. 
 
 In adults a rheumatic attack is not often directly fatal, unless the 
 heart is already much diseased, or hyperpyrexia supervene. The 
 patient will almost certainly survive ; but his future condition will 
 
 1 It must not be inferred from this statement that rheumatism is the only cause 
 of acute dilatation of the heart in a child. 
 
 VOL. I X 
 
3o6 MANUAL OF MEDICINE 
 
 depend to a great extent on the amount of the injury to the heart. 
 The mechanical effects of damaged valves will assert themselves as 
 time passes, but the chronic dilatation is in itself a factor of great 
 importance. And in adults also, though less frequently than in 
 children, the pernicious effect of a fresh rheumatism may some- 
 times be seen, entirely altering the prognosis previously formed. 
 
 Treatment. — Complete rest in bed is the first essential ; this 
 must be insisted on, even in the slightest cases, especially in children 
 and adolescents, and the practitioner must not allow himself to be 
 misled by the trivial nature of the arthritis. The condition of the 
 heart must be at once ascertained, its exact size defined by careful 
 light percussion, the position and character of the cardiac impulse 
 noted, the quality of its sounds, and of any murmurs present 
 observed. The temperature must be taken, and a chart at once 
 instituted. For a rheumatic patient, a mattress is better than 
 a feather bed, and cotton sheets are preferable to linen. The 
 patient should be protected from draughts. Where there is much 
 sweating, a flannel jacket should be worn over the night-dress, and 
 the latter should be changed as required. In the severer cases 
 the assistance of a trained nurse, strong enough to lift the patient, 
 is necessary. The diet should at first consist of milk and beef-tea 
 only. If constipation is present, a laxative may be administered ; 
 but active purgation should be avoided. If there is no constipation, 
 a single lo-grain dose of pulvis ipecacuanhae co. may be given (to 
 adults) for the relief of pain, and it may sometimes be repeated 
 with advantage. 
 
 Sodium salicylate should be given immediately, in doses propor- 
 tioned to the age : to children, about three-fourths of a grain for each 
 year, to adults in doses of 20 grains. This drug appears to be 
 as definitely antagonistic to the rheumatic process as mercury to the 
 syphilitic or quinine to the malarial. With the salicylate it is useful 
 to give sodium bicarbonate, in a dose twice as large as that of the 
 salicylate. The medicine should be taken hourly for the first three 
 hours, afterwards every three hours, during the day-time ; during the 
 night also, if the patient is awake. When the temperature has fallen 
 to 99° F., and the joint-pains have subsided, the frequency may be 
 reduced to thrice daily, and this should be continued for a week or 
 ten days after the pains have disappeared. Too early discontinuance 
 of the salicylate is very often followed by a relapse of the symptoms 
 — clear evidence of the power of the remedy. Necessity for reducing 
 the dose of salicylate is indicated by deafness and tinnitus, sometimes 
 by vomiting, occasionally by delirium, and in a few cases by irregu- 
 
ACUTE AND SUBACUTE RHEUMATISM 307 
 
 larity of pulse. If any of these symptoms are present, smaller doses 
 of the salicylate should be given ; but it should not be omitted 
 altogether, if this can possibly be avoided. Care, however, should 
 be taken to ensure that the drug used is of good quality, and free 
 from adulteration. 
 
 It is thought by some physicians that salicylate is depressing to 
 the heart ; probably a large part of the cardiac depression supposed 
 to be produced by the drug is really caused by the action of the 
 rheumatic poison, leading to toxic dilatation and myocarditis, 
 especially in hearts already damaged by previous rheumatism, and 
 suffering from chronic dilatation or serious valvular disease. No 
 doubt some patients are specially susceptible to the action of salicylate 
 as others are to that of quinine or of morphine ; but as a rule, in the 
 earlier attacks of rheumatism the doses above mentioned may be 
 given without fear of bad effects. If it seems necessary to omit the 
 salicylate, salicin may be substituted ; but it must be given in larger 
 doses (30 to 40 grains for adults), or quinine may be given with 
 alkalies in an effervescent mixture. Occasionally a small dose of 
 calomel may be useful. 
 
 The joints should be wrapped in cotton wool and kept at rest. 
 Only when an arthritis tends to become chronic should counter- 
 irritation be used, by small blisters or a moderately strong iodine 
 solution applied in the neighbourhood of the joint. Small doses of 
 potassium iodide may be of service for chronic pains about the 
 joints. 
 
 The heart must be carefully examined every day. If pericardial 
 friction become audible, an ice-bag should at once be applied over 
 the precordial region. The ice-bag must be water-tight, with an 
 accurately-fitting screw top ; it should rest directly on the skin, and 
 should be surrounded with cotton wool or a soft towel to absorb the 
 moisture which condenses on its outer surface. The area to which 
 it is to be applied should be outlined on the skin, and the nurse 
 must see that its position does not become shifted when the patient 
 moves. If there is much tenderness, the ice-bag may be suspended 
 so as to just touch the skin, but after a few hours it will be possible 
 to apply it thoroughly. For young children hot-water bottles must 
 previously be placed in the bed, so as to keep the feet and legs quite 
 warm ; the temperature should also be taken every half-hour at first. 
 If pericarditis is present when the case comes under observation, 
 and there is much cardiac dilatation, it will be wise to apply leeches 
 before having recourse to the ice. The use of the salicylate is not 
 to be omitted on account of pericarditis. In first attacks of rheu- 
 
3og Manual of medicine 
 
 matism it is usually possible to keep the ice-bag continuously in 
 position ; but in later attacks, when there is much dilatation present, 
 it must be removed at intervals. It may be applied for two or for 
 three hours, removed for one hour or for two, then reapplied, in 
 accordance with the condition of each case. Sometimes it is better 
 to omit it altogether during the night ; but it is desirable that the 
 application of the bag should be as persistent as possible. In many 
 cases it may be applied for a week or ten days, or even longer, with 
 great benefit to the patient. It is probable that the local use of ice 
 not merely controls the pericarditis, but that it also tends to check 
 myocarditis, and it may sometimes be used with benefit for the 
 latter purpose in a rheumatic attack in which there is acute dilatation 
 but no pericarditis. Whether its influence extends as deeply as 
 the endocardium is doubtful ; but we have no other means of 
 arresting endocarditis. If pericarditis is accompanied by pleurisy 
 or pneumonia, an additional ice-bag should be placed over the in- 
 flamed lung or pleura, and the strain on the right side of the heart 
 should be relieved by the application of leeches over the liver. 
 
 If ice cannot be obtained, small doses of opium or hypodermic 
 morphine are advisable to quiet the distress, and leeches should be 
 applied over the heart. It is uncertain whether blisters are of any 
 real service in the treatment of pericarditis, and they greatly impede 
 the examination of the heart. 
 
 Surgical measures are never necessary in rheumatic pericarditis, 
 and they are extremely dangerous on account of the great cardiac 
 dilatation. In suppurative pericarditis, on the other hand, they are 
 urgently necessary, and may save life. 
 
 In the later attacks of rheumatism, when there is tumultuous 
 action of the heart, great dilatation, and much cardiac distress, opium 
 or morphine, in small doses, often gives great relief. This may be 
 followed by digitalis ; but it must be clearly recognised that the 
 mere presence of a murmur is not to be taken as a signal for the 
 employment of this drug. 
 
 If the temperature is persistently high and rising, especially if, at 
 the same time, the arthritis subsides and the skin becomes dry, the 
 temperature must be taken every half-hour. When it reaches 105° F., 
 the patient should be sponged with cold water and covered only with 
 a sheet ; if this is insufficient to arrest the rise, decided measures 
 must be taken at once. When a bath can be obtained, and the 
 patient is not too heavy, it may be filled with water at 80° and the 
 patient immersed in it for fifteen or twenty minutes, the water being 
 meanwhile cooled to 60^ by the addition of lumps of ice. During 
 
ACUTE AND SUBACUTE RHEUM ATIS.AI 309 
 
 this time his temperature should be frequently taken by a ther- 
 mometer in the mouth ; as soon as this reaches 102 , he should be 
 taken out of the bath, replaced in bed, and covered with one blanket, 
 with a hot bottle to his feet. The temperature wnll fall 2' or 3'' 
 further after his removal from the bath. The procedure must be 
 repeated as often as necessary. It is sometimes more convenient 
 to cover the bed mth a large Mackintosh sheet, and to lay the 
 patient absolutely naked upon it, sousing him all over with ice-cold 
 water or rubbing him with lumps of ice. The temperature in the 
 mouth must be frequently taken during this process. 
 
 Prolonged rest in bed is of the greatest importance after a rheu- 
 matic attack, especially if pericarditis, fresh endocarditis, or much 
 acute dilatation has occurred. In such cases it is well to keep the 
 patient in bed for an entire month after the temperature has become 
 normal. The tendency to relapse is best averted by administering 
 one or two daily doses of the salicylate for three or four weeks \ in 
 some cases it is needed for an even longer period. Provided this 
 be done, it is safe and useful to prescribe iron for the anaemia, the 
 best preparation being the dialysed solution of iron, given in drachm 
 doses (to adults), in glycerine and water, after meals. If the heart 
 has suffered damage, gentle "resistance-movements," repeated once 
 or twice daily, should be practised for two or three weeks before 
 any active exertion is allowed. 
 
 Children who have suffered from rheumatism, especially if any 
 injury to the heart has been caused by it, need careful regulation of 
 their life both at home and at school. The danger of a second 
 attack, which will almost certainly cripple the heart still more, must 
 always be kept in mind by the physician, 
 
 D. B. Lees. 
 
3IO MANUAL OF MEDICINE 
 
 CHICKEN-POX 
 
 Syn. Water-pock, Glass-pock, Varicella 
 
 Chicken-pox is an infectious, though usually mild, febrile dis- 
 order, attended with an eruption of papules, which, for the most 
 part, rapidly develop into characteristic vesicles. These, after a 
 few days, dry up and form scabs, which ultimately separate, and 
 sometimes leave behind more or less persistent scarring of the skin. 
 
 Although the disease was described by Ingrassia as far back as 
 the year 1550, it was not until the latter half of the eighteenth 
 century that its specific distinctions from smallpox were clearly 
 recognised ; and even since, the two affections have often been 
 confused. The prevalence of chicken-pox seems to be regulated 
 by no known influences. Neither season nor climate appear to 
 be operative. The association of susceptible persons with one 
 suffering from the disease, and this under circumstances favourable 
 to personal contact, are the only conditions which are known to be 
 concerned in its diffusion. 
 
 Susceptibihty to infection varies with the state of a person's 
 general health, and whether or no he has had a previous attack. 
 Chicken-pox is particularly Hable to attack a child recently con- 
 valescent, or while actually suffering, from scarlet fever, measles, or 
 diphtheria, if accidentally exposed to infection. The protection 
 conferred by an attack is probably more complete than it is in the 
 case of any other infectious fever, with the possible exception of 
 whooping-cough. A second attack of chicken-pox is extremely 
 rare, although an instance is recorded in which a person was three 
 times attacked with the disease. Age does not appear to exert 
 much influence, though the large proportion of attacks occur 
 between the second and fifth years of life. The disease is rarely 
 seen in adults, probably because most grown-up persons have 
 already suffered from the disease in their childhood. Both sexes 
 are attacked indiscriminately. The infection of chicken-pox 
 does not seem to be readily conveyed indirectly. The disease, 
 however, frequently arises in a sporadic fashion, it being quite 
 impossible to trace any connection with a previous case. Its 
 inoculability is doubtful. 
 
 The length of incubation in chicken-pox in the large pro- 
 
CHICKEN-POX 3 1 1 
 
 portion of attacks varies between the limits of thirteen to fifteen 
 days, but it may be as short as ten, or as long as nineteen. A 
 quarantine of twenty days should be insisted on. 
 
 Symptoms. — An attack of chicken-pox may be either 7nild or 
 severe, the severity of the attack being commonly proportionate 
 to the amount of the eruption ; in other words, to the number of 
 the pocks. 
 
 In some attacks the eruption is the first symptom of the 
 disease, but frequently the child may be noticed to be fretful and 
 its temperature slightly raised for a few hours before the rash 
 comes out. Occasionally, conjunctival injection or an er}'thematous 
 flush on the trunk may be noted as well. This pre-eruptive stage 
 is rarely of twenty-four hours' duration, but in adults the symptoms 
 may be really severe, in which case pain in the back, shivering, 
 headache, and weariness, attended, perhaps, ttdth a temperature of 
 102°, or even more, may be present for two clear days before the 
 eruption declares itself. In such instances the invasion closely 
 simulates that of smallpox, and the rash as a rule is copious. 
 
 The chicken-pox eruptio?t comes out in successive crops of 
 slightly raised pinkish-red papules of variable size, most of which 
 in a few hours become converted into characteristic thin-walled, 
 limpid, glistening vesicles. Some of these develop so rapidly that 
 the papular stage may escape observation, in which case the 
 vesicles resemble little delicate blisters, such as might develop on 
 the skin as the result of drops of scalding water. Others are 
 obviously situated upon a red, injected, and slightly raised base, 
 the central portion of which alone may have become vesicular. 
 Some of the papules, especially the smaller ones, never develop 
 into vesicles at all, but remain as small red, acuminate, or irregularly 
 pyramidal pimples until they fade away. At the ver}- earliest 
 stage the papules appear as small, round, or ovoid spots, which, 
 before becoming ob\-iously raised, can be felt as slight points of 
 thickening in the superficial layers of the skin. The individual 
 pocks reach their full development at about the end of two days, 
 after which the contents of the vesicles become turbid. They 
 then rapidly shrink and dry up, forming brownish, horny-looking 
 scabs, which usually separate at the end of a week or ten days. 
 A slight areola can, as a rule, be seen around the base of the fully 
 developed vesicle, which is sometimes, though usually not, um- 
 bilicated. If the vesicle be pricked, a thin clear fluid readily 
 escapes, and the walls entirely collapse under pressure with the 
 finger, though a slight thickening of the skin at its base is still 
 
312 MANUAL OF MEDICINE 
 
 clearly distinguishable. The contents of some of the vesicles 
 when fully developed may become purulent, in which case the 
 areola is more pronounced, and a more or less permanent depressed 
 cicatrix remains after the scab has become detached. Suppuration 
 of the pock invariably results if it be scratched or otherwise 
 ruptured, and this most often occurs on the face and scalp. 
 
 The eruption, perhaps oftener than not, comes out earlier on 
 the trunk than elsewhere, but spots may appear first on the face 
 and scalp, or even, though far more rarely, on the limbs. Ulti- 
 mately the whole surface of the skin may be invaded, but it is 
 usual for the eruption to be relatively more copious on the trunk, 
 thighs, and upper arms than the face, scalp, or extremities. It is 
 not common for the palms or soles to be affected, unless the rash 
 be fairly extensive, and even then the spots may never get beyond 
 the papular stage. 
 
 The mucous membranes may also be invaded, especially those 
 of the palate, tongue, and buccal surface of the cheek. No true 
 vesicle is found, however, but the pock is represented by a white 
 sodden-looking papule, which usually breaks down into a shallow 
 ulcer, and then rapidly heals. Pocks occur, moreover, though far 
 more rarely, on the conjunctivae and the mucous surface of the 
 genitals. A pecuUarity of the chicken-pox eruption is that it comes 
 out in several crops, perhaps three or four, commonly on succeeding 
 days ; or an interval of a day or two may elapse between two con- 
 secutive crops. Hence it is that the length of the stage during which 
 the eruption is coming out is commonly three to five days, though 
 sometimes longer. The writer has seen it extend in one instance 
 to ten days, and even longer periods have been recorded. The 
 total number of pocks may vary from half a dozen or so up to 
 several hundred. MacCombie states that the number is frequently 
 from fifty to two hundred. The aggregate number of pocks will 
 depend upon the number of crops, and may be taken as a measure 
 of the duration and of the general severity of the attack. 
 
 The appearance of each crop of spots is commonly attended 
 with a rise of temperature, perhaps to ioo°, or 102°; sometimes 
 higher. The temperature usually falls in the interval, if not to the 
 normal, to something very near it. The second exacerbation is 
 usually the highest, and a few pocks can then generally be seen on 
 the mucous membranes, the subsequent ones, should there be any, 
 becoming gradually less pronounced. The pyrexia of chicken-pox, 
 then, is an irregular one, and if prolonged, shows wide daily varia- 
 tion. In some cases, especially when the rash is sparse and com- 
 
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314 MANUAL OF MEDICINE 
 
 prised in a single crop, the temperature remains normal throughout. 
 Some acceleration of pulse accompanies the pyrexia, and the tongue 
 is usually lightly furred. The eruption may lead to slight enlarge- 
 ment of the lymphatic glands adjacent to any of the pocks which 
 have suppurated, and is often attended with considerable itching 
 and consequent irritability of temper in young children. 
 
 In rare instances some of the vesicles are inordinately developed, 
 and form distinct bullae of varying size. They may even attain the 
 size of a hen's egg, in which case a raw denuded surface of corre- 
 sponding area remains after the fluid is let out. The condition 
 closely resembles pemphigus, and is sometimes described as a 
 variety of chicken-pox under the name of vmicella bullosa. Attacks 
 of chicken-pox are occasionally met with in which a necrotic change 
 occurs in the skin forming the base of the pock. K certain number 
 only are affected in most instances, but in some, almost all of 
 them undergo the same change. The attack begins in the ordinary 
 way, but as the case proceeds, the inflammatory areola surrounding 
 an affected pock gets larger and more intense, and the vesicle is 
 converted into a dark brownish, and ultimately, black scab, which 
 gradually becomes thickened and enlarged so as to resemble a 
 rupial crust. The underlying skin is found to have become 
 gangrenous, and from its margin a thin sanious or blood-stained dis- 
 charge escapes. After the slough has separated a clearly defined 
 punched-out ulcer remains, which may extend superficially or in 
 depth, and lead to a considerable loss of tissue. In fatal cases the 
 temperature remains elevated, emaciation becomes pronounced, 
 and the patient gradually sinks. The condition is known as vari- 
 cella gangrenosa, and is usually fatal ; but if a few pocks only are 
 affected, recovery will probably ensue. Occasionally in these 
 severe attacks an effusion of blood into the skin at the base of the 
 pocks and from some of the mucous membranes has been re- 
 corded, a condition to which the term varicella Juzmorrhagica has 
 been applied. 
 
 The only complication worth recording is a condition of 
 impetiginous eczema, which sometimes supervenes, probably as the 
 result of dirt or scratching, although various affections have been 
 observed to arise shortly after chicken-pox, such as nephritis, pneu- 
 monia, bronchitis, hemiplegia, and paraplegia ; their connection with 
 the disease is very much open to doubt. 
 
 Bacteriology. — No micro-organism has yet been satisfactorily 
 established as the specific infecting agent. Both staphylococci and 
 streptococci occur in the vesicles, as they do in those of smallpox 
 
CHICKEN-POX 315 
 
 and vaccinia, and a bacillus which normally inhabits the epidermis. 
 Protozoa and an oval coccus have been described, and Bareggi of 
 Milan claims to have isolated the latter and by its injection to have 
 successfully communicated the disease to children. 
 
 No morbid changes in the viscera special to varicella are 
 known ; nor does the disease ever seem to be fatal, except in the 
 gangrenous or hsemorrhagic forms. In the former variety, which is 
 probably determined rather by the constitutional predisposition of 
 the particular patient than by any augmentation in the virulence of 
 the specific contagion, the gravity is proportionate to the number 
 of pocks affected. 
 
 The differential diagnosis of chicken-pox and modified small- 
 pox is fully discussed in connection with the latter disease (p. 324), 
 but the importance of the following points justifies their special 
 mention. 
 
 In chicken-pox, pocks in all stages of development, macule, 
 papule, vesicle, pustule, and scab, can often be seen side by side 
 within a restricted area. In chicken-pox a tense, fully developed 
 vesicle may be found at a spot on which twenty - four hours 
 previously not even the suggestion of a papule could be detected. 
 Second attacks of chicken-pox are so exceptional, that the diagnostic 
 value of a few scars in a doubtful attack can hardly be over- 
 estimated. Concerning the nature of such scars, it is rare at the 
 present day in this country to find a person bearing the marks of 
 antecedent smallpox, especially if well vaccinated ; moreover the 
 cicatrices of variola are usually more abundant on the face than 
 elsewhere, whereas in chicken-pox the reverse obtains. 
 
 A case of varicella bullosa may closely simulate pemphigus, but 
 the presence of one or more normal pocks associated with the 
 bullae will decide its real nature. 
 
 The treatment of simple varicella is comprised in the pre- 
 vention of the patient from scratching his pocks. In the gan- 
 grenous form the administration of stimulants and a generous 
 diet will be necessary, and the affected pocks should be dressed 
 with warm boracic fomentations. The patient should be isolated 
 until all the scabs have separated. This usually means a detention 
 of from two to three weeks. 
 
 F. FooRD Caiger. 
 
3i6 MANUAL OF MEDICINE 
 
 SMALLPOX 
 Syn. Variola 
 
 Smallpox is an acute, specific, contagious disorder, characterised 
 by pyrexia and by the appearance, after a definite period of incuba- 
 tion, of an eruption which passes through the successive phases of 
 papule, vesicle, and pustule. 
 
 Smallpox affects all races, every age, and both sexes. In 
 countries in which smallpox has been prevalent for generations it 
 was, prior to the introduction of vaccination, a disease of early 
 childhood, owing to the fact that practically all the adults would 
 have previously passed through the disease. In vaccinated com- 
 munities this incidence of the disease is no longer found to persist. 
 Smallpox is not limited to any particular portion of the globe, 
 although it is apt to be more severe in warm climates. It has 
 usually been especially virulent on its first introduction into any 
 country, as an instance of which may be cited an epidemic which 
 occurred in Iceland in 1 707-1 709, from which about one-third of 
 the total population died. 
 
 Seasonal prevalence. — In England and other temperate 
 climates smallpox is apt to be most prevalent in spring, autumn, 
 and winter, comparatively few cases being met with in the summer. 
 MacCombie states that he has frequently noticed that in outbreaks 
 commencing in autumn, there has been a sudden drop in June the 
 following year, and that the lessened incidence prevailed during the 
 summer months. But he does not consider it probable that this 
 drop is mainly due, as has been suggested, to the more open-air 
 habits of life in summer. 
 
 Mode of conveyance. — Smallpox infection may be either 
 direct or indirect, and it has recently been shown by Mr. Power 
 and others that the contagium may be carried for a considerable 
 distance through the air from a smallpox hospital, especially at 
 times when the latter contains a number of acute cases. Most 
 frequently, however, a previously healthy person becomes infected 
 through close contact with a patient suffering from the disease. 
 Cases of smallpox must be considered as infectious from the eariiest 
 onset of the disease, although the danger is probably greater after 
 the appearance of the eruption, and perhaps especially so when the 
 
SMALLPOX 
 
 317 
 
 crusts are commencing to separate. The bodies of persons who 
 have died of smallpox are also capable of conveying the disease, 
 though it may be that actual contact is necessary in this case. In- 
 fection is also n jt unfrequently conveyed by articles of personal use, 
 such as clothing, bedding, and the like, even after considerable 
 intervals of time, during which they may have been stored, and 
 outbreaks have occasionally occurred in paper-mills from the use of 
 infected rags in the manufacture of paper. It is also possible that 
 healthy persons, who have been in contact with the sick, may 
 convey the disease to others by means of their clothing or hair. 
 
 Seasonal Curve of Smallpox Mortality (London), 
 Mean of 40 Years. 
 
 Jan. 
 
 1 
 
 Feb. 
 
 March 
 
 April 
 
 May 
 
 June 
 
 July 
 
 Aug. 
 
 Sept. 
 
 Oct 
 
 Nov. 
 
 Dec. 
 
 / 
 
 
 
 
 
 
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 Each division corresponds to lo per cent above or below the mean annual mortality indicated by 
 
 dotted line. 
 
 An individual is only to be considered as free from the liability to 
 transmit variola " when every scab has fallen off and the skin 
 lesions have all healed " (Medical Officers of Schools, Code of 
 Rules). 
 
 Incubation. — The period which may elapse after exposure to 
 infection, by which alone smallpox in the present day is con- 
 tracted, and before any definite symptoms pointing to invasion of 
 the system by the disease becomes obvious, has been variously 
 estimated, but in the great majority of cases is found to be, as 
 nearly as possible, twelve days. The Code enjoins an isolation for 
 sixteen days after exposure to infection and thorough disinfection 
 at the commencement of the period. 
 
3i8 MANUAL OF MEDICINE 
 
 Symptoms and progress. — During the incubation stage of 
 smallpox it is exceptional for any definite symptoms to present 
 themselves, although occasionally the patient may complain of a 
 feeling of languor and general malaise. The appearance of the 
 typical eruption is preceded for about a couple of days by certain 
 well-marked symptoms, commencing with a somewhat sudden and 
 often rapid rise of temperature, ushered in with chills or actual 
 rigors, or, in children, convulsions. In adults especially, heat and 
 perspiration of the skin may be profuse, and anorexia, thirst, and 
 constipation well marked, together with a feeling of nausea, or actual 
 vomiting. In children constipation is liable to be replaced by 
 diarrhoea. Symptoms pointing to invasion of the nervous system 
 usually present themselves early in the progress of the disease, of 
 which acute lumbar pain is at once the most typical and constant. 
 Headache and aching of the limbs are often complained of, together 
 with drowsiness, which may pass into stupor and coma. On the 
 other hand, delirium not unfrequently supervenes, occasionally 
 developing into a maniacal condition. The symptoms of this 
 stage are severe in proportion to the severity of the attack which they 
 usher in. Other things being equal, therefore, the higher the 
 temperature, the more persistent the vomiting, the acuter the pain 
 in the back, and the more pronounced the implication of the brain, 
 the more quickly will the disease assume grave proportions, and the 
 greater will be its intensity and the prospect of a fatal issue. 
 
 By about the third day these prodromal symptoms will attain 
 their maximum, and the eniption typical of the disease appears. 
 The rash commences as minute reddish papules, which are distinctly 
 hard, giving a " shotty " sensation when the finger is passed over the 
 skin. These are first found, and in greatest numbers, on those 
 parts of the body which are ordinarily uncovered, more particularly 
 the face, head, neck, and wrists. During the next two days the 
 chest, abdomen, and upper and lower extremities become invaded, 
 though to a less extent. The papules gradually enlarge, and in 
 the course of two or three days become converted into vesicles. 
 About three days later the vesicular contents, at first limpid, will 
 have become purulent. The resulting pustule increases in size, 
 and becomes surrounded by a dark red zone of inflammation, 
 termed the "areola." The inflammation, together with the swell- 
 ing of the underlying tissues due to inflammatory exudation, still 
 further increases up to about the ninth day (eleventh day of the 
 disease), or even a day or two later in the case of that portion of the 
 eruption on the lower part of the trunk and extremities. When the 
 
SMALLPOX 319 
 
 eruption is somewhat scanty, the separate pocks on the face remain- 
 ing distinctly isolated from one another, the attack is said to be 
 of the discrete variety, the papules in this form of the disease not 
 unfrequently showing a crescentic arrangement in their grouping. If, 
 on the other hand, the pocks are so numerous as to coalesce with 
 one another, the disease is said to be of the cotiflue?it form. In 
 certain specially severe cases, the so-called hcBt7iorrhagic smallpox, the 
 contents of the pocks at quite an early stage are found to be mixed 
 with blood, while in a still severer form of the disease, 7?ialig?iant 
 smallpox, minute punctiform hsemorrhages become visible at an 
 early stage just beneath the surface of the skin, the patient probably 
 dying collapsed before the appearance of the typical eruption. 
 
 Although most obvious on the skin, the rash of smallpox is by no 
 means confined to the outer surface of the body. It not unfrequently 
 develops to a considerable extent on the mucous membrane of the 
 mouth, nose, and throat, and even that of the larynx and trachea, 
 and of the conjunctiva. 
 
 Prodromal rashes. — The eruption typical of the disease is 
 occasionally preceded for a day or two by rashes bearing somewhat 
 of a resemblance to those which occur in measles and scarlet fever. 
 This is not unfrequently so in smallpox which has been modified by 
 antecedent vaccination. Again, in cases which eventually prove to 
 be of severe type an abundant rash either of somewhat similar 
 character or of a hasmorrhagic nature is apt to occur, more particularly 
 on the lower portion of the abdomen, where it usually occupies an 
 area between the umbilicus and the pubes similar in outline to an 
 inverted triangle, and also to a less extent on the chest and loins. 
 
 Specially characteristic of the disease is the fact that on the first 
 appearance of the eruption all the symptoms from which the patient 
 will previously have been suffering become ameliorated. To so 
 great a degree is this the case, that in the milder form of the 
 disease the patient may believe himself to have recovered, and 
 persist in going about his ordinary avocations. Owing to this fact 
 the disease is often spread by the peregrinations of tramps from 
 town to town. 
 
 Although in an ordinar}' attack of smallpox the typical 
 symptoms will thus in large measure have disappeared on the 
 outbreak of the eruption, this latter will itself in all probability 
 cause some inconvenience to the patient, as will also soreness of the 
 mouth and tongue, which are likely to be accompanied with 
 ptyalism. Owing to the eruption affecting to some extent the 
 upper part of the alimentary and respiratory tracts, the throat 
 
320 MANUAL OF MEDICINE 
 
 becomes painful and the voice hoarse, while the patient is often 
 troubled with a harsh cough. In severe cases laryngeal com- 
 plications are usually present from an early stage. 
 
 The after course of the disease will vary considerably in accord- 
 ance with the severity or reverse of the attack. In the mildest 
 cases the vesicles never become really pustular, commencing to 
 contract and dry up before this stage is reached. In such cases 
 the temperature, which will have fallen almost or quite to normal 
 on the appearance of the eruption, does not again appreciably rise, 
 and the patient speedily becomes convalescent. Ordinarily, however, 
 after a period of apparent convalescence extending to about the 
 eighth or ninth day of the disease the maturation of the pustules is 
 ushered in by a period of secondary fever, accompanied, it may be, 
 by chills or rigors and a rise of temperature as high as, or even 
 exceeding that reached at the commencement of the disease. The 
 pulse is quickened, anorexia again presents itself, and the patient may 
 become delirious. In the confluent form of the disease little or no 
 appreciable remission of symptoms accompanies the appearance of 
 the eruption, although the temperature may perhaps fall a degree or 
 so. Almost immediately, however, it mounts again, and both febrile 
 and nervous symptoms rapidly become aggravated, attaining their 
 maximum severity at about the period of maturation of the 
 pustules. 
 
 If the course of the temperature be noted in a typical attack of 
 the disease, it will be found to rise rapidly during the stage of in- 
 vasion, it may be to 104°, or even 106°. As previously stated, it 
 usually falls to a considerable extent coincidently with the appear- 
 ance of the eruption, although for the most part not descending 
 quite to the normal level. As the contents of the vesicles become 
 purulent the temperature once more rises to 102°, 7:03°, or even 
 104°, while in cases tending to a fatal termination this range may be 
 exceeded by two or three degrees. 
 
 The delirimn, which is so marked a symptom, more particularly 
 of the severer cases, like the temperature, may show a temporary re- 
 mission after the eruptive stage, reappearing once more, and even 
 in a severer form, with the occurrence of the secondary fever. In 
 sorjie cases the patient, already delirious, may become violently 
 maniacal. 
 
 'YYvQ. pulse becomes increased with the rise of fever, falls together 
 with the temperature after the appearance of the eruption and again 
 quickens with the period of secondary fever. Respiratio7i also be- 
 comes more or less hurried in correspondence with similar variations 
 
SMALLPOX 321 
 
 in the pulse rate. In severe confluent cases the breathing is apt to 
 become shallow and laboured. 
 
 The urine is febrile in character. During the pustular stage of 
 the disease the amount of urea excreted is markedly increased, and 
 albuminuria has been found to occur in about one-third of the total 
 number of cases. Haematuria is rare. 
 
 Thirst h a marked feature throughout, and in the milder forms 
 of the disease perspiratmis persist from first to last, except in the 
 case of children. In confluent smallpox, however, perspirations are 
 exceptional, while salivation is a common and troublesome symptom. 
 In such cases, on account of the swollen condition of both mucous 
 tnembrane and skin, the mouth cannot be closed, while, owing to the 
 sweUing of the eyelids, it is difficult or impossible to open the eyes. 
 The nose, ears, and lips also may become so enormously swollen as 
 to render the patient unrecognisable, even to his relatives. The 
 extremities in like manner are often so oedematous and painful that 
 even the weight of the bed-clothes can hardly be endured. 
 
 Within three or four days from the commencement of the 
 pustular phase of the eruption, by which time the secondary fever 
 in favourable cases will have practically subsided, the pustules will 
 either dry up, forming for the most part flattened, reddish-brown 
 scales, or they become ruptured, their contents escape, and, drying 
 up, dark-coloured, thick, adherent crusts result. Most typical of 
 this stage is a peculiar fetid odour, which has been likened to the 
 smell of mice, exhaled from the skin. 
 
 The swelling of the skin now subsiding, the features return more 
 or less to their previous appearance, and during the third week of 
 the disease the "crusts" commence to separate, but, owing to the 
 occasional formation and separation of successive "crusts," the re- 
 sulting sores may not be completely healed for another week or more. 
 
 From this period onwards, in favourable cases, rapid progress 
 towards convalescence may be expected, although even in the 
 milder cases there is a possibility that certain complications and 
 sequelce may intervene. 
 
 Complications and sequelae. — An attack of smallpox is 
 liable to be followed by various sequelae, whether the attack itself be 
 mild or severe, although serious complications more commonly 
 manifest themselves after the confluent form of the disease ; of 
 these perhaps the most common is ery'sipelas, particularly of the 
 face and head, together with boils, and probably, later on, abscesses, 
 both subcutaneous and deep-seated, which may attain a large size 
 and heal with difficulty. Otitis and coiijunctivitis may be met with, 
 
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SMALLPOX 323 
 
 ophthalmia occasionally ensuing in consequence of the formation 
 of pustules on the conjunctiva. These never occur on the cornea 
 itself, although a form of ulceration which is apt to extend slowly 
 from one side of the cornea to the other is occasionally observed. 
 
 Other possible complications include bronchitis, broncho-pneumonia, 
 and pleurisy ; paralysis of the extretnities or bladder has been observed. 
 
 As the result of the destruction of the cutis vera, which will be 
 more or less extensive according to the amount of the original 
 eruption, indelible cicatrices will be left ; the face specially, after a 
 severe confluent attack, often remaining scarred and seamed in all 
 directions. The ophthalmia, to which reference has already been 
 made, may result in permanent blindness. Permanent alopecia 
 only occurs after severe attacks, and chiefly in adults. Unless the 
 follicles have been destroyed, regeneration of hair, which may have 
 been shed during the course of the disease, takes place rapidly and 
 abundantly after recovery. 
 
 Morbid anatomy and histology. — Except in severe hsemor- 
 rhagic cases, in which blood will be found effused into the substance 
 of the solid viscera, and beneath the serous and mucous surfaces, 
 no special appearances are likely to be observed on post-mortem 
 examination. 
 
 Comparatively little is known as to the actual histological 
 changes occurring in the skin in smallpox during the development 
 of the eruption, there appearing to be no record of any continuous 
 study of the minute anatomy of this disease. So far as can be 
 judged from such examination as has been made of the micro- 
 scopical structure of the skin at various stages of the eruption, 
 there would appear to be a complete similarity with those observed 
 during the eruption of vaccina, for an account of which reference 
 may be made to the article dealing with this disease. The same 
 article may also be consulted for a brief account of the bacteriology 
 of these maladies. 
 
 Modified Smallpox or Varioloid is that form of the disease 
 which is met with in persons who, at some time previous to their 
 attack, have been vaccinated, but in whom the protection afforded 
 by the operation has been insufficient, either from the vaccination 
 having been imperfectly performed in the first instance, or because 
 its effect has diminished through lapse of time. 
 
 No definite rule can be laid down as to the extent to which any 
 one symptom or set of symptoms, are likely to be modified as the 
 result of previous vaccination, but for the most part the case re- 
 sembles a mild form of the discrete variety. Thus the disease may 
 
324 MANUAL OF MEDICINE 
 
 be exceedingly mild from the commencement, and the eruption 
 may be absent or be limited to the appearance of a few papules on 
 the face or hands. Or the attack may commence with fairly high 
 fever, generally, however, of short duration, accompanied by severe 
 headache, lumbar pain and vomiting, only to abort soon after, or 
 even before, the appearance of the eruption. If an eruption ■ does 
 present itself it usually does not develop beyond the vesicular or 
 possibly the papular stage, and secondary fever, if it supervenes, is 
 comparatively slight. It is in cases of modified smallpox that 
 generalised prodromal rashes resembling those of measles or scarlet 
 fever are most often observed. It is rare for a case of modified 
 smallpox to have a fatal termination. 
 
 Diagnosis. — The diseases from which smallpox is most likely 
 to be with difficulty distinguished are : — 
 
 In t/ie initial stages, measles, scarlet fever, syphilis, and the rashes 
 which occasionally appear as the result of the administration of 
 antitoxin or the bromides. 
 
 In the later stages the discrete or modified variety may simulate 
 chicken-pox or acne. 
 
 If an initial rash should present a difficulty, the appearance of 
 the typical rash will probably render the diagnosis certain. The 
 diagnosis of modified smallpox from chicken-pox, however, de- 
 serves more detailed description. 
 
 Differential diagnosis of modified smallpox and chicken- 
 pox. — A well-developed attack of natural smallpox could hardly be 
 mistaken for varicella, but in respect to the modified disease, especi- 
 ally with a sparse eruption, the diagnosis may present considerable 
 difficulty. Careful attention to the following points, however, will 
 usually serve to dispel any doubt as to the nature of the case. 
 
 {a) In modified smallpox the eruption, however scanty, is 
 almost invariably preceded by severe febrile symptoms of two days' 
 duration. In varicella this prodronial illness, except very occasion- 
 ally in adults, is wanting. The rash is usually the first sign, pre- 
 ceded possibly for a few hours by a feeling of malaise. 
 
 {b) In variola the eruption, whatever its amount, will all be 
 visible within thirty-six to forty-eight hours of its first appearance \ 
 but in varicella the eruption usually comes out in distinct crops, 
 extending over a period of three to five days, or more. 
 
 ic) The teftiperature in variola falls rapidly, immediately the 
 eruption appears, whereas in varicella each crop is commonly 
 attended with a fresh rise of temperature. 
 
 (^) Although in most cases of modified smallpox the vesicles 
 
SMALLPOX 325 
 
 are not fully formed until the third or fourth day of the rash, in- 
 stances are occasionally seen in which some of the papules show an 
 attempt at vesiculation within twenty-four hours of their first appear- 
 ance. The presence, however, of one single, well-developed, tense 
 vesicle by the end of the first day is practically sufficient to exclude 
 variola, though common enough in varicella, especially on the trunk 
 and thighs. 
 
 {e) The vesicle of variola usually shows more induration of its 
 base, and collapses less readily when pricked than does the vesicle 
 of varicella. 
 
 (/) In variola the pocks situated within a circumscribed area, 
 being for the most part of the same age, attain coincidently the 
 same degree of development, whereas in varicella, owing to the 
 eruption commonly appearing in successive crops, pocks in all 
 stages of development — from papule to scab — may often be de- 
 tected side by side. 
 
 {g) The relative distribution of the eri/ption varies ; in variola it is 
 apt to be more copious on the face and extremities, whereas in vari- 
 cella it is usually most prevalent on the trunk, upper arms, and thighs. 
 
 Valuable confirmatory evidence may be gleaned from a history 
 of exposure and infection, or by the discovery of scars indicative of 
 vaccination, or of previous varicella. The presence of the latter is 
 almost sufficient to exclude chicken-pox, so excessively rare is a 
 second attack, while in a child the presence of good vaccination 
 scars will similarly tend to exclude smallpox. Chicken-pox in an 
 adult is probably as rare as smallpox in a well - vaccinated child. 
 Additional evidence may be gained by vaccinating the patient and 
 observing what result, if any, follows the operation. 
 
 Treatment. — To Sydenham we owe the indications for the 
 treatment of smallpox, which is in use at the present day. He first 
 insisted on the absolute necessity of keeping the patient cool, while 
 avoiding chills, this being attained by thorough ventilation of the 
 bed-chamber, which should at the same time be kept at as equable 
 a temperature (about 6o'' F.) as possible. 
 
 No medicinal treatment appears to be of avail in cutting 
 short the course of the disease, although the various symptoms 
 and complications should receive appropriate treatment as they 
 arise. The comfort of the patient will be increased by the 
 free administration of cooling drinks, such as lemonade, soda- 
 water and milk, or toast and water, while at the same time 
 some sahne or acid medicine may be given. If the mouth 
 be sore some rehef may be obtained by allowing the patient to 
 
326 MANUAL OF MEDICINE 
 
 suck black-currant jelly, or by painting it with a solution of boro- 
 glyceride, while if there be much discharge from the nose and 
 throat, a solution of some mild antiseptic, such as boracic acid or 
 permanganate of potash, will be found of service as a wash. If 
 either constipation or diarrhoea be present, they must be treated 
 with suitable remedies. The drug most likely to be of service in 
 this disease is opium, since it is valuable both for the relief of the 
 delirium and of the severe pain which is commonly present during 
 the period of invasion. It is equally serviceable during the second- 
 ary phase of the disease. In severe cases the tendency to collapse 
 should be combated by the administration of ammonia, and of 
 alcoholic stimulants, such as brandy or champagne. The patient 
 should be placed on the ordinary fever diet, consisting for the most 
 part of milk and slops. Even in the milder cases of the disease 
 much discomfort is liable to be caused by swelling and irritation of 
 the skin, which may be considerably relieved by frequent sponging 
 with tepid water, followed by inunction of the skin with carbolised 
 oil or vaseline. The eyes should receive particular attention, being 
 carefully sponged at frequent intervals, whilst instillation of a weak 
 solution of nitrate of silver (gr. i. to water 5vi.) will be advisable if 
 there be any tendency to inflammation of the conjunctiva. 
 
 From the earliest times innumerable plans have been suggested 
 for the prevention of the pitting of the skin, which, especially after 
 recovery from severe attacks of the disease, is liable to cause great 
 disfigurement. It is, however, very doubtful whether such pitting 
 can be prevented by any means at our command ; — that perhaps 
 which is most likely to have the desired effect being the evacuation 
 of the contents of the pock as soon as the presence of fluid can be 
 detected. During convalescence it is of the utmost importance that 
 the patient's strength should be supported by the administration of 
 tonic remedies together with stimulants and a generous diet. 
 
 The success which has already attended the method of serum- 
 therapy, more particularly in diphtheria, has led to the hope that a 
 similar method may presently be available for the treatment of 
 smallpox, but thus far the object in view has not been attained. 
 
 As regards the prevention of this disease we have in efficient 
 vaccination and revaccination a prophylactic method of the utmost 
 value. This subject, however, will be treated of in a separate section. 
 
 Smallpox Inoculation. — By the term inoculation is meant the 
 purposeful implantation of smallpox virus beneath the surface of the 
 skin in the same manner in which vaccination is now carried out, 
 
SMALLPOX 327 
 
 The origin of this procedure is unknown, although undoubtedly 
 it has been practised by the Chinese and Hindoos for centuries. 
 From them it extended westwards into European Turkey, whence it 
 was brought to England in 1 721 by Lady Mary Wortley Montagu, 
 the wife of the then English Ambassador to the Ottoman Court. 
 
 The insertion of smallpox lymph beneath the skin was followed 
 by a series of events very similar to those arising from vaccination. 
 The mature vesicle, however, had a more irregular outline than the 
 vaccine vesicle, and was usually surrounded by a number of tiny 
 secondary vesicles, many of which eventually merged into the 
 primary one. Occasionally, as in the mild inoculations carried out 
 at the commencement of the present century by two brothers of the 
 name of Sutton and by Adams, no other result followed than the 
 appearance of the vesicle, or vesicles, at the site of operation. 
 Oftener, however, between the eighth and tenth days after the in- 
 oculation a general eruption followed, which might be limited to a 
 few vesicles on the forehead, or might result in a copious outbreak 
 involving almost every portion of the body. During the last century 
 the risk of any individual contracting smallpox was felt to be so 
 great that people, while still in good health, were ready to run the 
 risk of purposely contracting the disease, in what was usually under 
 these circumstances a mild form, in order to avoid the grave danger 
 to life which was inseparable from the disease contracted in the 
 ordinary manner. The process of inoculation was certainly of 
 value to those individuals on whom it was carried out, since, 
 although a certain number of these contracted the disease in 
 severe form and even died of it, yet the death-rate was in all prob- 
 ability no more than one in three hundred of those operated on, 
 whereas that of ordinary smallpox was apt to be as high as fifty 
 per cent. Although this was so, the practice of inoculation, by 
 carrying smallpox into remote districts where otherwise it might 
 not have penetrated, and owing to the fact that inoculated small- 
 pox, even in its mildest form, was apparently as contagious as the 
 ordinary disease, the actual amount of smallpox in the country, 
 during the period succeeding the introduction of inoculation, was 
 probably much higher than otherwise would have been the case. 
 At the present day inoculation has only an historic interest, seeing 
 that since the Vaccination Act of 1840 came into operation the 
 intentional communication of smallpox from person to person in 
 this manner has been a penal offence. 
 
 S, MONCKTON COPEMAN. 
 
328 MANUAL OF MEDICINE 
 
 VACCINIA 
 
 Syn. Cow-pox 
 
 Vaccination 
 
 Vaccinia is, in the human subject, a specific communicable 
 disorder, arising, except in very rare instances, from the accidental 
 or intentional inoculation of an individual with vaccine lymph. 
 The disease is characterised by the appearance of a local eruption, 
 passing through the stages of papule, vesicle, and pustule, associated 
 with more or less constitutional disturbance. 
 
 Similar symptoms are produced whether the lymph employed 
 for inoculation has been derived from the vesicles of a previous 
 case in the human being, or from the eruptive vesicles of a disease 
 of bovine animals called cow-pox. Such inoculation process, 
 whichever way induced, is known as vaccinatiofi. This name was 
 originally devised in accordance with the terminology of Jenner, 
 who wrote of the disorder under the title of Variolae vaccinae. In 
 this manner he gave expression to his belief that the malady 
 commonly known as cow-pox was in reality nothing more nor less 
 than smallpox of the cow. 
 
 Cow-pox in the cow. — For a description of cow-pox in typical 
 form, as it was known to Jenner and his contemporaries, it is 
 necessary to consult the writings of the early part of the century, 
 at which period the disorder was much more rife than at the 
 present day. According to observers such as Bryce and Ceely, 
 this affection, when once set going in a herd, tends to spread with 
 considerable rapidity, the " matter " of the vesicles which appear 
 on the teats and udders being carried by the hands of the milkers 
 from one cow to another. If the material happen to come in 
 contact with an abrasion of the skin of the milker's hand, such 
 person is apt to become infected with the disease. When the 
 ailment is communicated in this manner, it is termed casual cow- 
 pox, to distinguish it from that form which is intentionally pro- 
 pagated by vaccination, under which circumstances the affection is 
 less virulent than when communicated in the former way. 
 
 Inoculated cow-pox (vaccination) in man. — In the cow-pox 
 induced by inoculation the appearances which present themselves 
 differ in some respects from those occurring in the casual disease, 
 
VACCINIA 329 
 
 Thus about the third day after the insertion of vaccine lymph 
 a small inflamed spot may be observed at the point where the 
 vaccination was performed. Next day this spot appears more 
 florid, and on passing the point of the finger over it, a certain 
 degree of hardness and swelling is perceptible. By the fifth day a 
 small pale vesicle occupies the spot where the inflammation began. 
 This vesicle has a milky-white colour without any inflammatory 
 zone around it ; it is depressed in the centre, its edges being 
 distinctly elevated. For the next two days the vesicle increases 
 in size, assuming a circular form if the vaccination was performed 
 by a puncture ; if done by an incision, an oval shape. But in 
 both cases, the margin is regular and well defined. About the 
 eighth day an inflammatory zone (of a bright red colour, termed 
 the areola) begins to appear around the base of the vesicle. This 
 increases for two, or perhaps three, days more, by which time it may 
 extend for about a couple of inches from the vesicle. The vesicle 
 still retains its concave appearance, and a crust of a brownish 
 colour will have commenced to form in the centre. About the 
 eleventh day the vesicle has attained its greatest magnitude, and 
 the surrounding inflammation begins to abate. The fluid in the 
 vesicle, which before was thin and transparent, is now more viscid 
 and somewhat turbid. After this period the whole becomes quickly 
 converted into a smooth, shining, drj- crust of a dark-brownish or 
 red colour. This crust, unless forcibly removed, will adhere for a 
 week or more, and then fall off, leaving the skin beneath appar- 
 ently sound, but livid for a time, and more or less permanently 
 scarred. 
 
 Relationship of Variola and Vaccinia. — As evidence of a 
 definite relationship between smallpox and cow-pox, it may be 
 mentioned that whereas, prior to the introduction of vaccination, 
 epidemics of these disorders frequently occurred in relation to one 
 another, the so-called "natural" cow-pox has now in great 
 measure disappeared. There is, moreover, no appreciable diff'er- 
 ence in the anatomical characters or in the progress of the 
 eruption in the two aff'ections, both of which also appear to be 
 mutually protective against each other. But of far greater import- 
 ance in this connection are the results obtained by numerous 
 observers, who in various parts of the world, and almost from the 
 time of Jenner onwards, have set themselves the task of attempting, 
 by experimental methods, to solve the problem of the true relation- 
 ship of variola to vaccinia. As the outcome of this work it may 
 now be definitely stated that smallpox lymph, by passmg through 
 
330 MANUAL OF MEDICINE 
 
 the system of the calf, can be so altered in character as to become 
 deprived of its power of causing a generalised eruption, while 
 inducing at the site of inoculation a vesicle indistinguishable from 
 a typical vaccine vesicle ; and more important still, that when 
 transferred again to man, it has by such treatment completely lost 
 its former infectious character. Such being the case, it may fairly 
 be asserted that cow-pox — or rather that artificially inoculated form 
 of the disease which we term vaccinia — is nothing more nor less 
 than variola modified by transmission through the bovine animal. 
 
 Histology. — During the evolution of the local changes which 
 result from the insertion of vaccine lymph beneath the surface of 
 the skin, it is possible to recognise three more or less definite 
 stages of papule, vesicle, and pustule. The same statement holds 
 good with reference to the eruption of smallpox, whether this be 
 local, i.e. due to inoculation of the virus, or general, as the result 
 of infection. 
 
 In each instance the appearance of the first ox papular stage is 
 brought about by inflammatory reaction, causing an increase of 
 intercellular fluid, together with concomitant increase in volume and 
 number of epithelial ceUs, of the rete Malpighii more particularly. 
 The papule gradually becomes enlarged by a circumferential ex- 
 tension of the same process, and, owing to further changes in the 
 cells first affected, vacuoles arise in the central portion of the 
 papule, by the extension of which this ultimately becomes a vesicle. 
 The vesicle is a multilocular structure, the dissepiments, by means 
 of which its interior is divided up, being formed from the thinned 
 and extended remains of the original epithelial cells. Owing to the 
 fact that the process of vacuolation for a time increases more 
 extensively at the advancing edge of the vesicle, the central portion 
 remains somewhat less elevated, thus giving rise to the appearance 
 termed umbilication. At a quite early stage of the process an out- 
 flow of leucocytes takes place towards the point of injury. These, 
 by the increase in their numbers, eventually transform the originally 
 clear, inflammatory exudation into a purulent fluid. The vesicle is 
 said now to have become converted into z. pustule. By the thinning 
 and ultimate rupture of its trabeculae, the pustule finally becomes 
 unilocular. The turbid fluid contained in it now gradually dries up, 
 and, together with the necrosed remains of epidermal cells, takes 
 part in the formation of the crust., which, under the microscope, 
 appears as a homogeneous mass very deeply coloured by the ordinary 
 bacteriological stains. Meanwhile a regeneration goes on underneath 
 the crust, the new epidermis being formed from an ingrowth from the 
 
VACCINIA 331 
 
 surrounding stratum lucidum. The extent to which the cutis vera 
 has been involved determines the depth of the resulting scar. 
 
 Bacteriology. — There is much evidence to prove 'that the 
 results following on the process ol vaccination are due to a specific 
 contagium, and, moreover, that the particular micro - organism 
 concerned is capable of existing, during one period of its life cycle, 
 in a resting or spore form, which is more resistant to the germicidal 
 effects of glycerine than is the case with non-sporing microbes. Up 
 to the present, however, no satisfactory method has been devised by 
 which the micro-organism of vaccinia can be unfailingly cultivated 
 on artificial media while still retaining its specific properties. 
 
 History of vaccination. — Rather more than a century ago, in 
 the summer of the year 1798, there was published a pamphlet 
 entitled " An Inquiry into the Causes and Effects of the Variolse 
 Vacciniae, etc." This was the work of Edward Jenner, a country 
 medical practitioner living at Berkeley, in the Vale of Gloucester, 
 and in it the author set out the results of certain investigations on 
 the possibility of affording protection against human small-pox by the 
 intentional inoculation of a disease of cattle called cow-pox. 
 
 Many years before, while apprenticed to a medical man at Sod- 
 bury, near Bristol, Jenner's attention had first become directed to a 
 belief, widely prevalent in Gloucestershire during the latter half of 
 the eighteenth century, that those persons who in the course of 
 their employment on dairy farms happened to contract cow-pox 
 were thereby protected from a subsequent attack of smallpox. In 
 particular, his interest was aroused by a casual remark made by a 
 young countrywoman, who happened to come to the surgery one 
 day for advice, and who, on hearing mention made of smallpox, 
 immediately volunteered the statement that she could not take the 
 disease as she had had cow-pox. 
 
 On coming up to London in 1770 to finish his medical 
 education, Jenner became a pupil of John Hunter, with whom he 
 frequently discussed the question of the possibility of obtaining 
 protection against smallpox. On his return to his native village of 
 Berkeley in 1773 to practice as a medical man he took every 
 opportunity of talking over and investigating the matter, but it 
 was not until May 1796 that he commenced actual experiments. 
 Jenner's first case of vaccination was that of a boy, eight years of 
 age, whom he inoculated in the arm with cow-pox matter taken from 
 a sore on the hand of a dairymaid, who, in turn, had become in- 
 fected with the disease from milking cows suffering from cow-pox. 
 
332 MANUAL OF MEDICINE 
 
 It was apparently not until 1798 that he made his first attempt 
 to carry on a strain of lymph from arm to arm. In the spring of 
 this year he inoculated a child with matter taken directly from the 
 nipple of a cow ; and from the resulting vesicle on the arm of this 
 child first operated on, he inoculated, or, as it may now be 
 more correctly termed, "vaccinated," another. From this child 
 several others were vaccinated ; from one of these a fourth remove 
 was carried out successfully, and finally a fifth. Four of these 
 children were subsequently inoculated with small-pox — the " vario- 
 lous test " — without result. 
 
 Extent of the protection afforded by vaccination. — As 
 the result of prolonged investigation of the effect of vaccination in 
 reducing the prevalence of, and mortality from, smallpox the follow- 
 ing conclusions were arrived at by the majority of the members of 
 the Royal Commission on Vaccination, whose final report was 
 published in 1896. 
 
 1. That it diminishes the liability to be attacked by the disease. 
 
 2. That it modifies the character of the disease and renders it (a) 
 less fatal, and (d) of a milder or less severe type. 
 
 3. That the protection it affords against attacks of the disease is 
 greatest during the years immediately succeeding the operation of 
 vaccination. It is impossible to fix with precision the length of this 
 period of highest protection. Though not in all cases the same, if a 
 period is to be fixed, it might, we think, fairly be said to cover in 
 general a period of nine or ten years. 
 
 4. That after the lapse of the period of highest protective potency, 
 the efficacy of vaccination to protect against attack rapidly diminishes, 
 but that it is still considerable in the next quinquennium, and possibly 
 never altogether ceases. 
 
 5. That its power to modify the character of the disease is also 
 greatest in the period in which its power to protect from attack is 
 greatest, but that its power thus to modify the disease does not 
 diminish as rapidly as its protective influence against attacks, and its 
 efficacy, during the later periods of life, to modify the disease is still 
 very considerable. 
 
 6. That re-vaccination restores the protection which lapse of time 
 has diminished, but the evidence shows that this protection again 
 diminishes, and that, to ensure the highest degree of protection which 
 vaccination can give, the operation should be at intervals repeated. 
 
 7. That the beneficial effects of vaccination are most experienced 
 by those in whose case it has been most thorough. We think it may 
 fairly be concluded that where the vaccine matter is inserted in three or 
 four places, it is more effectual than when introduced into one or two 
 
VACCINIA 333 
 
 places only, and that if the vaccination marks are of an area of half a 
 square inch, they indicate a better state of protection than if their area 
 be at all considerably below this. 
 
 Re - vaccination. — The protection afforded by a primary 
 vaccination tends gradually to diminish and eventually to disappear 
 more or less completely with the lapse of time. In consequence, it 
 is desirable that the operation should be repeated at the age of from 
 seven, to ten years, and thereafter, if it be possible, at intervals 
 during later life. The Report of the Royal Commission on 
 Vaccination thus summarises the evidence as to the value of such 
 additional procedure. 
 
 Where re - vaccinated persons were attacked by, or died from, 
 smallpox, the re -vaccination had for the most part been performed a 
 considerable number of years before the attack. There were very few 
 cases where a short period only had elapsed between the re-vaccination 
 and the attack of smallpox. This seems to show that it is of import- 
 ance in the case of any persons specially exposed to the risk of con- 
 tagion that they should be re-vaccinated, and that in the case even of 
 those who have been twice re-vaccinated with success, if a long interval 
 since the last operation has elapsed, the operation should be repeated 
 for a third, and even for a fourth time. 
 
 It not unfrequently happens that iii the case of a re-vaccination 
 the process runs a somewhat different course to that witnessed in a 
 typical primary vaccination. Owing probably in large measure to 
 the age of the patient, and the consequent difficulty in keeping the 
 vaccinated arm completely at rest, somewhat extensive inflammation 
 of the skin is apt to ensue. This occasionally may be further com- 
 plicated, it may be with lymphangitis, swelling, and even suppura- 
 tion of the axillary glands and general malaise. In a successful 
 vaccination, papules make their appearance about the third to the 
 fifth day at the site of the operation. The papules may or may not 
 develop further into vesicles and pustules. Occasionally a second 
 or later vaccination appears to fail altogether, but as pointed out 
 by the Royal Commission, it is advisable, as in the case of a 
 primary vaccination, to make further attempts before concluding 
 that the individual is really insusceptible. 
 
 Alleged injurious effects of vaccination. — In a certain 
 small proportion of cases the operation of vaccination is apt to be 
 followed after a longer or shorter interval by various complications, 
 of which by far the most important are those of an inflammatory 
 nature, which " constitute the danger of any local lesion of the 
 
334 MANUAL OF MEDICINE 
 
 skin " (Acland). Those most liable to be met with include erysipelas, 
 septicaemia, and pysemia, abscess, and ulceration, simple or gan- 
 grenous. Dr. Acland has shown that, approximately, 60 per cent 
 of all cases of vaccinal injury in this country are probably due to 
 some form of inflammation, erysipelas being the most important 
 and of the most frequent occurrence. 
 
 There is unfortunately some reason for the assertion that 
 syphilis has, on occasion, been in-vaccinated, although the number 
 of authenticated cases are extremely few. Seeing, however, that 
 the use of calf lymph has now become practically universal, the 
 possibility of such untoward occurrence in the future may be dis- 
 regarded, seeing that the calf is not capable of contracting this 
 disease. 
 
 Tubercle in its various forms and leprosy have also been in- 
 cluded in the list of possible complications of vaccination, though 
 without any sufficient proof. The employment of calf lymph 
 treated with glycerine after the manner first advocated by the writer, 
 and now officially adopted by the Government, will obviate any 
 such danger, for even if bacilli of tubercle were by chance present 
 in the lymph material when collected, it has been found that they 
 are quite unable to survive the prolonged action of a fifty per cent 
 solution of glycerine in water. Leprosy is not communicable to 
 the calf. 
 
 Certain skin diseases, such as eczema and impetigo, sometimes 
 appear during the course of, or shortly after, vaccination ; but no 
 direct connection has been proved to exist between the operation 
 and the occurrence of these disorders. 
 
 In section 434 of the Final Report of the Royal Commission on 
 Vaccination the extent to which other inoculable diseases are liable 
 to complicate vaccination are thus summed up : — 
 
 " A careful examination of the facts which have been brought 
 under our notice has enabled us to arrive at the conclusion that 
 although some of the dangers said to attend vaccination are un- 
 doubtedly real and not inconsiderable in gross amount, yet when 
 considered in relation to the extent of vaccination work done they 
 are insignificant. There is reason further to believe that they are 
 diminishing under the better precautions of the present day, and 
 with the addition of the future precautions which experience 
 suggests will do so still more in the future." 
 
 The nature of the precautions most necessary to be observed 
 will be considered in a separate section. 
 
VACCINIA 335 
 
 Practice of Vaccination 
 
 CoUeetion and storagre of vaccine lymph. — Hitherto the use 
 of arm-to-arm human lymph has been insisted on in th-is country in 
 the case of all vaccinations performed at public stations, for the 
 reason that until recently this was the only method by which lymph 
 stocks could be perpetuated and the greatest possible purity of the 
 lymph ensured. In view, however, of the recommendations of the 
 Royal Commission, and under the provisions of the Vaccination Act 
 of 1898, this method will, as regards public vaccinations, be discon- 
 tinued in the future in favour of the use of calf lymph, partly with 
 the object of diminishing the very remote possibility of the convey- 
 ance of syphilitic infection by the operation. By this change of 
 method also the necessity for opening vaccination vesicles, and 
 thereby of affording opportunity for other local infections, will in 
 large measure be avoided. 
 
 If human lymph be required the vesicles should be opened by 
 a number of minute punctures, which must be made on its surface 
 and not around its base. The object of such multiple puncture is 
 to open the various cell-spaces in which the lymph is contained ; 
 that of puncturing on the surface, rather than around the base, is 
 to avoid any admixture with blood. Lymph soon collects in 
 droplets at the points of incision, and may be removed on a lancet, 
 or if required for use at a distance, may be taken up into capillary 
 tubes. 
 
 To fill a capillar}' tube it should be held in a more or less 
 horizontal position and one end applied to a drop of lymph exuding 
 from a vesicle which has been punctured, when the lymph im- 
 mediately enters by capillary attraction. No more should be allowed 
 to enter than is sufificient to fill the tube from one-half to two- 
 thirds of its length. The tube is sealed by applying the empty end 
 to the flame of a candle or spirit-lamp, as much as possible of the 
 contained air having been previously driven out by momentarily 
 plunging into the flame the whole of that portion of the tube in which 
 there is no lymph. By this means, as soon as the extremity is 
 sealed, the column of lymph is driven by atmospheric pressure 
 towards the end first closed, and the point at which the lymph found 
 entrance can then be sealed in the flame in the same manner as 
 was the other. 
 
 The method, formerly employed, of storing lymph in the 
 dried condition on ivory points is not to be recomme«ded. 
 
 Glyeerinated lymph. — The almost universal occurrence of 
 
336 MANUAL OF MEDICINE 
 
 extraneous microbes in vaccine lymph, and the chance of addition, 
 during or after vaccination, of pathogenetic micro-organisms by agency 
 of careless people, whether vaccinators or persons having charge of 
 infants, have been advanced as reasons for avoiding vaccination, on 
 the ground of the possible harmfulness of micro-organisms liable 
 to be introduced into the lymph at the time of the operation, or 
 subsequently in the course of the evolution of the resulting pock. 
 This argument, however, so far as the microbes usually intimately 
 associated with lymph are concerned, loses whatever weight it may 
 have had, since the writer has shown that by thoroughly incorporat- 
 ing the lymph or vesicle pulp with a sterilised fifty per cent solution 
 in water of chemically pure glycerine, and afterwards storing the 
 mixture for some weeks prior to use, protected from light and air, 
 all the ordinary saprophytes found associated with lymph are 
 eventually destroyed. This result is proved by the fact that no 
 growth arises in any of the ordinary culture media inoculated with 
 such glycerinated lymph. This statement applies equally to the 
 bacillus of tubercle and to the streptococcus of erysipelas, should 
 these microbes have been originally present in, or have been added 
 experimentally to, the lymph. The employment of glycerinated 
 calf lymph is now ofificially recognised by the Government, the 
 lymph being issued, free of charge, to public vaccinators in any 
 quantity required. 
 
 Insertion of vaeeine lymph. — This process may be carried 
 out either by scarification, by puncture, or by multiple superficial 
 incisions. Doubtless the individual operator will attain the greatest 
 measure of success by employing the method with which he is 
 most familiar ; but there can be little doubt that the method of 
 insertion by scarification is the one that is most satisfactory, more 
 particularly if the lymph has been preserved with glycerine. 
 
 The mode of operation is briefly as follows : — The arm should, 
 if possible, be first washed with soap and warm water, and after- 
 wards carefully dried with a soft towel, gentle friction being em- 
 ployed so as to cause a certain amount of distension of the 
 cutaneous capillaries. Drops of lymph, corresponding in number 
 to that of the vesicles which it is required to produce, are then to 
 be placed on the surface of the arm, and the skin put slightly on 
 the stretch with the fingers of the left hand. Next, the skin is 
 scarified by a system of "cross-hatching," through the drops of 
 lymph, by means of whatsoever instrument may be preferred, care 
 being taken not to place the insertions too closely together, lest the 
 vitality of the tissues between them be injured. 
 
MUMPS 337 
 
 An ordinary bleeding lancet, the point of which has been 
 slightly blunted, or a spear-pointed surgical needle, are both very 
 efificient for the purpose of scarification. Complicated instruments 
 should be avoided, since, as a rule, it is difficult to keep them 
 thoroughly clean. The special advantage of a needle is that a 
 new one can be employed on every occasion. If a lancet or like 
 instrument be employed, it is essential that it should be boiled 
 or otherwise sterilised immediately before use. 
 
 The strictest aseptic precautions should also be observed in the 
 immediate and subsequent treatment of the vaccinated area. With 
 the object of obtaining this result, the scarified spots should be 
 protected either by a dressing of boracic lint, or by being covered 
 over with a layer of collodion or other protective tissue, which, if 
 possible, should be allowed to remain undisturbed for at least a 
 week. On inspection, which, by the regulations of the Local 
 Government Board, is now required to be done in public vaccina- 
 tions between the sixth and fourteenth day, the dressing should be 
 renewed. If, by any chance, the vesicles should have become 
 ruptured, the use of a pad of absorbent wool (or wood-wool) may 
 be advisable ; otherwise a couple of layers of boracic lint, retained 
 in position by means of strapping, will suffice. This second dress- 
 ing should be left on the arm until the "crusts," to which the 
 vesicles will have given rise, have separated of their own accord, 
 and the regenerated skin-area beneath is soundly healed. 
 
 S. MONCKTON COPEMAN. 
 
 MUMPS 
 Syn. Epidemic Parotitis, Infectious Parotitis 
 
 ]\Iumps is an acute infectious disease, of which the characteristic 
 feature is inflammation of the salivary glands. 
 
 Etiology. — It has been known to occur in all parts of the 
 civilised world, chiefly in localised outbreaks, often limited to the 
 inhabitants of particular institutions, such as schools or barracks. 
 Occasionally its prevalence is more widely spread. 
 
 Of recorded epidemics, the largest number have arisen during 
 the winter and spring. While the disease is met with at all periods 
 vol. I 2 
 
338 MANUAL OF MEDICINE 
 
 of life, it is most common between the ages of five and fifteen. 
 Both sexes are equally liable to be attacked. The infection is 
 nearly always spread directly from the sick to the healthy, but it 
 may be conveyed by a third person or infected articles. 
 
 The incubation period is three weeks ; it may be as short as 
 fourteen, and as long as twenty-five days. The Medical Officers of 
 Schools Association recommend twenty-four days' quarantine, dating 
 from exposure to infection, if disinfection have been carried out at 
 the commencement. 
 
 Symptoms. — In some cases the attack is ushered in by 
 prodromal symptoms — slight sore throat, fever, chilliness, malaise, 
 headache, and vomiting. In others the illness begins with the 
 signs of parotitis. There is pain behind one angle of the jaw, 
 which is quickly followed by swelling of the parotid gland. For 
 two or three days the swelfing increases till it extends forwards on 
 the cheek and downwards to the neck ; it is elastic and very 
 painful. The skin over it may be inflamed. After a day or two 
 the swelling subsides, and disappears in three or four days. 
 
 Often the affection is not confined to one parotid gland. The 
 submaxillary and sublingual salivary glands on the same side 
 become involved, and, usually after an interval of a few days, the 
 salivar)' glands of the opposite side. When, as occasionally happens, 
 both sides are simultaneously affected, the swelling on each side 
 of and below the jaw gives rise to deformity so great as to render 
 the patient's features quite unrecognisable. 
 
 At the commencement of the attack the temperature may rise 
 to 102'' or 103- F., and for a day or two remains at about this 
 height ; then it gradually falls ta the normal, to rise again when 
 the second gland is affected. In some cases there is no pyrexia. 
 The pulse-rate is slightly increased. In severe cases there may be 
 delirium. During the period of parotid inflammation the patient 
 experiences great pain on all attempts at swallowing or speaking, and 
 sometimes he can hardly separate his teeth without discomfort. 
 The salivary secretion is diminished and the mouth becomes drj'. 
 Occasionally the gums are swollen. In addition to the salivary 
 glands the cervical lymph glands may become inflamed. 
 
 The disease assumes various forms. The swelling of the 
 parotid glands may be trivial. In rare instances the submaxillary 
 salivary glands alone are affected ; or the salivar}' glands escape 
 altogether, and the cervical lymph glands only are inflamed. 
 Lastly, orchitis may be the only local manifestation of mumps. 
 
 It is very rare for the parotitis to suppurate or to become chronic. 
 
MUMPS 339 
 
 Complications. — In a considerable proportion of males, usually 
 adults (2)3 per cent, Laveran), oixhitis follows an attack of mumps. 
 This event generally occurs in from six to eight days after the 
 parotitis, but it may be delayed for three weeks. In rare instances 
 it precedes the inflammation of the salivary glands. The body of 
 the testis, at times also the epididymis, becomes painful and 
 swollen, attaining a considerable size. The scrotum may be red 
 and oedematous. Even in slight cases pain may be felt extending 
 up the cord into the abdomen. Occasionally the orchitis is 
 attended by severe constitutional symptoms — pyrexia (102° to 
 105° F.), delirium, vomiting and diarrhcea, prostration, and in- 
 frequent pulse. The orchitis lasts four or five days, and is as a 
 rule one-sided. It is followed by atrophy of the testis in about 70 
 per cent of the cases (Laveran): suppuration is rare. In the adult 
 female also the sexual organs may be affected, but not so commonly 
 as in the male ; so that there is ovarian tenderness, inflammation of 
 the external genitals, and mastitis. 
 
 Other complications are exceptional, but some of them are 
 serious. Least uncommon are ear -complicaf ions. These may 
 either accompany or follow an attack of mumps. There may be 
 deafness, tinnitus aurium, vertigo and nausea depending upon 
 inflammation of the internal ear. The deafness may become 
 permanent, but is rarely double. In other cases there is otitis 
 media. With respect to the nervous system., three classes of cases 
 have been recorded : one in which the symptoms point to 
 meningitis ; a second in which they seem to depend on the 
 blocking of a cerebral vessel (aphasia, hemiplegia, etc.) ; and a 
 third where they are due to peripheral neuritis. 
 
 Amongst very rare complications may be mentioned — insanity, 
 inflammation of the lachrymal gland (with orbital pain and swollen 
 eyelids), jaundice, oedema glottidis, bronchitis, endocarditis, arthritis, 
 nephritis, urethritis and prostatitis, and certain skin eruptions. 
 
 Pathology and morbid anatomy. — Mumps is most probably 
 caused by a micro-organism, which, however, has not yet been 
 identified, that reaches the glands via the ducts, and induces an 
 inflammation which is chiefly interstitial. 
 
 Relapses and second attacks are uncommon. Catin, in 
 an epidemic of 157 cases, met with 2 relapses and 9 second 
 attacks. 
 
 The patient is infectious for two or three days before the 
 parotid swelling arises, and the aforesaid authorities advise an 
 isolation of the patient for "not less than three weeks from the 
 
34<3 MANUAL OF MEDICINE 
 
 commencement — provided that one clear week has elapsed since 
 the subsidence of the swelling." 
 
 Diagnosis. — The two conditions with which mumps is most 
 often confounded are diphtheria and enlargement of the parotid 
 gland due to other causes. 
 
 It is the extreme enlargement of the cervical glands present in 
 some cases of diphtheria which occasions the error. Inspection of 
 the fauces will settle the case. The parotid glands are unaffected 
 in diphtheria. 
 
 Inflammatory enlargement of the parotids sometimes com- 
 plicates other diseases, especially -enteric fever and various abdo- 
 minal and pelvic disorders. It then often results in suppuration. 
 
 Prognosis. — Mumps is very rarely fatal. The serious, though 
 unusual, nervous complications mentioned above nearly always 
 occur in cases where the testis has become involved. 
 
 Treatment. — To the painful parotid glands hot fomentations 
 with glycerine and belladonna, or laudanum, should be applied. 
 In many cases of orchitis the same treatment is applicable, but in 
 others ice affords more relief. The diet should be such as the 
 patient can take. 
 
 It is most important to bear in mind that orchitis may be 
 induced by allowing the patient to get up and resume his ordinary 
 duties too early. Hence caution should be exercised, and the 
 male patient kept in bed for eight or nine days, and in his room 
 for several days longer. 
 
 E. W. GOODALL. 
 
 WHOOPING-COUGH 
 Syn. Chin-Cough, Pertussis 
 
 An acute specific disease — distinguished by general catarrh of 
 the respiratory tract, with accompanying nervous phenomena, of 
 which by far the most important is the characteristic laryngeal 
 spasm. It is very infectious, and one attack usually affords com- 
 plete protection from a second for the rest of life. 
 
 Bacteriology.- — It is generally recognised that the contagium 
 must be a living organism, and several different forms have been 
 described, but the real one has not yet been isolated with certainty. 
 
WHOOPING-COUGH 341 
 
 Present opinion appears to be in favour of that found by Koplick 
 (and possibly previously by Afanasieff), who has isolated small 
 bacilli from the mucus discharged at the end of a paroxysm, which 
 he found to be present in thirteen out of sixteen cases examined. 
 He describes them as very minute rods with rounded ends, which 
 sometimes look like diplococci on account of the ends being the 
 more deeply stained. 
 
 Whatever may prove ultimately to be the specific organism, 
 there can be but little doubt that it causes an inflammation of the 
 mucous membrane of the larynx and trachea, and that the toxin 
 which it manufactures has a special influence on the centres of the 
 pneumogastric and superior laryngeal nerves. 
 
 Infection, how spread. — From the above it will be seen that 
 the infection is contained in the expectorated mucus. By this 
 means the disease is frequently spread through the medium of 
 clothes, bedding, curtains, etc., as is the case with scarlet fever, 
 though how long the virus may remain active in such circumstances 
 is very doubtful. From outbreaks recorded as having taken place 
 on board ship, the fomites would appear capable of conveying in- 
 fection for several weeks. By the same means individuals, them- 
 selves unaffected, may convey the complaint. 
 
 It may perhaps also be spread directly by the breath, but if so, 
 the infection does not apparently spread very widely — as it is a 
 matter of common experience to those connected with children's 
 hospitals that the tendency for the disease to extend to the sur- 
 rounding beds is but slight, when a case has been admitted accident- 
 ally into the wards. 
 
 Duration of infectivity. — A patient is infectious from the 
 very commencement of the catarrhal stage, but for how long a time 
 after has not been settled ; probably there is but little danger six 
 weeks after the onset of symptoms, even though the paroxysmal 
 cough may not have entirely disappeared. 
 
 In the 4th edition of A Code of Rules for the Prevention of In- 
 fectious and Contagious Diseases, issued by the Medical Officers of 
 Schools Association, the answer to the question when a patient 
 can be considered as free from infection is laid down as "in not less 
 than five weeks from the commencement of the whooping, and pro- 
 vided that the characteristic spasmodic cough and the whooping 
 have ceased for at least two weeks," and " provided patient and 
 clothes have been disinfected." 
 
 In the same work, twenty-one days from the date of exposure to 
 infection is given as the proper period of quarantine, with a similar 
 
342 MANUAL OF MEDICINE 
 
 proviso that disinfection has been carried out at the commence- 
 ment. 
 
 Predisposing causes. — The disease, as already stated, is ex- 
 tremely infectious, and persons of all ages are liable to be attacked. 
 The great majority of cases occur between the ages of one and 
 ten years, a period which includes the time at which most children 
 are first exposed to the infection. A good many infants of under 
 one year of age suffer, and with them it is nearly always a serious 
 and often a fatal disease. With adults and old people it is trouble- 
 some but hardly ever dangerous. Statistics show that girls are 
 slightly more susceptible than boys. 
 
 An attack of measles appears to render an individual unduly 
 susceptible to invasion by the virus of whooping-cough, at any rate 
 in this country there is a very general belief that there is some close 
 connection in this respect between the two diseases. No other 
 factor seems to have a direct bearing on predisposition. Ill- 
 nourished children and those that are rickety or unusually nervous 
 make bad subjects, as they appear to be far less able to resist the 
 pulmonary and other complications which so frequently arise. 
 
 Epidemics appear to be most prevalent during the late autumn, 
 winter, and early spring months ; certainly those that suffer during 
 this period of the year are far less likely to get well quickly than 
 those who have it during the warmer months. 
 
 The period of incubation is difficult to ascertain with precision, 
 and cannot be quite definitely stated. Thirteen days was found by 
 Dr. Murchison in one case to be the exact period ( Trans. Clin. Soc. 
 vol. xi. p. 243 et seq), and some other observers have confirmed 
 this. It probably varies, however, in different individuals from four 
 or five to eighteen days, or even longer. 
 
 Clinical history. — Incubation over, the active phase of the 
 disease sets in, and this may be conveniently divided into three 
 stages : (i) prodromal; (2) paroxysmal; and (3) that of defervescence. 
 Between the first and second the distinction is fairly sharp, but the 
 latter usually passes so gradually into the last as to make it im- 
 possible to say exactly where the one ends and the other begins. 
 
 Prodromal stage. — The first or prodromal stage generally lasts 
 about a week or ten days. It is often acute, having all the 
 characters of a severe cold, with considerable disturbance of the 
 respiratory tract, accompanied by more or less catarrh of its mucous 
 membrane. The temperature is generally moderately raised. The 
 amount of malaise varies greatly, but is often only slight. 
 
 The impossibility of recognising the disease during this early 
 
WHOOPING-COUGH 343 
 
 stage is unfortunate, as, owing to its extreme infectiousness, it is the 
 time at which much mischief in spreading the disease occurs. If a 
 cold seems to be particularly severe as compared to the physical 
 signs present, if the bouts of coughing have any tendency to be 
 more frequent by night than by day, and particularly if they are 
 accompanied by any tendency to vomiting, suspicion as to the case 
 being one of whooping-cough should always be roused, and if any 
 cases of the disease are known to be in the neighbourhood, these 
 suspicions would be very much strengthened. Towards the end of 
 this stage, the attacks of coughing will gradually get more severe, 
 increasing in frequency, especially at night, and tending to become 
 distinctly paroxysmal. With each attack the congestion of the face 
 becomes more marked, and some of them are very likely to be accom- 
 panied by, or finish up with an attack of vomiting. At length all 
 doubt is set at rest by one of the paroxysms ending with the peculiar 
 whoop, when the second or paroxysmal stage has become established. 
 
 Paroxysmal stage. — This is the typical period of the disease, 
 during which it is at its height, and when all its characteristics are 
 most marked. The chief of these are the paroxysmal bouts of 
 coughing. These may either come on apparently spontaneously or 
 be obviously started by some external stimulus, such as a draught of 
 cold air or the banging of a door, etc. The total number of attacks 
 during the twenty-four hours varies within wide limits, from some i o 
 or 12 in slight cases up to 50 or 60 in severe ones. A certain 
 grouping of the paroxysms is occasionally observable, one attack 
 being rapidly followed by a second or even a third, which, however, 
 are always less severe than the first of the series. The intervals 
 between one paroxysm or group of paroxysms and the next are of 
 more or less equal length, provided that no external stimulus, as 
 mentioned above, should excite an attack. There is, however, a 
 distinct tendency for the paroxysms to be more frequent and severe 
 at night. It is a good plan to keep a record of the paroxysms, as a 
 comparison of the numbers from day to day gives a fair indication 
 of the general progress of the case. 
 
 When an attack is about to occur the patient frequently appears 
 to have some sort of warning, and probably desists from whatever 
 he may be doing — such as playing with his toys. He assumes an 
 anxious look and may very likely get up and run to his mother or 
 nurse, amongst the folds of whose dress he tries to bury his head. 
 Then the spasm comes on. As a rule the child holds his head forward 
 with the face looking a little downwards, with the mouth partly open 
 and the tongue pushed forward as far as the lips, or even protruding 
 
344 MANUAL OF MEDICINE 
 
 slightly beyond them. The spasm consists essentially in a series of 
 expiratory explosions — during which all the usual appearances of 
 asphyxia arise, and may persist until the onlooker begins to wonder 
 if the child will not actually die from suffocation, as he assumes a 
 horrible look with puffy eyelids, deeply congested face, with engorged 
 veins and turgid neck. Then there is sudden relaxation with a long 
 inspiration, during which the air rushing in through the larynx 
 produces the whistling whoop or crowing sound, which may be 
 repeated after a second or even a third spasm, and then, as the 
 attack passes off, the child very frequently vomits the contents of 
 the stomach. At the same time, or may be later, a pellet or even 
 a tolerably large quantity of translucent, perhaps stringy, mucus is 
 expectorated. 
 
 A period of quiescence now sets in, which varies very markedly 
 in duration and intensity in different individuals and in accordance 
 with the severity of the spasm ; it may hardly exist. The child 
 almost directly resumes his previous occupation, such as playing with 
 his toys, apparently quite free from trouble and as though he had 
 forgotten all about the attack. The play with which he occupies 
 himself is nearly always, however, of some quiet kind. From this 
 there are all stages, up to an extreme degree of collapse, the child 
 falling back perfectly exhausted and apathetic, from which he may 
 only be aroused by the onset of the next paroxysm. 
 
 Physical signs in the chest. — Where there are no severe com- 
 plications the signs are very few. During the inspiratory stage of 
 the spasm nothing can be heard in the chest with the stethoscope 
 but the whoop, which is conducted to the surface. In the intervals 
 a few rhonchi may be audible. Often, however, there is singularly 
 little to be heard, and this is a point of some value in diagnosis— 
 where a history is given of attacks of coughing which in severity 
 are out of all proportion to the physical signs discoverable in the 
 lungs and are especially frequent and troublesome at night. 
 
 In infants occasionally a slight emphysema occurs, which, with 
 their soft-walled chests, may lift the sternum slightly forwards. This 
 emphysema is probably due to over-inflation of the individual alveoli 
 merely, without any breaking down of their walls, though this may 
 occur, and indeed spread beyond the lungs and air passages into a 
 more or less extensive " surgical emphysema." 
 
 The expression during an attack, as mentioned above, is very 
 characteristic. The tongue, from its being pushed forward against 
 the lower teeth, is likely to become abraded, and when only the two 
 lower central incisors are present two small ulcers are frequently 
 
WHOOPING-COUGH 345 
 
 formed on its under surface, one on each side of the frgenum, which 
 are exceedingly suggestive, though not absolutely pathognomonic of 
 the disease. The tongue, as indeed the whole face, is often a little 
 swollen. 
 
 The entire alimentary canal is probably congested or even 
 inflamed, as not. only does the vomit frequently contain a good deal 
 of mucus, but there is often also a decided looseness of the bowels, 
 which, however, only very rarely becomes at all serious. 
 
 Complications. — The most important complications, owing to 
 their frequency, are those connected with the lungs, and it is note- 
 worthy that the whoop is liable to disappear in those which are 
 accompanied by fever. 
 
 Bronchitis. — There is almost always some catarrhal inflammation 
 of the bronchial tubes present, which may, however, be so slight that 
 the only evidence of it is that an occasional rhonehus may be 
 heard. Generally, however, the bronchitis is well marked, the larger 
 and medium tubes especially being affected — giving rise to well- 
 marked sonoro-sibilant rhonchi ; but occasionally it extends into the 
 smallest tubes, when the grave signs and symptoms of acute capillary 
 bronchitis are present, and this condition is nearly always accom- 
 panied with a greater or less extent of pulmonary collapse. 
 
 Broncho-pneuvionia. — In addition to the bronchitis, patchy pneu- 
 monic consolidation not unfrequently occurs, and is of very great 
 importance, as the high mortality of whooping-cough is very largely 
 due to this complication ; hence its onset is always serious, and if 
 the child be constitutionally weak, and particularly if he be the 
 subject of rickets, the outlook becomes extremely grave. The 
 condition is recognised by the physical signs in the chest and re- 
 mittent pyrexia and dyspnoea. 
 
 Lobar pneumo7iia with occasional pleurisy. — Lobar pneumonia 
 occasionally occurs, but is very much less frequent than the other 
 form. Pleurisy with or without effusion may accompany either form 
 of pneumonia. 
 
 Acute bronchiectasis. — A rare condition recently described by 
 Dr. Sharkey (St. Thomas's Hospital Reports, vol. xxii.) appears 
 occasionally to start during an attack of whooping-cough. The 
 physical signs and symptoms are so obscure that it has not yet been 
 recognised during life as distinct from bronchitis. 
 
 Hceinoi-rhages. — Subconjunctival ecchymoses or slight attacks of 
 epistaxis are common, but not in any way serious ; on the other 
 hand, should the haemorrhage occur from a vessel in connection 
 with the brain or spinal cord an extensive paralysis may be the result. 
 
346 MANUAL OF MEDICINE 
 
 Aade nephritis has very rarely been met with after pertussis. 
 
 Nervous disturbafices. — Various other nervous phenomena may 
 occur which cannot be attributed to hsemorrhage. 
 
 There can be no doubt that the nervous system is profoundly 
 disturbed. The very paroxysm of whooping-cough is like a nerve 
 storm which originates in the pneumogastric centres of the medulla 
 oblongata. 
 
 Epilepsy and insanity have been reported as having become 
 apparent for the first time during an attack of whooping-cough or 
 shortly afterwards, and localised paralyses, which from their mode of 
 onset have been attributed to neuritis, have also been seen. Con- 
 vulsions frequently occur, particularly at the termination of a severe 
 paroxysm. They should always be carefully noted, as, although 
 they may be merely the result of venous congestion produced by 
 the paroxysm, and have no significance beyond bemg an evidence 
 of the unsettled condition of the nervous tissue, they may be the 
 prelude of some grave complication. They are also serious on 
 their own account, as there is some evidence to show that death 
 may be directly produced by them. 
 
 Defervescence. — The acuteness of the paroxysmal period gradu- 
 ally subsides. After about a month to six -weeks from the onset of 
 the disease the parox}'sms become less frequent, and the whoop less 
 definite and characteristic, so that in six weeks from when it was 
 first heard it has generally subsided. If it should continue longer 
 this is generally due either to habit or to the presence of adenoids 
 in the pharynx. Occasionally, a week or two after the paroxysmal 
 stage has begun to subside, there is a recrudescence, apparently due 
 to the " catching " of a fresh cold, but unless this passes on to an 
 attack of something more serious, it soon subsides and merges into 
 the next stage, that of convalescence. 
 
 Convalescence. — This period may be rapid, particularly in the 
 warm months of the year, but it may be very protracted, the child 
 remaining listless and below par for a long time. It is during this 
 stage that any latent weakness or tendency is so liable to manifest 
 itself. The lungs are often long in clearing up, traces of bronchitis 
 remain, and this condition may become chronic. However, 
 fortunately, convalescence, though so often tedious, is usually 
 complete, and the patient recovers perfectly. 
 
 Sequelse. — Sequelse, in contradistinction to complications, are 
 not numerous. Any latent weakness, such as quiescent tubercle, is 
 very likely to break out into renewed activity, and the occasional 
 appearance of epilepsy, etc., has already been referred to. 
 
WHOOPING-COUGH 347 
 
 Morbid anatomy. — After death, the changes that are found in 
 the tissues are those of the various compHcations which have been 
 already alluded to ; there are none which can be considered as dis- 
 tinctive of the disease. 
 
 Diagnosis. — In the early stages it may be, and often is, impos- 
 sible to make a diagnosis. There is usually but little difficulty when 
 once the whoop has been heard. 
 
 Infants by no means always develop the whoop ; but in their 
 case a clue is often obtained from the fact that other members of the 
 family have whooping-cough. In the absence of any such help the 
 diagnosis is frequently extremely difficult. The paroxysmal character 
 of the cough, accompanied by marked congestion of the face, vomit- 
 ing, and possibly some nervous phenomena, are then the signs and 
 symptoms on which the diagnosis is made ; but the whole course of 
 the disease may be run through without its true nature ever being 
 suspected. The crow of laryngismus stridulus somewhat resembles 
 the whoop of this disease, but the other characters of that condition 
 are so well marked that there is but little practical difficulty in 
 distinguishing between them. Some children have occasionally a 
 whistling inspiration when they cough ; this may cause some trouble 
 at first, but a consideration of the other characters of the cough is 
 generally sufficient to prevent a mistake. 
 
 There is a real difficulty in separating whooping-cough from 
 certain cases with enlarged bronchial glands in the posterior medi- 
 astinum. In these cases the cough is paroxysmal, and accompanied 
 by a regular whoop. It is only after some time has elapsed, and 
 repeated examinations made, with a most careful weighing of all the 
 evidence, that a correct conclusion can be arrived at. 
 
 Prognosis. — The prognosis of the uncomplicated cases is favour- 
 able ; nevertheless the mortality is high, and is affected by one or 
 more of the following factors : In early infancy the disease is always 
 attended with anxiety, owing to the liability of extensive pulmonary 
 collapse supervening, and this danger will persist beyond the first 
 year of life if the subject be rickety, the softened ribs, the malnutri- 
 tion and disturbance of the nervous system, all contributing to 
 undermine the patient's chances of recovery. Lung affections, at all 
 ages, are the most serious consideration, and in the large majority of 
 cases the prognosis hinges on their severity. The condition of the 
 nervous system is also an important factor. Very emotional children, 
 and those who come of a highly neurotic stock, make bad subjects, 
 and frequently have the disease in an aggravated form. Should a 
 haemorrhage occur, the prognosis is determined by its seat and 
 
348 MANUAL OF MEDICINE 
 
 extent ; but the general testimony of observers is one rather of 
 astonishment that nerve lesions, which at first seemed so serious, are 
 so frequently completely recovered from. Adenoids are justly credited 
 with prolonging the convalescence. 
 
 Treatment. — Ordinary hygienic rules must be carefully followed. 
 As soon as the condition is suspected or recognised, the child should 
 be isolated from any that have not yet had it. He should be kept 
 in two rooms — one for the day and the other for the night ; and the 
 atmosphere of the one in which he is should be maintained at an 
 equable temperature of 65° Fahr. The importance of the two rooms 
 is, that when the one is occupied the other may be thoroughly well 
 ventilated by having the windows left wide open, care, of course, 
 being taken that it is of the proper temperature before he returns to 
 it. If at the onset any fever be present, it may be advisable to keep 
 him entirely confined to bed until this subsides ; but then, unless 
 complications have set in, it is better for him to be up. It is of 
 advantage to charge the air of the room with some vapour — by vola- 
 tilising Friar's balsam, carbolic acid, creasote, naphthalene, turpentine, 
 or eucalyptus oil. The suggestion for this came from the old- 
 fashioned remedy of stirring Stockholm tar with a hot poker, or of 
 taking children into the purifying chambers at gasworks. If the 
 weather be favourable, the child may go out ; but exposure to any 
 inclemency of the weather must be carefully guarded against, and if 
 any acute complication be present he must be kept within doors, 
 where he should be allowed to amuse himself quietly, but be kept 
 as far as possible from any form of excitement or emotional dis- 
 turbance. 
 
 Feeding and diet. — So long as the vomiting is not troublesome, 
 no precautions need be taken beyond ensuring that the food be light 
 and wholesome. Meals should be frequent and small in quantity, 
 and consist of beef-tea, gravy, milk, eggs, fish, bread, sponge-cakes, 
 custards, stewed and fresh fruit. If the vomiting becomes at all 
 serious, it is a good plan to give some food as soon after the paroxysm 
 as possible. 
 
 The list of drugs that have been brought forward at one time or 
 another, as specifics for this disease, is a long one, yet none have 
 been proved to be worthy of the title ; still, some are found occa- 
 sionally to be of decided use. 
 
 In uncomplicated cases belladonna, in combination with bromide 
 of potassium, has been a general favourite ; a very suitable prescrip- 
 tion for a child about two or three years of age being — 
 
m 
 
 i. 
 
 gr- 
 
 iii 
 
 in 
 
 X 
 
 ad 
 
 5 ii 
 
 WHOOPING-COUGH 349 
 
 Extract! belladonnae liquid! 
 
 Potassii bromidi .... 
 
 Glycerini ..... 
 
 Aquam destillatam 
 Misce. Fiat haustus. 
 To be taken every four hours. 
 
 The belladonna should be pushed until slight flushing occurs, but 
 not so far as to cause dryness of the mouth or stomach irritation. 
 Trousseau recommended that the belladonna, or preferably atropine, 
 should be gradually increased over a period of three days, until the 
 pupils began to dilate, and then in just sufficient quantity to maintain 
 this condition for about a week. 
 
 Antipyrin or phenacetin have given good results in one, two, or 
 three grain doses, every four or six hours. 
 
 Carbolic acid is useful, and well borne even by infants, the 
 glycerinum acidi carbolici being a good preparation to use in doses of 
 four or five minims. 
 
 If there be much insomnia, or any tendency to convulsions, butyl 
 chloral hydrate, given in grain doses every hour, is often most effi- 
 cient. In very severe cases, where the number of spasms exceed 
 twenty in the day. Dr. Henoch has pushed morphine in doses varying 
 from ^^2" to \ grain, with the best results. Bromoform, in minim 
 doses, has considerable effect in controlling the vomiting, and appears 
 frequently to distinctly reduce the severity of the paroxysm. 
 
 Expectorants are useful, especially if there is any considerable 
 degree of bronchitis present, ipecacuanha or squills being generally 
 used. They can, of course, be combined with almost any of the 
 foregoing drugs. 
 
 Local treatment. — Local treatment, by direct application either by 
 brush or spray, has been very strongly advocated. The latter is 
 probably preferable, as the use of a brush is liable to terrify the child, 
 and emotional disturbances should be avoided. However, excellent 
 results have been recorded from the frequent painting of the larynx 
 and adjacent parts with a two per cent solution of resorcin, and quite 
 recently very weak solutions of formalin have been recommended to 
 be tried in a similar way. 
 
 The external application of turpentine, or ammoniated camphor 
 liniment, or other stimulant to the chest wall has many advocates. 
 
 F. G. Penrose. 
 
350 MANUAL OF MEDICINE 
 
 DENGUE 
 
 Syn. Dandy Fever, Break Bone Fever 
 
 A specific infectious malady occurring in rapidly spreading 
 epidemics, and attended by the sudden onset of severe pains in 
 the limbs and joints, a high temperature, and a marked eruption 
 of a rubeolar character. 
 
 Geographical distribution. — So far as is known, dengue may 
 occur anywhere in tropical or sub-tropical countries. In Europe it 
 has appeared in the Turkish, Grecian, and Russian (Black Sea) 
 ports ; in America it affects chiefly the West Indies, but has been 
 known to extend northwards as far as Philadelphia, and southward 
 to the Argentine. All countries bordering on the Indian Ocean 
 have been frequently visited by dengue, and the Far East and 
 Australia have suffered from epidemics of the disease. It especially 
 tends to spread along the sea coasts, and inland along the banks of 
 rivers, thus resembling yellow fever, and rarely invades elevated 
 districts. 
 
 Dengue attacks all and sundry, from young children to persons 
 of extreme age. When it breaks out in a village, in a school, or 
 barracks, the majority of persons of the community are quickly 
 seized. The disease tends to follow the lines of human intercourse; 
 a ship bearing infected passengers frequently setting up fresh foci of 
 infection at each port of call. Hot weather favours its development, 
 and as a general rule cold weather stays its progress. Like other 
 maladies of this class it exhibits recurrent periods of greater intensity 
 and wider distribution. 
 
 Nothing is known concerning the bacteriology of the disease. 
 
 Incubation. — One to five days is the period of incubation 
 usually assigned to dengue. During incubation symptoms seldom 
 show themselves, but in some instances muscular aches and joint 
 pains precede the onset of fever. 
 
 Symptoms. — Dengue usually attacks quite suddenly ; in the 
 majority of instances it is ushered in by headache, pains in the 
 back, limbs and joints, fever, chilliness, or even a rigor and an 
 intense feeling of weakness. Or the initial feeling of prostration 
 may continue for a few days, accompanied by giddiness, nausea, 
 alternate sensations of chilliness and heating, flushings, and a 
 
DENGUE 351 
 
 gradual development of rheumatic pains in the limbs, body, and 
 joints. The joint pain is peculiar ; the first symptom may be a 
 sudden seizure of pain in one finger, or the pain may rapidly extend 
 to almost every joint in the body ; or it may fly from one joint 
 to another, disappearing as suddenly as it came. 
 
 The first eruption. — On the third day the temperature rises, it 
 may be, to 102° F., or even to 106^ F. ; the pulse becomes rapid ; 
 the skin hot and dry ; the face looks swollen, and the whole body 
 is covered by a rash resembling that of scarlet fever; the tongue, 
 moreover, presents an appearance similar in many respects to the 
 " strawberry " tongue of scarlet fever, and the throat shows a some- 
 what similar congestion. 
 
 The re?!iission. — In from twenty-four to forty-eight hours the 
 first eruption disappears, all feverish symptoms subside, and for a 
 period of from two to four days the patient feels fairly comfortable. 
 
 The secotid, or terminal rubeolar eruption. — A return of fever, 
 it may be of slight amount and duration, is attended by a recru- 
 descence of joint-aches and an eruption of circular, somewhat elevated, 
 discrete, reddish spots on the hands, wrists, and forearms ; and in a 
 few hours the neck and face, the trunk, and finally the lower 
 extremities are similarly covered. A coalescence of spots may give 
 the eruption an urticarial appearance, or even cause a general diffuse 
 redness of the skin. In a day or two, attended by a profuse sweat- 
 ing, epistaxis, or an intestinal flux, the temperature falls to the 
 normal, and then below it. Desquamation of a furfuraceous character 
 succeeds, and for some twenty days the patient continues to shed 
 the epidermis in fine, dusty particles. 
 
 Sequelse. — The symptoms, after the temperature falls, gradually 
 fade away into rheumatoid pains, at times, however, of a distressing 
 character, attended by swollen and painful joints. Both large and 
 small joints are attacked, and, as the muscles are involved in the 
 affection, considerable stiffness, and it may be inability to move 
 freely induce wasting of the limbs from non-use. Convalescence is 
 often tedious, except in the case of children, and it may be interrupted 
 by relapses which continue the disease for several months. 
 
 More remote sequelae are — adenitis, more particularly of the 
 cervical glands ; orchitis ; albuminous urine ; haemorrhage from nose, 
 mouth, bowels, or uterus ; and such cutaneous ailments as boils, 
 pruritus, and evanescent eruptions. 
 
 Variety in t3rpe. — Dengue in some cases is so mild in type 
 that it causes the patient but little inconvenience. A slight sore 
 throat with some pains in the limbs and back, and a feeling of 
 
352 MANUAL OF MEDICINE 
 
 lassitude may be the extent of the symptoms. Instead of the 
 favourable course, however, dengue may assume a serious form ; 
 the skin and features become cyanotic, collapse supervenes, and the 
 patient dies in a comatose state. This form constitutes the " black 
 fever " of Calcutta natives. Variations occur in the appearance of 
 the rash, which at times is scarcely perceptible, or the primary rash 
 may be rubeolar in character. Children, when the temperature 
 runs higli, frequently develop delirium, and alarming convulsions 
 sometimes usher in the disease. 
 
 Diagnosis. — In tropical countries the initial symptoms are apt 
 to be confounded with a malarial fever. As the disease advances 
 influenza suggests itself; but the appearance of the rash raises the 
 question of scarlet fever or measles. Influenza is frequently con- 
 founded with dengue, and the outbreak of the modern epidemic of 
 influenza in 1888, in Hong-Kong, was at first regarded as being one 
 of dengue, the more so as in many cases a marked rash was occa- 
 sionally present. Scarlet fever does not appear in epidemic form in 
 tropical countries. Measles occur in the tropics, but it seldom attacks 
 adults, and is slow in its progress and spread compared with dengue. 
 Prognosis. — An attack of dengue of average severity justifies a 
 favourable prognosis, although several of the complications and 
 sequelae in the young or old may lead to a serious or a fatal issue. 
 The "black fever" of Calcutta already referred to shows, however, 
 how severe dengue may become. One attack of dengue confers 
 some degree of immunity against a recurrence. 
 
 Treatment. — In all respects dengue is to be treated as other 
 specific eruptive fevers, such as scarlet fever or measles. The 
 patient is to be confined to bed, and placed on the usual febrile 
 regimen as to diet. Constipation may be relieved by saline aperients. 
 Joint and muscular pains may be so severe as to require the external 
 application of anodyne liniments, and the administration of morphia 
 either by the mouth or subcutaneously ; the tincture of belladonna, 
 in 15 minim doses, repeated thrice at intervals of one hour, has 
 attained a reputation as a means of allaying the suffering peculiar to 
 dengue. Cold or tepid sponging affords considerable relief if the 
 temperature be high. 
 
 Convalescence may be usually considered to commence after 
 the tenth day, when a general tonic treatment is required. 
 
 Isolation of the sick and removal of exposed persons to a non- 
 infected house or district affords but small protection when dengue 
 is epidemic. 
 
 James Cantlie. 
 
BERl-BERI 353 
 
 BERI-BERI 
 
 A specific peripheral polyneuritis, characterised by disorders of 
 sensation, paresis, changes in the electrical response of the muscles 
 and nerves, and widespread vasomotor disturbances of such a nature 
 as to cause either a general anasarca or an atrophic appearance of 
 the body. The disease is one of environment, and may become 
 endemic in localities or abodes. It is usually attended by a high 
 mortality, death resulting from exhaustion, paralysis of the heart, or 
 of the muscles concerned in respiration. 
 
 Geographical distribution. — Originally described by Bontius 
 in India, the disease has in recent years been scientifically studied 
 in many tropical, sub-tropical, and even temperate climates, more 
 especially in Japan, in Brazil, and in the Dutch East Indies. In 
 addition to its occurrence in these several countries beri-beri is met 
 with in the southern provinces of China, in Annam, throughout 
 Malaya, Borneo, Fiji, New Caledonia, and even amongst natives of, 
 and the Chinese immigrants in, Australia. In America it is found 
 amongst the fishermen of the North Atlantic sea-board, in Havana, 
 at Panama, in Brazil, and in the Sandwich Islands. In Africa cases 
 have been met with from the neighbourhood of Lake Nyassa and 
 the Congo (Manson). Lastly, attention has been drawn to the 
 disease in several places in Europe, more especially in Ireland, where, 
 in the Richmond Asylum, Dublin, during 1896, 1897, and 1898, a 
 marked outbreak of the disease has been described by Dr. Conolly 
 Norman. 
 
 Etiology. — The cause of beri-beri has not yet been ascertained. 
 A bacterium was figured and described by Pekelharing and Winkler 
 as the result of their investigations in Java and Sumatra, but the 
 specific nature of the organism has not been confirmed by subse- 
 quent observers. 
 
 A diet deficient in nitrogen, such as rice, especially when the 
 grain is of inferior quality and deprived of its outer covering, is by 
 many competent observers held to be associated with outbreaks of 
 beri-beri. The chief reason for this belief is that a change to a 
 more nitrogenous diet is frequently followed by the disappearance 
 of the disease. In the Japanese navy, where beri-beri (kakke) was 
 very frequent, a change in diet of the kind indicated was followed 
 by highly satisfactory results. There are several arguments against 
 VOL. I 2 A 
 
354 MANUAL OF MEDICINE 
 
 rice being a direct factor in the etiology, none being more potent 
 than the late peculiarly isolated outbreak in the lunatic asylum in 
 Dublin. By some the disease has been ascribed to the consumption 
 of certain species of fish imperfectly cooked. 
 
 Of other assigned causes there are many. Overcrowding, 
 malaria, climate, angemia, may furnish a favourable nidus for an 
 outbreak of beri-beri by lowering the \dtality and diminishing 'the 
 bodily powers of resistance, but they cannot determine the onset of 
 a disease of so specific a character. Beri-beri is essentially the 
 disease of environment or habitation. It would seem as though a 
 dwelling or ship became infected, and that the disease clung to the 
 place. As a consequence healthy persons taking up their residence 
 in quarters vacated by beri-beri patients readily become infected. 
 
 The evidence goes to show that beri-beri is dependent upon a 
 toxic influence, probably parasitic in nature, having its habitat, in 
 all probability, outside the human body. The disease is not regarded 
 as directly contagious, nor is the beri-beric considered to be personally 
 infectious. The writer, however, found what appeared to be direct 
 communicability take place in a hospital for Chinese in Hong- 
 Kong. A number of cases of beri-beri had been admitted to a 
 general ward, and after a time beri-beri developed in several patients 
 suffering from open sores in the same ward, whilst it passed over 
 those who showed no wounds. Young men are most frequently 
 the subjects of beri-beri, but with the exception of infants and octo- 
 genarians it has been known to attack persons of any age and of 
 either sex. The rich as well as the poor suffer, but the disease is 
 propagated and thrives in the overcrowded, insanitary native hovels, 
 in the barracks where native soldiers congregate, in the ill-con- 
 structed, insanitar}', and crowded temporary dwellings on newly- 
 opened plantations. Beri-beri is also most frequently met with at 
 low levels, and more especially, but by no means exclusively, along 
 the sea-coast. 
 
 The Dutch observers in Sumatra established the fact that 
 between the period of exposure and the development of clinical 
 signs and symptoms of the disease, or, in other words, during the 
 incubation period, careful investigation will show that there exist 
 several latent signs. Of these the chief are a slight oedema along 
 the crests of the tibise, and important variations in the response of 
 the muscles and nerves to electrical stimuli. The minimum period 
 of incubation of beri-beri is about five weeks. The maximum period 
 may extend over several months. 
 
 Symptoms. — The "invasion" period of beri-beri — the "initial 
 
BERI-BERI 
 
 003 
 
 phase " — presents the following signs and symptoms : — slight cedema 
 along the tibial crests ; pale and swollen-looking features ; a slight 
 rise in temperature, which may be very evanescent, lasting only a 
 few hours, but nevertheless none the less constant ; palpitation ; a 
 small, irritable pulse; some apparent increase of cardiac dulness ; 
 violent cardiac impulse ; a prolonged first and reduplicated second 
 sound ; shortness of breath on exertion ; difificulty in walking quickly 
 and going up and down stairs owing to muscular stammering ; 
 circumscribed anaesthesia and pain on pinching the muscles of the 
 lower extremities. 
 
 When beri-beri has developed there will always be found in the 
 calf of the legs a patch which is insensible to a light touch, and to 
 both galvanic and faradic currents. The leg muscles, and after- 
 wards the muscles of the thigh, become painful when pinched, and 
 the anaesthetic areas increase in extent. The muscles become 
 weaker, their quantitative irritability is diminished, and ver}" slight 
 resistance is sufficient to stop extension of the leg and flexion of the 
 thigh. The muscles of the calf, when contracted, bulge abnormally, 
 but although painful to pressure there is seldom found any idio- 
 muscular contraction, nor are they usually irritable to percussion. 
 ^Vhen the patient attempts to rise from his bed, or to lie down, 
 considerable awkwardness is noticeable, and when he attempts to 
 walk the gait is markedly abnormal. He wavers when he tries to 
 stand with his eyes closed, nor can he stand on tip-toe, nor on one 
 foot. During walking the patient raises the foot from the floor with 
 difficulty, the toes leaving the floor last, and, after lifting the foot 
 high and pushing it forwards, suddenly drops it on the floor. The 
 dynamometer also shows that the muscular power of the hands 
 and arms is distinctly lessened. As the disease progresses the 
 anaesthetic areas in the legs may extend from the knee along the 
 inside of the limbs to the heel ; and the thenar and hypothenar 
 eminences in the hands become anccsthetic, whilst as yet the parts 
 of the hand beyond are unaffected. The muscular sense is un- 
 disturbed, the patient localises well and can imitate with one limb 
 passive movements made for him with the other. The condition of 
 the reflexes is characteristic. The knee jerk completely disappears, 
 either from the onset of the initial phase or after a few days. 
 Ankle clonus is absent, but the superficial abdominal and scrotal 
 reflexes are readily elicited. The muscles, more especially those 
 supplied by the external popliteal nerve, exhibit the reaction of 
 partial degeneration. Irritability to the faradic current is sup- 
 pressed, whether the current is applied directly or indirectly, and 
 
356 MANUAL OF MEDICINE 
 
 there is also diminution of direct and indirect irritability to the 
 galvanic current. The subsequent symptoms depend largely on 
 the seat of the nerves attacked. 
 
 The dilated heart may give out, or this condition, combined 
 with a sudden effusion into the pericardium, may cause cyanosis, 
 dyspnoea, or syncope. The respiratory muscles, on the other hand, 
 may become paralysed, causing sudden death by asphyxia. Vomit- 
 ing is a grave sign, and death, when it occurs, is usually sudden. In 
 favourable cases the oedema, if it exists, disappears, the paralytic 
 signs are first stayed in their advance and then abate in their 
 intensity. Power returns to the hands and legs, the irritabiUty of 
 the heart lessens, dyspnoea disappears, and after three months or so 
 the patient is usually able to get about, or even follow his employ- 
 ment. Occasionally it happens that paresis remains for an indefinite 
 period. During the development of these paralytic signs and 
 symptoms the general health of the patient is wonderfully good. 
 The digestive organs present nothing amiss, and the urine seldom 
 betrays any signs of renal disturbance. 
 
 Vapieties. — The three most pronounced types of beri-beri are 
 the oedematous, wet, moist, dropsical; the atrophic, dry; and the 
 mixed. In addition to these names, however, we are familiar with 
 such terms as "acute" and "chronic" beri-beri, "foudroyante," etc. 
 It is doubtful whether any one of these is worthy of the name of a 
 variety, as it is possible the one is but the precursor or sequel of 
 another, a mere predominant symptom being seized upon to 
 constitute the basis of differentiation. 
 
 1. The (edematous, dropsical, '■'■wet'''' or ^^ moist" form of beri- 
 beri is characterised by a fairly general oedema. The anasarca 
 closely resembles that met with in a case of acute Bright's disease, 
 but the urine, although presenting occasionally a slight albuminous 
 cloud on boiling, shows none of the characteristic features con- 
 sequent on acute nephritis. The oedema is at times partial, often 
 missing the scrotum, and at times changing its site. The serous 
 cavities may be the seat of a large amount of effusion, the peri- 
 cardial cavity being especially liable to effusion ; but the pleural 
 cavities may be filled to such an extent that breathing is greatly 
 hampered and the lung space so dimmished that asphyxia super- 
 venes. 
 
 2. The atrophic, '■'■dry," or purefy paraplegic variety of beri-beri is, 
 as the names imply, associated with shrinking of the tissues of the 
 body. The muscles are flabby and the fat of the body disappears. 
 The patient, as regards his alimentary and renal condition, may 
 
BERI-BERI 357 
 
 be pronounced healthy, and it is to a paralysis of the laryngeal or 
 respirator)' muscles that he usually succumbs. 
 
 3 . Atrophic and cedematous — ' ' mixed ' ' — beri-beri. — When atrophic 
 symptoms are obscured by serous effusion into the muscular 
 and the connective tissues, and when, also, the serous cavities are 
 the seat of a similar effusion, the cHnician, pledged to the cognisance 
 of a " wet " and a " dry " variety of beri-beri, will find great difficulty 
 in referring the disease to its particular variety. Hence the adoption 
 of the term " mixed," in which the signs and symptoms of the " wet " 
 and " dry " varieties are combined. 
 
 In all these divergencies, however, one symptom remams con- 
 stant, viz. the electrical modifications of the ner\'es and muscles. 
 It would be well to dispense with these distinctions, except in so far 
 as they indicate stages in the disease, because oedema is only a 
 secondary phenomenon, and if the mixed form is taken as the type, 
 the dropsical and dry forms are but a quantitative modification 
 of it. 
 
 The motor disordeis. — The most constantly paralysed muscles are 
 the groups supplied by the external popliteal nerves, viz. the 
 peronei, and the extensors of the toes ; the next most frequently 
 affected muscles are the flexors of the toes. The extensors of the 
 knee and the gluteal muscles are also liable to be involved in the 
 paresis, whilst the adductors and the knee flexors escape. In the 
 upper extremities the extensors of the hand and fingers, the supinator 
 longus, the triceps, the flexors of the hand and fingers are, in the 
 order given, the muscles liable to attack. In addition to these the 
 abdominal muscles, the diaphragm, and the intercostal muscles 
 suffer. Even the muscles supplied by the cranial nerves may 
 become involved ; the muscles of expression and the muscles of 
 the eyeball having been known to become paralysed. The laryngeal 
 muscles are also frequently involved, with the result that sudden 
 death ensues from asphyxia. 
 
 Disorders of sensory nerves. — The sense of touch is first lost on 
 the inner aspect of the calf of the leg, then on the dorsum of the 
 foot, and finally sensation may be lost everywhere below the knee. 
 In the upper extremities sensation disappears first on the anterior 
 aspect of the wrist, then over the thenar and hypothenar eminences, 
 and finally over other parts of the hand ; the ends of the fingers 
 being the last places from which it vanishes. Anaesthesia may over- 
 take the whole of the upper limb as far as the shoulders. Ansesthetic 
 areas may also be met with over the anterior aspect of the trunk, 
 reaching as low as the umbilicus, 
 
358 MANUAL OF MEDICINE 
 
 Heart affections. — The heart is early affected in beri-beri. Not 
 only are there marked subjective symptoms, but there is a pro- 
 nounced enlargement of the cardiac area, especially towards the 
 right, and pathological evidence shows that there is hypertrophy 
 accompanied by dilatation of the right ventricle. The state of 
 the ventricle explains the dropsical effusion into the tissues and the 
 serous cavities and the other effects of venous obstruction. 
 
 Post-mortem appearances. — According to the type of beri- 
 beri which has proved fatal, so do the post-mortem evidences vary. 
 In the " wet " variety serous effusions may be found in the sub- 
 cutaneous and intermuscular tissues and in the serous cavities of the 
 body ; in the " dry " variety, on the other hand, the muscles when 
 cut into reveal the yellowish- brown colour characteristic of atrophy. 
 It must be remembered, however, that oedema to some extent has 
 always existed at some period of the disease, and pericardial 
 effusion in particular is one of the most constant features of beri- 
 beri. It is in the heart itself, however, that pathological change is 
 to be sought for. Hypertrophy of the right ventricle is always 
 present, accompanied by a dilatation var)'ing from, it may be a small, 
 to an enormous extent. The heart muscle is often pale, but 
 microscopic examination shows that this is not usually due to 
 fatty degeneration. Of the other organs the lungs may be cedema- 
 tous, the liver congested, the spleen increased in bulk and weight, 
 and the blood in the large veins in a fluid state. The examination 
 of the nervous system shows that, in the nerves generally, a state of 
 peripheral neuritis and nerve degeneration exists, and that the 
 lesion diminishes in intensity as the centre is approached. The 
 anterior roots of the spinal nerves show no pathological change, 
 but in the posterior roots, more especially in the part between the 
 ganglion and the nerve trunk, atrophied fibres are met with. In 
 the central nervous system the most constant change is an alteration 
 (it may be an atrophy) in the large cells occupying the anterior 
 cornua of the spinal cord. 
 
 Prognosis. — During an attack of beri-beri it is well-nigh im- 
 possible to venture on a prognosis ; for cases of seeming mildness 
 prove fatal, whilst cases of apparently a severe type recover. In 
 general about 20 per cent of those attacked die; but the numbers 
 vary, it may be as much as i o or even 1 5 per cent either wa)'. Un- 
 favourable signs are : cardiac and vascular changes, such as a quick 
 and feeble pulse, epigastric pulsation, throbbing of the blood vessels 
 in the neck and increase in the cardiac area ; extensive serous 
 effusions into the peritoneal, pleural or pericardial cavities ; failure 
 
BERI-BERI 359 
 
 in power of the respiratory muscles ; marked diminution in the 
 quantity of urine passed ; and vomiting. The last - mentioned 
 feature supervening, as it sometimes does during the course of an 
 acute attack of beri-beri, is a very unfavourable sign. 
 
 Diagnosis. — Beri-beri has to be diagnosed from peripheral 
 neuritis, due to alcohol or to malaria, from locomotor ataxy, and from 
 epidemic dropsy. In epidemic forms of the disease the diagnosis 
 is readily enough arrived at, but when sporadic cases, or when even 
 limited outbreaks occur in what are regarded as non-beri-beric 
 countries, as in Ireland, the recognition of the disease is attended by 
 obvious difficulties. Reliance must be placed upon the presence of 
 oedema, limited, it may be, to the front of the shins ; upon the 
 absence of knee jerk ; upon the tumbling action of the heart ; pain 
 on pinching the limb muscles and patches of anaesthesia on the 
 legs and perhaps the arms. If electrical testing is available the 
 diagnosis is greatly facilitated. 
 
 Treatment — Prophylaxis. — Seeing that beri-beri is a disease of 
 environment it is necessary to correct or alter th6 immediate 
 surroundings of those exposed to the disease. Disinfecting the 
 abode, the furniture, and the clothing of beri-berics serves to check 
 the numbers of those attacked; but it is only by evacuating the 
 premises, and it may be leaving the locality where beri-beri is 
 endemic, that an outbreak, say, amongst troops ' in barracks, coolies 
 in coolie quarters, and prisoners in a jail, may be stamped out. In 
 the case of the individual it is only by removal to an untainted 
 locality that a cure can be confidently hoped for. 
 
 Rest in bed ought to be insisted upon and sudden movement or 
 exertion forbidden. The diet must be liberal in the item of 
 nitrogenous elements, and if rice has been the staple food heretofore 
 it should be supplanted by bread, meat, milk, and fresh vegetables. 
 When it is impossible to immediately quit the abode, as on board 
 ship, those afflicted with beri-beri should be granted the best sleeping 
 accommodation possible, and during the day should be brought out 
 into the open air. 
 
 The state of the heart and of the circulatory organs generally calls 
 for medicinal treatment. Cardiac stimulants, such as digitalis, may 
 be administered with good effect ; nitroglycerine in the form of the 
 liquor trinitrini (i min.), or tabellce nitroglycerini B.P. (i tablet) 
 should be at hand for emergencies of cardiac failure. Amyl nitrite 
 may be inhaled from a crushed capsule with the same intention. 
 The functional condition of the heart in beri-beri is so little under- 
 stood that it is difficult to justify, far less to explain the beneficial 
 
36o MANUAL OF MEDICINE 
 
 action of these drugs, except it be that by the administration tem- 
 porary relief is afforded to the enlarged right ventricle, by diminishing 
 the resistance of the blood vessels to the onward passage of the 
 blood. 
 
 Aspiration of first one, and (if necessar}') later the other pleural 
 cavity affords relief in dyspnoea, and the writer found benefit by 
 venesection in one case of threatened asphyxia and by aspiration of 
 the pericardial effusion in another. 
 
 \\'hen the patient is convalescing strychnine is the best medicinal 
 tonic ; but massage, electrical stimulation and general tonic treat- 
 ment favours recover)'. It was at one time believed that beri-beri 
 always relapsed, and that in about twelve months a recrudescence was 
 to be looked for. No doubt this is the case when the patient 
 returns to an infected environment, but by residence in a healthy 
 locality such a relapse may be almost certainly avoided. 
 
 James Cantlie. 
 
 EPIDE^IIC DROPSY 
 
 An epidemic disease of variable mortality and lasting from three 
 to six weeks ; characterised by oedema of the lower extremities or 
 of the entire body, accompanied by pyrexia, by gastric and intestinal 
 irritation, by aching in the limbs and trunk, and frequently by a 
 cutaneous rash of a rubeolar appearance. 
 
 Geographical distribution. — Since Dr. Kenneth M'Leod 
 first described the disease in Calcutta in 1877, several observers 
 have recorded outbreaks of the disease. In Assam, in Lower 
 Bengal, and in Mauritius, well-defined occurrences have taken 
 place, and, in all probability, outbreaks of this particular malady 
 have developed at several places on the littoral of the Indian 
 Ocean. 
 
 Etiology. — Epidemic dropsy appears to be communicable 
 from one member of the community to another, and is mainly con- 
 fined to the adults of both sexes of a family. It occurred in 
 Calcutta during the cold weather, disappeared completely during 
 the hot season, and for three successive winters, 1887 to 1890, 
 recurred persistently ; since then the disease does not seem to 
 have re-appeared, Nq European is known to have contracted the 
 disease. 
 
EPIDEMIC DROPSY 361 
 
 No bacteriological investigations have been as yet communicated 
 concerning the causation of epidemic dropsy. 
 
 Symptonis. — Initial symptoms vary. In some instances the 
 disease is ushered in by the dropsical effusion ; in others, fever first 
 attracts attention ; or again general malaise or intestinal flux precede 
 all other manifestations. 
 
 The oedema appears in the feet and ankles and may extend 
 beyond the lower extremities to the whole body, sometimes lasting 
 for a considerable period. Pleural and pericardial effusions have 
 sometimes been noticed. Fever may usher in the symptoms, may 
 accompany the dropsy or appear only during its subsidence. It is 
 seldom the thermometer registers higher than 102°. Vomiting is 
 seldom distressing ; diarrhoea or even dysentery of a mild type occa- 
 sionally occurs. In addition to itching and burning of the skin, a 
 general exanthematous rasli, of a rubeolar character, is a common, 
 but by no means a constant, accompaniment. The general signs 
 and symptoms include a weakened pulse, breathlessness, and marked 
 ansmia and prostration. Nocturnal pains in the hmbs have been 
 frequently observed. 
 
 Occasional signs and symptoms of pneumonia, oedema of the 
 lungs, cardiac dilatation, scurvy, and albuminous urine have all been 
 recorded as complications of the disease. 
 
 Diagnosis. — The only disease likely to be confused with epi- 
 demic dropsy is beri-beri. In fact many observers positively assert 
 their identity ; whilst on the other hand it is possible, nay probable, 
 that many cases at present classed as beri-beri will prove to be of the 
 nature of epidemic dropsy. The one characteristic feature of beri- 
 beri which serves definitely to stamp its specific nature is the nervous 
 and paralytic affections, and these are absent in epidemic dropsy. 
 Moreover, beri-beri is more chronic and never complicated by a 
 cutaneous eruption, nor is fever a prominent feature. 
 
 Mortality. — -In the Calcutta epidemics a death-rate of from 
 twenty to forty per cent of those attacked occurred. On the other 
 hand, in the Assam outbreak, no fatal cases were known. 
 
 Treatment. — Such remedial treatment as a weakened circula- 
 tion demands, and as is appropriate in urgent cases of dyspnoea 
 or apnoea is called for in the treatment of epidemic dropsy. 
 
 Southey's trocars are indicated as a means of relieving the 
 dropsical effusion, and even aspiration of the pleura or pericardium 
 may be necessary. During convalescence anaemia is the most 
 prorninent condition which requires treatment. 
 
 James Cantlie, 
 
362 MANUAL OF MEDICINE 
 
 ORIENTAL SORE 
 Syn. Delhi Boil ; Bagdad Sore ; Biskra Button ; Aleppo Evil 
 
 A specific inflammatory affection of the deeper layers of the 
 skin, which, commencing as a papule, soon crusts over, and spread- 
 ing by phagedsena, develops an ulcer of an indolent character. 
 The healing is protracted, and a permanent scar, a " date " mark, 
 remains to indicate the seat of the affection. 
 
 Geographical distribution. — The various synonyms indicate 
 the principal places in which this peculiar affection is met with. In 
 Europe, Greece and Crete seem to be the only countries in which 
 the disease has been noted. In Africa it occurs in Morocco, Egypt, 
 and certain parts of the Sahara. In Asia: Bagdad in 'Mesopotamia, 
 Aleppo in Syria, Delhi and Mooltan in India, are the chief seats 
 of the disease. But Arabia, Persia, and Turkestan are known also 
 to harbour the malady. Some ten years ago persons residing in tlie 
 town of Bahia, Brazil, were declared to be affected with true 
 "Oriental Sore." 
 
 What the specific infective matter may be is unknown. Objects 
 that appear to be minute parasites in the " boil " have been described 
 by Dr. Smith as the ova of Distoma, by Dr. V. Carter as the 
 spheroids and mycelium of a special parasite, and by Dr. Cunning- 
 ham as zoocysts or sporocysts which are also met with in the water 
 in some of the districts where Oriental sore is endemic. Biting 
 insects are in all probability the carriers of the infectious matter, as 
 it is the exposed parts of the body that are almost solely attacked. 
 
 Etiology. — It would seem as though a special state of climate and 
 constitution were necessary for the development of the disease, as it 
 occurs in countries possessing for the most part a dry, even arid, 
 climate, and it appears towards the end of the hot season, when the 
 vigour of those attacked is probably at its lowest. Insanitary surround- 
 ings favour the development of Oriental sore. All nationalities, both 
 sexes and all ages, are liable to attack, and the disease seems to 
 occur in special prevalence, not only at certain seasons, but also 
 during certain years. 
 
 One attack as a rule confers a permanent immunity. 
 
 Communicability. — The disease is not confined to human 
 beings. Dogs and horses are stated by Fayrer to suffer from a 
 
ORIENTAL SORE 363 
 
 disease in India closely resembling Oriental sore. Both man and 
 the lower animals can be inoculated by discharge from the surface 
 of ulcers. Attempts at inoculations from cultures of certain micro- 
 cocci obtained from the centre of the papules have hitherto failed. 
 
 Symptoms. — On some exposed part, or parts, of the body, 
 usually the face, neck, or extremities, the attention of the patient is 
 drawn to a small itching papule, or to a number of similar pimples on 
 different parts of the body. When looked at carefully the papule 
 appears pink in colour ; it is frequently situated around a hair 
 follicle, and the epidermis over it is seen to be dry and loose. 
 Gradually the subcutaneous tissues around become infiltrated and 
 feel boggy to the touch ; the intense itching alternates with occa- 
 sional stinging pains ; and a slight oozing from the surface and 
 moistening of the skin causes the epidermal cells to cake, and 
 finally to crust. Underneath the crust an ulcerating surface 
 develops, at first quite superficially, but gradually the ulceration 
 extends deeper and wider, presenting a rather sharply cut and 
 indurated edge. The crusts fall and re-form from the thin ichorous 
 material which exudes. Around the primary papule others form, 
 and, as these coalesce, they add to the extent and intractability 
 of the sore. An individual sore is usually about one inch in 
 diameter, and there may be several on different parts of the body. 
 It is believed also that any ordinary boil or wound may take on the 
 characters peculiar to Oriental sore. After many weeks, or more likely 
 months, the wound shows signs of healing. Slow in its development, 
 however, the " sore " is still slower in its disappearance, and it leaves 
 behind the peculiar " date " scar, indelibly impressed. The cheek 
 and nose are favourite sites of the disease, and a large " date " mark 
 on either of these may be followed by permanent unsightliness. 
 
 Prognosis. — There is but little danger to life from Oriental 
 sore. Were the wound to be attacked by erysipelas, or become 
 markedly phagedaenic, alarming symptoms might ensue. 
 
 Treatment. — Destruction by caustics or cautery of the primary 
 seat of infection has been frequently attempted, but the results are 
 not encouraging ; and in the absence of any known specific appli- 
 cation, it is wiser to pursue an expectant treatment, viz. attending 
 to the general health, seeing to the sanitation of the house and 
 environment, applying soothing antiseptic remedies to the sore 
 whilst it is indurated and irritable, and promoting healing by 
 cleansing the wound and protecting its surface. 
 
 James Cantlie. 
 
364 MANUAL OF MEDICINE 
 
 VERRUGA PERUANA 
 
 A specific, general, infective, inoculable disease, characterised by 
 constitutional symptoms and a special granulomatous eruption. It 
 seems to be quite distinct from framboesia. 
 
 The disease is peculiar to certain defiles penetrating the tropical 
 Andean mountainous districts of the departments of Ancache and 
 Lima, which are watered by rivers overflowing each January and 
 June. There are no limitations as to age, sex, or race. Domestic 
 animals, such as dogs, pigs, fowls, turkeys, horses, mules, llamas, 
 cows, and asses contract the disease, which assumes remarkable 
 proportions in the solipeds. 
 
 Eight to forty days are generally allowed to be the incubation 
 period ; some observers give even a longer range. 
 
 The invasion symptoms may be of very different degrees of 
 severity. The malady may be so intensely virulent that the patient 
 succumbs before the eruption appears. Usually there is an in- 
 sidious onset with general malaise, which gradually becomes inten- 
 sified. Pain and fever are prominent. Rheumatoid pains, with 
 nocturnal exacerbations, shift from joint to joint, and are often 
 terribly severe. Muscular pains, also, may produce rigidity and 
 contractions. A great variety of febrile types are observed, of which 
 the acute arthritic and low typhoid may be especially noted. ' The 
 fever may be intermittent, and is generally hectic ; the intensity 
 corresponds with the virulence of the infection. A marked ansemia 
 sets in, with profound prostration, and these states are apt to be 
 increased by the subsequent ulceration and bleeding of the eruption. 
 Hgemic murmurs may develop, serous effusions are frequent, and 
 the spleen, and sometimes the liver, enlarges. The eruption appears 
 after a period of twenty days, or only after six or eight months, or 
 even one year, it is said, and when it evolves the general symptoms 
 tend to abate. Its duration may be put at about two to eight months, 
 but varies widely according to the number of outbursts, and the 
 quantity and volume of the elements and attending complications. 
 It appears usually in the skin of the extremities and face, and spreads 
 thence to more or less of the rest of the body, and to the mucous 
 membranes, and even the splanchnic organs and serous membrane. 
 The distribution is, however, most variable. The eruptive elements 
 may be small and superficial, or develop more deeply in the cutis 
 
FRAMBCESIA 365 
 
 and subcutaneous tissue, and then attain the size of an orange, or 
 more, and give rise to grave cachexia by their sloughing and bleeding. 
 The smaller type begins as a tiny red spot, which develops into an 
 itching, shining papule, and finally into a very vascular, red " wart " 
 (whence the name verruga), which may become pedunculated. The 
 eruptions gradually die away with exfoliation or bleeding, or ulcera- 
 tion and crusting. Histologically the granulomata are said to bear a 
 striking resemblance to sarcomata, and to be specially characterised 
 by a remarkable vascularity. According to Yzquierdo, they are 
 caused by a specific bacillus, which is found between the cells, and 
 also thrombosing the vessels. 
 
 The diagnosis, in the pre-eruptive stages from malaria, rheu- 
 matic and typhoid fevers, is often very difficult. Verruga is a very 
 serious and dangerous affection. 
 
 There is no specific treatment known to be effective. The 
 sufferer should be removed at once to as healthy a locality as possible 
 at the sea level. 
 
 T. CoLCOTT Fox. 
 
 FRAMBCESIA 
 
 A highly contagious, but not hereditary, specific, general, 
 chronic, infective disorder, characterised by a cutaneous granulo- 
 matous eruption of special aspect, resembling a raspberry, whence 
 the name is derived through the French " framboise." It is endemic 
 in some of the West Indian Islands ("yaws "'), especially Dominica ; 
 in parts of Brazil and the Spanish South American colonies 
 ("bubas") and Guiana; in Fiji ("koko "), Loyalty, New Caledonia, 
 and other Melanesian Islands; in Ceylon (" paranghi "), along the 
 Coromandel Coast, Assam, and the East Indies ; in the Moluccas, 
 the East Coast of Africa, along the Mozambique Channel, and 
 on the West Coast about Sierra Leone. One attack renders the 
 subject immune for the most part. It is not syphilis altered by 
 race, climate, and locality, for both diseases breed true in the 
 same community ; syphilis can be inoculated and run a typical 
 course in a yaws subject, and healthy children are born of women 
 actually, or recently, suffering from yaws. Moreover, the incubation 
 stages are different, and many of the secondary symptoms character- 
 istic of syphilis, such as iritis, sore throat, and usually the adeno- 
 
366 MANUAL OF MEDICINE 
 
 pathy, are absent. Tertiary symptoms do not follow, it is said, 
 though ulceration is not unfrequent. 
 
 Inoculation occurs through any of the breaches of surface, so 
 frequent in unclothed people living under unhygienic, crowded, 
 miserable conditions. 
 
 After an incubation period, variously stated from two to ten 
 weeks, or a somewhat shorter average time (twelve to twenty days) 
 in experimental inoculations, an initial papule appears at the seat 
 of inoculation in a considerable proportion of cases, though not 
 invariably, and develops into a moist, yellow, fungating granuloma, 
 similar to those of the generalised eruption, and sometimes persist- 
 ing for a long period as the " mother-yaw." Simultaneously with 
 the initial papule, or shortly after, but usually within ten days, a 
 granulomatous, more or less generalised, eruption appears in 
 successive crops, and may last as a whole from three months to four 
 years, averaging about two years. The eruption evolves as itching 
 papules, the size of pin-heads, which may abort in the early stages 
 with the separation of corresponding scales. Some authors draw 
 special attention to the occurrence of such furfuraceous desquama- 
 tion in the earlier stages of the effection or at later periods. As a 
 rule the enlarging papule bursts through the epidermis and discloses 
 a central, yellowish, softened point which may simulate a pustule. 
 Finally, an abruptly -raised, painless excrescence is formed like 
 " proud flesh," or somewhat resembling mucous tubercles or condy- 
 lomata, or, in certain rarer dry states, warts. These efflorescences may 
 reach the size of a small pea, or even a walnut, and may form 
 larger patches by confluence, or become annulate. They tend to 
 be covered with a thin scab, and on disappearance after some weeks 
 leave a stain lasting a few or many months. In many cases succes- 
 sive crops continue to appear. The eruption may be generalised 
 and copious, or scanty and localised. The lips and nostrils may be 
 implicated, but otherwise the mucous membranes appear to escape, 
 as do the viscera. In the conditions under which framboesia occurs 
 it is not surprising that secondary ulcerations should result in many 
 cases. The causal micro-organism has not yet been definitely 
 established. 
 
 Constitutional symptoms, such as fever, are absent, slight, or rarely 
 severe, and, as a rule, the subjects continue their usual avocations. 
 
 Treatment. — Isolation is necessary to prevent the spread of 
 the disease. In ordinary cases, where the general health is good, 
 the disease runs its natural mild course under proper feeding and 
 hygiene, and the prognosis is most favourable. Mercury and iodide 
 
SYPHILIS 367 
 
 of potassium have been much used, and the reports as to their action 
 are most conflicting. The local application twice daily of chromic 
 acid, or a mixture of picric and carbolic acid to dry up the granulo- 
 mata is recommended ; and for some of the later and more per- 
 sistent lesions nitrate of silver and sulphate of copper are useful. 
 
 T. CoLCOTT Fox. 
 
 SYPHILIS 
 
 Syphilis is a specific contagious disease, communicable by direct 
 inoculation. Its course is characterised by a primary lesion (chancre), 
 by early constitutional (secondary) symptoms, and by late constitu- 
 tional (tertiary) symptoms. 
 
 Frequently a final stage is to be observed, a post -syphilitic fibrosis, 
 especially well marked in the blood vessels, nervous tissues, and bones, 
 in which there is an overgrowth of the connective-tissue elements of 
 those structures, the fibrous overgrowth being such that although it 
 appears to be the result of the continued action of the syphilitic 
 virus, yet it refuses to yield to the usual anti-syphilitic remedies. 
 For this reason some authorities do not regard it as an integral part 
 of the syphilitic attack, and it may more properly be regarded as an 
 expression of the profound nutritional perversion of fibrous and 
 other tissues which syphilis produces. 
 
 Etiologically syphilis is met with either as the acquired or the 
 hereditary form. In the former case the disease is implanted by 
 direct inoculation, in the latter case by inoculation of the foetus 
 through the placenta. 
 
 It is now generally thought that some form of micro-organism is 
 the cause of syphilis, and Lustgarten has found bacilli similar in 
 appearance to those of tubercle in the cells of gummata. 
 
 Acquired Syphilis in the Adult 
 
 The sites of inoculation are the mucous membrane of the genitals, 
 lips, anus, or even, there is reason to believe, the unbroken skin of 
 the finger, as following digital examinations. Feeding, and other 
 contaminated utensils, have been known to be the means whereby 
 the virus has been conveyed. 
 
368 MANUAL OF MEDICINE 
 
 Course and symptoms. — After a period of incubation, lasting 
 from fourteen to sixty-three days, the average being thirty-five days, 
 the primary chancre appears at the point of inoculation as a red pain- 
 less papule, which gradually enlarges until it forms an elevated sore, 
 with steep, well-defined margins and flattened top. The base of the 
 sore is much indurated, the induration being of a cartilaginous 
 consistence, the tissues around sharing in this. This is the typical 
 hard or Hunterian chancre, which, unless irritated, never suppurates. 
 Its surface is often covered by a brown scab which arises from a 
 clear serum-like secretion oozing from the surface of the sore. 
 Many modifications of this typical chancre are met with, and it is 
 often difficult to be sure of the identity of a lesion without awaiting 
 the time necessary for the development of secondary syphilitic symp- 
 toms. In cleanly persons, and if the inoculation is on the glans 
 penis, a " coppery " desquamating papule may be the only sign of 
 the implantation of disease, and the typical Hunterian chancre does 
 not follow. It is important to recognise such a variety as this, as it 
 may be readily overlooked by the patient, and even by the medical 
 man, so that the disease may be untreated in its earlier stages, when 
 it is essential that thorough treatment should be carried out. It seems 
 also that such chancres are sometimes followed by secondary symp- 
 toms of so shght a character as to pass unnoticed, but it is just in 
 these cases that degeneration of the central nervous system and 
 of the vessels often follows in middle Hfe. In other cases the in- 
 fection is of the mixed variety, i.e. the virus of "soft" and of "hard" 
 chancre are implanted at the same time, and one or more of the 
 soft chancres may heal, and then undergo the characteristic in- 
 duration of syphilis, and a hard chancre ensues. The indura- 
 tion may be like a piece of parchment or a button let into 
 the mucous membrane or skin. It lasts for a variable time, for 
 about two to four months, and then the ulcer heals and a scar is 
 left. In women chancres on the mucous membrane of the genitals 
 are by no means so well marked nor so well defined as in men. 
 The diagnosis of a typical hard chancre is not difficult, but the 
 identification of the disease when the desquamating papule, or 
 when soft chancres are present, and when the hard chancre has been 
 irritated by caustics, so that it suppurates, is not easy. A chancre 
 and herpes of the penis are sometimes confused. 
 
 From the seat of inoculation the virus spreads to the lymphatic 
 glands of the groin and these become enlarged and hard. They 
 are painless, non-adherent to the skin, and do not suppurate unless 
 the chancre be irritated or be of the mixed variety, i.e. " hard " and 
 
BERI-BERI 353 
 
 BERI-BERI 
 
 A specific peripheral polyneuritis, characterised by disorders of 
 sensation, paresis, changes in the electrical response of the muscles 
 and nerves, and widespread vasomotor disturbances of such a nature 
 as to cause either a general anasarca or an atrophic appearance of 
 the body. The disease is one of environment, and may become 
 endemic in locahties or abodes. It is usually attended by a high 
 mortality, death resulting from exhaustion, paralysis of the heart, or 
 of the muscles concerned in respiration. 
 
 Geographical distribution. — Originally described by Bontius 
 in India, the disease has in recent years been scientifically studied 
 in many tropical, sub-tropical, and even temperate climates, more 
 especially in Japan, in Brazil, and in the Dutch East Indies. In 
 addition to its occurrence in these several countries beri-beri is met 
 with in the southern provinces of China, in Annam, throughout 
 Malaya, Borneo, Fiji, New Caledonia, and even amongst natives of, 
 and the Chinese immigrants in, Australia. In America it is found 
 amongst the fishermen of the North Atlantic sea-board, in Havana, 
 at Panama, in Brazil, and in the Sandwich Islands. In Africa cases 
 have been met with from the neighbourhood of Lake Nyassa and 
 the Congo (Manson). Lastly, attention has been drawn to the 
 disease in several places in Europe, more especially in Ireland, where, 
 in the Richmond Asylum, Dublin, during 1896, 1897, and 1898, a 
 marked outbreak of the disease has been described by Dr. Conolly 
 Norman. 
 
 Etiology. — The cause of beri-beri has not yet been ascertained. 
 A bacterium was figured and described by Pekelharing and Winkler 
 as the result of their investigations in Java and Sumatra, but the 
 specific nature of the organism has not been confirmed by subse- 
 quent observers. 
 
 A diet deficient in nitrogen, such as rice, especially when the 
 grain is of inferior quality and deprived of its outer covering, is by 
 many competent observers held to be associated with outbreaks of 
 beri-beri. The chief reason for this belief is that a change to a 
 more nitrogenous diet is frequently followed by the disappearance 
 of the disease. In the Japanese navy, where beri-beri (kakke) was 
 very frequent, a change in diet of the kind indicated was followed 
 by highly satisfactory results. There are several arguments against 
 
 VOL. I 2 A 
 
354 MANUAL OF MEDICINE 
 
 rice being a direct factor in the etiology, none being more potent 
 than the late peculiarly isolated outbreak in the lunatic asylum in 
 DubUn. By some the disease has been ascribed to the consumption 
 of certain species of fish imperfectly cooked. 
 
 Of other assigned causes there are many. Overcrowding, 
 malaria, climate, anaemia, may furnish a favourable nidus for an 
 outbreak of beri-beri by lowering the vitality and diminishing the 
 bodily powers of resistance, but they cannot determine the onset of 
 a disease of so specific a character. Beri-beri is essentially the 
 disease of environment or habitation. It would seem as though a 
 dwelling or ship became infected, and that the disease clung to the 
 place. As a consequence healthy persons taking up their residence 
 in quarters vacated by beri-beri patients readily become infected. 
 
 The evidence goes to show that beri-beri is dependent upon a 
 toxic influence, probably parasitic in nature, having its habitat, in 
 all probability, outside the human body. The disease is not regarded 
 as directly contagious, nor is the beri-beric considered to be personally 
 infectious. The writer, however, found what appeared to be direct 
 communicability take place in a hospital for Chinese in Hong- 
 Kong. A number of cases of beri-beri had been admitted to a 
 general ward, and after a time beri-beri developed in several patients 
 suffering from open sores in the same ward, whilst it passed over 
 those who showed no wounds. Young men are most frequently 
 the subjects of beri-beri, but with the exception of infants and octo- 
 genarians it has been known to attack persons of any age and of 
 either sex. The rich as well as the poor suffer, but the disease is 
 propagated and thrives in the overcrowded, insanitary native hovels, 
 in the barracks where native soldiers congregate, in the ill -con- 
 structed, insanitary, and crowded temporary dwellings on newly- 
 opened plantations. Beri-beri is also most frequently met with at 
 low levels, and more especially, but by no means exclusively, along 
 the sea-coast. 
 
 The Dutch observers in Sumatra established the fact that 
 between the period of exposure and the development of clinical 
 signs and symptoms of the disease, or, in other words, during the 
 incubation period, careful investigation will show that there exist 
 several latent signs. Of these the chief are a slight oedema along 
 the crests of the tibiae, and important variations in the response of 
 the muscles and nerves to electrical stimuli. The minimum period 
 of incubation of beri-beri is about five weeks. The maximum period 
 may extend over several months. 
 
 Symptoms. — The " invasion " period of beri-beri — the " initial 
 
BERI-BERI 
 
 355 
 
 phase " — presents the following signs and symptoms : — shght cedema 
 along the tibial crests ; pale and swollen-looking features ; a slight 
 rise in temperature, which may be very evanescent, lasting only a 
 few hours, but nevertheless none the less constant ; palpitation ; a 
 small, irritable pulse; some apparent increase of cardiac dulness ; 
 violent cardiac impulse ; a prolonged first and reduplicated second 
 sound ; shortness of breath on exertion ; difficulty in walking quickly 
 and going up and down stairs owing to muscular stammering ; 
 circumscribed anaesthesia and pain on pinching the muscles of the 
 lower extremities. 
 
 When beri-beri has developed there will always be found in the 
 calf of the legs a patch which is insensible to a light touch, and to 
 both galvanic and faradic currents. The leg muscles, and after- 
 wards the muscles of the thigh, become painful when pinched, and 
 the ancesthetic areas increase in extent. The muscles become 
 weaker, their quantitative irritability is diminished, and very slight 
 resistance is sufficient to stop extension of the leg and flexion of the 
 thigh. The muscles of the calf, when contracted, bulge abnormally, 
 but although painful to pressure there is seldom found any idio- 
 muscular contraction, nor are they usually irritable to percussion. 
 When the patient attempts to rise from his bed, or to lie down, 
 considerable awkwardness is noticeable, and when he attempts to 
 walk the gait is markedly abnormal. He wavers when he tries to 
 stand with his eyes closed, nor can he stand on tip-toe, nor on one 
 foot. During walking the patient raises the foot from the floor with 
 difficulty, the toes leaving the floor last, and, after lifting the foot 
 high and pushing it forwards, suddenly drops it on the floor. The 
 dynamometer also shows that the muscular power of the hands 
 and arms is distinctly lessened. As the disease progresses the 
 ancesthetic areas in the legs may extend from the knee along the 
 inside of the Umbs to the heel ; and the thenar and hypothenar 
 eminences in the hands become anaesthetic, whilst as yet the parts 
 of the hand beyond are unaffected. The muscular sense is un- 
 disturbed, the patient localises well and can imitate with one limb 
 passive movements made for him with the other. The condition of 
 the reflexes is characteristic. The knee jerk completely disappears, 
 either from the onset of the initial phase or after a few days. 
 Ankle clonus is absent, but the superficial abdominal and scrotal 
 reflexes are readily elicited. The muscles, more especially those 
 supplied by the external popliteal nerve, exhibit the reaction of 
 partial degeneration. Irritability to the faradic current is sup- 
 pressed, whether the current is applied directly or indirectly, and 
 
3 56 MANUAL OF MEDICINE 
 
 there is also diminution of direct and indirect irritability to the 
 galvanic current. The subsequent symptoms depend largely on 
 the seat of the nerves attacked. 
 
 The dilated heart may give out, or this condition, combined 
 with a sudden effusion into the pericardium, may cause cyanosis, 
 dyspnoea, or syncope. The respiratory muscles, on the other hand, 
 may become paralysed, causing sudden death by asphyxia. Vomit- 
 ing is a grave sign, and death, when it occurs, is usually sudden. In 
 favourable cases the oedema, if it exists, disappears, the paralytic 
 signs are first stayed in their advance and then abate in their 
 intensity. Power returns to the hands and legs, the irritabihty of 
 the heart lessens, dyspncea disappears, and after three months or so 
 the patient is usually able to get about, or even follow his employ- 
 ment. Occasionally it happens that paresis remains for an indefinite 
 period. During the development of these paralytic signs and 
 symptoms the general health of the patient is wonderfully good. 
 The digestive organs present nothing amiss, and the urine seldom 
 betrays any signs of renal disturbance. 
 
 Varieties. — The three most pronounced types of beri-beri are 
 the oedematous, wet, moist, dropsical; the atrophic, dry; and the 
 mixed. In addition to these names, however, we are familiar with 
 such terms as "acute" and "chronic" beri-beri, "foudroyante," etc. 
 It is doubtful whether any one of these is worthy of the name of a 
 variety, as it is possible the one is but the precursor or sequel of 
 another, a mere predominant symptom being seized upon to 
 constitute the basis of differentiation. 
 
 1. The xde7!iatous, dropsical, '■'■wet'''' or '■'■ moist ''"' form of beri- 
 beri is characterised by a fairly general cedema. The anasarca 
 closely resembles that met with in a case of acute Bright's disease, 
 but the urine, although presenting occasionally a slight albuminous 
 cloud on boiling, shows none of the characteristic features con- 
 sequent on acute nephritis. The oedema is at times partial, often 
 missing the scrotum, and at times changing its site. The serous 
 cavities may be the seat of a large amount of effusion, the peri- 
 cardial cavity being especially liable to effusion ; but the pleural 
 cavities may be filled to such an extent that breathing is greatly 
 hampered and the lung space so dimmished that asphyxia super- 
 venes. 
 
 2. The atrophic, "dry," or purely paraplegic variety of beri-beri is, 
 as the names imply, associated with shrinking of the tissues of the 
 body. The muscles are flabby and the fat of the body disappears. 
 The patient, as regards his alimentary and renal condition, may 
 
BERI-BERI 357 
 
 be pronounced healthy, and it is to a paralysis of the laryngeal or 
 respiratory muscles that he usually succumbs. 
 
 3 . Atrophic and (jedetnatous — ' ' mixed ' ' — beri-beri. — When atrophic 
 symptoms are obscured by serous effusion into the muscular 
 and the connective tissues, and when, also, the serous cavities are 
 the seat of a similar effusion, the clinician, pledged to the cognisance 
 of a " wet " and a " dry " variety of beri-beri, will find great difficulty 
 in referring the disease to its particular variety. Hence the adoption 
 of the term " mixed," in which the signs and symptoms of the " wet " 
 and " dry " varieties are combined. 
 
 In all these divergencies, however, one symptom remams con- 
 stant, viz. the electrical modifications of the nerves and muscles. 
 It would be well to dispense with these distinctions, except in so far 
 as they indicate stages in the disease, because oedema is only a 
 secondary phenomenon, and if the mixed form is taken as the type, 
 the dropsical and dry forms are but a quantitative modification 
 of it. 
 
 The motor disorders. — The most constantly paralysed muscles are 
 the groups supplied by the external popliteal nerves, viz. the 
 peronei, and the extensors of the toes ; the next most frequently 
 affected muscles are the flexors of the toes. The extensors of the 
 knee and the gluteal muscles are also liable to be involved in the 
 paresis, whilst the adductors and the knee flexors escape. In the 
 upper extremities the extensors of the hand and fingers, the supinator 
 longus, the triceps, the flexors of the hand and fingers are, in the 
 order given, the muscles liable to attack. In addition to these the 
 abdominal muscles, the diaphragm, and the intercostal muscles 
 suffer. Even the muscles supplied by the cranial nerves may 
 become involved ; the muscles of expression and the muscles of 
 the eyeball having been known to become paralysed. The laryngeal 
 muscles are also frequently involved, with the result that sudden 
 death ensues from asphyxia. 
 
 Disorders of sensory nerves. — The sense of touch is first lost on 
 the inner aspect of the calf of the leg, then on the dorsum of the 
 foot, and finally sensation may be lost everywhere below the knee. 
 In the upper extremities sensation disappears first on the anterior 
 aspect of the wrist, then over the thenar and hypothenar eminences, 
 and finally over other parts of the hand ; the ends of the fingers 
 being the last places from which it vanishes. Anaesthesia may over- 
 take the whole of the upper limb as far as the shoulders. Auccsthetic 
 areas may also be met with over the anterior aspect of the trunk, 
 reaching as low as the umbilicus. 
 
358 MANUAL OF MEDICINE 
 
 Heart affections. — The heart is early affected in beri-beri. Not 
 only are there marked subjective symptoms, but there is a pro- 
 nounced enlargement of the cardiac area, especially towards the 
 right, and pathological evidence shows that there is hypertrophy 
 accompanied by dilatation of the right ventricle. The state of 
 the ventricle explains the dropsical effusion into the tissues and the 
 serous cavities and the other effects of venous obstruction. 
 
 Post-mortem appearances. — According to the type of beri- 
 beri which has proved fatal, so do the post-mortem evidences var}-. 
 In the " wet " variety serous effusions may be found in the sub- 
 cutaneous and intermuscular tissues and in the serous cavities of the 
 body ; in the " dry " variety, on the other hand, the muscles when 
 cut into reveal the yellowish-brown colour characteristic of atrophy. 
 It must be remembered, however, that oedema to some extent has 
 always existed at some period of the disease, and pericardial 
 effusion in particular is one of the most constant features of beri- 
 beri. It is in the heart itself, however, that pathological change is 
 to be sought for. Hypertrophy of the right ventricle is always 
 present, accompanied by a dilatation varj-ing from, it may be a small, 
 to an enormous extent. The heart muscle is often pale, but 
 microscopic examination shows that this is not usually due to 
 fatty degeneration. Of the other organs the lungs may be cedema- 
 tous, the liver congested, the spleen increased in bulk and weight, 
 and the blood in the large veins in a fluid state. The examination 
 of the ner^'ous system shows that, in the nerves generally, a state of 
 peripheral neuritis and ner\'e degeneration exists, and that the 
 lesion diminishes in intensity as the centre is approached. The 
 anterior roots of the spinal nerves show no pathological change, 
 but in the posterior roots, more especially in the part between the 
 ganglion and the nerve trunk, atrophied fibres are met with. In 
 the central nervous system the most constant change is an alteration 
 (it may be an atrophy) in the large cells occupying the anterior 
 cornua of the spinal cord. 
 
 Prognosis. — During an attack of beri-beri it is well-nigh im- 
 possible to venture on a prognosis ; for cases of seeming mildness 
 prove fatal, whilst cases of apparently a severe type recover. In 
 general about 20 per cent of those attacked die; but the numbers 
 vary, it may be as much as i o or even 1 5 per cent either way. Un- 
 favourable signs are : cardiac and vascular changes, such as a quick 
 and feeble pulse, epigastric pulsation, throbbing of the blood vessels 
 in the neck and increase in the cardiac area ; extensive serous 
 effusions into the peritoneal, pleural or pericardial ca^dties ; failure 
 
BERI-BERI 359 
 
 in power of the respiratory muscles ; marked diminution in the 
 quantity of urine passed ; and vomiting. The last - mentioned 
 feature supervening, as it sometimes does during the course of an 
 acute attack of beri-beri, is a very unfavourable sign. 
 
 Diagnosis. — Beri-beri has to be diagnosed from peripheral 
 neuritis, due to alcohol or to malaria, from locomotor ataxy, and from 
 epidemic dropsy. In epidemic forms of the disease the diagnosis 
 is readily enough arrived at, but when sporadic cases, or when even 
 limited ' outbreaks occur in what are regarded as non-beri-beric 
 countries, as in Ireland, the recognition of the disease is attended by 
 obvious difficulties. Reliance must be placed upon the presence of 
 oedema, limited, it may be, to the front of the shins ; upon the 
 absence of knee jerk ; upon the tumbling action of the heart ; pain 
 on pinching the limb muscles and patches of anaesthesia on the 
 legs and perhaps the arms. If electrical testing is available the 
 diagnosis is greatly facilitated. 
 
 Treatment — Prophylaxis. — Seeing that beri-beri is a disease of 
 environment it is necessary to correct or alter the immediate 
 surroundings of those exposed to the disease. Disinfecting the 
 abode, the furniture, and the clothing of beri-berics serves to check 
 the numbers of those attacked \ but it is only by evacuating the 
 premises, and it may be leaving the locality where beri-beri is 
 endemic, that an outbreak, say, amongst troops in barracks, coolies 
 in coolie quarters, and prisoners in a jail, may be stamped out. In 
 the case of the individual it is only by removal to an untainted 
 locality that a cure can be confidently hoped for. 
 
 Rest in bed ought to be insisted upon and sudden movement or 
 exertion forbidden. The diet must be Uberal in the item of 
 nitrogenous elements, and if rice has been the staple food heretofore 
 it should be supplanted by bread, meat, milk, and fresh vegetables. 
 When it is impossible to immediately quit the abode, as on board 
 ship, those afflicted with beri-beri should be granted the best sleeping 
 accommodation possible, and during the day should be brought out 
 into the open air. 
 
 The state of the heart and of the circulatory organs generally calls 
 for medicinal treatment. Cardiac stimulants, such as digitalis, may 
 be administered with good effect ; nitroglycerine in the form of the 
 liquor trinitrini (i min.), or tabellae nitroglycerini B.P. (i tablet) 
 should be at hand for emergencies of cardiac failure. Amyl nitrite 
 may be inhaled from a crushed capsule with the same intention. 
 The functional condition of the heart in beri-beri is so little under- 
 stood that it is difficult to justify, far less to explain the beneficial 
 
360 MANUAL OF MEDICINE 
 
 action of these drugs, except it be that by the administration tem- 
 porary reUef is afforded to the enlarged right ventricle, by diminishing 
 the resistance of the blood vessels to the onward passage of the 
 blood. 
 
 Aspiration of first one, and (if necessar}') later the other pleural 
 cavity affords relief in dyspnoea, and the writer found benefit by 
 venesection in one case of threatened asphyxia and by aspiration of 
 the pericardial effusion in another. 
 
 When the patient is convalescing strjxhnine is the best medicinal 
 tonic ; but massage, electrical stimulation and general tonic treat- 
 ment favours recover}\ It was at one time believed that beri-beri 
 always relapsed, and that in about twelve months a recrudescence was 
 to be looked for. No doubt this is the case when the patient 
 returns to an infected environment, but by residence in a healthy 
 locality such a relapse may be almost certainly avoided. 
 
 James Caxtlie. 
 
 EPIDEMIC DROPSY 
 
 An epidemic disease of variable mortality and lasting from three 
 to six weeks ; characterised by oedema of the lower extremities or 
 of the entire body, accompanied by pyrexia, by gastric and intestinal 
 irritation, by aching in the limbs and trunk, and frequently by a 
 cutaneous rash of a rubeolar appearance. 
 
 Geographical distribution. — Since Dr. Kenneth M'Leod 
 first described the disease in Calcutta in 1877, several observers 
 have recorded outbreaks of the disease. In Assam, in Lower 
 Bengal, and in Mauritius, well-defined occurrences have taken 
 place, and. in all probability, outbreaks of this particular malady 
 have developed at several places on the littoral of the Indian 
 Ocean. 
 
 Etiology. — Epidemic dropsy appears to be communicable 
 from one member of the community to another, and is mainly con- 
 fined to the adults of both sexes of a family. It occurred in 
 Calcutta during the cold weather, disappeared completely during 
 the hot season, and for three successive winters, 1887 to 1890, 
 recurred persistently ; since then the disease does not seem to 
 have re-appeared. No European is known to have contracted the 
 disease. 
 
EPIDEMIC DROPSY 361 
 
 No bacteriological investigations have been as yet communicated 
 concerning the causation of epidemic dropsy. 
 
 Symptoms. — Initial symptoms vary. In some instances the 
 disease is ushered in by the dropsical effusion ; in others, fever first 
 attracts attention ; or again general malaise or intestinal flux precede 
 all other manifestations. 
 
 The oedema appears in the feet and ankles and may extend 
 beyond the lower extremities to the whole body, sometimes lasting 
 for a considerable period. Pleural and pericardial effusions have 
 sometimes been noticed. Fever may usher in the symptoms, may 
 accompany the dropsy or appear only during its subsidence. It is 
 seldom the thermometer registers higher than 102°. Vomiting is 
 seldom distressing ; diarrhoea or even dysentery of a mild type occa- 
 sionally occurs. In addition to itching and burning of the skin, a 
 general exanthematous rasli, of a rubeolar character, is a common, 
 but by no means a constant, accompaniment. The general signs 
 and symptoms include a weakened pulse, breathlessness, and marked 
 anaemia and prostration. Nocturnal pains in the limbs have been 
 frequently observed. 
 
 Occasional signs and symptoms of pneumonia, oedema of the 
 lungs, cardiac dilatation, scurvy, and albuminous urine have all been 
 recorded as complications of the disease. 
 
 Diagnosis. — The only disease likely to be confused with epi- 
 demic dropsy is beri-beri. In fact many observers positively assert 
 their identity ; whilst on the other hand it is possible, nay probable, 
 that many cases at present classed as beri-beri will prove to be of the 
 nature of epidemic dropsy. The one characteristic feature of beri- 
 beri which serves definitely to stamp its specific nature is the nervous 
 and paralytic affections, and these are absent in epidemic dropsy. 
 Moreover, beri-beri is more chronic and never complicated by a 
 cutaneous eruption, nor is fever a prominent feature. 
 
 Mortality. — In the Calcutta epidemics a death-rate of from 
 twenty to forty per cent of those attacked occurred. On the other 
 hand, in the Assam outbreak, no fatal cases were known. 
 
 Treatment. — Such remedial treatment as a weakened circula- 
 tion demands, and as is appropriate in urgent cases of dyspnoea 
 or apncea is called for in the treatment of epidemic dropsy. 
 
 Southey's trocars are indicated as a means of relieving the 
 dropsical effusion, and even aspiration of the pleura or pericardium 
 may be necessary. During convalescence anaemia is the most 
 prominent condition which requires treatment. 
 
 James Cantlie, 
 
362 MANUAL OF MEDICINE 
 
 ORIENTAL SORE 
 Syn. Delhi Boil ; Bagdad Sore ; Biskra Button ; Aleppo Evil 
 
 A specific inflammatory affection of the deeper layers of the 
 skin, which, commencing as a papule, soon crusts over, and spread- 
 ing by phagedasna, develops an ulcer of an indolent character. 
 The healing is protracted, and a permanent scar, a " date " mark, 
 remains to indicate the seat of the affection. 
 
 Geographical distribution. — The various synonyms indicate 
 the principal places in which this peculiar affection is met with. In 
 Europe, Greece and Crete seem to be the only countries in which 
 the disease has been noted. In Africa it occurs in Morocco, Egypt, 
 and certain parts of the Sahara. In Asia: Bagdad in Mesopotamia, 
 Aleppo in Syria, Delhi and Mooltan in India, are the chief seats 
 of the disease. But Arabia, Persia, and Turkestan are known also 
 to harbour the malady. Some ten years ago persons residing in the 
 town of Bahia, Brazil, were declared to be affected with true 
 "Oriental Sore." 
 
 What the specific infective matter may be is unknown. Objects 
 that' appear to be minute parasites in the " boil " have been described 
 by Dr. Smith as the ova of Distoma, by Dr. V. Carter as the 
 spheroids and mycelium of a special parasite, and by Dr. Cunning- 
 ham as zoocysts or sporocysts which are also met with in the water 
 in some of the districts where Oriental sore is endemic. Biting 
 insects are in all probability the carriers of the infectious matter, as 
 it is the exposed parts of the body that are almost solely attacked. 
 
 Etiology. — It would seem as though a special state of climate and 
 constitution were necessary for the development of the disease, as it 
 occurs in countries possessing for the most part a dry, even arid, 
 climate, and it appears towards the end of the hot season, when the 
 vigour of those attacked is probably at its lowest. Insanitary surround- 
 ings favour the development of Oriental sore. All nationalities, both 
 sexes and all ages, are liable to attack, and the disease seems to 
 occur in special prev^alence, not only at certain seasons, but also 
 during certain years. 
 
 One attack as a rule confers a permanent immunity. 
 
 Coramunicability. — The disease is not confined to human 
 beings. Dogs and horses are stated by Fayrer to suffer from a 
 
ORIENTAL SORE 363 
 
 disease in India closely resembling Oriental sore. Both man and 
 the lower animals can be inoculated by discharge from the surface 
 of ulcers. Attempts at inoculations from cultures of certain micro- 
 cocci obtained from the centre of the papules have hitherto failed. 
 
 Sjmaptoms. — On some exposed part, or parts, of the body, 
 usually the face, neck, or extremities, the attention of the patient is 
 drawn to a small itching papule, or to a number of similar pimples on 
 different parts of the body. When looked at carefully the papule 
 appears pink in colour ; it is frequently situated around a hair 
 follicle, and the epidermis over it is seen to be dry and loose. 
 Gradually the subcutaneous tissues around become infiltrated and 
 feel boggy to the touch ; the intense itching alternates with occa- 
 sional stinging pains ; and a slight oozing from the surface and 
 moistening of the skin causes the epidermal cells to cake, and 
 finally to crust. Underneath the crust an ulcerating surface 
 develops, at first quite superficially, but gradually the ulceration 
 extends deeper and wider, presenting a rather sharply cut and 
 indurated edge. The crusts fall and re-form from the thin ichorous 
 material which exudes. Around the primary papule others form, 
 and, as these coalesce, they add to the extent and intractability 
 of the sore. An individual sore is usually about one inch in 
 diameter, and there may be several on different parts of the body. 
 It is believed also that any ordinary boil or wound may take on the 
 characters peculiar to Oriental sore. After many weeks, or more likely 
 months, the wound shows signs of healing. Slow in its development, 
 however, the " sore " is still slower in its disappearance, and it leaves 
 behind the peculiar " date " scar, indelibly impressed. The cheek 
 and nose are favourite sites of the disease, and a large " date " mark 
 on either of these may be followed by permanent unsightliness. 
 
 Prognosis. — There is but little danger to life from Oriental 
 sore. Were the wound to be attacked by erysipelas, or become 
 markedly phagedasnic, alarming symptoms might ensue. 
 
 Treatment. — Destruction by caustics or cautery of the primary 
 seat of infection has been frequently attempted, but the results are 
 not encouraging ; and in the absence of any known specific appli- 
 cation, it is wiser to pursue an expectant treatment, viz. attending 
 to the general health, seeing to the sanitation of the house and 
 environment, applying soothing antiseptic remedies to the sore 
 whilst it is indurated and irritable, and promoting healing by 
 cleansing the wound and protecting its surface. 
 
 James Cantlie, 
 
;64 MANUAL OF MEDICINE 
 
 VERRUGA PERUANA 
 
 A specific, general, infective, inoculable disease, characterised by 
 constitutional symptoms and a special granulomatous eruption. It 
 seems to be quite distinct from framboesia. 
 
 The disease is peculiar to certain defiles penetrating the tropical 
 Andean mountainous districts of the departments of Ancache and 
 Lima, which are watered by rivers overflowing each January and 
 June. There are no limitations as to age, sex, or race. Domestic 
 animals, such as dogs, pigs, fowls, turkeys, horses, mules, llamas, 
 cows, and asses contract the disease, which assumes remarkable 
 proportions in the solipeds. 
 
 Eight to forty days are generally allowed to be the incubation 
 period ; some observers give even a longer range. 
 
 The invasion symptoms may be of very different degrees of 
 severity. The malady may be so intensely virulent that the patient 
 succumbs before the eruption appears. Usually there is an in- 
 sidious onset with general malaise, which gradually becomes inten- 
 sified. Pain and fever are prominent. Rheumatoid pains, with 
 nocturnal exacerbations, shift from joint to joint, and are often 
 terribly severe. Muscular pains, also, may produce rigidity and 
 contractions. A great variety of febrile types are observed, of which 
 the acute arthritic and low typhoid may be especially noted. The 
 fever may be intermittent, and is generally hectic ; the intensity 
 corresponds with the virulence of the infection. A marked anaemia 
 sets in, with profound prostration, and these states are apt to be 
 increased by the subsequent ulceration and bleeding of the eruption. 
 Hsemic murmurs may develop, serous effusions are frequent, and 
 the spleen, and sometimes the liver, enlarges. The eruption appears 
 after a period of twenty days, or only after six or eight months, or 
 even one year, it is said, and when it evolves the general symptoms 
 tend to abate. Its duration may be put at about two to eight months, 
 but varies widely according to the number of outbursts, and the 
 quantity and volume of the elements and attending complications. 
 It appears usually in the skin of the extremities and face, and spreads 
 thence to more or less of the rest of the body, and to the mucous 
 membranes, and even the splanchnic organs and serous membrane. 
 The distribution is, however, most variable. The eruptive elements 
 may be small and superficial, or develop more deeply in the cutis 
 
FRAMBCESIA 365 
 
 and subcutaneous tissue, and then attain the size of an orange, or 
 more, and give rise to grave cachexia by their sloughing and bleeding. 
 The smaller type begins as a tiny red spot, which develops into an 
 itching, shining papule, and finally into a very vascular, red " wart " 
 (whence the name verruga), which may become pedunculated. The 
 eruptions gradually die away with exfoliation or bleeding, or ulcera- 
 tion and crusting. Histologically the granulomata are said to bear a 
 striking resemblance to sarcomata, and to be specially characterised 
 by a remarkable vascularity. According to Yzquierdo, they are 
 caused by a specific bacillus, which is found between the cells, and 
 also thrombosing the vessels. 
 
 The diagnosis, in the pre-eruptive stages from malaria, rheu- 
 matic and typhoid fevers, is often very difficult. Verruga is a very 
 serious and dangerous affection. 
 
 There is no specific treatment known to be effective. The 
 sufferer should be removed at once to as healthy a locality as possible 
 at the sea level. 
 
 T. CoLCOTT Fox. 
 
 FRAMBCESIA 
 
 A highly contagious, but not hereditary, specific, general, 
 chronic, infective disorder, characterised by a cutaneous granulo- 
 matous eruption of special aspect, resembling a raspberry, whence 
 the name is derived through the French " framboise." It is endemic 
 in some of the West Indian Islands (" yaws "), especially Dominica ; 
 in parts of Brazil and the Spanish South American colonies 
 (" bubas ") and Guiana ; in Fiji (" koko "), Loyalty, New Caledonia, 
 and other Melanesian Islands ; in Ceylon (" paranghi "), along the 
 Coromandel Coast, Assam, and the East Indies ; in the Moluccas, 
 the East Coast of Africa, along the Mozambique Channel, and 
 on the West Coast about Sierra Leone. One attack renders the 
 subject immune for the most part. It is not syphilis altered by 
 race, climate, and locality, for both diseases breed true in the 
 same community ; syphilis can be inoculated and run a typical 
 course in a yaws subject, and healthy children are born of women 
 actually, or recently, suffering from yaws. Moreover, the incubation 
 stages are different, and many of the secondary symptoms character- 
 istic of syphilis, such as iritis, sore throat, and usually the adeno- 
 
366 MANUAL OF MEDICINE 
 
 pathy, are absent. Tertiary symptoms do not follow, it is said, 
 though ulceration is not unfrequent. 
 
 Inoculation occurs through any of the breaches of surface, so 
 frequent in unclothed people living under unhygienic, crowded, 
 miserable conditions. 
 
 After an incubation period, variously stated from two to ten 
 weeks, or a somewhat shorter average time (twelve to twenty days) 
 in experimental inoculations, an initial papule appears at the seat 
 of inoculation in a considerable proportion of cases, though not 
 invariably, and develops into a moist, yellow, fungating granuloma, 
 similar to those of the generalised eruption, and sometimes persist- 
 ing for a long period as the "mother-yaw." Simultaneously with 
 the initial papule, or shortly after, but usually within ten days, a 
 granulomatous, more or less generalised, eruption appears in 
 successive crops, and may last as a whole from three months to four 
 years, averaging about two years. The eruption evolves as itching 
 papules, the size of pin-heads, which may abort in the early stages 
 with the separation of corresponding scales. Some authors draw 
 special attention to the occurrence of such furfuraceous desquama- 
 tion in the earlier stages of the effection or at later periods. As a 
 rule the enlarging papule bursts through the epidermis and discloses 
 a central, yellowish, softened point which may simulate a pustule. 
 Finally, an abruptly -raised, painless excrescence is formed like 
 " proud flesh," or somewhat resembling mucous tubercles or condy- 
 lomata, or, in certain rarer dry states, warts. These efflorescences may 
 reach the size of a small pea, or even a walnut, and may form 
 larger patches by confluence, or become annulate. They tend to 
 be covered with a thin scab, and on disappearance after some weeks 
 leave a stain lasting a few or many months. In many cases succes- 
 sive crops continue to appear. The eruption may be generalised 
 and copious, or scanty and localised. The lips and nostrils may be 
 implicated, but otherwise the mucous membranes appear to escape, 
 as do the viscera. In the conditions under which frambcesia occurs 
 it is not surprising that secondary ulcerations should result in many 
 cases. The causal micro-organism has not yet been definitely 
 established. 
 
 Constitutional symptoms, such as fever, are absent, slight, or rarely 
 severe, and, as a rule, the subjects continue their usual avocations. 
 
 Treatment. — Isolation is necessary to prevent the spread of 
 the disease. In ordinary cases, where the general health is good, 
 the disease runs its natural mild course under proper feeding and 
 hygiene, and the prognosis is most favourable. Mercury and iodide 
 
SYPHILIS 367 
 
 of potassium have been much used, and the reports as to their action 
 are most conflicting. The local application twice daily of chromic 
 acid, or a mixture of picric and carbolic acid to dry up the granulo- 
 mata is recommended ; and for some of the later and more per- 
 sistent lesions nitrate of silver and sulphate of copper are useful. 
 
 T. CoLCOTT Fox. 
 
 SYPHILIS 
 
 Syphilis is a specific contagious disease, communicable by direct 
 inoculation. Its course is characterised by a primary lesion (chancre), 
 by early constitutional (secondary) symptoms, and by late constitu- 
 tional (tertiary) symptoms. 
 
 Frequently a final stage is to be observed, a post-syphilitic fibrosis, 
 especially well marked in the blood vessels, nervous tissues, and bones, 
 in which there is an overgrowth of the connective-tissue elements of 
 those structures, the fibrous overgrowth being such that although it 
 appears to be the result of the continued action of the syphilitic 
 virus, yet it refuses to yield to the usual anti-syphilitic remedies. 
 For this reason some authorities do not regard it as an integral part 
 of the syphilitic attack, and it may more properly be regarded as an 
 expression of the profound nutritional perversion of fibrous and 
 other tissues which syphilis produces. 
 
 Etiologically syphilis is met with either as the acquired or the 
 hereditary form. In the former case the disease is implanted by 
 direct inoculation, in the latter case by inoculation of the foetus 
 through the placenta. 
 
 It is now generally thought that some form of micro-organism is 
 the cause of syphilis, and Lustgarten has found bacilli similar in 
 appearance to those of tubercle in the cells of gummata. 
 
 Acquired Syphilis in the Adult 
 
 The sites of inoculation are the mucous membrane of the genitals, 
 lips, anus, or even, there is reason to believe, the unbroken skin of 
 the finger, as following digital examinations. Feeding, and other 
 contaminated utensils, have been known to be the means whereby 
 the virus has been conveyed. 
 
368 MANUAL OF MEDICINE 
 
 Course and symptoms. — After a period of incubation, lasting 
 from fourteen to sixty-three days, the average being thirty-five days, 
 the primary chancre appears at the point of inoculation as a red pain- 
 less papule, which gradually enlarges until it forms an elevated sore, 
 with steep, well-defined margins and flattened top. The base of the 
 sore is much indurated, the induration being of a cartilaginous 
 consistence, the 'issues around sharing in this. This is the typical 
 hard or Hunterian chancre, which, unless irritated, never suppurates. 
 Its surface is often covered by a brown scab which arises from a 
 clear serum-like secretion oozing from the surface of the sore. 
 Many modifications of this typical chancre are met with, and it is 
 often difficult to be sure of the identity of a lesion without awaiting 
 the time necessary for the development of secondary .syphilitic symp- 
 toms. In cleanly persons, and if the inoculation is on the glans 
 penis, a " coppery " desquamating papule may be the only sign of 
 the implantation of disease, and the typical Hunterian chancre does 
 not follow. It is important to recognise such a variety as this, as it 
 may be readily overlooked by the patient, and even by the medical 
 man, so that the disease may be untreated in its earlier stages, when 
 it is essential that thorough treatment should be carried out. It seems 
 also that such chancres are sometimes followed by secondar}' symp- 
 toms of so slight a character as to pass unnoticed, but it is just in 
 these cases that degeneration of the central nervous system and 
 of the vessels often follows in middle life. In other cases the in- 
 fection is of the mixed variety, i.e. the virus of "soft" and of "hard" 
 chancre are implanted at the same time, and one or more of the 
 soft chancres may heal, and then undergo the characteristic in- 
 duration of syphilis, and a hard chancre ensues. The indura- 
 tion may be like a piece of parchment or a button let into 
 the mucous membrane or skin. It lasts for a variable time, for 
 about two to four months, and then the ulcer heals and a scar is 
 left. In women chancres on the mucous membrane of the genitals 
 are by no means so well marked nor so well defined as in men. 
 The diagnosis of a typical hard chancre is not difficult, but the 
 identification of the disease when the desquamating papule, or 
 when soft chancres are present, and when the hard chancre has been 
 irritated by caustics, so that it suppurates, is not easy. A chancre 
 and herpes of the penis are sometimes confused. 
 
 From the seat of inoculation the virus spreads to the lymphatic 
 glands of the groin and these become enlarged and hard. They 
 are painless, non-adherent to the skin, and do not suppurate unless 
 the chancre be irritated or be of the mixed variety, i.e. " hard " and 
 
SYPHILIS 385 
 
 they often stand apart and slope towards each other, they are 
 pegged, i.e. they are broader near the gum than at their free edge, 
 and they are notched from the breaking away of the central portion 
 of the free edge. The other mentioned teeth, too, are often 
 dwarfed and ill-developed, but lack the characteristic features of the 
 central incisors. Incurable nerve deafness, affecting both ears and 
 of sudden onset, may also occur as a later sequela. Associated 
 with the deafness, or independently of it, there is often headache 
 of a very- intractable nature. A subacute symmetrical synovitis of 
 the larger joints, most usually the knees, attended by little or 
 no pain, is very rare apart from inherited syphilis. The only 
 skin affection in the later stages is the gummatous infiltration 
 of the skin and subcutaneous tissues known as "syphilitic lupus." 
 This consists usually of somewhat large patches of inflammation 
 and hardening of the cutaneous tissues, breaking down in some 
 places into deep ulceration, and healing in others with persistent 
 serpiginous scarring. Interstitial keratitis is seldom seen before 
 the age of seven years, and is commonest between this age and 
 puberty, but may come on at the age of twenty or later. Both 
 eyes are invariably affected, but one is usually attacked before 
 the other. Iritis is occasionally met with. Nodes on the long 
 bones, and gummata in the skin, abdominal viscera, and the 
 brain and elsewhere, may appear at any age after infancy^ but 
 are commonest at the times when interstitial keratitis usually 
 appears. One case, at least, is on record where, in addition to 
 nodes, there was a diffuse osteitis of the right tibia, leading to 
 partial gigantism of the limb. In older children, usually at the age 
 of puberty, gummata may occur in the tongue and soft palate, and, 
 breaking down, may lead to perforation and destruction of the last. 
 Care should be taken, however, to make sure that such cases are 
 not of the acquired disease, as this, unfortunately, is by no means 
 a rarity in children. Syphilitic orchitis occasionally occurs soon 
 after infancy, but is commonest at the usual times of the later 
 manifestations. Lardaceous disease is almost unknown at any 
 stage of the inherited complaint, but it is quite conceivable that it 
 might occur in the rare event of suppurative bone lesions of long 
 persistence. In a few instances locomotor ataxia, commencing at 
 the early age of puberty, has followed on inherited syphilis in 
 infancy, and it is stated by some alienists that general paralysis of 
 the insane, when developed in early Hfe, is invariably attributable 
 to this cause. 
 
 It must be strictly remembered that, with the exceptions of 
 
 VOL, I 2 C 
 
386 MANUAL OF MEDICINE 
 
 Hutchinsonian teeth and interstitial keratitis, any of the above- 
 mentioned later manifestations of inherited syphilis are very ex- 
 ceptional in occurrence. 
 
 Acquired syphilis in infants. — From the nature of things, 
 acquired syphilis is of necessity an extreme rarity in infants. As 
 with adults, it can only occur through the agency of a primary 
 chancre, and the periods of primary and secondary incubation are 
 the same at all stages of life. Acquired syphilis in infants does not 
 differ materially in its manifestations from the same complaint in 
 adults, although it markedly does so from the inherited form in 
 many respects. In the acquired syphilis of infants there is an 
 absence of the bony affections of the skull, the early involvement of 
 the abdominal viscera, and the specific epiphysitis, all of which are 
 frequent and characteristic of the inherited form, and marasmus and 
 snuffles are much less prominent features in the former than in the 
 latter complaint. The throat and fauces are affected in the same 
 manner, and at the same time, in the infantile acquired form as in 
 the adult one, and the usual eruptions are the same in both. The 
 eruptions, too, are chiefly manifested over the front of the trunk and 
 flexor surfaces of the limbs, and show no peculiar predilection for 
 the buttocks and chin, as in the inherited form. A marked feature 
 of the acquired form in infancy is the scanty development and 
 evanescent nature of the eruptions, and the early and luxuriant 
 growth of condylomata. The power of infecting the healthy, more- 
 over, is vastly greater in the acquired than in the inherited form in 
 infancy. 
 
 Diagnosis. — The diagnosis of acquired syphilis in infants is 
 precisely the same as in adults. That of inherited syphilis is 
 perfectly simple in the majority of instances ; the marked snuffling, 
 the character of the eruptions, and their pecuUar selection of sites 
 leave little room for error or doubt. The snuffles may long precede 
 any other symptom, and cases of marked and persistent snuffles, 
 even with a total absence of all other signs, are most probably due 
 to syphilis. Obstinate and progressive wasting, especially if un- 
 associated with any obvious digestive disturbance, is not very un- 
 frequently the only objective sign of the inherited complaint. The 
 diagnosis in some of these last cases may be supported by the 
 peculiar " cafe-au-lait " tint of the skin which, as Henoch has pointed 
 out, is confined to the marasmic cases, and not to those of syphilis 
 in general, as Trousseau supposed. In some cases pseudo-paralysis 
 or epiphysitis may be the first symptom to call attention to the 
 
SYPHILIS 387 
 
 malady, and In others, but very rarely, enlargement of the spleen 
 may furnish the only evidence of it. A single well-formed mucous 
 tubercle, or condyloma, is absolutely pathognomonic of syphilis. 
 The family history as regards miscarriages and snuffles and rash in 
 the older children is of prime importance, as it may help to confirm 
 the diagnosis in the better marked cases, and in the more doubtful 
 ones it may furnish evidence of more value than the existing clinical 
 signs. Even after the intelligent use of all available criteria, there 
 still remains a large class of cases in which the diagnosis is a matter 
 of doubt. In such cases snuffles, rash, and other symptoms may be 
 so ill-developed, and the family history so dubious, that a confident 
 diagnosis is only possible with the self-sufficient. Here recourse 
 may be made to the effect of treatment. Many such doubtful 
 cases, it is true, improve and recover under the administration of 
 mercury. But it must be remembered that many infants who are 
 not syphilitic improve under mercury, and in the case of syphilis, 
 as in other diseases, a diagnosis founded upon the mere effects of 
 treatment can never be one that is quite satisfactory or convincing. 
 
 Prognosis. — In cases presenting signs of the disease at birth 
 the prognosis is all but fatal. It is equally so in those in which 
 jaundice or pemphigus supervene. Wasting dating from birth is 
 seldom, if ever, recovered from, and the prognosis attaching to 
 wasting in later months is scarcely more hopeful. Unfavourable 
 signs are an early appearance, or extensive development, of the 
 eruption, and any undue enlargement of the abdominal viscera. 
 Cases where the rash is pustular from the onset generally die. Of 
 the rest of the cases, if the infant be well nourished, and if the 
 symptoms have not appeared before the beginning of the second 
 month, the prognosis is good. As regards the future, too, it is only 
 a small minority of those surviving the stage of infancy that present 
 signs of the complaint in later years. Children, however, who 
 have seemingly recovered from inherited syphilis are much more 
 prone to succumb to the stress of other disorders than those less 
 heavily handicapped at the start of life. 
 
 Treatment. — The essentials of treatment are comprised in the 
 maintenance of nutrition and the due administration of mercury. 
 For the first of these it is a bounden duty that the mother should, 
 if possible, suckle her infant. If she be seemingly healthy, the 
 small chance there may be of her contracting the disease from her 
 infant by suckling it ought to be incurred. The great mortality 
 amongst syphilitic infants lies largely amongst those that are hand- 
 fed, and the difference between suckling and hand-feeding means 
 
388 MANUAL OF MEDICINE 
 
 possibly one between life and death for many an infant. When the 
 mother cannot suckle it, the infant must be either wet-nursed or hand- 
 fed. The questions as to the dangers incurred by a healthy wet- 
 nurse, and the details involved in a proper system of hand-feeding, 
 are too lengthy for discussion here. It cannot, however, be too 
 emphatically asserted that a proper diet is equally important with 
 the drug treatment of the complaint. 
 
 For the second essential in treatment, the administration of 
 mercury, only two methods need be considered, that of giving it by 
 the mouth, and that by inunction. The former has two strong recom- 
 mendations in its favour — simplicity and efficacy. The usual prepara- 
 tion given is the ordinary grey powder, and this generally meets 
 all the requirements of most cases. It can be given in doses of one 
 grain three times a day to infants of all ages. Given in these doses 
 it rarely, if ever, causes diarrhoea, and if the latter supervene, it is 
 generally due to some error in diet, or to the fact that the complaint 
 is epidemic at the time. When diarrhoea is present, each dose of 
 the grey powder can be combined with a third or half of a grain of 
 Dover's powder, according to the age of the infant. If in spite of 
 this addition the diarrhoea should persist, or if it be considered that 
 the internal administration of mercury causes digestive disturbance, 
 then recourse can be had to the method of inunction. In this last, 
 from twenty grains to half a drachm of mercury ointment should be 
 rubbed into the inner sides of the thighs or the axillae, or upon the 
 surface of the belly binder, once a day. Under such a treatment 
 it is undoubted that the eruptions and other manifestations of the 
 disease rapidly disappear. The amount of mercury absorbed by 
 the skin, however, is an uncertain quantity, and some observers, 
 believe that more infants treated by inunction come back in later 
 months presenting symptoms of the disease than is the case with 
 those who have been treated with mercury by the mouth. If this 
 be so, then the method of administration by the mouth should have 
 preference, unless otherwise contra-indicated, over that of inunction. 
 Whichever method be adopted, the treatment should be faithfully 
 carried out for a course of at least four months' duration, and longer 
 if any symptoms are present. The fear of causing symptoms like 
 those belonging to the salivation of adults can be dismissed ; such 
 salivation is practically unknown in infants. 
 
 Except in the rare contingency of nodes or gummata being 
 present, there is no need of any addition of the iodides to the 
 mercury given. The iodides merely assist in the more speedy 
 removal of such complications, and have no real power in the way 
 
RABIES 389 
 
 of curing the disease. For this last, mercury is all essential at all 
 stages. 
 
 If the nasal discharges cause blocking, a two per cent solution of 
 the oleate of mercury, or a little dilute ammoniated mercury oint- 
 ment, should be passed into the nostril with a camel's hair brush. 
 Condylomata should be dusted with calomel, and if long persisting, 
 be lightly touched over with one of the ordinary caustics. In the 
 event of ulceration of any moment occurring, then the mercury 
 given should be supplemented by doses of opium appropriate to the 
 age of the child. In all the ulcerative conditions of infancy, 
 syphilitic or otherwise, there is no drug, perhaps, of such value as 
 opium. 
 
 J. A. COUTTS. 
 
 RABIES 
 Syn. Hydrophobia 
 
 An acute infective malady of the central nervous system, the 
 symptoms being dependent on the action of a poison which is 
 developed throughout these organs, but more especially in the 
 medulla. 
 
 Rabies or hydrophobia is a disease that is sometimes very 
 prevalent in animals, and is occasionally seen in man. The name 
 of rabies is usually restricted to the disease in the former, and the 
 term hydrophobia used for the same malady in man. Hydrophobia 
 is, however, a misnomer, since there is, strictly speaking, no fear of 
 water, but only a difficulty in swallowing, more marked with liquids 
 than with solids. 
 
 Occurrence in animals. — Rabies is most prevalent in dogs, 
 cats, wolves and foxes ; it is occasionally seen in horses, very 
 rarely in pigs, and several outbreaks have occurred in deer. The 
 frequency of rabies in the carnivora is associated with the fact that 
 it is usually propagated by biting. 
 
 It is met with both sporadically and in epidemics, and frequently 
 the latter can be traced to foci of the disease in certain parts of 
 the country where it may be more or less endemic, and at intervals 
 affecting large numbers of animals over wide tracts of councry. In 
 certain districts it is unknown, as, for instance, in Norway and 
 Australia. It is rare in Germany, but it is more comrnon in France 
 
39° MANUAL OF MEDICINE 
 
 and Russia, and also in the East. In this country the incidence 
 of the malady varies considerably; in the years 1895 and 1896 
 there was an extensive outbreak, but at the present time, 1899, 
 the disease has greatly diminished in amount. 
 
 Virus of rabies. — The virus of rabies is remarkable in the 
 fact that it is distributed throughout the nervous system, central and 
 peripheral. In addition to this it is found in the secretion of 
 certain glands, such as the salivary (especially the parotid), the 
 lachrymal, the mammary, and the pancreas. The virus is not 
 found in the blood, tissues, urine, nor in other excretions. When 
 the malady is fully established, and a fortiori at death, it is found 
 throughout the nervous system ; in the earlier stages of the disease, 
 however, it is limited to the medulla. The virus of rabies is com- 
 paratively readily destroyed by the action of sunlight, by heat, by 
 dessication, and by the action of powerful antiseptics. Putrefaction 
 destroys its activity more slowly, and the carcase of an animal dead 
 from rabies has been found virulent as long as forty-five days after 
 burial. 
 
 Mode of infection. — Rabies is usually communicated both 
 to animals and to man by the bite of the rabid animal infecting the 
 wound by means of the saliva. It is for this reason that hydro- 
 phobia is more frequent after bites on exposed surfaces, such as 
 the face and hands, than when the person is bitten through clothes. 
 Similarly animals covered with fur are less liable to contract the 
 malady when bitten than shaved animals, or animals destitute of 
 fur. The disease is not communicable from one animal to 
 another by the carcase of the rabid animal being eaten by another. 
 It is probable that infection is more readily conveyed if the injury 
 involve a nerve, as it has been shown that the virus travels along 
 the nervous system from the periphery to the centre. Thus, if 
 the spinal cord be experimentally divided in the mid-dorsal region, 
 and inoculation of the virus of rabies be made in the posterior half of 
 the body, the lower segment of the spinal cord will contain the virus 
 at a time when the upper half is free from it. From this it is held 
 that the virus is propagated through the nervous system, and is not 
 conveyed from the peripheral to the central nervous structures by 
 the lymph or blood. Deep lacerated wounds involving the muscular 
 planes are more liable to be followed by rabies than superficial 
 wounds involving the skin and subcutaneous tissue. It is estimated 
 that in the human subject from 16 to 25 per cent of persons 
 bitten by rabid animals contract hydrophobia, the others escape 
 for various reasons, but more especially from the clothes, boots, 
 
RABIES 391 
 
 etc., preventing the inoculation of the wound. Bites inflicted by 
 a rabid wolf or cat are more liable to communicate the disease to 
 man owing to the greater likelihood of the exposed parts of the 
 body being bitten. 
 
 The incubation period of rabies varies greatly. In man 
 it is usually six weeks, but it has been asserted that it may be as 
 short as three weeks, and as long as twelve or eighteen months ; 
 in some quite exceptional cases an incubation period of from two 
 to five -years has been described. In animals the incubation 
 period varies with the species. Thus in dogs it ranges from 
 fifteen to sixty days, and in at least 50 per cent it is less than a 
 month, whilst it is rare after 120 days. In cattle the incubation 
 period varies from one to three months. In the rabbit it is usually 
 fourteen to nineteen days. The variation in the duration of the in- 
 cubation period depends to a great extent on the degree of virulence 
 of the poison, and in street rabies, la rage des rues, there are great 
 individual variations. In the laboratory, however, by transmitting 
 rabies from one animal to another by inoculation, it is possible to 
 elaborate a virus in which the incubative period, at any rate in the 
 rabbit, becomes fixed at seven days. 
 
 Symptoms. — During the incubation period, both in animals 
 and man, there is but little to be noted, and usually the wound 
 heals with no symptoms of general disturbance. At the end of 
 the period of incubation the site of the wound becomes irritable, 
 and tingling and itching may be noticed, and in man it has been 
 asserted that the wound may open up again. Soon both in 
 animals and in man restlessness, agitation, and nervousness become 
 marked. The subsequent course of the malady depends on which 
 of two types it assumes. The most common clinical type is that 
 known as "furious rabies," and in this condition t?i the dog or 
 other animal the agitation and restlessness become increased, and 
 the animal suffers from hallucinations ; at this time, however, it 
 is not savage, and it does not show any tendency to attack those 
 near. Soon the bark becomes altered, exceedingly prolonged, 
 high pitched, and, to a certain extent, stridulous. The seat of the 
 bite, from being irritable, becomes anaesthetic, and it is not un- 
 common for the animal to inflict on itself severe wounds by 
 gnawing the part. Some difficulty is experienced with deglutition, 
 more especially with liquids ; the restlessness leads the animal to 
 wander about, and even to travel long distances, although at the 
 onset of the malady it may have shown a tendency to withdraw 
 itself from observation by hiding in dark corners. The animal 
 
392 MANUAL OF MEDICINE 
 
 now rapidly becomes furiously maniacal, attacking animate and 
 inanimate objects, and biting and swallowing at this period all sorts 
 of foreign bodies, such as pieces of wood, bone, coal, rugs, its own 
 faeces, etc. After the furious stage has lasted for two to three 
 days palsy rapidly sets in, affecting first the muscles of the jaw, 
 then those of the extremities, and finally the respiratory muscles, 
 and so causing death from asphyxia. The total duration of the 
 illness in the dog is usually from four to five days ; it may, how- 
 ever, last ten days, and it may run its whole course in two. 
 
 The other clinical variety of rabies is "dumb" or "paralytic 
 rabies." This is really similar to the terminal phenomena of 
 furious rabies. Dumb rabies is more especially characteristic of the 
 disease in the rabbit and rodents generally. It is, however, occa- 
 sionally seen in dogs, and it is probable that it has occurred in 
 man. In dumb rabies the sensory troubles are not marked. The 
 dog is anxious and agitated, and this condition is rapidly followed 
 by paralysis, affecting, it may be, the jaw, or causing paraplegia or 
 hemiplegia, or even monoplegia. In dumb rabies the animal is 
 necessarily unable to bite, and the disease is of far shorter duration, 
 viz. two to three days. The urine frequently contains sugar, both 
 in dumb rabies and in the later stages of furious rabies. 
 
 In ma?t during the early stages the patient is anxious, fearful, 
 depressed, often complains of thirst, and there is marked pallor. 
 He is quite conscious and rational, and able to talk, although even 
 at the early stages respiration is slightly interfered with, leading to 
 interruption of his sentences ; the restlessness and ■ agitation in- 
 crease, but the most striking phenomenon which the writer has 
 seen in three cases of hydrophobia is the intense fearfulness of the 
 patients and their extreme dread. Slight and intermittent delirium 
 may be present and delusions may supervene, exceptionally the 
 delirium passes into maniacal excitement. Thirst is a prominent 
 symptom, but there is great difficulty in deglutition, especially 
 of liquids, and any attempt to swallow causes violent spasmodic 
 contraction of the muscles of deglutition, so that the fluid is often 
 expelled from the mouth. Very soon the spasmodic contractions 
 spread to other muscles, more especially those of respiration, and 
 general convulsive attacks, with marked opisthotonos, supervene 
 and recur at every attempt to swallow. These attacks rapidly 
 exhaust the patient, the pulse becoming quick and irregular; the 
 convulsive seizures increase in frequency, and death usually super- 
 venes from asphyxia. The convulsive attacks are in the fully 
 established disease produced not only by attempts at swallowing,, 
 
RABIES 393 
 
 but also by slight reflex stimuli, such as a draught of air, or a strong 
 light, etc. During the convulsive seizures the mental excitement of 
 the patient is greatly increased. In very exceptional cases a condition 
 similar to that of paralytic rabies has been seen in the human sub- 
 ject, namely, a rapid ascending palsy, affecting first the extremities, 
 and then the muscles of respiration. It is possible that some of the 
 cases described formerly under the term of Landry's paralysis may 
 really have been cases of paralytic rabies. There is usually slight 
 fever at- the onset of the malady, and the temperature may rise to 
 105° F. Albumen and sugar may be present in the urine. 
 
 The statement that the patient barks like a dog has arisen from 
 the fact that the accumulation of mucus in the throat, together 
 with the partial palsy of the respiratory muscles, leads to a peculiar 
 cough ; and the frothing at the mouth sometimes described is due 
 to the unswallowed saliva and mucus which hangs about the lips. 
 
 The duration of the disease in man is usually two to four days. 
 
 Morbid anatomy. — In animals the mucous membrane of the 
 mouth, the tongue and larynx are congested and covered with an 
 abundant dry mucus. The stomach, especially in the dog, con- 
 tains no food, but a number of substances of the most diverse 
 description ; frequently there are petechial haemorrhages in the 
 mucous membrane and even haemorrhagic ulcers; these may also 
 be present in the intestines. The spinal bulb and brain are usually 
 congested. Other lesions, such as petechial extravasations in the 
 serous membranes, are perhaps more dependent on the mode of 
 death than on the action of the virus of rabies. It is difficult to 
 diagnose rabies from a post-mortem examination in animals, and is 
 frequently impossible owing to the fact of the animal having been 
 killed at an early stage of the disease before the lesions are fully 
 developed, and it is for this reason that the experimental diagnosis 
 by inoculation is of much value. The combination of the absence 
 of food and the presence of a great variety of foreign bodies in the 
 stomach is suggestive. 
 
 In man the main post-mortem features are the congestion of the 
 fauces, larynx, trachea, ston ach, and also of the central nervous 
 system and meninges. Microscopically, hemorrhages have been 
 found by Gowers and others in the nerve centres, more especially 
 in the fourth ventricle. Several observers have noted objective 
 changes in the cells of the bulb and even the presence of collections 
 of leucocytes, to which Gowers gave the name of " miliary abscess " 
 
 Diagnosis. — In diagnosing rabies, both in animals and in man, 
 three methods are open to us — by the clinical characters, by the 
 
394 MANUAL OF MEDICINE 
 
 post-mortem appearances, and by experimental inoculation. Clinic- 
 ally the most satisfactory method in animals is to isolate the sus- 
 pected animal with due regard to the safety of others ; if it be 
 rabid, death will soon supervene with the characteristic paralytic 
 symptoms, as the course of the disease is short after the establish- 
 ment of the initial symptoms. On the other hand, if the suspected 
 animal be killed, it may take several weeks to determine the exist- 
 ence of rabies by inoculation, and it is impossible to diagnose rabies 
 on post-mortem examination in the early stages of the disease. The 
 most common diseases in dogs mistaken for rabies are epilepsy, 
 epileptiform seizures as a result of ear disease, and enteritis. The 
 impaction of a foreign body in the throat often leads to a mistaken 
 diagnosis of dumb rabies in animals. 
 
 In the human subject hystero- epilepsy, mania, tetanus, and 
 Landry's paralysis are the maladies most apt to be confounded with 
 hydrophobia. It is more difficult to separate mania than hystero- 
 epilepsy from rabies, but such patients do not suffer from the 
 characteristic respiratory spasm which is seen in hydrophobia. 
 Tetanus which may follow the bite of a dog has a shorter incuba- 
 tion period and there is not that peculiar fearful expression that is 
 so characteristic of rabies. 
 
 The term "lyssophobia" has been applied to a group of symptoms 
 occurring in persons who are in great dread of rabies after having 
 been bitten by an animal not necessarily rabid. A difficulty in 
 swallowing, resembling the globus hystericus, together with hysterical 
 convulsions, form the prominent symptoms. True spasm of respira- 
 tion, such as is seen in rabies, is, however, absent. The real malady 
 has more often been thought to be spurious than the converse. 
 
 After death the diagnosis of rabies can be made with certainty by 
 inoculation of an emulsion of the medulla from the suspected case. 
 It is possible, however, that putrefaction may in some cases prevent 
 the detection of rabies even when present. The suspected medulla 
 or spinal cord should be placed in glycerine for two or three days. 
 An emulsion of it should then be made in sterilised salt solution or 
 broth and a few drops injected subdurally in the rabbit. This plan 
 is followed because it is the most certain method of communicating 
 the disease, but inoculation into the aqueous humour is also 
 efficacious. If the virus of rabies is present the rabbits develop 
 paralytic rabies after an incubative period of from fourteen to nine- 
 teen days, sometimes, however, prolonged to six weeks. The 
 characteristic features of this experimental rabies in the rabbit are 
 a progressive paralysis occurring at the time when the general 
 
RABIES 395 
 
 nutrition of the animal is still good and accompanied with attacks 
 of clonic spasm and dyspncea. The mere occurrence of palsy of 
 the extremities is not sufficient to diagnose rabies experimentally. 
 The rabbits usually live for two or three days after the onset of 
 palsy. The only fallacies in this method are, on the one hand, that 
 exceptionally the presence of putrefaction in the suspected spinal 
 cord has prevented the development of rabies owing to the destruc- 
 tion of the virus, and, secondly, that if the spinal cord is contaminated 
 with some other virus, as for instance that of septicaemia, the 
 inoculated animals may die before the incubation period of rabies 
 has elapsed. This method of diagnosis is equally applicable to the 
 spinal cord or medulla of man, and has been of use on several 
 occasions in determining whether a patient has succumbed to mania 
 or to rabies. 
 
 Treatment. — The part bitten should be washed as soon as 
 possible, and temporary compression above the seat of the bite to 
 delay and prevent absorption should be employed. The wound 
 should then be thoroughly cauterised with strong nitric acid or 
 with some strong antiseptic, such as carboHc acid. Nitrate of 
 silver is not so efficacious as nitric acid and the latter should be 
 used if possible. 
 
 The fully-established disease in man is beyond treatment, the 
 only thing that can be done is to keep the patient absolutely quiet 
 in a darkened room and to combat the violence of the spasms 
 by chloroform or chloral. The Pasteur treatment is, however, of 
 the greatest value in preventing the development of rabies both 
 in animals and in man after exposure to the virus. It is 
 essential that that treatment should be entered upon with as 
 little delay as possible, and it is most unwise for the victim bitten 
 by an animal to wait until the inoculation of rabbits with the 
 suspected material has shown the animal to be rabid ; in this way 
 three weeks may be lost, and the disease may declare itself before 
 the protective inoculations can be carried out. If, after a person 
 has been bitten, the suspected animal be isolated, a delay of a very 
 few days will determine whether there is or is not reasonable ground 
 for looking upon the case as one of rabies, and the inoculation test 
 can then be used to confirm this, but if there are good grounds 
 for suspecting the animal to be rabid the Pasteur treatment of the 
 person bitten should not be delayed for the results of the inocula-' 
 tion test. The essence of the Pasteur treatment is to inject sub- 
 cutaneously an emulsion prepared from dessicated spinal cords of 
 rabbits which have been inoculated with rabies. The potency of 
 
396 MANUAL OF MEDICINE 
 
 the virus is gradually destroyed by dessication, and in this way by 
 varj-ing the period of dessication a series of emulsions of gradually 
 increasing strengths can be prepared. The injection of these not 
 only does not produce rabies but renders the animal or person 
 immune to rabies at any rate for a time. The statistics of the 
 Pasteur Institute not only show the great value of the treatment in 
 preventing the onset of hydrophobia in those bitten by rabid 
 animals, but they also show that the modern treatment as conducted 
 there is free from risk, 
 
 John Rose Bradford. 
 
 FOOT AND MOUTH DISEASE 
 SvN. Aphth.« Epizootic/e 
 
 An acute febrile affection, the most prominent feature of which 
 is a vesicular eruption, occurring chiefly on the mucosa of the 
 mouth, but also on the skin of the hands and feet, and sometimes 
 on other parts of the body. 
 
 This epizootic malady, said to have been first imported into 
 England in 1839, chiefly affects ruminants and pigs, but is trans- 
 missible to man. The contagium may be conveyed directly or in- 
 directly, that is to say, it may be inoculated on a sore, or wound of 
 the skin, or mucous membrane, or the infection may be derived 
 from partaking of tainted milk, butter, or cheese. 
 
 Notwithstanding the severe and extensive outbreak among the 
 cattle in the British Islands between 1876 and 1885, when the 
 numbers attacked were counted by hundreds of thousands, and a 
 further outbreak in 1892 of over 5000 cases, English medical 
 literature relative to human infection seems confined to a few 
 scattered cases, and an epidemic at Dover in 1884, where 144 
 persons were attacked. Therefore, either the disease, if it have 
 occurred, has not been recognised as such, and has been assigned 
 to some other cause, or the transmission of the infection to man is 
 attended with some difificulty. On the continent of Europe, how- 
 ever, it seems to be fairly common, and there aphthous stomatitis 
 in children is almost invariably assigned to infected milk and to a 
 bovine origin. 
 
FOOT AND MOUTH DISEASE 397 
 
 The virus.— The actual exciting cause is still undecided, but 
 claims have been raised on behalf of — a streptococcus (Klein, 
 Kurth) ; a bacillus, pure cultures of which are stated to reproduce 
 the disease (Starcovici) ; a protozoon, Protamoeba aphthogenes^ which 
 _has been detected in the vesicles and circumjacent tissue (Plana 
 and Fiorentini). But whatever the virus may be it is certain that 
 it is highly contagious to cattle, and may retain its infective power 
 for quite three months. 
 
 The incubation period in cattle is stated to be a week, but in 
 man it varies from two to eight days, the difference probably 
 depending on the direct or indirect method of infection. 
 
 Symptoms. — The disease declares itself by a rigor, soon 
 followed by pyrexia (ioi°-io2°), malaise, and headache. The 
 mouth feels hot and dry, and the feet and hands may burn and 
 .tingle. After lasting two to seven days the general symptoms are 
 followed by an eruption of small vesicles on the mucosa of the 
 mouth, any part of which may be affected, on the skin of the hands 
 and feet, and sometimes on other parts of the body, notably the 
 lips and face. 
 
 In the mouth the number of vesicles, except in bad cases, is 
 rarely more than ten or twelve, and their distribution may be 
 discrete or confluent. The vesicles are small yellowish -white 
 blisters with turbid fluid contents, and may attain the size of hemp 
 seeds or even of peas. After. some hours to one or two days the 
 vesicles burst, leaving shallow ulcers with red base and margins. 
 The eruption in the mouth is accompanied by dysphagia, ptyalism, 
 difficulty of speaking, and sometimes by offensive discharge from the 
 nose. With the stomatitis are also associated pain in the mouth 
 and swelling of the retro-maxillary glands. In severe cases symptoms 
 of gastro-intestinal inflammation may be present, such as vomiting, 
 diarrhoea, and occasionally sanious stools, symptoms which suggest 
 that the alimentary mucosa may be in the condition of aphthous 
 enteritis, as is the case in animals. 
 
 The stomatitis subsides gradually and the ulcerations heal in a 
 week to a fortnight. The average duration of the disease is from 
 two to three weeks, but it may be protracted to four weeks, or not 
 last more than one. 
 
 The prognosis is extremely favourable, for nearly all the cases 
 recover. But there are several instances where young children 
 have succumbed to an attack. 
 
 There is no evidence to show whether one attack confers 
 immunity. 
 
398 MANUAL OF MEDICINE 
 
 The diagnosis should be comparatively easy if there be a 
 vesicular eruption on the mouth, and on the hands and feet, 
 especially in the inter-digital folds, occurring in a district infected 
 with the epizootic. In large towns, however, and in cases where 
 the eruption is limited to the mouth, the diagnosis becomes more 
 speculative ; but it should on no account be confused with aphthous 
 stomatitis or with "thrush." The only disease with which this 
 aphthcc epizooticse is likely to be confounded is varicella. This 
 might arise when the eruption in foot and mouth disease is 
 scattered over the trunk and face. These cases are, however, 
 rare, and the converse is more common ; that is to say, the 
 vesicular eruption is more frequently confined to the mouth. 
 
 The treatment of foot and mouth disease is simple. It is 
 advisable to wash the mouth out frequently with mild solutions of 
 chlorate of potash or of borax ; to protect the eruption on the 
 hands and feet from becoming contaminated with dirt, and dress 
 them with lead lotion ; and to feed the patient with a nutritious 
 and liquid diet. 
 
 It would be advisable to boil the milk if there were an outbreak 
 of foot and mouth disease in the district. 
 
 R. G. Hebb. 
 
 COINCIDENT OR MIXED INFECTIONS 
 
 It has for a long time been a common opinion that it is very 
 rare, if not impossible, for more than one of the specific infectious 
 diseases to simultaneously attack the same individual. This idea, 
 for which John Hunter appears to have been very largely responsible, 
 is still widely prevalent. But a search through the medical 
 literature of the past century will reveal the error of his teaching, 
 and its final refutation has been brought about within the last few 
 years. The experience of any of the large fever hospitals furnishes 
 ample evidence of the concurrence in the same subject of two or 
 more infectious diseases. To illustrate this statement a reference 
 to recent statistical reports published by the Metropolitan Asylums 
 Board will sufifice. Of 41,483 cases of infectious disease (chiefly 
 scarlet fever, diphtheria, and enteric fever) admitted into the fever 
 hospitals of London during 1896 and 1897, 1191 or 2.8 per cent 
 
. COINCIDENT OR MIXED INFECTIONS 399 
 
 were at the time of admission suffering from more than one 
 infection. By far the most common combination of diseases was 
 that of scarlet fever and diphtheria, 589, or nearly half the cases. 
 Frequent were scarlet fever and whooping-cough (186); scarlet 
 fever and chicken-pox (163); diphtheria and measles (66) ; and 
 scarlet fever and measles (65). Less common were diphtheria and 
 whooping-cough (34); diphtheria and chicken-pox (2 7) ; and the 
 combinations of scarlet fever or diphtheria with rubella or enteric 
 fever, of which there were but a few instances. In addition to 
 these cases, however, and usually in consequence of their having 
 been unwittingly introduced during their incubation period to the 
 general wards, there were those in which the patient contracted one 
 infectious disease while convalescing from another. Thus, among 
 30,417 completed cases of scarlet fever — i.e. the cases discharged 
 and fatal during the years in question — there were 1501 cases of 
 diphtheria, 1018 of chicken-pox, 302 of measles, 197 of whooping- 
 cough, and 168 of rubella. The number of diphtheria cases is large, 
 doubtless because many are included in which the diagnosis was 
 made on bacteriological evidence. Among 9789 completed cases 
 of diphtheria there occurred 768 of scarlet fever, 100 of chicken- 
 pox, 70 of measles, and 38 of whooping-cough ; while among 1277 
 cases of enteric fever there were 9 each of scarlet fever and 
 diphtheria. 
 
 The diseases to which the figures just given relate are those 
 most prevalent in this country at the present day. But with them, 
 as well as with one another, may be combined the following 
 infections — smallpox, mumps, erj'sipelas, t}'phus fever, pyemia, 
 pneumonia, syphilis, tuberculosis, and malaria. There appears in 
 fact to be no reason why any one specific infectious disease should 
 not co-exist with any other. Usually two only are met with at the 
 same time; but the writer has had under his obser\-ation several 
 cases in which three or even four have attacked the same patient 
 within a ver}' limited period. 
 
 Inquiry into the relative frequency of concurrence shows that 
 it depends considerably upon the etiolog}' of the affections concerned. 
 For instance, while it must be admitted that the figures given above 
 afford only a rough estimate of the comparative frequency, yet it 
 will be noticed that enteric fever does not often enter into these 
 combinations. One of the reasons foi this is that scarlet fever, 
 diphtheria, measles, chicken-pox and whooping-cough -ar-e chiefly 
 diseases of childhood, whereas enteric fever attacks individuals who 
 have passed that period of life, Differences, therefore, of age- 
 
400 MANUAL OF MEDICINE 
 
 incidence, of seasonal or annual prevalence, and of virulence, 
 partly account for varying frequency of concurrence. But when 
 allowance is made for these factors it still appears that diphtheria 
 and scarlet fever have a great liking for one another, and that 
 diphtheria is very ready to ally itself with several of the other 
 specific diseases. 
 
 Another question of some interest is — Are patients, the subjects 
 of one infectious disease, more likely, ceteris paribus, to contract 
 another if exposed to its infection than healthy persons ? Such 
 facts as are forthcoming with respect to diphtheria occurring during 
 convalescence from scarlet fever and vice versa lead us to answer 
 the question affirmatively, and it is certainly reasonable to suppose 
 that a person weakened by one disease would less easily resist 
 infection by another. 
 
 On one point clinical experience is quite clear ; and that is, 
 that when infectious diseases occur together, or quickly follow one 
 another in the same patient, the symptoms are, as a rule, more 
 serious than when they occur alone. The fatality of diphtheria co- 
 existing with or immediately following scarlet fever, measles, or 
 whooping-cough, is much higher than when it occurs singly, as also 
 is that of measles following scarlet fever ; and so on. If measles 
 or scarlet fever attack a person already the subject of any tuber- 
 culous lesion, not only is the latter apt to be aggravated, but 
 complications due to the former diseases are the more likely to 
 arise. Beyond, however, this intensification of severity, concurrent 
 infectious diseases do not appear to influence one another's course. 
 From all that has been said, it is quite clear that one infectious 
 disorder does not protect against another, a fact which may be 
 used as an argument in favour of the opinion that vaccinia is 
 essentially the same as smallpox. If not, then the antagonism of 
 vaccinia and smallpox forms a striking exception to the general 
 rule. 
 
 So far we have dealt with diseases of which the symptoms are 
 well defined, and whose distinct entity has been known for long 
 periods, in some instances for centuries. But bacteriology has 
 shown us that certain forms of disease, hitherto included under 
 such general terms as pyaemia and septicccmia, are due to the 
 action of certain pathogenic micro-organisms ; and it has further 
 demonstrated that many of the morbid processes associated with 
 diseases, whether specific or not, are due to the secondary invasion 
 of the tissues or fluids of the body by these micro-organisms. As 
 an example, we may refer to measles. One of the most common 
 
COINCIDENT OR MIXED INFECTIONS 401 
 
 and fatal complications of this disease is broncho-pneumonia. 
 There is good evidence, both bacteriological and clinical, to show 
 that this affection is not due to the essential cause of measles. 
 The infective agent of measles appears to set up catarrh of the 
 respiratory tract, and thus to weaken its resistance to the action 
 of such organisms as the pneumococcus and certain strepto- and 
 staphylo-cocci. In a case of measles, therefore, complicated with 
 broncho -pneumonia, we have an example of a mixed infection. 
 Some of the complicated cases of scarlet fever, enteric fever, and 
 diphtheria, furnish us with similar illustrations. Probably further 
 investigation will prove this principle to be of very wide application. 
 There is reason to believe that the various organisms of which we 
 have been speaking may lead a saprophytic existence, and that it 
 is only under certain circumstances that they become pathogenetic. 
 This is true of so specific and malignant an organism as the 
 diphtheria bacillus. It may, therefore, be suggested that these 
 organisms have their seasonal variations of prevalence and virulence 
 in much the same way as do such primary infections as smallpox, 
 scarlet fever, and diphtheria ; and that the difference in type of 
 the latter (primary) is due largely to the variations in type of the 
 former (secondary) infections. 
 
 The concurrence of two or more infectious diseases in the same 
 patient is a frequent source of difficulty in diagnosis. It would, 
 in fact, be quite impossible to detect some combinations, such as 
 rubella co-existing with measles. But a careful attention to the 
 individual symptoms of each separate disease will often assist the 
 avoidance of error. 
 
 The only point worthy of mention here with respect to treatment 
 is the necessity of providing in hospitals for infectious diseases a 
 sufficient number of separate rooms or wards for the isolation of such 
 cases of mixed or coincident infections as are sure to occur. 
 
 E. W. GOODALL. 
 
 VOL. I 2 D 
 
402 MANUAL OF MEDICINE 
 
 DYSENTERY 
 
 Although the word "dysentery" serves to designate a disease 
 possessing fairly well-defined clinical and anatomical characteristics, 
 it is possible, nay probable, that several ailments which ought to rank 
 separately are associated under the term. Of these, dysentery ascribed 
 to hepatic derangement, to malarial infection, to scorbutus, to bad 
 food, impure water, or other sanitary defect, to the presence of the 
 amoeba coli, and to other micro-organisms in the intestines, are a 
 few of the varieties commonly enumerated. The catarrhal form 
 of the disease met with in colder climates, and the dysentery met 
 with in the tropics in an endemic form, illustrate further the wide 
 divergence of types which obtain. Of these, however, the only 
 variety which approaches scientific precision is the so-called "amoebic 
 dysentery." That the amoeba coli is met with frequently, but by no 
 means invariably, in dysenteric stools is undoubted ; that it is met 
 with in every case during certain epidemics may be also true, and 
 yet its presence may in no sense bear the pathological significance 
 claimed for it by many writers. With this equivocal exception, 
 therefore, no scientific division of the group of diseases, beUeved to 
 be covered by the name " dysentery," as determined by their 
 parasitology, etiology, or pathology, has been as yet arrived at. 
 
 Acute dysentery is characterised by an intestinal flux, consist- 
 ing, at the commencement of the illness, of loose foeculent matter 
 mixed with blood and mucus. The foeculence speedily disappears, 
 and the stools present a flocculent, slimy, jelly-like substance, mixed 
 with blood. In aggravated forms of the disease the mucous and 
 submucous coats of the intestine undergo necrosis, when the 
 evacuation yields a putrid .odour and contains gangrenous sloughs 
 floating in a thin, brownish, blood -tinged liquid. The flux is 
 accompanied by febrile disturbance, by acute abdominal pains, by 
 tenesmus, and by nervous and physical prostration. Dysentery 
 may end in resolution and complete recovery, in permanent 
 damage to the gut (chronic dysentery), in causing liver abscess, in 
 gradually advancing asthenia, or in death so speedy that the term 
 "■ malignant " is applied to it. 
 
 Etiology. — That several varieties of dysentery possess a specific 
 cause is the present-day belief, although little or no direct evidence 
 can be said to justify the conclusion ; malaria is held to be a cause 
 
DYSENTERY 403 
 
 of dysentery, because dysentery prevails endemically in malarial 
 countries, because the febrile disturbance accompanying the disease 
 resembles malarial fever, but more directly still because some cases 
 of dysentery are " cured " by quinine. The frequent association 
 of malarial infection with dysentery must never be lost sight of; 
 many hold the opinion that malaria is the principal determining 
 factor in the etiology of the disease, and it is well-nigh imperative, 
 before proceeding to treat a case of dysentery, that the blood be 
 carefully examined for malarial parasites. Malaria, whether as a 
 cause, a complication, or a sequela, is so intimately associated with 
 dysentery that quinine must not be altogether neglected in the 
 treatment of the disease. 
 
 Scurvy, if not an etiological factor, is not unfrequently a con- 
 comitant ailment in dysentery. In simple scurvy the bowels are 
 usually constipated, but as lowering of the vitality is apt, under 
 certain conditions, to invite a scorbutic condition, so in dysentery 
 of some standing, when the patient is unable to consume anti- 
 scorbutic nourishment, scurvy may supervene. The appearance 
 of the symptoms of scurvy in the course of an attack of dysentery 
 will determine the line of treatment to be adopted. 
 
 In climates such as the Soudan, in which there is a marked 
 difference between the night and day temperatures, chill is a potent 
 factor in causing dysentery. During a military campaign, be it in 
 India, Southern Europe, or the United States, when the troops are 
 insufficiently protected from the cold of the night, dysentery 
 develops with a rapidity and certainty which can only be put down 
 as cause and effect. Whether it is the liver and consequently the 
 portal circulation which is primarily affected by the cold, or 
 whether it is the direct action of cold on the intestines themselves, 
 is not known ; possibly both viscera directly suffer. 
 
 Dysentery is also enumerated as one of the water-borne diseases, 
 and certainly in those towns in which an improved water-supply 
 has been obtained, dysentery has abated in virulence, and in the 
 extent of its prevalence. On board ship confirmatory evidence as 
 to the pollution of the water-supply being a direct cause of dysentery 
 is plentiful. The possibility of direct infection by the use of a 
 common latrine must not be lost sight of, whether the virus is 
 considered to enter by the anus, the mouth, or the nostrils. Any 
 condition which tends to lower the strength or derange the health 
 of the individual during the prevalence of dysentery, especially in 
 an epidemic form, is calculated to reduce the powers of resisting 
 the toxic agency of the disease. 
 
404 MANUAL OF MEDICINE 
 
 Parasitology. — In 1875 Losch described a protoplasmic 
 parasite, the ama'ba coli, as occurring in the stools of dysenteries 
 in Russia, and since then the amoeba has been found by observers 
 in many countries. The writer met with the amoeba in nine con- 
 secutive cases of dysentery in Hong-Kong; in three cases of 
 malignant dysentery, however, he failed to find it ; and others 
 record a similar experience. When a small fleck of the flocculent 
 mucus of a dysenteric stool is placed on a warm (100° F.) micro- 
 scope stage, immediately after being passed, the presence of the 
 amoeba coli may be recognised. Its large size (6 to 35 /x), its 
 mobility, its pale-greenish colour, and its strongly refractive powers, 
 arrest the attention. The mobility is in most cases, though not in all, 
 very marked. Pseudopodia are extruded from the circumference, 
 and then withdrawn to again appear at another part of the mass. 
 The amoeba is not only altered in shape by the pseudopodia, but the 
 mass changes its place, travelling either towards the point of least 
 resistance, or in the direction of alimentation. Cold (75° F.) and 
 heat (110° F.) arrest the movements which, under favourable 
 circumstances, might continue for a couple of hours or more. At 
 rest, the body of the amoeba coli is seen to consist of a thin, pale- 
 greenish, outer covering or ectoplasm, and an inner, granular, 
 darker endoplasm. A nucleus is present, and in stained specimens 
 a nucleolus. The amoeba may engulf red corpuscles, micrococci, 
 bacilli, and more rarely leucocytes and pigment. Vacuoles are 
 a fairly constant phenomenon. The arguments for and against 
 the amoeba coli being the cause of dysentery are — (i) That many 
 observers have found it in scores, in one case in hundreds, of well- 
 nigh consecutive cases. (2) That the injection of material con- 
 taining active amoebfe into the rectum of several varieties of 
 animals has been productive of dysenteric symptoms. (3) The 
 amoeba coli, however, is met with in health, with or without the 
 exhibition of a severe purge, and it is possibly a constant occupant 
 of the cgecum and upper part of the large intestine. 
 
 Dysentery has also been ascribed to other micro-organisms, 
 some of them normal inhabitants of the intestines, such as the 
 bacterium coli commune, which is accredited by some with taking 
 on special pathological properties. Others refer dysentery and 
 liver abscess to streptococci, and on quite inconclusive grounds 
 other toxin-producing micro-organisms have been regarded as the 
 cause of the disease. 
 
 The difficulty of framing an accurate definition of dysentery, or 
 a satisfactory conception of its pathology, due to the uncertainty 
 
DYSENTERY 405 
 
 both as regards the nature of the specific cause of the disease and 
 of the real value to be attributed to the several conditions which 
 experience shows are so frequently associated with its occurrence, 
 is further complicated by the variety in its clinical course and features 
 which is to be observed in various epidemics and in different locali- 
 ties. " These and other circumstances seem to point to radical 
 differences in the several forms — differences of cause as well as 
 differences of symptoms, course, and sequelae. It is well, therefore, 
 to regard the term ' dysentery ' as but the name of a symptom, or 
 group of symptoms, indicating an inflamed condition of the colon, 
 and not as indicating a single and well-defined disease. Dysentery 
 simply means inflammation of the colon. There may be many 
 kinds of inflammation of the colon " (Manson). 
 
 Greographical distribution. — Leaving the epidemic dysen- 
 teries of colder climates out of the question, dysentery increases 
 in frequency as the Equator is approached. Dysentery is endemic 
 in many tropical localities, but may spread thence in an epidemic 
 form to adjacent countries. It may be safely stated that in those 
 countries in which a real improvement in sanitation has taken 
 place, dysentery has well-nigh disappeared. 
 
 Symptoms. — A typical case of acute dysentery, as met with 
 in practice in the tropics, is characterised by the following signs 
 and symptoms :- — During what appears to be a simple intestinal 
 catarrh, or commencing suddenly, shreds of mucus appear in the 
 evacuations ; the stools become more frequent, and are attended 
 by some sweating and a feeling of abdominal weakness after being 
 passed. Blood tinges the mucus, or is in sufficient quantity to stain 
 the whole fluid of the stool. Gripings (tormina), tenesmus, and an 
 increasing desire to pass a motion supervene, and the patient's calls 
 for the bed-pan become almost incessant. All trace of foeculence 
 disappears, and at an evacuation a tablespoonful of blood-stained, 
 foul-smelling, jelly-like material, attended by great straining, may 
 be all that is passed. The tongue becomes coated and furred, the 
 mouth is clammy, the saliva tenacious, a feeling of nausea fre- 
 quently occurs during the early stools, but vomiting is rare. The 
 abdomen is tender, especially over the lower part of the colon in 
 the left iliac fossa, the anus is excoriated, hot and burning, and 
 the bowel may be prolapsed. Movement causes palpitation, and 
 the pulse becomes small and frequent. Urine is scanty, high 
 coloured, and occasionally suppressed ; strangury and retention 
 are also possible complications. Increase in temperature is con- 
 stant, but, except in the malignant form, the thermometer seldom 
 
4o6 MANUAL OF MEDICINE 
 
 registers more than ioi° or 102^. In the acute form dysentery 
 may continue several days, or in young strong men for as many as 
 twenty or more days, and yet the patient may make a good and 
 permanent recovery. Frequently, however, if signs of abatement 
 do not appear towards the end of the first week or earlier, the 
 disease assumes a type which betokens danger to Hfe. The stools 
 may contain shreds and sloughs floating in a fluid of dark-brown 
 hue and smelling abominably. The tongue looks red and glazed, 
 or is coated by a brown fur ; sordes cover the teeth, the abdomen 
 becomes tympanitic and tender, and haemorrhage may occur from 
 the bowel, or from the mouth and nose. The temperature rises to, 
 and continues at, 104° or higher; the pulse at the wrist is small, 
 feeble, extremely rapid, and frequently irregular. Hiccough may 
 become persistent, and the patient, after passing through a low, 
 nervous state, during which all painful sensations abate or cease, 
 dies in a state of coma. 
 
 The disease may end in one of three ways : — In convalesence 
 and complete recovery ; in chronic dysentery, with permanent 
 damage to the intestinal wall ; or in death from collapse, from 
 haemorrhage, from peritonitis caused occasionally by perforation, 
 from exhaustion, or after passing through a typhoid state. Sudden 
 death, attributed to heart failure, may occur during convalescence, 
 even when the stools are assuming a natural consistence. 
 
 Varieties. — Acute dysentery receives a variety of names according 
 to the assumed cause, and the signs and symptoms that predominate. 
 Most of these names, coined from mere clinical variations, are 
 counterfeit, and but add to the chaos of nomenclature. Malarial 
 dysentery presents few specific clinical phenomena. Apart from 
 the history, the presence of the malarial parasite in the blood, and 
 the variations in the temperature of the body, the most marked 
 symptoms are a tendency to early prostration and algidity, and the 
 loss of a large quantity of blood by the bowel. The curative effect 
 of quinine, however, has done most to stamp this variety of dysen- 
 tery as malarial. The so-called ptirulent, gangrenous, and fibriiioiis 
 or pseudo-diphtheritic varieties are all preceded by, and are but the 
 natural sequelae of an unchecked, simple, or catarrhal dysentery. 
 The continuance of the specific irritation of the bowel may lead to 
 the infiltration of its walls with fibrinous material or with pus, to 
 the formation of ulcers, and, when the infection is still more 
 virulent, to obstruction of the blood vessels and sloughing of the 
 mucous and submucous coats of the bowel. When the wall be- 
 comes extensively infiltrated with a fibrinous deposit, the gut 
 
DYSENTERY 407 
 
 becomes somewhat rigid, the calibre variable, wide in parts and 
 narrow in others, and an incision into its tissue betrays a rather 
 tough semi-cartilaginous consistence. The names scorbutic dysentery 
 and typJioidal dysentery indicate either the association of an intes- 
 tinal flux resembling dysentery occurring during an attack of scurvy, 
 typhus, or typhoid, or, that a dysenteric attack assumes, during 
 its course, features peculiar to either scurvy, typhus, or typhoid. 
 Hepatic dysentery is a convenient term whereby the early implica- 
 tion of the liver in the dysenteric attack is prominently noted. On 
 the one hand the condition of the liver may be a primary etiological 
 factor or, on the other hand, the liver may be infected during ihe 
 course of the disease in the bowel by way of the portal vein. When 
 vomiting is prevalent, the liver enlarged and tender, and considerable 
 pain in the right hypochondrium supervenes during an attack of 
 dysentery, it is usual to stamp the variety as hepatic. The dysentery 
 of war and fafiiine occurs independently of climate and season; it 
 is an extremely fatal form, and there seems little doubt it is con- 
 tagious. So-called atncebic dysentery is stated to exhibit marked 
 chronicity, frequent relapses, and a pronounced tendency to cause 
 liver abscess. In the stools the amoeba coli is necessarily present, 
 but none of the signs or symptoms are sufficiently constant to 
 define the amoebic form as a specific clinical variety. 
 
 Chronic dysentery. — The acute form of the disease frequently 
 results in a chronic dysenter)'. After the acute symptoms have 
 subsided, and stools possessing fceculence and some consistency are 
 passed, instead of complete recoveiy following, the mucous flux may 
 persist, pain of a subacute character remains, and the general health 
 of the patient does not improve satisfactorily. As time passes the 
 stools may become fairly well formed or constipated, and yet jelly- 
 like or muco - purulent matter, and occasionally blood, accom- 
 pany them. This fluid material, as a rule, precedes the stool, 
 showing that the seat of the trouble is just within the anus. 
 Haemorrhoids, and painful ulcer of the rectum, are frequently 
 associated with or mistaken for dysentery, and it is at times difficult 
 to ascertain the origin of the trouble. Pressure in the left iliac 
 fossa over the sigmoid flexure, and sometimes in the right iliac 
 fossa over the csecum, elicits pain ; and the sigmoid flexure may be 
 felt to be indurated, enlarged, and tender. The stools are irregular 
 as to the time of their being passed as well as in the character of 
 their consistence. Exposure, fatigue, and inadvertence in diet may 
 induce a semi-acute attack, causing an aggravation of the diseased 
 state. This may continue until a chronic state is established, the 
 
4oa MANUAL OF MEDICINE 
 
 bowel being so altered that the ulcerated surfaces become incapable 
 of healing, or, should they do so, pronounced cicatrices and 
 narrowing of the gut ensue. In chronic dysentery the tongue may 
 become red, raw, and fissured, the appetite at times may be 
 voracious, and at others in abeyance ; the stools retain some of their 
 disagreeable odour, and in some cases are of unusual bulk, and 
 seemingly fermenting. The patient's health suffers ; he becomes 
 sallow, emaciated, cachectic, and in the gravest cases hectic appears, 
 attended by anaemia and sweatings ; a fatal issue is then at hand, 
 and death results either from gradual exhaustion, or from some 
 concomitant ailment, with dropsy, pneumonia, or cardiac failure. 
 
 Dysentery afid liver abscess. — The relation between dysentery and 
 liver abscess is an important one clinically and pathologically. 
 Many observers believe that in almost all, if not in all, cases of liver 
 abscess, a previous historj' of dysentery can be elicited ; whilst, on 
 the other hand, a few attempt to disassociate the ailments. 
 Analogy, however, favours the conclusion that the two are associated, 
 as in most ulcerative and inflammator)' lesions of the intestine, other 
 than dysenteric, there is a marked tendency to the deposit of in- 
 fective and purulent matter in the liver substance. Clinical ex- 
 perience shows that liver abscesses were found by Woodward in 2 1 
 per cent of autopsies on patients dying of dysenteiy; and in as many 
 as 60 per cent of cases of liver abscess a history of dysentery was 
 elicited by Kartulis in Egypt. Many circumstances, however, pro- 
 nounce against the conclusion that dysentery is an invariable ante- 
 cedent of abscess. None more so perhaps than the fact that although 
 dysentery is very prevalent amongst natives, abscess of the liver is 
 rarely met with. The whole question, however, turns upon the 
 question whether there are not several varieties of liver abscess. In 
 the majority of intra-hepatic abscesses no doubt dysenter}' is the 
 primary factor, but in those abscesses which form not in., but upon 
 the liver, and most frequently between the layers of the broad liga- 
 ment of the hver, it is difficult to explain a positive connection. 
 Although the presence of the amoeba coli in the intestines and in 
 liver pus would seem to point to a relationship of cause and effect, it 
 must be noted that the parasite is not usually found in pus issuing 
 from a liver abscess until the third or fourth day after the abscess 
 has been opened or tapped. Not only so, but liver pus is peculiar 
 in that it is frequently " sterile " when first drawn off, none of the 
 usual purulent organisms being demonstrable. 
 
 In a paper read at the annual meeting of the British Medical 
 Associationj 1899 {Brit, Med. Journ. 9th Sept. 1899), the writer 
 
DYSENTERY 409 
 
 divided liver abscesses into two varieties, suprahepatic and intra- 
 hepatic. The latter is the result of dysentery ; the pus shows the 
 usual purulent organisms, streptococci, etc., and the amoeba coli is 
 perhaps present from the first. The suprahepatic abscess is non- 
 dysenteric in origin, the pus is sterile and the amoeba coli does not 
 appear in the pus until after the third day of drainage. The pus 
 from an intrahepatic abscess tends to reach the surface by way of 
 the abdominal wall, but may burst into the peritoneum, the stomach 
 or duodenum, the ilio-lumbar region, the bile duct, the vena cava, 
 or even into the kidney. Suprahepatic pus tends towards the 
 thorax, and, pointing upwards through the diaphragm, may reach 
 a bronchus, when it is expectorated or may find its way into the 
 cavity of the pleura or pericardium. 
 
 Post-mortem appearances. — In the simple forms of acute 
 dysentery, although the opportunities of study are necessarily limited, 
 the conditions are primarily similar to those met with in acute 
 colitis and enteritis. In rapidly fatal cases of the gangrenous or 
 malignant type, however, the lesions are unfortunately more fre- 
 quently seen. The changes in the bowel in the latter form are 
 destruction of extensive areas of the mucous and submucous coats 
 of the large and occasionally of the small intestine ; ulcers of all 
 sizes with undermined edges, and frequently with sinuses com- 
 municating between neighbouring ulcers, exist in large numbers. 
 The ulcers in the wall of the gut frequently coalesce, and a ragged, 
 uneven, patchy surface may extend the entire length of the colon. 
 In the swollen mucosa small abscesses, varying in size from a pin's 
 head to a pea, stud the tissue. When cut into they are seen to be 
 closed sacs containing a tenacious pus, but the apices of others may 
 be found open, emitting pus when squeezed, and it is possible, nay 
 probable, that the formation and bursting of these abscesses is but 
 the initial stage of the ulcerative process. What remains of the 
 inner coats of the intestine appears swollen, raised and injected, or 
 here pale and there red and congested. The floors of the ulcers 
 present an ashen-gray colour, where the sloughs have been detached, 
 or the muscular coat may even be exposed to view. The lesion is 
 usually most marked in the rectum, sigmoid flexure, and descend- 
 ing colon, but the disease may involve the whole of the large gut, 
 the caecum becoming the seat of advanced ulceration and sloughing. 
 The disease may also spread through the ileo-csecal valve and in- 
 volve the small intestine to the extent of a foot or two. Although 
 in dysentery the gut is so deeply ulcerated that a mere transparent 
 film of tissue remains, perforation is rare. Frequently a protective 
 
4IO MANUAL OF MEDICINE 
 
 local peritonitis bars the way to extravasation of the intestinal 
 contents. Everything points to the rectum being the primary seat 
 of the disease ; so markedly is this the case, that it would seem in 
 fact as though the infective process started from the anus, and 
 several observers are of this belief Many believe that defecation 
 over a freshly passed dysenteric or choleraic stool is a source of 
 direct infection by way of the bowel in these respective diseases, 
 and there seems some evidence in favour of the assumption. 
 
 In chronic dysentery the gut presents very diverse conditions. 
 The colour of the mucous surface becomes for the most part much 
 darker, and in parts brownish black. Old irregular cicatrices of 
 healed ulcers are everywhere met with between the elevated, 
 thickened, and indurated mucous ridges. The whole wall of the 
 bowel is in parts hypertrophied and the lumen narrowed, in parts 
 thinned and atrophied, as if a mere touch would cause rupture. 
 Recent abscesses may be present, and sinuses may be found passing 
 beneath bridges of cicatricial bands and constrictions. The mucous 
 and glandular structures are never reproduced when once destroyed. 
 In consequence of these conditions, dilatations and contractions of 
 the calibre of the intestine are frequently seen. 
 
 The liver in acute dysentery is congested and enlarged, and 
 with single or multiple intrahepatic abscesses. In chronic dysentery 
 the liver is more frequently met with of reduced size ; but owing 
 to subacute attacks of dysentery supervening, the liver may be 
 deeply congested, or become the seat of abscess. 
 
 The spleen varies in size and consistence ; in acute dysentery 
 it is usually full, soft, and deeply congested, whereas in the chronic 
 form of the disease it is either considerably and permanently 
 enlarged or markedly diminished in bulk. 
 
 Towards the end of a fatal case, the lungs and kidneys may 
 become involved, but these viscera are not primarily affected during 
 dysentery. 
 
 Diagnosis. — The signs and symptoms stamp dysenter}', in the 
 sense of a dysenteric flux, decisively ; but the variety of the disease 
 under treatment may be difficult to decide upon. It is frequently 
 by a process of exclusion during the progress of a case that one 
 decides whether the dysenter}- is of the hepatic, the amoebic, the 
 scorbutic or of the malarial variety, and this information may be 
 gathered solely by the effects of treatment upon the disease. Chronic 
 dysentery is diagnosed chiefly by the history of the case, but in part 
 also by the nature of the stools. Several affections may set up a 
 condition allied in symptoms to dysentery. A fibrous stricture of 
 
DYSENTERY 411 
 
 the rectum, malignant or syphilitic, especially in old tropical residents, 
 may either mask, or be masked by, dysentery. Proctitis, painful 
 ulcer of the rectum, the diarrhcea of Sprue, or in fact any intestinal 
 flux may complicate, or be mistaken for chronic dysenterj'. In 
 certain tropical countries the presence of the round worm or of 
 other intestinal parasites may produce a foecal irregularity which 
 may lead to mistakes in diagnosis and consequent errors in treat- 
 ment. 
 
 Although, however, the term dysenter}' is regarded as a con- 
 venient name for, it may be, a number of ailments arising from in- 
 dependent causes, there are a number of signs and symptoms which 
 determine its presence; of these the chief are: general abdominal 
 tenderness, tormina immediately before, and tenesmus during and 
 after a motion ; the stools consist of mucoid material tinged with 
 blood, but if the disease persists, they contain a bloody slime, 
 gelatinoid particles, and, in advanced cases, gangrenous sloughs 
 smelling abominably. An increase in temperature, intense thirst, 
 a furred tongue and rapid loss of strength ser\-e, with the above 
 abdominal symptoms, to stamp the disease as dysenteric. Ulcera- 
 tive colitis is the name assigned to a condition of the bowel which, 
 in pathological and in many clinical features, resembles dysentery. 
 Colitis, however, occurs in temperate climates and in persons who 
 have never visited the tropics ; moreover, the tenesmus, the burn- 
 ing pain at the anus, the unceasing desire to go to stool, etc., so 
 harassing in dysentery are not met with in ulcerative colitis. 
 
 In all cases of doubtful nature, a digital and specular examina- 
 tion of the rectum ought to be made. 
 
 Prognosis. — AVhen the malignant characters set in early in the 
 disease, there is but little hope of saving the patient ; and when a 
 chronic dysenter}' continues for a year or two, there is little chance 
 of a permanent cure. Simple acute dysenterj', however, is not in 
 itself a fatal disease, the only sequela likely to happen being a 
 chronic dysenter}' of some duration ; at any moment, however, a 
 simple case may assume a malignant type. 
 
 Mortality. — The death - rate in dysentery varies with race, 
 environment, and type of the disease. Natives succumb more 
 readily than Europeans in the tropics ; the former show a case 
 mortaUty of from 37 to 40 per cent, whilst the latter, according to 
 Indian statistics, show one of from 3 to 22 per cent. Emaronment 
 plays an important part in the chances of recover)'. A European 
 enjoying good sanitary surroundings, good food, and scientific treat- 
 ment stands a much better chance of recovery than the native in 
 
412 MANUAL OF MEDICINE 
 
 his squalid abode, with his crude medicines and indifferent food. 
 The type of the disease, however, largely determines the mortality, 
 malignant dysentery allowing but a small chance of recover)-, for 
 it must be considered one of the most fatal ailments known. The 
 danger of an attack of dysentery, however, is by no means over 
 when the acute symptoms have subsided ; chronic intestinal troubles 
 are apt to be set up, leading to contraction and obstruction of the 
 intestine, loss of power of assimilation and consequent wasting, 
 chronic diarrhoea, and greater vulnerability to attacks of intercurrent 
 diseases. 
 
 Treatment. — The principles of treatment of acute dysentery 
 are rest, suitable diet, and either arrest of the intestinal flux by 
 appropriate remedies or its elimination by purgatives. The rest 
 should be absolute ; the patient should be confined to bed, and the 
 use of the bed-pan insisted upon. The writer, however, goes 
 further than merely obtaining general rest, and recommends the 
 application of a large, thick, firm pad, big enough to cover the whole 
 front of the abdomen ; retaining the pad by a broad, tightly applied 
 binder round the body. Alternately applied wet and dry pads, or a 
 continuously applied wet pad increases the effectiveness of this 
 device. Rest may be further procured by morphia hypodermically, 
 or by opium given by the mouth or rectum ; the plan of giving 
 castor oil 3iij, with 20 minims tincture of opium, in the ver}- early 
 stages of dysenter}', has everything to recommend it. At the onset 
 of an acute attack food should be reduced to a minimum. Rice- 
 tea (rice, browned in the oven and infused with boiling water), or 
 whey are to be given in sips, and ice pellets may be sucked if the 
 thirst is intense. Ordinary' weak tea, without milk or sugar, is a 
 very grateful beverage in dysentery. 
 
 When dysentery proves intractable to these simple remedies, 
 ipecacuanha should be given. The formula for administration is 
 as follows : — Two hours before the time selected to give the 
 drug all food is to be withheld, and only small pieces of ice given 
 to suck. Twenty minutes before giving the ipecacuanha, half a grain 
 of morphia may be administered hypodermically, or 25 minims of 
 laudanum is to be exhibited by the mouth. Ten minutes before 
 the ipecacuanha is given, place a mustard leaf, or mustard plaster 
 the size of the hand, on the epigastrium. Give 30 grains of ipecacu- 
 anha root freshly prepared, in pills, cachets, or wafer paper. Five 
 or ten minutes after the administration, remove the mustard plaster. 
 Insist upon the patient keeping quiet with the head low, and give 
 particles of ice to suck. No other food or drink is allowed until 
 
DYSENTERY 
 
 413 
 
 at least three hours afterwards, when sips of weak tea or rice-tea will 
 be found to be most beneficial. The continuance of the ipecacu- 
 anha treatment will depend upon the character of the stool. One 
 dose may bring down a foeculant stool, but, failing improvement, 
 the drug may be continued twice a day in i o-grain doses for several 
 consecutive days. 
 
 Malaria may be either a cause or a complication of dysentery, 
 and, should ipecacuanha fail, quinine is indicated in, say, 5 -grain 
 doses every six hours for two days. In pregnant women both 
 ipecacuanha and quinine may be given if opium is freely administered 
 at the same time. Scorbutus is not unfrequently the genesis of 
 dysentery, and the reputation gained by several "native" remedies 
 arises no doubt from their efficacy in this variety of the disease. 
 The fresh plants, leaves, or fruit supply the vegetable acids re- 
 quired for the treatment of scurvy in whatever form it may 
 appear. Simariiba bark is much in vogue in the southern 
 countries of North America. It is exhibited in a variety of ways ; 
 the best, perhaps, is in the form of infusion obtained by boiling 
 I oz. of the powdered bark in 3 pints of water until the quantity 
 is reduced to half the bulk. One-half the quantity may be given 
 morning and evening. The writer has experience of viangostine 
 rmd in the treatment of dysentery ; and in the Straits Settlements 
 and throughout Malaya it is held in high esteem. It is best pre- 
 pared by boiling the rinds of three dried mangostines in i| pint 
 of water until the quantity is reduced to i pint. One-third of 
 the pint is given thrice daily. The Mofisonia ovata is a South 
 African plant from which a tincture (i in 8, alcohol, 90 per cent) 
 is made and administered in doses of i to 4 drachms every four 
 hours. In India bael fruit is extensively used. The preparation 
 must, however, be made from the fresh fruit, so that its efficacy 
 can, like many other native remedies, be only ensured locally. 
 
 The aperient treatment may be tried when ipecacuanha, quinine, 
 etc., fail, or it may be employed from the onset. There are two 
 methods of administration : (a) \ oz. of the sulphate of sodium 
 or magnesium dissolved in a small quantity of hot water may be 
 given to commence with, followed by smaller doses every six or 
 eight hours ; (b) or 60 grains of either of these salts may be given 
 every quarter of an hour or every half hour until the stools show 
 signs of foeculence. When drugs fail, the writer places most reliance 
 on an ample cold (ice cold if necessary) wet pack applied to the 
 whole front of the abdomen. Pressure is maintained by a bath 
 towel wrapped tightly round the body from mammse to groins. 
 
414 MANUAL OF MEDICINE 
 
 Re-apply the wet pack every two hours, and persevere with the treat- 
 ment for thirty-six or forty-eight hours. In many cases this plan 
 of treatment well deserves the title " specific." The treatment by 
 calomel and opium is worthy of trial when other means fail, either 
 with, or without, ipecacuanha. These are given in combination, 
 in doses of i grain of each every six hours. 
 
 Although the stools become foeculent, they may remain quite 
 loose, and this diarrhoea may require to be arrested by some one 
 of the many astringents in use ; bismuth and opium usually suffice, 
 but sulphate of copper, of zinc, or of iron, are also employed for 
 the purpose. 
 
 Attempts at disinfection of the bowel by such substances as 
 salol in gr. 20 doses, by creolin (gr. 3), by napthalin (gr. 5), by tar 
 (gr. 5), by creasote (min. 20), and a host of other drugs have been 
 employed, and with but ephemeral success. Injections also of 
 disinfectants by the bowel can only be of evanescent value, as to 
 keep the intestine "sweet" a constant stream of the injection 
 would have to be kept up. 
 
 In malignant dysentery, when sloughs are being passed and the 
 patient's strength is becoming rapidly exhausted, " specific " drugs 
 are well-nigh useless. Instead, every form of rational stimulant 
 must be employed to, if possible, tide the patient over the stage of 
 acute depression. In this variety the use of disinfectants for the 
 intestine is theoretically sound, but practically the plan is not of 
 much value owing to the difficulty of its application. 
 
 When dysentery becomes chro7iic, the use of drugs is dis- 
 appointing. Ipecacuanha loses its power, and it would seem as 
 though the ragged, ulcerated, and congested gut demanded local 
 treatment. A copious enema of plain boiled water (allowed to 
 cool to 100° F.), followed, when the water has been passed, by an 
 injection of i or 2 pints of boracic acid (saturated solution) or 
 nitrate of silver (\, |, or i grain to the ounce of warm distilled 
 water) are efficient remedies. The injection ought not to be 
 forcibly given by an enema syringe, but by an india-rubber tube 
 and a funnel held not more than two feet above the level of the 
 patient's body as he lies in bed. The astringent injection should 
 be retained for an hour if possible. After many trials of the long 
 tubi for the bowel, the writer has discarded it as unnecessary and 
 dangerous. The injected fluid finds its way along the gut, if 
 introduced slowly, more readily by syphonage than when adminis- 
 tered by either an enema syringe or by a long tube. 
 
 Of the many drugs and methods employed in the treatment of 
 
DYSENTERY 415 
 
 chronic dysentery, the writer relies on rest in bed ; cold wet packs 
 twice a day, morning and evening, for two hours ; an occasional 
 dose of castor oil ; subnitrate of bismuth in gr. 20 doses, given 
 in combination with i drachm of the confection of black pepper, 
 and washing out the intestine by astringent lotions. In the consti- 
 pation which so frequently follows dysentery, cascara in moderate 
 doses, administered daily for a month or two, is an effective 
 remedy. 
 
 Diet, — A purely milk diet is the usual routine of treatment in 
 intestinal flux, whatever is the cause. The milk is given in sips, 
 or in very small quantities repeated frequently. Some prefer the 
 milk warmed, others exhibit it with ice. In the acute initial 
 stages of the disease, however, milk does not seem suitable, and 
 in its stead rice - tea, weak chicken broth, whey, ordinary very 
 weak tea (cold or warm), barley water, or koumiss may be 
 given. In chronic dysentery the writer finds the treatment 
 by meat and " meaty substances " the most eflScacious. The 
 patient is fed thrice daily on beef, reduced to a fine mince, 
 which, after being very lightly cooked, is served up 5 oz. at a 
 time. Nothing but salt, and maybe the white of an egg, is given 
 with the meal. Between meals and during the night the patient 
 is allowed to eat calves' foot jelly freely. Hot water is the best 
 drink, taken a quarter of an hour before or half an hour after meals. 
 If the patient is too weak to take beef in this form, he may be 
 fed on teaspoonfuls of freshly-made raw meat juice every ten 
 minutes ; scraped raw beef, and raw meat sandwiches being added 
 as the strength gains, and the intervals lengthened as the power of 
 digestion improves. A change to a temperate climate is an 
 essential element in the treatment of Europeans suffering from 
 dysentery when the disease threatens to become chronic. When 
 hepatic derangements are concomitant, a course of treatment at 
 a medicinal spa, more especially that of Carlsbad, is highly to 
 be recommended. 
 
 James Cantlie. 
 
4i6 MANUAL OF MEDICINE 
 
 MALARIA AND MALARIAL FEVERS 
 
 A group of specific diseases, characterised by fever of an 
 intermittent, continued, or remittent type, giving rise to anaemia, 
 with pigmentary deposits, and tissue changes in the spleen, liver, 
 and other organs. The parasites occupy and destroy the red 
 blood corpuscles. Certain species of mosquitoes and possibly other 
 blood-sucking insects serve as intermediate hosts in the life cycle of 
 the parasites. 
 
 Distribution. — While yet Western Europe and the Mediter- 
 ranean littoral were the only countries known to civilisation, malarial 
 diseases were almost universally distributed within them. In Eng- 
 land, and even in Scotland, malaria at one time prevailed, but with 
 better drainage, reclamation of swampy lands and improved sanita- 
 tion generally, malaria has receded from its more northerly sphere. 
 
 When other continents became known to European travellers 
 and colonists, it was found that no country north of the Equator 
 from the Arctic circle to the Tropics was free from malaria ; but as 
 the Tropics were approached, however, it was found that malarial 
 disease became more prevalent. In North America also malaria is 
 gradually receding before drainage and cultivation, until at the 
 present time it is seldom met with north of the 45th degree of 
 latitude. Countries to the south of the equatorial belt are less 
 malarial than similar latitudes to the north, and in those south of 
 the 30th degree of latitude malaria is all but unknown. 
 
 Etiology. — Although not the only factors in determining the 
 prevalence of malarial fevers, there is no doubt that a marshy soil 
 and a high mean temperature are favouring agents. The delta of a 
 great river, and low-lying land possessed of a high subsoil humidity, 
 as at the foot of a mountain range, are the special habitats of 
 paludism. Freshly-broken soil, especially virgin soil, is often inti- 
 mately connected with outbreaks of malaria. 
 
 In all warm climates particular seasons of the year are associated 
 with special hability to fever, and to the different seasons fevers 
 possessing different types are ascribed. So pronouncedly is this the 
 case, that such names as " spring and early summer intermittents " 
 and " gestivo-autumnal " are used to divide one class from the other, 
 which, as their names indicate, prevail during the spring and 
 autumn respectively. The " unacclimatised " European seems more 
 
MALARIA AND MALARIAL FEVERS 417 
 
 predisposed to attacks of malarial fever than the coloured races 
 native to hot countries. Children and young adults are specially 
 liable to malarial infection, but old people of long residence in tropical 
 countries are by no means immune. Females are not less prone to 
 malaria than males, but they are usually less exposed to its influence. 
 
 The malarial parasites. — It was not until the year 1880, 
 when Laveran discovered the parasites in the blood of persons 
 suffering from malarial fever, that we had any scientific knowledge 
 of the etiology of malaria. 
 
 The organism is termed, usually, the " plasmodium malarise." 
 The name is biologically incorrect, as the parasite is in no sense the 
 large multinuclear mass of protoplasm which the designation would 
 indicate. Zoologically, the malarial parasite is referred to the 
 Protozoa, grade Corticata, class Sporozoa ; and of the Sporozoans it 
 most nearly resembles the Coccidia. 
 
 Examination of the blood for the Plasmodium malar ice. — Wash the 
 tip of a finger with soap and water ; dry the part and then wipe it with 
 ether or alcohol. Tie a cord round the root of the finger and prick the 
 pulp with a sterilised needle. Wipe away the first drop of blood that 
 issues, and with a clean cover-glass Ughtly touch the issuing blood so 
 that a minute quantity adheres to its under surface. Place the cover- 
 glass so charged on a clean slide without pressure and examine by yVth 
 inch oil-immersion lens. A number of such specimens may be mounted 
 in a similar manner, and to prevent evaporation it is well to " ring " the 
 cover-glass with vaseline. Freshly -drawn blood so prepared may be 
 used for several hours for purposes of examination. 
 
 To staiji the malarial parasite. — Instead of using a cover-glass to 
 receive the blood, Manson recommends that a piece of thin paper be 
 made to touch the drop of blood as it issues from the finger. The 
 paper so charged is then drawn along the surface of the slide so that the 
 blood is smeared on the glass in a thin layer. When the blood stain is 
 dry, absolute alcohol is dropped upon its surface and allowed to remain 
 for five minutes, when the alcohol is run off and the specimen again 
 dried. To the blood thus fixed a staining fluid of one or other of the 
 following substances is added : — {a) a simple, weak, aqueous solution of 
 methylene blue ; (b^ 30 c.c. of a concentrated alcoholic solution of 
 methylene blue, and 100 c.c. of solution of caustic potash (i in 10,000) ; 
 or (f) an aqueous, 2 per cent solution of methylene blue, mixed with 
 equal parts of a 5 per cent solution of borax. To the dried and fixed 
 blood on the slide a few drops of the staining fluid is added, allowed 
 to remain for thirty seconds, when the stain is washed off with distilled 
 water, and the specimen dried between layers of filter paper and held 
 over the flame of a spirit lamp, and mounted in xylol balsam. 
 
 VOL, I 2 E 
 
41 8 MANUAL OF MEDICINE 
 
 In specimens so prepared, the red blood corpuscles will be found 
 unstained, while the parasites and the nuclei of the leucocytes are tinged 
 blue. 
 
 The benign tertian parasite. — i. When the blood of a patient 
 suffering from tertian fever, to whom quinine has not been administered, 
 is examined some eight hours after the temperature attending a paroxysm 
 of fever has fallen to the normal, the characteristic parasites may be 
 seen within the red corpuscles. They occur as small, colourless bodies, 
 changing, by amceba-like movements, to shapes resembling a disc, a star, 
 a cross, or a ring. At first, pigment is not to be seen except occa- 
 sionally, as a few irregularly distributed granules near the periphery of 
 the parasites. 2. If a specimen of blood from the same patient is 
 examined some eight hours later, it will be observed that the hyaline- 
 looking bodies within the red corpuscles have increased in size, that the 
 amoebic movements are more active, that the pigment has increased in 
 quantity and activity, that the red corpuscle enveloping the parasite is 
 paler in colour and has increased in bulk beyond its normal limits. 
 3. Were the blood of the same patient submitted to exammation towards 
 the end of the forty-eight hours' interval which characterises the disease, 
 further important changes can be made out. The parasite has increased 
 in bulk to such an extent that it is difficult to see the pale attenuated 
 remnant of the distended red corpuscle. The pigment movement is 
 arrested and its granules collect towards the centre of the organism in 
 two or three clumps. The hyaline -looking surface of the parasite 
 becomes more granular, and, commencing at the periphery and extending 
 towards the centre, fine striations appear which finally cause a complete 
 segmentation, dividing the parasite into twelve to thirty leaflets. This 
 is no doubt a true segmentation, the whole process being connected with 
 reproduction, and the resulting leaflets are the young spores. Finally, 
 the red corpuscular tissue containing the parasite gives way and the spores 
 and pigment escape into the liquor sanguinis. The free spores appear 
 as hyaline protoplasmic spherules possessing a central refracting area. 
 Although the process has not actually been observed, the free spores are 
 believed in many instances to gain access to adjacent red corpuscles, 
 where the phenomena of growth and sporulation are again proceeded 
 with. Others of the parasites appear to increase in size, exhibit a dancing 
 movement in their pigment, and after violent agitation throw out unpig- 
 mented flagella, which become detached and float away, losing them- 
 selves amongst the corpuscles. 
 
 When the blood of a person subject to malarial fever is examined, 
 by one experienced in the microscopical phenomena of malaria, it is 
 easy to state not only what type of fever prevails, but also to predict the 
 hour at which the paroxysm may be expected. Segmentation occurs 
 immediately before the paroxysm, and with the rupture of the containing 
 red corpuscles, and the escape of the spores and pigment, it would seem 
 
MALARIA AND MALARIAL FEVERS 419 
 
 as though a toxic agent found its way into the blood, causing the signs 
 and symptoms of an attack of ague or other form of fever. 
 
 ^\'hen all the parasites in the blood mature at the end of forty-eight 
 hours, tertian fever will result, but if a certain number mature twenty- 
 four hours earlier than the remaining half, the fever will exhibit the 
 quotidian type. 
 
 The benign quartan parasite. — When the blood of a patient 
 suffering from the quartan type of malarial fever is examined within 
 twelve hours after the subsidence of a paroxysm, a parasite will be found 
 within the red corpuscles well-nigh indistinguishable from the pale 
 amoebic body described as met with in the tertian type. When, how- 
 ever, the time for the recurrence of the paroxysm approaches, say sixty- 
 two hours after the last attack, sufficiently marked differences are met 
 with, which enable a conclusive diagnosis to be established by micro- 
 scopical examination, whereby the quartan may be distinguished from all 
 othe types. 
 
 The quartan, as compared with the tertian, parasite, (i) possesses a 
 more definite outline ; (2) the amoebic movements are slower ; (3) the 
 pigment is darker in colour and coarser ; (4) segmentation begins 
 some ten hours before the expected paroxysm, when some six to twelve 
 leaflets (spores) only are formed. Subsequently the escaped spores 
 behave, as regards occupation of other corpuscles and flagellation, as in 
 the case of the tertian parasite. 
 
 \\Tien the quartan parasites, present in the blood, preserve the same 
 stage of development, fever will recur every seventy-two hours. With 
 quartan parasites exhibiting two cycles of maturation, paroxysms of fever 
 will occur two days running, with a third day's freedom from pyrexia. 
 This type is known as the "double quartan." When quartan parasites, 
 presenting three groups of development, are met with, paroxysms of 
 fever will recur daily — the " triple quartan." 
 
 Malignant or aestivo-autumnal parasites : the parasites of the 
 irregular malarial fevers. — Three forms of parasite — (i) the pigmented 
 quotidian ; (2) the unpigmented quotidian ; and (3) the malignant tertian 
 ■ — are associated with the so-called malignant types of fevers ; and the 
 crescent-shaped parasite, the "gamete" — sexual form — of the malignant 
 tertian parasite. The differences between the benign and malignant 
 parasites may be summed up as follows : — (i) The cycle of development 
 of the parasites of the malignant type are not so clearly defined as 
 is the case with the benign ; it is believed to extend to twenty-four and 
 forty-eight hours ; (2) the malignant parasites do not mature in groups, 
 but independently, as it were, sonie appearing in the early intra-corpuscular 
 stage, whilst others are met in all stages up to complete maturation and 
 sporulation in the same specimen ; (3) the peripheral blood shows but 
 little evidence of the presence of the segmenting parasites ; they have 
 to be searched for post-mortem in the deeper viscera, especially the 
 
420 MANUAL OF MEDICINE 
 
 spleen and in the marrow of the bones ; (4) in their earliest stages the 
 benign and malignant parasites resemble one another closely, but later 
 fairly well-marked features serve to differentiate them ; in the malignant 
 varieties the parasite is much smaller, rarely occupying more than one- 
 third of the red corpuscle ; the shape varies from a ring-like body with 
 high refractive power and a central darker area to that of a hyaline mass 
 endowed with active amoeboid-like movements ; these conditions may 
 alternate once, twice, or thrice, the one shaped body changing to the other 
 with alacrity ; (5) the pigment is for the most part scanty ; (6) the red 
 corpuscle containing the parasite becomes crenate and wrinkled, and 
 often assumes a dark green hue — the "brassy body" of some writers. 
 Sporulation proceeds as in the benign forms, and the ultimate destina- 
 tion of the benign and malignant parasites seems analogous. 
 
 Cresceiit-shaped bodies. — In a case of remittent or continued malarial 
 fever, which has lasted a week or more, the " crescent-shaped " body is 
 to be met with, first in the blood of the organs, and later in smaller 
 numbers in the peripheral blood. As the name implies, the parasite is 
 crescent-shaped, and in the concavity of the arch stretching between the 
 horns is to be seen the remains of the red corpuscular host, altered some- 
 what in shape and colour. The pigment may be either diffused through 
 the mass of the parasite, or it may appear as rods collected into a 
 central clump. 
 
 The significance of the "crescent" bodies is subject to several 
 interpretations. Some have believed them- to be a separate parasite, 
 others that during the continuance of the fever a certain number of the 
 recognised parasites, instead of sporulating, increase in size, acquire 
 pigment, and destroy the red corpuscles they inhabit. They are now 
 known to be the gametes of the malignant parasite. ]\Ianson"s inter- 
 pretation of the crescent bodies is, that, as they seem incapable of 
 further development in the blood, and as they are passive agents so far 
 as the appearance of fever is concerned, they are the means by which 
 the " extra-corporeal " life of the parasite is maintained in media other 
 than the human blood and body, and that their flagellation is a neces- 
 sary part in the life-history of the parasite. 
 
 When crescent - bearing blood is exposed to the air for a few 
 minutes, and examined microscopically, the crescent body, after some 
 fifteen to thirty minutes, shows signs of activity. The pigment accumu- 
 lates in the centre of the parasite, its granules dance about, and its 
 whole body becomes agitated, until suddenly, from the circumference, 
 flagella, two to five in number, shoot forth and lash about in restless 
 activity. The flagella subsequently separate from the parasite, and move 
 away amongst the corpuscles, leaving the parent body still and passive. 
 T]ie part the mosquito plays as the ^'■extra-corporeal" host of the 
 Plasmodium malarice. — Several observers lay claim to the suggestion 
 that the spread of malaria was in some way connected with mosquitoes. 
 
MALARIA AND MALARIAL FEVERS 421 
 
 Manson, however, was the first to put the theory on a scientific basis, 
 and Major Ross in 1895 undertook the investigation of the subject 
 practically. Manson was prompted in his contention by his investigations 
 as regards the part the mosquito played in the life-history of the filariae, 
 and by his firm belief that the flagellation of the parasite after its 
 removal from the body had a meaning and purpose. He believed that 
 the mosquito, after extracting the blood of malarial persons, served as 
 the host in which flagellation was carried on, and that this process was 
 but one stage in the extra-corporeal life of the parasite. Ross, when he 
 commenced his investigation, soon proved the truth of the initial stages 
 by finding that in the mosquito's stomach 70 per cent of the crescent 
 bodies developed flagella. For a time no further trace of the organism 
 could, however, be found, until, after a long and patient search, the 
 pigmented bodies characteristic of malarial infection were found in the 
 walls of the mosquito's stomach. Not, however, in all mosquitoes, 
 and it was only after lighting upon the " dappled-winged " and the 
 " gray" mosquitoes that this phenomenon was discovered. Following 
 the teaching and example of Professor M 'Galium of the Johns Hopkin's 
 University, U.S.A., Ross turned his attention to the parasites met with 
 in the blood of certain birds. In the stomachs of birds ample proof 
 was to hand of flagellation. The flagella were found to break away 
 and impregnate, or at least occupy neighbouring cells, and produce 
 melanin in quantity. The cells so impregnated Ross traced into the 
 stomach walls of the mosquito, and observed that they protruded on the 
 outer surface of the stomach towards the body cavity of the animal. 
 Whilst this " coccidia "-like process was going forward, the protoplasm 
 of the cells changed to rod-like bodies — sporozoids. In the body cavity 
 Ross was able to find these dark rod-like bodies freed of their enclosing 
 envelope, and scattered throughout the cavity and in the blood of the 
 mosquito. Finally, they were found in what appeared to be the salivary 
 or poison glands of the mosquito, and even in the ducts of these 
 glands leading to the proboscis. 
 
 Inferring that these rods might be the infective medium, Ross next 
 subjected healthy birds to mosquito bites, and had the satisfaction of 
 finding the developed parasite in the blood of these birds after an 
 incubation period of from five to nine days. So far as bird and 
 mosquito relations go, the cycle of their parasites has been proved, 
 and the facts accumulated around the human malarial parasite seem 
 to indicate an analogous, if not an identical process. In fact Grassi, 
 Bastianelli, and Bignami, have lately proved by direct experiment this 
 phenomenon also in man. 
 
 The parasite.- — The anatomy of the parasite is most readily studied 
 when subjected to staining by the boro-methylene method. It is then 
 seen to possess a deeply-stained nucleolus, a clear, unstained, vesicular 
 nucleus, and a lightly-stained protoplasmic surrounding. 
 
422 MANUAL OF MEDICINE 
 
 The tnelanin. — The pigment met with in malaria is derived from 
 the disintegrated haemoglobin. It resists the action of strong mineral 
 acids ; it is decolorised by ammonimn sulphide in solution, and also by 
 free alkalies. Although derived from so richly heematinic a substance 
 as haemoglobin, no iron is found in its composition. 
 
 Phagocytosis. — Many leucocytes in the blood of persons suffering 
 from any form of malarial fever are seen to contain either one or 
 more of the parasites, or the leucocyte may engulf the parasite and the 
 red corpuscle containing it. The power of the phagocytes to attack 
 foreign elements in the blood extends also to the flagellse and flagellate 
 bodies, and in many the melanin granules are all that is to be seen to 
 represent what once was a living parasite. The phagocytes have no 
 doubt a salutary influence, and were they in sufficient numbers to cope 
 with the influx of parasites, they would annul their baneful effects entirely. 
 It can easily be believed that the blood of all persons living in a paludal 
 area is infected to some extent by the prevailing parasite, and it is in 
 the power of the phagocytes, by their scavenging properties, to afford 
 protection or so-called immunity. The writer has found phagocytes in 
 numbers in the blood of healthy persons dwelling in malarial districts, 
 but when fever seized them the phagocytes almost entirely disappeared, 
 to re-appear once more as the paroxysm subsided. 
 
 Clinical features of malarial infection. — I. Intermittent 
 FEVERS. — Quotidian, tertian, and quartan fevers exhibit the three 
 stages characteristic of ague. 
 
 (i) The cold stage is ushered in by a feeling of lassitude, frontal 
 headache, yawning and stretching, or a feeling of nausea. Soon 
 the patient looks cold and feels cold, and a violent rigor supervenes. 
 The skin is cold to the touch, but the temperature of the mouth, or 
 more marked still that of the rectum, is raised from the first, and 
 speedily rises, even during the rigor, to the maximum 105° or 106°. 
 The cold stage may last from a few minutes to an hour or more. 
 
 (2) The hot stage. — The skin during the hot stage- is dry and 
 burning to the touch, the face flushes and the pulse strikes full and 
 strong. The patient desires to be rid of warm covering, and com- 
 plains of intense thirst, a throbbing headache and pains in the limbs. 
 Delirium, characterised usually by a rambling talk in adults, and 
 not unfrequently accompanied by convulsions in children, is not 
 uncommon. The hot stage continues for an hour or two and bears 
 an inverse ratio to the cold stage ; the shorter the cold stage the 
 longer the hot and vice versa. 
 
 (3) The sweating stage. — With the appearance of profuse 
 perspiration the restlessness and pains subside, and after free 
 perspiration for two or three hours the paroxysm is over. 
 
MALARIA AND MALARIAL FEVERS 423 
 
 Strictly speaking there is no such disease as a quotidian ague ; 
 as already explained, the daily recurrence of fever is either a double 
 tertian or a triple quartan. The typical intervals of the regular 
 intermittent are twenty-four, forty-eight, and seventy-two hours ; 
 when succeeding attacks appear earlier than the typical times the 
 fever is said to " anticipate " ; when, on the other hand, the period 
 is delayed the fever is said to be "postponed." The latter type is 
 regarded as evidence of abatement in severity. After a paroxysm 
 of fever is over the temperature falls considerably below the normal, 
 and according to the excess of the high temperature so is the fall 
 proportionate. The writer estimated, from a careful study of many 
 temperature charts, that for every degree of rise above the normal 
 there was a corresponding fall of one-eighth of a degree below the 
 normal, after allowing for the diurnal rise and fall of health. 
 
 11. Remittent fever. — At the onset remittent fever is 
 attended by a feeling of dullness which may extend over several 
 days, or it may be ushered in by a sharp rigor. The usual initial 
 signs and symptoms of " feverishness " are present, and these are 
 followed by a heightened temperature, which continues with but 
 slight abatements or remissions. Abortive attempts at sweating 
 may occur, accompanied by a corresponding decline of the body 
 heat, but the temperature does not fall to the normal. So per- 
 sistently is the fever maintained in some cases that the fever is 
 named "continuous" or "continued" fever. When vomiting is 
 severe the name "bilious remittent" is employed to designate the 
 type. Other names, such as "gastric and typhoid remittent and 
 typho-malarial fever," indicate the resemblance of the remittent type 
 of malarial fever to typhoid. So pronounced is this at times that it 
 is only by examination of the blood and the evidence of a carefully 
 kept temperature chart that the diagnosis can be established. 
 !Many, if not most of the so-called aborted typhoids may be real 
 remittents. There is no doubt we have in the tropics a fever which 
 is wont to follow a weekly cycle. Should quinine prove of uncertain 
 benefit after a two or three days' trial, and the fever, if malarial, be 
 left to run its course, it will end on either the seventh or the four- 
 teenth day. So persistently did these dates of subsidence occur in 
 the practice of the writer, that he termed them a one week, a two 
 week, and even a three week fever, and by observing the behaviour 
 of the temperature during the first two or three days of the illness, 
 it was possible to predict the day of its prospective fall. 
 
 In the blood of persons suffering from remittent fever the 
 malignant or Estivo-autumnal parasite is found ; and after the 
 
424 MANUAL OF MEDICINE, 
 
 fever has lasted one week the crescent -shaped bodies are to be 
 seen. 
 
 III. Irregular forms of fever are also associated with the 
 presence of the malignant parasite in the blood. When intermissions 
 are short and the paroxysms long, extending even to twenty hours or 
 more, these fevers form a connecting link between true intermittents 
 and the remittent group. 
 
 IV. Pernicious malarial fever. — When any one organ, or 
 group of organs, is singled out to bear, as it were, the intensity of the 
 attack of fever, and the organ is seriously affected, the name 
 " pernicious " is applied to the condition. (a) In the cerebral, 
 comatose, or apoplectic type the nervous system is so severely 
 implicated that unconsciousness supervenes and the patient may 
 die in coma ; {b) algide malaria attacks the gastro-intestinal tract so 
 violently that the symptoms resemble those of cholera ; {c) should 
 the kidneys have to bear the brunt of the paroxysm, hematuria may 
 be present. 
 
 V. Long interval fevers. — It is not uncommon to meet with 
 patients who get attacks of fever at intervals of months or years, or 
 who have recurrences of fever long after they have settled in a 
 non-malarial country. In fact, many tropical residents never get an 
 attack of fever until they take up their abode in a temperate or cold 
 climate. In such cases the parasite attains a " latent phase " and 
 develops into activity only after its human host has been exposed to 
 some severe mental or bodily strain. 
 
 The effect of malarial infection. — Anaemia and enlarged 
 spleen are the two prominent conditions set up by long-continued ex- 
 posure to paludal infection. Anaemia is regarded as a constant result 
 of residence of Europeans in tropical countries ; and in all prob- 
 ability this is to be ascribed, in the majority of instances, even in 
 persons who have never had ague or remittent fever, to the direct 
 action of the malarial parasites on the blood corpuscles, rather than 
 to the effect of mere " climate." 
 
 With each paroxysm of fever the red corpuscles decrease in 
 number. Instead of the normally estimated 5,000,000 red corpuscles 
 in I cubic mm. of the blood, oligocythaemia may proceed to such 
 an extent that their number may be reduced to one-fifth or even 
 one-tenth of the normal quantity. It is estimated that in each cubic 
 mm. of blood 1,000,000 red corpuscles may disappear in a single 
 paroxysm. 
 
 Poikilocytosis^ more especially in fevers of the malignant t\pes, is 
 to be observed, the red corpuscles showing numerous differences in 
 
MALARIA AND MALARIAL FEVERS 425 
 
 shape. Not only is the actual quantity of hcemoglobin diminished, 
 but after continued recurrences the remaining haemoglobin is 
 lessened in physiological value. 
 
 Malarial angemia is characterised by the usual pallor of the skin 
 and mucous membranes, and the attendant circulatory, digestive, and 
 renal troubles. Vitality is markedly lowered and the spirits subject 
 to fits of serious depression. 
 
 The liver is to be found enlarged and somewhat tender, and the 
 spleen in all chronic malarial affections increased in bulk, it may be 
 to an enormous extent. 
 
 Post-mortem appearances. — In addition to evidence of 
 anemia, parasitic infection of the red corpuscles and widely spread 
 pigmentation, the following conditions are met with. 
 
 The spleen is enlarged at times so that it weighs several pounds, 
 and the splenic tissue, when death has resulted after long-standing 
 illness, is dark -gray in colour, and firm in consistence. Micro- 
 scopically examined the melanin will be seen to occupy the 
 txabeculae and blood-vessel walls, and the macrophages are deeply 
 pigmented. The liver is usually somewhat enlarged, the tissue is of 
 a dark gray colour, and microscopically the capillary walls and the 
 phagocytes are found to be loaded with parasites. Cirrhosis is some- 
 times met with, or again small necrotic areas are seen scattered 
 through the liver substance. 
 
 The kidneys, in addition to their darkened colour, are somewhat 
 enlarged, and in the glomeruli pigment is readily detected. 
 
 The peritoneum and the mucous membrane of the alimentary 
 canal from the stomach to the rectum is stained a slate-gray colour. 
 
 The brain appears darkened in colour, and in the red corpuscles 
 in the capillaries are seen parasites in large numbers. Even the 
 endothelial lining of the capillaries is found swollen and pigmented. 
 The marrow of the long bodies becomes almost black, as the result of 
 prolonged malarial infection. Macrophages similar to those met with 
 in the spleen are found loaded with pigment, and in the marrow 
 itself pigmentary masses are not uncommon. 
 
 Prognosis. — The prognosis in the case of benign forms of 
 fever, so far as the life of the patient is concerned, is good, but 
 repeated attacks may so enfeeble a patient the subject of malaria 
 that a chronic cachexia of very grave import may supervene. 
 
 The malignant malarial fevers are attended by considerable 
 direct danger to hfe, and paroxysm may succeed paroxysm, leading 
 to fatal results. When pneumonia, dysentery, or nephritis com- 
 plicate malarial infection, the prognosis is grave indeed. Malarial 
 
426 MANUAL OF MEDICINE 
 
 cachexia tends to disappear after the patient has spent a couple of 
 years in a healthy non-malarial locality ; but any subsequent illness 
 is liable to assume features of a malarial type. Several forms of 
 neuritis and paralysis are ascribed to malaria ; these also tend to 
 disappear when the malarial district is left behind. 
 
 Prophylactic measures. — I. Personal prophylaxis consists 
 of — avoiding chills, changing damp clothing at once, sleeping 
 under mosquito netting and not on the ground level, moderation in 
 eating, drinking, and smoking, wearing flannel next the skin, and 
 protecting the head by a sun hat. Loss of sleep, fatigue and mental 
 anxiety conduce to pave the way for incursion of fever. 
 
 II. Afedkinal prophylactic measures resolve themselves into the 
 taking of quinine. Quinine should be taken before going out of 
 doors when the place of temporary residence is known to be highly 
 malarial, or when the season of the year predisposes to attack. Five 
 grains is the usual dose, but if the drug has to be continued for 
 several weeks three grains will be sufficient. Plehn holds that five 
 grains every fifth day is ample protection. When a person living in 
 a malarial district is over- fatigued, catches cold, or is run down 
 from any cause, a five-grain dose of quinine taken immediately may 
 prevent evil consequences resulting. 
 
 III. General prophylaxis. — Subsoil drainage is the only known 
 expedient of public sanitation which can be said to directly and 
 primarily affect the prevalence of malarial fever. Cultivation of the 
 soil, planting trees, especially, it is averred, the eucalyptus tree, the 
 supply of good water, and the improvement of house and town 
 drainage are important adjuncts. From what we know of the 
 mosquito, its habits and its proved connection with the life of the 
 malarial parasite, boiling the water used for drinking, cooking, and 
 even for bathing purposes is a safe precaution. The anopheles 
 species of mosquito is the insect which has so far been accredited as 
 the intermediary host of the malarial parasite. The ova of the 
 insect are deposited in shallow, stagnant pools, and there the 
 mature insect is developed. Local prophylaxis consists in sweeping 
 out these pools or in covering the water by kerosine, turpentine, or 
 other oily substances. 
 
 Treatment. — During the paroxysm of malarial fever the patient 
 should, whenever possible, get into bed. Flannel should be worn 
 and the linen sheets dispensed with. During the cold stage hot- 
 water bottles and extra blankets are necessary, and warm drinks of 
 weak tea, hot water and freshly-made lemonade are comforting. 
 During the hot stage the patient must be prevented throwing off the 
 
MALARIA AND MALARIAL FEVERS 427 
 
 extra clothing to too great an extent, and warm drinks are to be freely 
 supplied unless vomiting supervenes, when ice may be given to 
 suck. When the sweating stage arrives the hot bottles must be 
 removed from the bed, the excess of covering reduced, and if the 
 pulse is weak a stimulant may be given with the warm drinks. 
 After the temperature has fallen to the normal the surface of the 
 body should be wiped dry, and fresh flannels and blankets supplied. 
 
 Antipyretic remedies of the nature of antifebrine, antipyrin, and 
 phenacetin are largely used in the treatment of malarial fevers. 
 Unless, however, the temperature during the hot stage becomes 
 excessive there is no justification for their use. They no doubt 
 procure a freer perspiration, but it is improbable that they curtail 
 the period of the paroxysm. When, however, the temperature, 
 in adults more especially, rises above 105°, phenacetin is perhaps 
 the safest of the specially antiphlogistic remedies, and it may be 
 given in ten-grain doses every twenty minutes until thirty grains are 
 given. The same rule may be followed with antipyrin, and it is 
 wise with each dose to give a drachm or two of brandy. The 
 writer has had excellent results with the hypodermic injection of 
 antipyrin, on one occasion reducing a temperature of 107.6° in 
 twenty minutes to 103°, and in twenty minutes more to 100° by a 
 hypodermic of five grains of the drug. Should other means fail, 
 resort may be had to the wet pack, or to baths in which the tem- 
 perature is gradually reduced from that of the body warmth to 
 extreme coolness by the addition of ice to the water. 
 
 Medicines. — The medicinal treatment of malarial diseases, be 
 the variety what it may, is quinine ; whether as the sulphate, the 
 bisulphate, or the hydrochlorate is, for the most part, a question 
 of choice. It may be administered in solution with a few drops of 
 mineral acid, in tabloids, in powders, or hypodermically ; quinine 
 in the form of pills, more especially when coated, is to be avoided. 
 The amount of quinine to be exhibited need not be excessive ; a 
 fifteen-grain dose to start with, followed by five grains every four 
 hours, is sufficient, the interval and amount of the dose increasing 
 and decreasing respectively as the symptoms and paroxysm abate. 
 The time of administration is of some consequence ; in intermittent 
 fevers the period of apyrexia is selected and the drug continued up to 
 the onset of the paroxysm. In remittent fevers and in those of the 
 more continuous type quinine must be given at regular intervals 
 without regard to decline in temperature. It is possible that 
 antiphlogistic medicines — antipyrin or phenacetin causing a lowering 
 of the temperature and sweating — may be employed with some 
 
42 8 MANUAL OF MEDICINE 
 
 advantage, the quinine being given during the temporary abate- 
 ments. It may be taken as an axiom that, if quinine in five-grain 
 doses has been administered every four hours for three days with- 
 out decided effect, the case is most certainly not one of malaria. 
 When vomiting annuls the giving of quinine by the mouth it may be 
 injected hypodermically. The soluble hydrobromate or lactate ot 
 quinine, or the bisulphate, may be used dissolved in tartaric acid 
 (five grains of tartaric acid dissolving thirty grains of the sulphate). 
 A fifteen, twenty, or even thirty-grain dose of either of these drugs 
 may be injected into the subcutaneous tissues or into the substance 
 of the muscles. Quinine is accused of possessing several disad- 
 vantages ; headache, delirium, deafness, hasmaturia, hsemoglobinuria, 
 gastro-intestinal derangements, etc., are laid to its charge, for the 
 most part, if not wholly unjustifiably. The most untoward objec- 
 tion is the tendency to a deep-seated abscess and wide destruction 
 of the skin after hypodermic injection. Opium is a favourite drug 
 in many countries, and hypodermic injections of morphia, by allaying 
 feelings of malaise and nausea, have many advocates as accessories 
 to quinine. When pernicious fever assumes the comatose, algide, or 
 cerebral types, suitable remedies must be promptly adopted. Food 
 must be administered by the rectum if necessary ; heart failure must 
 be combated by stimulants and hypodermics of either atropin or 
 strychnine. Of prepared remedies Warburg's tincture is by far the 
 most reliable and beneficial ; methylene blue, arsenic, eucalyptus, 
 ergot, etc., etc., are used by but few practitioners. Euchinin, the 
 ethyl carbonate of quinine, also finds some supporters. 
 
 Malarial cachexia is best treated by removal of the patient 
 to a non- malarial district. A temperate or even cold climate is 
 most advantageous for invalids suffering from chronic tropical 
 malaria. Towns and the sea-side are to be avoided, and prolonged 
 residence on high ground is imperative if speedy and thorough 
 recovery is desired. Drugs, when cachexia is marked, are of little 
 avail. Arsenic and iron serve as adjuvants at times, and at times 
 iron does harm. Enlargements of the spleen, if recent, disappear, 
 bnt a rhronicnlly enlarged spleen may defy both internal and 
 external remedies to reduce its size. 
 
 James Cantlie. 
 
H^MOGLOBINURIC FEVER 429 
 
 H^MOGLOBINURIC FEVER 
 
 Syn. Blackwater Fever, West African Fever ■ 
 
 A specific fever restricted in its geographical distribution and 
 characterised by the presence of haemoglobin and its derivatives 
 in the urine. 
 
 Geographical distribution. — The disease is especially pre- 
 valent in the river basins of Equatorial Africa, but is also well 
 known in the Western Hemisphere, in Cuba, Venezuela, and the 
 Southern States of North America. It has been met with in a more 
 sporadic form in East Africa, especially in the Zambesi basin ; in 
 Europe it has been seen in Italy and in Greece. Cases have been 
 reported from India, Java, New Guinea, and the writer met with a 
 well-marked case in Hong-Kong occurring in a medical man recently 
 arrived from the gold-fields of Siam. Blackwater fever may occur 
 after the patient has left the countries in which it is endemic. 
 
 Etiology. — Three beliefs obtain at the present day as to the 
 cause of blackwater fever. 
 
 (i) That it is of malarial origin. In favour of this contention 
 it is argued that the disease occurs only in those who have suffered 
 from and are broken down by malaria. The parasites of malaria 
 are usually met with in the blood, and all the features of a malarial 
 paroxysm accompany blackwater fever. 
 
 Against this view, it must be stated that Laveran's parasite is 
 not invariably found in the blood of persons suffering from, 
 hgemoglobinuric fever ; that in some rare cases the disease may 
 occur within four or five weeks after landing on the West Coast of 
 Africa, and before malaria has had time to cause either ansemia or 
 cachexia ; that the very limited geographical distribution of the 
 disease betokens either a special form of the malarial infection, or 
 a toxic agent independent of the malarial parasite. 
 
 (2) Quinine is adduced as a causative agent. The chief reason 
 for this belief no doubt lies in the statement that the administration 
 of quinine, in large doses, seems to cause a recurrence of haemo- 
 globinuria in those who have become the subject of the disease. 
 This may be a clinical phenomenon, but it is hardly worthy of 
 being accepted as a pathological axiom. Malaria is so general 
 and the administration of quinine in large doses so universal in 
 
430 MANUAL OF MEDICINE 
 
 warm climates, that, were quinine in any way a determining cause 
 of the disease, the geographical distribution of hsemoglobinuria 
 would not be confined to a few definite and restricted regions. 
 That quinine may do harm during a paroxysm, or may induce a 
 relapse, is beside the question of the etiology of the disease. 
 
 (3) A specific agent is claimed by many observers as the cause 
 of blackwater fever. For this belief there is much to be said ; every 
 scientific inference points in this direction. Laveran's parasite 
 may be, and no doubt is associated with the disease, but the 
 association may be, and probably is, nothing more than a means 
 whereby the patient's strength is reduced and he becomes thereby 
 liable to infection by the specific agent of hasmoglobinuria. 
 
 Dr. Sambon holds the opinion that the haimoglobinuric fever 
 in man is caused by a parasite similar to that which causes the 
 hgemoglobinuric fever of cattle ; in other words, its specific agent 
 belongs to that group of hsemosporids which multiply by simple 
 binary division. He further believes that paroxysmal haemoglo- 
 binuria stands to blackwater fever in the same relation as entero- 
 colitis (the dysentery of northern latitudes) to tropical dysentery, the 
 difference in mortality arising from the fact of blackwater fever 
 usually supervening on persons already weakened by tropical 
 malaria. 
 
 Symptoms. - — Haemoglobinuric fever is often preceded or 
 accompanied by symptoms of malarial infection. 
 
 It is seldom until after the first year of residence in a black- 
 water fever country that the disease develops, and the third year is 
 considered to be the most likely period of its appearance. At any 
 time during the second and third years of residence, during what 
 seems to be a relapse of an irregular attack of fever, the patient is 
 seized with marked rigors, accompanied by headache, pain in the 
 loins, numbness in the extremities, pain in the epigastrium, and 
 distressing vomiting of bile-stained fluid. The temperature suddenly 
 rises to 103° or 104° F., the pulse becomes quick and small, the 
 breathing increases in frequency, and the patient is restless, anxious, 
 and apprehensive. The urine has at first merely a red hue, but 
 speedily acquires a dark -brown colour and a thickened consistency ; 
 calls to micturate are frequent, often attended with pain, and more 
 especially if the urine is scanty. When the fever has lasted some 
 hours the conjunctivae and the skin generally assume a yellow 
 tint, caused in all probability by the acute hsemolysis which is 
 taking place. After eight to twelve hours in favourable cases the 
 temperature falls rapidly, with profuse and exhausting perspiration, 
 
H.'EMOGLOBINURIC FEVER 431 
 
 to below the normal, the urine soon clears, and all the aches and 
 pains disappear. A trace of albumen may remain in the urine 
 for some days and the patient continues in a weak state for a 
 considerable time. 
 
 It may happen that no subsequent recurrence takes place, but 
 more often on the following day all the signs and symptoms are 
 repeated, or, on the other hand, the feverish attacks resembling 
 malarial paroxysms may occur without the accompanying alterations 
 in the urine. 
 
 Pathology. — The blood in blackwater fever usually indicates a 
 pronounced anaemia. The red corpuscles show advanced poikilo- 
 cytosis, their shapes being multiform. All the red corpuscles ap- 
 pear blanched as if deprived of their haemoglobin. Leucocytosis 
 is also a feature of the blood of blackwater fever, the polynuclear 
 cells being especially increased in numbers. The whole of the 
 haemoglobin-producing powers of the blood appear to be concerned 
 in the process, and it would seem, as suggested by IManson, that 
 some toxic solvent agent is at work, whereby not only the 
 disintegrated corpuscles, but also the uninfected red corpuscles, 
 by being despoiled of their hcemoglobin, contribute to the urinary 
 feature. When the urine passed during a paroxysm of blackwater 
 fever is allowed to stand a sediment results, which, when examined, 
 shows granular and pigmentary amorphous matter, large granular 
 casts of hemoglobin, some hyaline casts, a few red blood corpuscles 
 and epithelial scales. 
 
 The viscera are not characteristically affected. Black pigmentary 
 deposits are seen in the situations characteristic of malarial in- 
 fection ; the kidneys show cloudy swelling of the cells lining the 
 tubules, the tubes are blocked, and yellow and black pigments are 
 met with everywhere, except in the Malpighian corpuscles. The 
 spleen and liver cells are similarly affected as regards pigmentary 
 deposits, both black and yellow. 
 
 Staff Surgeon -Major Stendel of the German Army made an 
 examination of the blood by means of Fleischl's hsemometer, and 
 found that the amount of haemoglobin present oscillated between 
 50 and 21 per cent of the normal standard. In two other cases 
 the quantity was too small to be determined {Lancet, July 27, 1895, 
 p. 225) by the instrument, but it was estimated by the obser\'er at 
 not more than 5 and 8 per cent respectively. He lays stress upon 
 the prognostic value of h?ematological examinations. 
 
 Diagnosis.' — -Yellow fever is the disease with which blackwater 
 fever is most apt to be confounded. In yellow fever the urine 
 
432 MANUAL OF MEDICINE 
 
 contains albumen at an early stage and without hjemoglobin ; in 
 blackwater fever it contains cell-globulin, not albumen, and only 
 when dark in colour from haemoglobin. Dark urine is an early 
 feature in blackwater fever. The vomited matters are not merely 
 the bile-stained fluid met with in hsemoglobinuria, but consist of 
 the disintegrated red corpuscles and coagulated blood. Neither 
 thg spleen nor liver are enlarged in yellow fever, and post-mortem 
 evidence of pigmentation is wanting. 
 
 But hgemoglobinuria may be caused by organic or inorganic 
 toxins, such as potassium chlorate, arseniuretted hydrogen, sulphuric 
 acid, hydrochloric acid, phenol, naphthol, aniline, chrysarobin, pyro- 
 galhc acid, etc., and by the influence of cold or arduous muscular 
 exertions. The diagnosis between haemoglobinuria arising from 
 such causes and blackwater fever is made, however, without diffi- 
 culty. The paroxysmal haemoglobinuria of temperate climates in 
 many respects resembles blackwater fever, but it is rarely a fatal 
 disease. Moreover, it is a disease but occasionally met with over 
 widely diffused areas. The blackwater fever of West Africa (and 
 elsewhere) is, however, a frequent ailment in these regions, and 
 may be attended by a mortality as high as 60 per cent of those 
 attacked. 
 
 Prognosis. — A single attack of blackwater fever may be 
 followed by complete recovery. Repeated attacks may in like 
 manner result in disappearance of the malady. When, however, 
 the disease persists, when remission and not intermission of symp- 
 toms prevail, when the urine becomes scanty or is suppressed, a 
 grave prognosis is called for. Recovery, however, takes place from 
 what seems well-nigh hopeless conditions. 
 
 Unfavourable symptoms are a continuance of high fever, 
 persistent vomiting, purging of marked severity, suppression of 
 urine, mental depression, restlessness and delirium, deepening of 
 the jaundiced hue, a dry tongue, and a feeble pulse. Symptoms 
 of uraemia usually precede a fatal termination. 
 
 Treatment. — During the paroxysm of blackwater fever 
 quinine should be withheld. Attempts must be made to allay 
 excessive retching by giving ice to suck, and by mustard plasters 
 over the epigastrium. Strength must be maintained by rest in bed, 
 by giving sips of brandy and water or champagne, by ether hypo- 
 dermically, by rectal nutritive enemata, etc. 
 
 Perspiration should be encouraged by any of the usual methods. 
 The writer has found good results from the administration during 
 the attack of ten drops of oil of turpentine every two or three hours. 
 
KALA-AZAR 433 
 
 When blood examinations show the presence of the malarial parasite, 
 quinine must be resorted to when once the paroxysm of blackwater 
 fever has abated. Should repeated attacks of haemoglobinuria recur 
 coincidently with the administration of quinine, the drug must be 
 withheld, and the patient removed, if possible, from the district 
 where the disease is endemic to a temperate climate. 
 
 The nephritis which sometimes accompanies an attack of black- 
 water fever must be treated on general principles. 
 
 James Cantlie. 
 
 KALA-AZAR 
 
 An epidemic communicable disease, probably malarial in nature, 
 characterised by an acute onset and recurrent accessions of fever, 
 by enlargement of spleen and liver, by anaemia and cachexia, and 
 by a high death-rate. The disease has been accurately observed in 
 Eastern Bengal and Assam only. 
 
 Kala-dukh and kala-jwar, met with in the Purnea (Bengal) and 
 Darjeeling districts respectively, are, in all probability, kala-azar 
 under different names. 
 
 Etiology. — Considerable divergence of opinion concerning the 
 cause of kala-azar has up to the present obtained, nor can it be con- 
 sidered that the question is yet settled. The first systematic inquiry 
 into the etiology of the disease was made by Major Giles, I. M.S., 
 who believes kala-azar to be "a mixed anaemia brought about by 
 ankylostomiasis acting on a population worn down by chronic 
 malarial poisoning." Captain Rogers, I. M.S., as the result of his 
 investigations made subsequently to Major Giles's report, came to 
 the conclusion that kala-azar is malarial in origin. Against the 
 theory of the disease being ankylostomiasis it may be urged that 
 ankylostomiasis is so widespread, not only in Assam, but also 
 throughout India, the Malay Peninsula, and the Archipelago that 
 it is improbable so definite a set of symptoms as are described 
 under the kala-azar of Assam could be set up in one district only, 
 and, as far as we know, be unobserved in the others. 
 
 We are indebted to Major Ronald Ross, I. M.S., for extending 
 and systematising our knowledge of the disease. In his masterly 
 report upon "The Nature of Kala-azar" to the Government of 
 
 VOL. I 2 F 
 
434 MANUAL OF MEDICINE 
 
 Lodia, published in 1899, occurs the following statement: 
 '"That Ka]a-azar is malaria] fever in which the original invasion 
 gtadoallj dies out daring the first stage of the disease, leaving, in 
 the second stage; an acute tumour of the spleen and liver accom- 
 panied by a constant secondary or symptomatic fever, and finally 
 lesoEting in a cachexia in the third stage." 
 
 Although the initial symptoms of kala-azar, which pre\-ail in 
 malarial districts, are almost, if not quite, identical with those of 
 malarial fev^ yet against the malarial theory of the nature of the 
 malady the folowing points have to be considered : — the existence 
 of a low constant fever not amenable to quinine, and totally unlike 
 malarial f&FSX in the second stage of the disease : the apparent 
 absence of the parasites and melanin of paludism, both during life 
 and aftar death, from many established cases of the disease ; the 
 communicability of kala-azar from the sick to the healthy ; its 
 epidemicity and its hi^ death-rate. 
 . The eridaoce derived firom post-mortem examinations points to 
 death by typical paludism, as far as the liver, spleen, and kidneys 
 are concerned. The structure of these organs is practically 
 unaltoed, there being no neoplasms or necrotic areas. Melanin, 
 however, is absent or in minute quantity. Yellow pigment prevails, 
 but that is ftequaady due to a variety of agencies. 
 
 SymptoiEn& .firsf stage. — Kala-azar is ushered in by a 
 marked rigoar and fever of a severe nature. The fever at first is 
 remittent in nature but soon becomes intermittent ; and, in the 
 majcHrity of cases, rigors usher in the recurrent accessions. After 
 the initial fever, which lasts fi-om ten days to twenty-one days, a 
 period of apyresia usually supervenes, which may continue for 
 weeks or months, when a succession of relapses may occur, the 
 fever in each case resembling the initial, except that there may be 
 no rigors. On the othar hand, a continued low fever is established 
 in many cas^; soon aiier the jaimary attack, and continues through- 
 out the period <^ infection. 
 
 Enlargement of the spleen and liver are met with from almost 
 the first onset of the fever. The spleen is tender to palpation, 
 and qtdckfy inoreases in size. Anaemia and even emaciation may 
 appear during tibe first stage so rsqiid is the blood change, and it is 
 this quickly supervening anaemia which gives rise to the dark 
 leaden appearance rf the features and skin, which serves to give 
 die name to the disease — " kala " signifying black or deadly. 
 
 The second stage. — When the fever assumes a constant low 
 type and the spleen enlargement is established, the second stage of 
 
KALA-A2AR 435 
 
 the disease is said to commence. In regard to the temperature the 
 diurnal cur\"e remains the same day after day for weeks or even 
 months. If between 96' and 99' one day, the temperature chart 
 on succeeding days, for weeks or months, will show the same ; or 
 should the range be between 98'' and 102', the same obtains, show- 
 ing but a small range of variation. The splenic dulness may 
 occupy most of the left half of the abdomen, and the Hver exceeds 
 its normal limit downwards by from 2 to 3 inches. On percussion 
 both organs exhibit signs of tenderness. Anaemia is pronounced, 
 but not excessive, during the second stage of the fever. Emaciation 
 is usual ; and epistaxis, ascites, oedema of the feet, and sometimes 
 of the face, are commonly met with, and a slight degree of icterus 
 is frequently noted. 
 
 Third stage. — WTien the abdominal organs lose their tenderness, 
 when their enlargement ceases and fever declines, the third stage is 
 said to commence. Cachexia is the marked symptom of this period. 
 Ascites and occasionally oedema of the feet continue, and diarrhcea, 
 dysentery, and pneumonia are wont to supervene. The patient may 
 succumb to asthenia, or he might recover ; but when cachexia is 
 once firmly established recovery would seem to be impossible. 
 
 The duration of the &st stage is usually from one to two 
 months, and the beginning of the third stage occurs nine months or 
 more after the commencement of the illness. 
 
 Diagnosis. — Kala-azar can only be diagnosed when it has 
 reached the second stage of its course. Before this period is 
 reached ordinary paludism, beri-beri, and the anaemic state resulting 
 from ankylostomiasis, have all been mistaken for it. 
 
 Prognosis. — " The death-rate is high, but recovery often 
 occurs " (Ross). Death takes place occasionally during the second 
 stage of the disease, but it is the third stage during which marked 
 fatality occurs. 
 
 Treatment. — Most observers maintain that quinine is not only 
 useless, but even harmful in kala-azar. The first dut)' of the 
 practitioner is to examine the stools for the ova of the ankylostoma 
 and, if present, administer the appropriate remedies for their expulsion. 
 This step is taken not in the belief that the ankylostoma are the 
 cause of the disease, but in order to remove the lowering tendency 
 a number of intestinal parasites have on the general health. Further 
 treatment consists in maintaining the patient's strength, counter- 
 acting the anaemia, relieving the ascites, and obtaining, if possible, a 
 change of air. 
 
 James Cantlie. 
 
INDEX 
 
 Actinomycosis, 244 
 
 diagnosis, 248 
 
 histology, 245 
 
 symptoms, 246 
 
 treatment, 248 
 Anthrax, 152 
 
 bacteriology, 152 
 
 diagnosis, 154 
 
 post-mortem appearances, 155 
 
 prognosis, 155 
 
 symptoms, 153 
 
 treatment, 156 
 Antitoxin, 44 
 
 cholera, 124 
 
 diphtheria, 177 
 
 erysipelas, 67 
 
 plague, 137 
 
 tetanus, 161 
 
 typhoid, 106 
 Aspergillar mycosis, 249 
 Atmospheric pressure, variations of, ; 
 causing disease, 15 
 
 diminished pressure — symptoms, 19 
 
 increased pressure, 16 
 pathology of, 18 
 post-mortem appearances in, 18 
 symptoms of, 17 
 treatment of, 18 
 
 Bacteria, characters of, 25 
 
 cultivation of, 28 
 
 parasitism of, 27 
 
 spore formation, 26 
 
 structure of, 26 
 
 toxic products of, 29 
 Beri-beri, 353 
 
 atrophic form, 356 
 
 diagnosis, 359 
 
 etiology, 353 
 
 heart s-ffections in, 358 
 
 Beri-beri, incubation period, 354 
 
 mixed form, 357 
 
 motor disturbances, 357 
 
 cedematous form, 358 
 
 post-mortem appearances, 358 
 
 prognosis, 358 
 
 symptoms, 354 
 
 treatment, 359 
 Blackwater fever. See Haemoglobinuric 
 
 Fever, 429 
 Boil, 59 
 
 etiology of, 59 
 
 pathology of, 59 
 
 symptoms of, 60 
 
 treatment of, 61 
 Break bone fever. See Dengue, 350 
 
 Caisson disease, 16 
 
 Calmette's anti-plague serum, 139 
 
 Carbuncle, 59 
 
 etiology of, 59 
 
 pathology of, 59 
 
 symptoms, 60 
 
 treatment, 61 
 Cerebro - spinal fever. See Epidemic 
 
 Cerebro-spinal Meningitis, 182 
 Chicken-pox, 310 
 
 bacteriology, 314 
 
 complications, 314 
 
 diagnosis, 315 
 
 incubation, 310 
 
 symptoms, 311 
 
 treatment, 315 
 Cholera, 116 
 
 anti- choleraic inoculations, 121 
 
 bacteriology of, 118 
 
 diagnosis, 122 
 
 etiology, 117 
 
 geographical distribution, 116 
 
 incubation, period of, 120 
 
438 
 
 MANUAL OF MEDICINE 
 
 Cholera, mortality of, 123 
 
 post-mortem appearances in, 123 
 
 prognosis, 123 
 
 sequelae, 122 
 
 symptoms, 120 
 
 treatment, 124 
 Cold, morbid conditions due to, 14 
 
 treatment of, 15 
 Coley's fluid, 66 
 Cow-pox, 328 
 Crescent bodies in malaria, 420 
 
 Delhi boil. See Oriental Sore, 362 
 Dengue, 350 
 
 diagnosis, 352 
 
 geographical distribution, 350 
 
 incubation, 350 
 
 prognosis, 352 
 
 sequelafe, 351 
 
 symptoms, 350 
 
 treatment, 352 
 
 varieties, 351 
 Diazobenzol reaction of the urine, 94 
 Diphtheria, 163 
 
 bacteriology, 174 
 
 complications, 170 
 
 diagnosis, 176 
 
 etiology, 163 
 
 incubation period, 165 
 
 post-mortem appearances, 176 
 
 prognosis, 172 
 
 symptoms, 166 
 
 treatment, 177 
 Diseases excited by atmospheric influ- 
 ences, 10 
 Dysentery, 402 
 
 chronic, 407 
 
 diagnosis, 410 
 
 etiology, 402 
 
 liver abscess in, 408 
 
 parasitology, 404 
 
 post-mortem appearances, 409 
 
 prognosis, 411 
 
 symptoms, 405 
 
 treatment, 412 
 
 varieties of, 406 
 
 Ehrlich's test, 94 
 
 Electricity, morbid conditions due to, 21 
 
 pathology of, 22 
 
 post-mortem appearances, 22 
 
 symptoms of, 21 
 
 treatment of, 23 
 Endemic disease, 47 
 Enteric fever. See Typhoid Fever, 86 
 
 Epidemic cerebro-spinal meningitis, 182 
 
 bacteriology, 186 
 
 complications, 184 
 
 diagnosis, 187 
 
 post-mortem appearances, 185 
 
 prognosis, 186 
 
 symptoms, 183 
 
 treatment, 187 
 Epidemic disease, 48 
 Epidemic dropsy, 360 
 
 diagnosis, 361 
 
 etiology, 360 
 
 geographical distribution, 360 
 
 symptoms, 361 
 
 treatment, 361 
 Epidemic pneumonia, 178 
 Erysipelas, 64 
 
 bacteriology of, 63 
 
 etiology, 64 
 
 pathology, 62 
 
 symptoms, 65 
 
 treatment, 67 
 
 Famine fever. See Relapsing Fever, 139 
 Farcy. See Glanders, 217 
 
 buds, 218 
 Fever, symptoms of, 50 
 Foot and mouth disease, 396 
 
 diagnosis, 398 
 
 symptoms, 397 
 
 treatment, 398 
 FrambcEsia, 365 
 
 symptoms, 366 
 
 treatment,. 366 
 Frostbite, 15 
 
 General diseases — definition and classifi- 
 cation of, 9 
 German measles. See Rotheln, 269 
 Glanders, 217 
 bacteriology, 217 
 diagnosis, 219 
 symptoms, 218 
 treatment, 219 
 Gonorrhoeal infection, 82 
 arthritis, 82 
 
 diagnosis of, 84 
 symptoms of, 83 
 treatment, 85 
 
 Haemoglobinuric fever, 429 
 diagnosis, 431 
 etiology, 429 
 pathology, 431 
 prognosis, 432 
 symptoms, 430 
 treatment, 432 
 
f INDEX 
 
 439 
 
 Haffkine's anti-cholera vaccine, 124 
 
 anti-plague fluid, 137 
 Heat-apoplexy, 11 
 
 morbid conditions due to, 10 
 pathology of, 13 
 post-mortem appearances, 12 
 Heat-stroke, cause and symptoms, 10 
 sequelae, 12 
 treatment, 13 
 Hydrophobia. See Rabies, 389 
 Hyperpyrexia, post-mortem appearances 
 of, S7 
 treatment of, 57 
 
 Immunity, 35 
 
 active, 39 
 
 passive, 38 
 Infections, the, 24 
 
 classification of, 47 
 
 general course and characters of, 45, 
 398 
 
 post-mortem appearances in, 47 
 
 terminations of, 46 
 Infective endocarditis, 77 
 
 clinical varieties of, 80 
 
 diagnosis, 81 
 
 pathology and post-mortem appear- 
 ances, 77 
 
 symptoms, 79 
 
 treatment, 81 
 Infective meningitis, 182 
 Infective roseola, 273 
 Influenza, 202 
 
 abdominal type, 204 
 
 bacteriology, 212 
 
 complications, 204 
 
 course, 204 
 
 diagnosis, 208 
 
 etiology, 211 
 
 post-mortem appearances, 211 
 
 prognosis, 213 
 
 pulmonary type, 203 
 
 sequelae, 204 
 
 simple type, 202 
 
 special symptoms, 204 
 
 treatment, 214 
 
 Kala-azar, 433 
 
 diagnosis, 435 
 
 etiology, 433 
 
 prognosis, 435 
 
 symptoms, 434 
 
 treatment, 435 
 Kernig's sign, 184 
 
 Leprosy, 235 
 
 Leprosy, bacteriology, 237 
 
 diagnosis, 241 
 
 etiology, 236 
 
 geographical distribution, 235 
 
 incubation period, 238 
 
 prognosis, 241 
 
 symptoins, 238 
 
 treatment, 242 
 
 varieties, 238 
 Liver abscess in dysentery, 408 
 Lockjaw. See Tetanus, 158 
 Lyssophobia, 394 
 
 Madura foot, 249 
 Malaria, 416 
 
 clinical characters, 422 
 
 effects of, 424 
 
 etiology, 416 
 
 parasites of, 417 
 
 post-mortem appearances, 425 
 
 prognosis, 425 
 
 prophylaxis, 426 
 
 treatment, 426 
 
 varieties of, 424-426 
 Malignant pustule. See Anthrax, 152 
 Malta fever. 5^^ Mediterranean Fever, 110 
 Measles, 259 
 
 bacteriology, 266 
 
 complications, 264 
 
 diagnosis, 267 
 
 etiology, 259 
 
 prognosis, 266 
 
 symptoms, 263 
 
 treatment, 268 
 Mediterranean fever, no 
 
 diagnosis of, 114 
 
 etiology of, in 
 
 geographical distribution, no 
 
 morbid anatomy, 114 
 
 prognosis, 114 
 
 prophylaxis, 114 
 
 symptoms, in 
 
 temperature charts in, 114 
 
 treatment, 115 
 Membranous croup. See Diphtheria, 163 
 Mixed infections, 398 
 
 frequency of occurrence, 399 
 Mosquito, relation to malaria, 420 
 Mountain sickness, 19 
 Mumps, 337 
 
 complications, 339 
 
 diagnosis, 340 
 
 etiology, 337 
 
 incubation period, 338 
 
 prognosis, 340 
 
 symptoms, 338 
 
440 
 
 MANUAL OF MEDICINE 
 
 Mumps, treatment, 340 
 Mycetoma, 249 
 Mycoses, 243 
 
 Oriental sore, 362 
 etiology, 362 
 
 geographical distribution, 362 
 prognosis, 363 
 symptoms, 363 
 treatment, 363 
 
 Pertussis. See Whooping-Cough, 340 
 Phagocytosis, 34 
 Plague, 128 
 
 bacteriology, 129 
 
 communicability, 130 
 
 diagnosis, 134 
 
 etiology, 129 
 
 geographical distribution, 128 
 
 Haffkine's anti-plague fluid, 137 
 
 morbid anatomy, 135 
 
 mortality, 137 
 
 prognosis, 136 
 
 prophylaxis, 137 
 
 symptoms, 131 
 
 treatment, 138 
 
 variations in type, 132 
 Posterior basic meningitis, 189 
 
 bacteriology, 190 
 
 complications, 192 
 
 diagnosis, 194 
 
 etiology, 189 
 
 post-mortem appearances, 195 
 
 prognosis, 193 
 
 symptoms, 190 
 
 treatment, 195 
 Predisposition, 39 
 Ptomaines, 31 
 Pyaemia, nature of, 74 
 
 post-mortem appearances, 75 
 
 symptoms, 76 
 
 treatment, 78 
 Pyrexia, 50 
 
 excretion of COg and N in, 56 
 
 occurrence in various diseases, 52 
 
 post-mortem appearances of, 57 
 
 production of, 51 
 
 treatment, 57 
 
 Rabies, 389 
 diagnosis, 393 
 " dumb rabies," 392 
 incubation period, 391 
 mode of infection, 390 
 morbid anatomy, 393 
 symptoms, 391 
 
 Rabies, treatment, 395 
 
 virus, 390 
 Relapsing fever, 139 
 
 diagnosis, 142 
 
 pathology, 141 
 
 post-mortem appearances, 142 
 
 prognosis, 142 
 
 symptoms, 140 
 
 treatment, 142 
 Resistance of the tissues, 33 
 Rheumatic fever, 291 
 
 nodules, 294 
 Rheumatism, acute and subacute, 291 
 
 chorea in, 296 
 
 cutaneous manifestations in, 295 
 
 heart affections in, 291 
 
 joints in, 294 
 
 pathology, 302 
 
 prognosis, 304 
 
 tonsillitis in, 295 
 
 treatment, 306 
 
 urine in, 295 
 Rotheln, 269 
 
 diagnosis, 272 
 
 symptoms, 270 
 
 treatment, 272 
 
 Sapraemia, nature of, 69 
 
 symptoms, 71 
 
 treatment, 73 
 Scarlet fever, 274 
 
 bacteriology, 287 
 
 complications, 286 
 
 diagnosis, 288 
 
 etiology, 274 
 
 incubation, 276 
 
 post-mortem appearances, 287 
 
 prognosis, 288 
 
 septic form, 282 
 
 simple form, 276 
 
 toxic form, 284 
 
 treatment, 288 
 Septicaemia, nature of, 72 
 
 diagnosis, 73 
 
 post-mortem appearances, 73 
 
 treatment, 74 
 Serum diagnosis, 32, 102 
 Siriasis, 11 
 Smallpox, 316 
 
 complications, 321 
 
 diagnosis, 324 
 
 histology, 323 
 
 incubation, 317 
 
 inoculation for, 327 
 
 mode of conveyance, 316 
 
 modified, 323 
 
INDEX 
 
 441 
 
 Smallpox, prodromal rashes, 319 
 seasonal prevalence, 316 
 symptoms, 318 
 treatment, 325 
 Splenic fever. See Anthrax, 152 
 Subcutaneous nodules in rheumatic fever, 
 
 294 
 Suppurative meningitis, 196 
 bacteriology, 197 
 diagnosis, 199 
 etiology, 197 
 
 post-mortem appearances, 200 
 prognosis, 199 
 sjTnptoms, 198 
 treatment, 201 
 Syphilis, 367 
 
 acquired in adults, 367 
 acquired in infants, 386 
 diagnosis, 372, 386 
 prognosis, 373 
 symptoms, 368 
 treatment, 373 
 inherited, 374 
 Colles's law, 377 
 effect on mother, 376 
 prognosis, 387 
 symptoms, 378 
 treatment, 387 
 
 Tache bleuatre, 93 
 Temperature, normal, 50 
 Tetanus, 156 
 
 bacteriology, 156 
 
 diagnosis, 160 
 
 etiology, 158 
 
 incubation, 158 
 
 ner\-atorum, 158 
 
 post-mortem appearances, 160 
 
 prognosis, 160 
 
 symptoms, 158 
 
 treatment, 161 
 Thermic fever, 11 
 Trismus. See Tetanus, 158 
 Tuberculosis, 220 
 
 bacteriology, 220 
 
 contagiousness, 231 
 
 curability, 232 
 
 distribution in various organs, 223 
 
 duration of, 234 
 
 histology, 221 
 
 influence of age and sex, 230 
 
 invasion, 223 
 
 symptoms, 232 
 
 treatment, 234 
 Typhoid fever, 86 
 
 bacteriolog}' of, 86 
 
 T)'phoid fever, cold baths in, 107 
 
 complications of, 96 
 
 diagnosis of, 102 
 
 diet in, 106 
 
 etiology of, 87 
 
 incubation of, 92 
 
 onset of, 90 
 
 post-mortem appearances in, 90 
 
 preveritive inoculation in, 106 
 
 prognosis, 104 
 
 prophylaxis, 105 
 
 rash in, 93 
 
 relapses in, loi 
 
 sequelae, 96 
 
 stools, disposal of, 105 
 
 s}anptoms, 92 
 
 treatment, 106 
 
 varieties of, 95 
 
 without intestinal lesions, 87 
 " Typhoid state," 95 
 Typhus fever, 252 
 
 bacteriolog}', 252 
 
 complications, 256 
 
 diagnosis, 256 
 
 etiolog}-, 252 
 
 morbid anatomy, 253 
 
 symptoms, 253 
 
 treatment, 257 
 
 Vaccination, 39, 328 
 
 alleged injurious effects of, 333 
 
 glycerinated lymph, 335 
 
 history' of, 331 
 
 practice of, 335 
 
 protection afforded by, 332 
 
 revaccination, 333 
 Vaccinia, 328 
 
 histologj', 330 
 
 relation to variola, 329 
 Varicella. See Chicken-pox, 310 
 
 bullosa, 314 
 
 gangrenosa, 314 
 Variola. See Smallpox, 316 
 Varioloid, 323 
 Verruga peruana, 364 
 
 diagnosis, 365 
 
 symptoms, 364 
 
 treatment, 365 
 
 WTiooping-cough, 340 
 bacteriology, 340 
 clinical course, 342 
 complications, 345 
 convalescence, 346 
 diagnosis, 347 
 paroxysmal stage, 343 
 
442 
 
 MANUAL OF MEDICINE 
 
 Whooping-cough, prodromal stage, 342 
 
 prognosis, 347 
 
 treatment, 348 
 Widal's serum reaction, 32, 102 
 Woolsorters' disease. See Anthrax, 153 
 
 Yaws. See Frambcesia, 365 
 Yellow fever, 143 
 bacteriology, 144 
 
 Yellow fever, diagnosis, 146 
 
 morbid anatomy, 147 
 
 prognosis, [46 
 
 seasonal prevalence, 143 
 
 symptoms, 144 
 
 treatment, 147 
 Yersin's anti-plague serum, 139 
 
 Zenker's vitreous degeneration, 91, 253 
 
 END OF VOL. I 
 
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