intbeCitpotittlu^ork l&tUvma ffitbrarg Digitized by tine Internet Archive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/cletails/handbookoffeversOOmccl A HANDBOOK OF FEVERS. J. Campbell McClure, M.D. To THE Memory of The Late SIR WILLIAM GAIRDNER, K.C.B., AND The Late J. B. RUSSELL, M.D., THE TWO FIRST MeDICAL OFFICERS OF HeALTH FOR THE City of Glasgow. A HANDBOOK OF FEVERS BY J. CAMPBELL MCCLURE, M.D. (Glasgow). PHYSICIAN TO OUT-PATIENTS, THE FRENCH HOSPITAL, LONDON, AND PHYSICIAN TO THE MARGARET STREET HOSPITAL FOR CONSUMPTION AND DISEASES OF THE CHEST, LONDON. FORMERLY— SENIOR RESIDENT ASSISTANT PHYSICIAN, ASSISTANT SUPERINTENDENT, AND RESIDENT MEDICAL OFFICER IN CHARGE OF THE SMALLPOX HOSPITALi BELVIDERE FEVER HOSPITAL, GLASGOW. PAUL B. HOEBER, 6 7-6 9, EAST 59 th STREET, NEW YORK. 19U. V '/fe - - -^0 5 LONDON : Shaw & Sons, Printers, Fetter Lane, Fleet Street, E.G. V n \ '12.. PREFACE rpiHIS book pretends to be no more than a -^ handbook for the use of students and general practitioners, and the author has endeavoured as far as possible to confine his attention to the more practical aspects of the diseases under consideration, devoting more space to treatment than many will perhaps approve of. Detailed descriptions of the pathological anatomy of the various diseases have been purposely avoided, and only such points in epidemiology and bacteriology have been dwelt upon as seem to be absolutely necessary. Only those tropical diseases have been included in this small volume as may possibly be met with in Great Britain in the ordinary course of practice. Beriberi has been included since, although it is not strictly a febrile disease, it appears to be due to some specific infection, and is not infrequently seen in our larger seaport towns. The inclusion of a chapter on Pellagra has been rendered necessary by the discovery that the disease is prevalent in the United States of America to a degree undreamed of half a dozen years ago, and by the fact that it seems likely that in the next vi Preface. few years a considerable number of cases will be discovered in this country. The disease is unknown to the majority of practitioners in the British Islands, and it is probable that increased knowledge of the symptomatology and course of this interesting disorder will, as was the case in the summer of 1913, lead to the discovery of the disease in areas hitherto unsuspected. 59, Harley Street, W. CONTENTS. CHAPTER I. Introductory PAGE 1 Fevers of Known Bacteriology. II. Enteric Fever III. Diphtheria ... IV. The Plague V. Cholera' VI. Relapsing Fever VII. Malaria VIII. Epidemic Cerebro-Spinal Meningitis IX. Anthrax ... ... X. Glanders XI. Influenza XII. Pulmonary Tuberculosis ... XIII. Dysentery XIV. Kala Azar 10 47 72 84 97 105 125 137 146 154 166 194 208 viii Contents. Fevers of Uncertain Bacteriology. CHAPTER PAGE XV. Scarlet Fever 216 XVI. Measles 252 XVII. German Measles 274 XVIIL Small-pox 283 XIX. Chicken-pox 313 XX. Typhus ..) 321 XXI. Mumps 347 XXII. Rheumatic Fever 358 XXIII. Yellow Fever ... 379 XXIV. Whooping Cough 395 Acute Diseases frequently attributed to a Diet consisting largely of certain Cereals. XXV. Beriberi 414 XXVI. Pellagra ... 426 Appendix The Serum Treatment of Tuberculosis ... 439 Ceiapter I. INTRODUCTORY. The febrile state, to whatever cause it may be due, is characterised by certain general signs and symptoms which are met with almost constantly whenever there is any con- siderable rise of temperature above the normal. The patient may at the onset of the febrile attack experience a sense of exaltation, of well-being above the normal, and may present a facies suggestion of mental excitement with more or less flushing of the cheeks and unusual brightness of the eye. In other cases the onset of fever may be marked by a sensation of chill, amounting in some cases to an undoubted rigor, with pallor of the face and an appearance of apprehension and uneasiness. In any case, the patient is soon the subject of indefinite malaise, headache, loss of appetite and a general feeling of enfeeblement. He may be quiet and drowsy, or restless and delirious. He feels hot, complains of thirst, may suffer from nausea, may be con- stipated, or may have slight diarrhoea. The face is flushed more or less generally according to the disease, the eye is usually bright, but sometimes dull and bloodshot, and there is a suggestion of "remoteness" about the expression of the sick person. The pulse and respiration are quickened, in varying proportion to the rise in temperature according to the disease of which the fever is a manifestation. The urine is scanty and high coloured, rich in urates and frequently deficient in chlorides. It is usual now-a-days to consider that fever is the effect of toxins of bacterial origin on the heat- regulating mechanism, so that there is at the same time an increase in heat production, the result of increased metabolic processes, and a decrease in heat-loss, due to the poisoning of 2 Chapter I. the central vasomotor areas. The increase in the rate of respiration is probably due to two causes — (a) an attempt to aerate blood unduly charged with the waste-products of metabolism, and (b) a poisoning of the respiratory centres, while the increase in heart-rate may be due to a direct in- hibition of the vagus, or stimulation of the sympathetic cardiac fibres by the circulating toxins. Fever is usuallj^ described according to its height, and also according to the type of its daily variation. A temperature of 100° F. or over is considered to be febrile, and it is com- mon to call all fever over 105° F. liyyer'pyrexia. In febrile co7iditions the ordinary daily variation of temperature — slight morning fall and evening rise — is usually preserved. In some few cases, however, the evening temperature is lower" than the normal, and it is possible that in such cases this has been the ordinary habit of the individual in health. A fever is called continued when the daily variation is only two degrees Fahrenheit or less. It is called reTnittent when the daily variation is over 2° F. and when the lowest point does not fall to normal, while a fever which has a daily variation of more than 2° F. and when the lowest point falls to or below normal is called intermittent. The onset of a fever varies greatly in different cases. Sometimes the invasion is sudden and severe, with a tempera- ture rising to high pyretic or hyperpyretic registers in a few hours, while sometimes the invasion is slow and gradual — days elapsing before the fastigiuTn or height of the fever is reached. Similarly the termination of the fever may be sudden and complete in a few hours, or it may be gradual, taking seA^eral days to reach the normal. The former is called termination by crisis, the latter termination by lysis. Before the actual complete termination of a fever, a fall of the temperature to normal, or nearly so, may suddenly occur, but instead of remaining in normal regions the tem- perature may rise again as suddenly to heights as great or even greater than before the fall. Such an occurrence is termed a yseudo-crisis. Accompanying a crisis it is common to have a great in- crease in the output of urine, which at this time is often pale Introductory. 3 and may contain crystals of uric acid. Sweating is usually profuse, and there may be a tendency to diarrhoea. These "critical discharges" have been observed by the earliest writers on the subject. In estimating the temperature of a patient certain pre- cautions must be observed. A reliable thermometer is the j&rst essential, and it is wise to have an instrument furnished with a certificate from Kew showing the actual error in its registering. The thermometer should be sensitive, one sup- posed to register the temperature accurately in 30-60 seconds should be used, but it should be kept in place for some two minutes before reading. The temperature of the axilla, groin, mouth or rectum may be taken, and it must be remembered that the' skin of the axilla and groin should be thoroughly dried before the thermometer is introduced. The normal temperature is considered to be 98.4° F. in the axilla or groin, 98.8° — 99° F. in the mouth or rectum, but considerable phj^siologieal variation is frequently observed. Roughly speaking, a temperature of 97.4° — 98.8° F. in the axilla may be considered normal; above that to 100° F. it may be_ described as subfebrile, while 100° F. and over may be reckoned as fehrile, and below 9T.4° F. anay be considered subnormal. The observer should remain beside the patient while the thermometer is in position to prevent accidental moving of the instrument, or manipulation of it by malingerers and hysterical patients. It is important to take care as to the hours at which the temperature is taken. Where fever is suspected, it is not enough to take a usual "morning and evening" temperature, at 8 or 9 a.m. and 8 or 9 p.m. Where only two readings are taken, the maximum temperature is often missed and the physician has but little knowledge of the daily variation in the temperature-curve. It is often very- difficult in practice to have accurate observations on the temperature made where no trained nurse is in attendance, but in these days, when a clinical thermometer is as common a piece of furniture as a hot-water bag, it is not usually difficult to have a series of fairly dependable observations made by some responsible member of the household. Among the poorer and less 4 Chapter J. educated classes, the district nurse can usually be relied upon to make a couple of calls a day at liours which, together with visits of the physician, will help towards a reasonably complete series of observations of the temperature. Regularity in the hours of taking the temperature is of the greatest importance. Where possible the temperature should be observed every four hours, 4 a.m., 8 a.m., 12 noon, 4 p.m., 8 p.m., and 12 midnight, or tlie liours of 2 a.m., 6 a.m., 10 a.m., 2 p.m., C p.m., and 10 p.m. may be chosen. The early morning ob- servations at 2 a.m. or 4 a.m. may be omitted if circum- stances demand. By these means the temperature is recorded at the same time each day, and it is unlikely that any very important variation will be missed. In certain cases more frequent observations may be necessary or at least ad- visable. In cases of puhuonary phthisis who do not require to be kept in bed, it is necessary to observe the temperature before and after exercise. There are certain general principles which underlie the treatment of the febrile state whatever the disease be in which the fever is a symptom. As a result of poisoning by bacterial toxins, tissue waste is abnormally active, and at the same time, the powers of secretion and ex- cretion are below the normal. It is necessary to prevent, and replace as far as may be, this increased wasting, and at the same time to increase the power of the bactericidal and anti- toxic elements, and also to encourage excretion in every possible way. Hest in bed is the first essential during the whole period of fever, and for such time after as the con- dition of the patient may demand. From very early times it has been recognised clinically that rest is a necessity in the treatment of the acute fevers, and it is interesting to note that the researches of Almroth Wright have confirmed this practice. Wright has pointed out that it is possible in cer- tain chronic infective processes to produce by movement and exercise a toxaemia which is beyond the immediate capacity of the patient's resisting powers. This process of "auto-inocula- tion" may be used for curative purposes under certain condi- tions, but the realisation of the meaning of the process will make it very evident that the production of an "auto-inoculation" Introductory. 5 by movement and restlessness on the part of a patient acutely ill with a fever, whose powers of immunisation are already taxed beyond their capacity for immediate response, must be followed by evil results and may adversely influence the progress of the disease. Wright's work has added another reason for the absolute quiet of a febrile patient, for the necessity of procuring sleep for him, and subduing his delirium and restlessness. Attention must be paid to the functions of the gastro- intestinal tract, liver and kidneys, and it must not be for- gotten that the skin is a most important organ of elimination. The comfort of the patient must be carefully looked after — much depends on the withdrawal of all powerful sensory stimuli during a fever — quiet and freedom from emotional disturbance is essential, and serious effort must be made to procure sleep. The effect of a sense of well-being on the patient is being more and more realised in the treatment of disease, and it is a matter of common knowledge that the removal of an apparently trivial but troublesome symptom may influence favourably the course of a grave illness. The height of the temperature may in itself call for treatment, although it is to be remembered that fever is only a symptom of a generalised diseased condition, and that interference by certain methods with this symptom may be attended by the worst results. It is a good rule never to give antipyretic drugs. In doses suificient to reduce temperature they are apt to induce collapse, and sometimes death from cardiac failure. Most physicians have had the experience of being called in to see a case of pneumonia or enteric fever which has been treated with antipyretic drugs in a comparatively early stage of the disease, and have found the patient cyanosed and col- lapsed, with a feeble flickering pulse and every sign of im- minent death. The height of the temperature in itself is a matter of small import. It is the effect of the high temperature and the general toxaemia on the cardiac strength and cerebral mechanism of the patient that the physician must observe with care and combat if necessary. Fever, if too high for safety, or continued in high registers for a prolonged period, should be reduced by external applications of tepid, cold or 6 Chapter I. iced water, either by sponging, packing, applying compresses or bathing. Where such applications fail to give the patient relief it is not probable that any known drug will reduce the temperature without jeopardising the safety of the patient. In one or two instances, apart from malaria, quinine may be of service. The diet should be fluid and bland; milk, prepared and modified, if necessary, in various ways, should be the chief article of food, alternated with clear soups, rich in ex- tractives. The extractives supply a stimulus to gastric secretion similar to the normal psychic stimulation in health. Soluble carbohydrates may be added to the milk in some cases, and certain specially prepared proprietary foods will be found to be of use. Of these special foods many are almost entirely nitrogenous, and are given with the object of directly repairing tissue waste, e.g., somatose and plasmon. Cath- cart's experiments have shown that, without a due proportion of carbohydrate admixture, nitrogenous food is quite incap- able of preserving or replacing nitrogenous tissue-wasting, and it has always been my principle in the dieting of fevers to supply as much soluble carbohydrate as can be tolerated by the patient, in the belief that by this means an easily com- bustible material is offered to the body and the proper utilisa- tion of the nitrogenous food in the dietary assured. I can- not see that benefit ensues from the exhibition of gelatine. It is an end-product, and save as a vehicle for sugar and a way of inducing a patient to take milk, can be of little ser- vice in nutrition. Tea and coffee well diluted with milk form a very useful adjunct to the dietary of the fevered. Many people who have a distaste for milk in the natural state may be induced to take fairly large quantities when it is sweetened and flavoured with coffee, while the action of caffeine is not to be despised in the treatment of fevers, especially those of long duration. The addition of eggs, raw and cooked, to the food of those suffering from fever will be discussed later. During convalescence, a mixed diet should be gradually resumed, but its hasty resumption is to be avoided, save in moderate cases of typhus and smallpox, as much permanent damage to digestion has often been done by careless and hasty feeding after many of the acute fevers. Water may be given freely. Introductory. 7 It encourages elimination, and its deprivation is a source of irritation to a patient whose mouth is parclied and dry. It should he given frequently and in small quantities. Regu- larity in feeding is of great importance, but sleep should not be interfered with for the sake of a feed. Everything taken should be accurately recorded by the attendant and added up at the end of the day. The mouth should be washed out several times a day with a warm alkaline solution and the teeth and gums should be cleaned before feeding with a piece of cotton wool dipped in a mixture of equal parts of glycerine of borax and warm water. The use of alcohol in the treatment of acute disease has been discussed of late years ad nauseam. The truth lies, as is so often the case, between the views of the extremists. If used with discretion and in moderation it is often of the greatest service; used carelessly and in excessive quantities it is often dangerous. It is ridiculous to condemn a drug like alcohol because when given indiscriminately and to excess it may do harm to the sick person, and it is all the more ridiculous if such condemnation is not the result of unfor- tunate experience in treating the sick, but is due to a fanatical hatred of alcohol from the social point of view. Opium, chloral, cocain, antipyrin and phenacetin have all been used by drug maniacs to satisfy their hedonistic propensities, yet no sane person would condemn the use of these drugs in medical practice because, taken to excess and apart from the necessities of disease, they have been the cause of the final col- lapse in the career of certain neurotics. On the other hand, there is some excuse for the anti-alcoholic enthusiasts. The routine treatment of fevers by alcohol in doses which now astonish us, was fairly common among physicians of the last generation, and like all routine forms of drug treatment, has rightly fallen under suspicion. There is little doubt, also, that the careless prescribing of alcohol during convalescence has often helped to revive or establish habits of excessive alcoholism. Alcohol, like all other drugs, must be used, in acute disease, only to tide over certain emergencies, and so used, will be found effective in doses which, compared with the daily allowance of 5x. and 5xx., which used to be 8 Chapter I. common iu the treatment of typhus, are positively liliputian. Apart from its use as a diffusible stimulant, alcohol is of the greatest service as a hypnotic and sedative in many of the acute fevers, and it will rarely be found necessary to give more than 511. to §iv. in the day, and that only for very limited periods. A drug which can with safety and in moderate doses bring rest and sleep to a child with whooping- cough or to a patient with pneumonia, or quiet the delirium of typhus, cannot be thrown aside to satisfy the prejudices of a few who judge it only by its effects on society when taken to excess and apart from medical necessity. To save re-iteration, I think it best to give' in this introduc- tory chapter certain details in the management of the patient which are common to all the infectious fevers, and to mention under the heading of "home prophylaxis" at the end of the description of each disease those particular points which are specially necessary for the disease under consideration. If a patient is nursed at home strict isolation from all ex- cept his immediate attendants must be maintained. The sick-room sliould be as large as possible, stripped of all hang- ings and pictures, and kept well ventilated, but I do not think that the stripping of the carpet is necessary or even wise, if it be brushed damp each day, because it acts to a certain extent as a prevention against the entrance of germs into the spaces between the planks of the floor, and can be easily disinfected at the end of the illness. A polished parquet floor is, of course, the ideal for a sickroom, but this is not often obtain- able in Great Britain. The hanging of carbolised sheets over the door is of no service in isolation, and the smell of carbolic acid is ver}- distasteful to many people. Similarly, spray- ing or vaporising a room with some carbolic preparation is equally useless and impleasant. "Sanitas Fluid" or some such aromatic disinfectant in the form of a spray is useful as a deodorant. All vessels which have been in contact with the patient or, indeed, have been in the patient's room, should be cleansed with boiling water immediately after use. The water must not only be hot but actually boiling. Sheets and body clothing should all be steeped in a disinfectant solution and boiled before washing, and sponges should be boiled Introductory. 9 frequently. Brushes may be elfectively cleaned by thorough washing in a strong hot solution of carbonate of soda. It is well for the patient's attendant to have the arms bare to the elbow; no long sleeves or cuffs should be worn by a fever- nurse while on duty. She should wear, while in the sick- room, an overall which should be changed every two days and steeped in 1-20 carbolic solution and boiled before being sent to be washed. Where possible, the attendant should never eat in the sick room, and should always wash the hands and brush the nails thoroughly before a meal. She should eat every four hours ; the food should be light and easily digested ; the meal should be eaten leisurely; and no one ought to be in charge of a fever patient who is ansemic, who suffers from dyspepsia, or whose teeth are not well kept and free from caries. All attendants on fever-cases should have two hours daily in T^hicli to take the air, and the time on duty should not be longer than twelve hours, inclusive of the time spent at meals, 30 minutes at least being allowed for each meal. Of course, the exigencies of particular cases must modify this. One has no sympathy with either the physician or the nurse who are so bound down by rule as to insist on regular routine at times of danger to the patient, and it is to be remembered that, in the nursing of infectious cases in private houses, the care of the room and of the fire and the preparation of simple food should be cheerfully undertaken by the nurse if she is to be of real service to the physician and the patient. The position of the nurse in a private house is often difficult and sometimes unpleasant, but the physician has daily to experience similar discomforts at the hands of ignorant and arrogant people, and if a woman is not possessed of sufficient tact and resource to tide over such difficulties satisfactorily, she should adopt any other profession than that of nursing. In nursing, as in every other calling, people who are continually insisting on their "rights" have a singu- larly unpleasant time, while those who quietly and without fuss establish their position in each new situation in which they find themselves, are surprised how pleasant work may be. A change of environment necessitates a modification of con- duct, and the fittest survive. FEVEES OF Kl^OWN BACTERTOLOGY. Chapter II. ENTERIC FEVEE. Synonyms. — Typhoid fever : Gastric fever : Pytliogenic fever. French : Fievre typlioide. German: Typhus Abdominalis ; Abdominaltyphus. Definition. — An acute exanthematous fever, characterised usually by a slovt^ and insidious onset, having a duration of some three to five weeks, and associated with a general blood- infection and an invasion of the lymphoid tissue of the ileum causing infiltration and ulceration of Peyer's patches and the solitary follicles, by a specific organism, the B. typhosus, dis- covered by Eberth in 1880. Incubation Period. — This is extremely variable, from 2 to 21 days, the usual period being from 10 to 15 days. Rash. — The rash of enteric fever is very typical. About the 6th to the 10th day of the disease, small "rose-spots" ap- pear on the skin, the abdomen being the most usual situation. They are slightly raised above the surface of the skin, and when firmly pressed upon disappear for a moment. The duration of each spot is three or four days, but they tend to appear in successive "crops," so that the eruption may be A'isible for weeks. In most cases the spots have all faded some 10 days after the first has appeared. As a rule the eruption is scanty, limited to a few spots on the abdomen, but in some cases the whole abdomen and the lower part of the chest may be thickly covered with typical rose-spots, while in other cases the skin of the body generally may present a very abundant rash. The Enteric Fever. 11 rash is present in a large proportion of all cases of enteric fever, but cases do occur in which no rash is visible, and an eruption of rose-spots, quite indistinguishable from a true enteric fever rash, is sometimes met with in cases of abdominal tuberculosis and acute or subacute gastro-intestinal catarrh, so that a typical eruption of rose-spots, although it may strongly suggest enteric fever, is by no means patho- gnomonic. A tdclie hletidtre having the appearance of faint violet finger-tip marks has been frequently observed as a prodromal rash, or appearing in conjunction with the ordinary rash, but as it occurs in many conditions other than enteric fever it is of no diagnostic value. Clinical types, — Period of Invasion : It is, in most instances, a matter of extreme difficulty to fix accur- ately the beginning of the period of invasion in enteric fever. The onset of the disease is commonly so insidious and the symptoms so slight at the com- mencement, that it takes the patient several days to discover that his health is much below normal. He usually becomes gradually aware that his appetite is poor and his tongue furred ; he has a "bad taste in the mouth," while he suffers from a feeling of slight general malaise and listlessness ; he may have some headache and find that his powers for work are below normal. In other words, he feels unaccountably "run down," and at this stage of his illness, if he be a person of sedentary occupation, he frequently takes more exercise than usual in the hope of bracing himself up. In spite of this, however, he finds that the feeling of lassitude grows, and he is con- scious of a real increasing enfeeblement, which at last makes him take to bed, while headache, which may have been only slight and transitory at first, very frequently becomes an urgent symptom. At the same time he may suffer from deaf- ness, and his friends notice that he is a curious compound of listlessness and irritability. Sore throat, with congestion of the fauces and tonsils, is a frequent symptom. The period of invasion lasts usually for about a week, sometimes more and rarely less, and it is in this period that a patient may do himself unconscious harm by endeavouring to 'Svork off" what 12 Chapter II. appears to him to be a slight temporary ailment. In a small proportion of cases the period of invasion is short and the symptoms urgent. The patient may be suddenly seized to all appearance with an acute pneumonia, and only the subsequent course of the illness will shew that the pneumonia has been due to an invasion of the B. typhosus. In certain of the cases with sudden onset the disease may simulate an attack of scarlet fever, with high temperature from the onset, in- flamed fauces and tonsils and a bright scarlatiniform rash, and it is only when the rash fades without abatement of the fever and the characteristic "rose-spots," which in such cases are usually yerj profuse, appear, that enteric fever is even suspected. In other cases a rapid and severe onset is not attended by any such manifestations as to make the attack likely to be confused with any other of the acute eruptive fevers, and it is in such cases that a hasty diagnosis of " influenza" is often made. In those cases with a scarlatiniform prodromal rash the pulse-rate is a help in the differential diagnosis, since even in such cases the comparatively slow pulse, so generally met with in the early stages of enteric fever, is the rule. In a few cases the period of invasion is characterised, perhaps after a day or two of indefinite malaise, by violent symptoms of a cerebral kind. The patient may be wildly delirious, or com- pletely unconscious ; he may complain of severe headache, may suffer from vomiting of a cerebral type, have an irregular pulse, and exhibit a typical '^tache cerebrale," and such cases are often reasonably mistaken for meningitis. The bowels during the period of invasion are frequently constipated, more rarely loose. It is very common during this stage of the disease to find a little diffuse bronchial catarrh, which may lead the practitioner astray, especially as fever may be moderate, and even, save in the evening, absent. As a rule, the physician is called to see the patient just as the period of invasion is over and the fastigium is reached. In the typical or classical case the patient lies on the back, disinclined to move, his whole attitude being one of profound exhaustion. The face generally is pale, with some flushing in the malar regions. The eyes are clear and the pupil is Enteric Fcuei'. V-*) most usually dilated. The tongue is coated at the back and centre with a white creamy fur and the patient is conscious of a disagreeable taste in the mouth and has lost all appetite. The pulse is moderate in rate, between 80 and 90 liei minute, although the temperature may be ranging between 101° and 103° F. Respirations are quiet in the absence of any pul- monary implications, or where there is only the slight catarrh of the larger bronchi that is so commonly met with. Head- ache may be a troublesome symptom and may interfere with sleep. Deafness is more often present than not, and although usually slight, may be almost complete. So frequently is deafness a symptom in the early stages of the disease that an unexplained rise of temperature continuing over some days and associated with deafness, should always, in the absence of any gross lesion of the middle ear, suggest to the mind of the physician that the illness is enteric fever. The spleen is usually appreciably enlarged after the eighth day. The abdomen is often slightly dis- tended, more particularly in the right iliac region, and manipulation in this region may give rise to a feeling of dis- comfort on the part of the patient, and the physician may be aware of some gurgling under his hand. Examination of the abdomen should always be made with the greatest care, as rough handling may precipitate the occurrence of haemorrhage or a general peritonitis. The fastigium is said by older writers to last for a week, but it is seldom that its duration is so short, save in the mildest cases. In cases even of moderate severity it is usually prolonged to 10 days or a fortnight, and it is characterised by an increase in the symptoms described above. The patient's feebleness is striking; even slight move- ment is an effort, and he needs constant attention from the nurse. The fur on the tongue becomes brown and sordes is apt to collect on the teeth. Emaciation is marked. As the third week of the disease is entered upon, there is a tendency for congestion to appear at the bases of the lungs, the pulse grows rapid and very soft, while delirium, sometimes low and muttering, sometimes loud and violent, may be present. The intestines may be distended with flatus, and colicky pains are sometimes very troublesome. A little vague pain apart from 14 Chapter II. colic is sometimes felt in the right iliac fossa, but this is rarely more than a slight uneasiness. Throughout the fastigium the temperature remains fairly high, between 101° and 103° F, as a rule, with sometimes a rise to 104° F., and the daily variation is rarely more than 2° P., so that the fever is at this stage of the "continued" type. Diarrhoea may be troublesome, four or five motions in the day being not un- common, and sometimes the patient is troubled with very frequent small evacuations. But constipation is quite as common, necessitating the moving of the bowels by artificial means, either by drugs or enemata. In a simple uncomplicated case, even of fair severity, one may reasonably expect an abatement of the disease at some time in the third week, or after the fastigium has been main- tained for some 8 or 10 days. The morning remissions of temperature become greater, although in the early stages of the i^eriod of declension the evening temperature may be maintained at its former high level. Gradually the morning remissions fall to a lower level, the evening exacerbations fail to reach the height of the previous day, and the fever declines by a gradual lysis, which may proceed for a week or a fort- night before the evening temperature remains normal. Rarely the fever terminates by crisis, slightly less rarely by a rapid lysis occupying only two or three days. Occasionall}^ at the beginning or during the course of the lysis, the temperature may shew very large daily excursions. It may rise suddenly, sometimes associated with rigor, to very high registers, even 105° or 106° F., and may fall, with signs of collapse on the part of the patient, to normal or subnormal levels in a few hours. This "swinging" temperature may continue, in varying degree, for some days, and, although it is not in itself a particularly ominous sign, shew^ing as it does that the patient is capable of powerful reaction, it may cause alarm to the patient's friends and to those among his attendants who are not familiar with the conditions. It usually occurs in a severe attack of enteric fever, and is, I think, indicative of the sudden separation of extensive sloughs in the intestine. With the declension of the fever, the patient becomes less dazed and delirious, the tongue becomes cleaner and there is Enteric Fever. 15 an increasing tendency to sleep. The pulse grows less rapid, and begins to recover its tone. If bronchial catarrh or pul- monary congestion has been present it tends to disappear, while the patient may regain his appetite to a considerable extent, even before the temperature has reached normal. Dis- tension of the abdomen passes away, and, when diarrhoea has been a feature in the case, the stools become less frequent. When constipation has been present, however, there is usually no corresponding relaxation of the bowels, which may require to be moved artificially well into the period of convalescence. The stools in a case of enteric fever which is not constipated are often very typical, being loose and yellow in colour during the first fortnight, so that they have been likened to pea soup. Their odour is usually rather offensive. During the third week of the disease their appearance alters and they become greenish in colour and may contain sloughs. After the temperature has remained normal for about a week, one may say in most cases that convalescence is es- tablished and that the further progress of the case will be uneventful, although relapses have been known to occur long after that period. Such is the course of the moderatel}^ severe and uncompli- cated case of enteric fever, but the type of the disease varies very much in different epidemics, so that in some years this moderate type forms the vast majority of the cases met with, while in others a much more severe type occurs with great frequency. A Tnore severe type is that in which the fastigium is ushered in by high fever with marked nervous symptoms, much diarrhoea, and an early tendency to pulmonary con- gestion. In such cases the abdomen is frequently enormously distended with flatus and the patient may suffer much from colic. The early delirium and restlessness combined with great cardiac enfeeblement make the patient's recovery a matter of doubt from a very early stage, apart from the occur- rence of any complication. In many of these cases death occurs from sheer toxaemia late in the second or early in the third week, with very high temperature and rapidly failing heart. In such cases the face and even the skin 16 Chapter II. generally are dusky and livid, and the extremities are frequently very cold. Where recovery does take place, it is only after a prolonged fever, slow declension, and very tedious convalescence. On the other hand certain cases of enteric fever present a type of the disease so mild that it is difficult of recognition. It is sometimes so slight that the patient may be conscious only of a little general malaise and may never take to bed or consult a physician. Such cases are described as " ambulato7'y ," and are extremely dangerous to the community from their capacity for widely spreading infection. Attacks of "ambulatory" enteric fever are not without their danger to the patient, since, in spite of their mildness, they may be attended by one or other of the more dangerous complications of the disease, and a haemorrhage from the bowel, a perfora- tion of the intestine, or a severe venous thrombosis may make it plain that the patient is the subject of a grave disorder, although his symptoms up to the time of such an occurrence may have been of the most trifling description. In other cases the disease, although very mild in type, is sufficiently marked to make the patient take to bed. He may have no nervous symptoms, no pulmonary congestion or bronchial catarrh ; his sleep may not be interfered with ; his bowels may be normal in their action, and save for a slight daily fever and sense of weakness, no symptom may present itself that is apparently worthy of serious attention. Even in such mild cases, however, the spleen may be perceptibly enlarged during the second week, and an eruption of rose-spots may be present. It is of the greatest importance to the patient who suffers from a mild attack that his physician should be fully alive to the gravity of the condition, because, as in the "ambulatory" type of the disease, complications may arise that may threaten life, and any laxity in treatment may readily encourage their occurrence. Complications. — The more common complications to be met with in enteric fever are : — 1. Perforation of one of the ulcers in the ileum. 2. Eupture of a suppurating mesenteric gland. Enteric Fever. 17 3. General peritonitis without an apparent local focus. 4. Haemorrhage from the bowel. 5. Yenous thrombosis. 6. Arterial thrombosis and the formation of abs- cesses in the subcutaneous or inter-muscular connective tissue. 7. Lymphangitis. 1. Perforation of the Intestine. — This is, perhajis, the g-ravest of all the complications. While its occurrence is easily recognised when the symptoms are typical, it is often difficult of recognition on account of the masking of the symptoms by the general condition of the patient. The symptoms usually described as tyj^cal of the occurrence of perforation are severe pain in the right iliac region, accom- panied by a feeling of great distress on the part of the patient and the general facies of collapse. Yomiting may be present. The temperature falls and the pulse-rate rises. The rise in the pulse-rate may be followed in an hour by a fall to its primary level, but thereafter it gradually rises again. The abdomen is distended; there is an encroachment on the hepatic dullness and possibly on the splenic dullness. Respira- tion is thoracic in type and increased in rate. The patient's expression is anxious and "pinched," and his strength is rapidly reduced, so that speech is faint and difficult. The abdomen is rigid, either generally or only on the right side. Sweating is not usually a marked symptom in the early stages of perforation, though it may occur in association with a wide-spread general peritonitis. It is true that if all these signs and symptoms are present, no one can help making a diagnosis of perforation, but, unfortunately, it is not the rule that all such signs and symptoms appear early after the occur- rence of perforation, and, if they are present early, it augurs badly for the success of the one form of treatment which offers any hope to the patient, operative interference. A certain amount of pain is usually present, but it may not be severe and stabbing in character, and may not be associated with the typical facies of collapse. The temperature may fall, but for about an hour after perforation has occurred it may remain 18 Chapter 11. stationary or even rise. Alter that time, however, it falls, to some extent at least. The type of respiration may or may not be altered. The patient's expression, however, is always anxious and slightly "pinched," suggestive of some occurrence out of the ordinary, and as a general rule the pulse-rate is dis- tinctly raised. The occurrence of abdominal pain, accom- panied by rise in pulse-rate and some rigidity, either general or limited, of the abdominal wall, and a new anxious look oii the patient's face, are the signs which should make the physician at least suspect the occurrence of perforation, and take immediate steps accordingly. To wait until the diagnosis is completed by the occurrence of abdominal disten- sion and encroachment on or disappearance of the liver-dullness is, in view of modern surgical technique, criminal. In many cases the abdomen may be rather sunken for a little time after the occurrence of perforation, and by the time that it has become distended all hope of successful interference may be gone. Tn certain cases ihe gut may be so distended as to dis- place the heart and cause disappearance or diminution of the prsecordial area of dullness, and similarly the hepatic area of dullness may be greatly lessened, without the occurrence of perforation. The sudden onset of a pleurisy or a heemorrhagic infarction in the lower part of the right lung may give rise, by referred pain, to a simulation of an attack of perforation. I have known one patient operated on after such an occurrence, and it was only on post-mortem examination that the existence of a large hsemorrhagic infarction in the lower lobe of the right lung was discovered. Sometimes before the occur- rence of a perforation of the intestine the patient may complain for some hours of considerable pain in the right iliac fossa without other symptoms. This has been called "pre-perforative" pain. Occasionally, one or two loose motions, streaked with blood, in a case not previously afflicted with diarrhoea, may immediately precede a perforation. 2. Rupture of a {Suppurating gland presents symptoms practically identical with those of perforation of the intestine, but on the occurrence of rupture the temperature rises at once. Enteric Fever. 19 3. General peritoiiitis loithout perforation of f/ie intestine or rupture of a gland. — This condition is coiupuratively rure, but Macrae of Glasgow lias met with it in ten out of sixty-six cases of general peritonitis in enteric fever on which he has operated. The symptoms are those ordinarily met with in general peritonitis from any cause, and it is only on operation, sometimes followed by more detailed observation post-mortem, that the true nature of the condition has been discovered. In such cases the most careful search fails to reveal any local focus, and one can only come to the conclusion that the peritonitis is due to the general blood infection either directly or through the medium of several tiny venous or arterial thromboses such as are met with elsewhere. 4. Ho27norrhage from, the bowel is a complication which is met with frequently, and its severity is very variable. The amount of blood lost may amount only to a few drachms, or it may resemble a post-partum haemorrhage and be so pro- fuse as to soak the m.attress. Like all complications of enteric fever it usually occurs in the third or fourth week of the disease, or, to put it in another way, at some time after the process of ulceration has begun. But hsemorrhage is not always associated with deep ulceration of the intestine. The most copious hsemorrhage which I ever saw in enteric fever occurred in the old i'ever Hospital in Paisley, and was so profuse that within an hour the mattress was soaked through and blood dripped on the floor. Post-mortem examination revealed no deep ulceration of Peyer's pafches, but only an enormous number of the fine haemorrhagic points situated in the last two feet of ileum and associated with an extraordinary congestion of the whole mucous membrane. The patient was a woman who had had ordinary menstrual periods and whose family showed no trace of the hsemorrhagic diathesis. Apart from these rare cases of intestinal flooding, the amount of blood lost during the attack has little value as regards prog- nosis. In some of the most rapidly fatal cases which I have seen, the amount of blood lost has been trifling, although the haemorrhage has been repeated many times. I speak now only of those cases where the amount of blood lost has been small and where no large amount of clot has been found in the C ^ 20 Chapter II. bowel post-moitem. It is uecessaiy to be thus explicit, as in many cases where the loss of blood has been apparently trilling, post-mortem examination has revealed the existence of a large concealed haemorrhage. It is of the greatest im- portance for the practitioner to realise the significance of haemorrhage as regards prognosis, and one should always give a guarded prognosis when haemorrhage has occurred, however slight the amount may be, since the passage of a merely blood streaked stool may be followed by the occurrence of a fairly copious flow of bright blood, the passage of a stool consisting almost entirely of clots, or a large stool of faecal material intimately mixed with dark altered blood. The prognosis must always be given after consideration not only of the amount of the haemorrhage but of the other signs and symptoms which the patient may present. My own experience has always led me to give a very grave prognosis when liaemorrhage occurs, even though slight, with a rising tem- perature and pulse-rate, which is not disturbed by the occur- rence of the bleeding. On the other hand, a slight haemorrhage, occurring towards the period of declension, not accompanied by any very grave signs of general disturbance, may augur nothing of danger if accompanied by a sudden and well marked fall in temperature, and I have known cases which have terminated favourably by a crisis which followed on the occurrence of a large haemorrhage. Haemorrhage in a patient who shows marked signs of toxaemia is always a grave symptom, because in such profoundly poisoned cases it is often repeated, and is dangerous, like frequent diarrhoea, if only on account of the extra movement of the patient which it involves, while it indicates a condition of great gravity in the same way as does the haemorrhagic type of other acute fevers. It is common to publish charts which show a considerable fall in temperature at the occurrence of a haemorrhage, but while this does frequently occur, sometimes with all the symptoms of profound collapse, lividity and coldness of the skin, accompanied by profuse cold sweating, a haemorrhage may occur without the slightest dis- turbance of the temperature curve. Most commonly no general symptoms give warning of the attack, but in some Enteric Fever. 21 cases the patient may suddenly collapse, complain of a vague abdominal discomfort, and have a general sense of uneasiness ; he may grow livid and cold, the temperature may fall, the pulse-rate rise and beads of cold perspiration stand out on his face, and it may not l)e till upwards of un hour afterwards that occurrence of an intestinal haemorrhage may explain the general disturbance. Such cases may for a moment suggest perforation, but the absence of pain and of the pinclied "abdominal" facies will guide in the formation of a diagnosis, and in any case the haemorrhage will have declared itself before any surgical interference can be made. Profuse cold sweating is always a grave symptom in association Avith haemorrhage. 5. Venous tJirombosis is often a troublesome com- plication, and, as in puerperal septicai^mia, one or other femoral vein is its commonest situation. It occurs also in the saphenous and popliteal veins and has been observed, very rarely, in the axillary and sub-clavian veins. Such throm- bosis is usually one-sided. It occurs late in the disease, and may, indeed, appear only during the period of convalescence. 6. Arterial thrombosis and ahscess- formation in the sub- cutaneous or intermuscular connective tissue. — Thrombosis of any of the larger arteries is a comparatively rare condition, but it has been observed as giving rise to gangrene of the toes, the whole foot, and even of the leg to above the knee, the arteries usually involved being the femoral, popliteal or posterior tibial. The middle cerebral artery has also been described as being the seat of thrombosis, giving rise to apoplectiform and convulsive attacks. Such thrombosis occurs usually in the third, fourth or fifth weeks of the disease. But it seems likely that thrombosis of small arterial twigs is fairly common. It is difficult to explain otherwise the occurrence of those subcutaneous and intermuscular ab- scesses that are so frequently met with late in the disease. The thigh, leg, lumbar region and buttocks are the com- monest sites for such abscesses, but they may occur au3^wliere. 22 ChapUr 11. 7. LyTnphangitis. — As in puerperal infectioiivS, a lym- phangitis of the thigh is a fairly common complication of enteric fever, and it is very likely that many cases of swelling and pain in the thigh have been labelled as venous throm- liosis -which were really lymphangitis. Many believe that lymphangitis is much more common in enteric fever than venous thrombosis, and there is much evidence in support of their view. The diffuse tenderness and the uniformly pale colour of the swelling, are points in favour of the diagnosis of lymphangitis. Other complications occur in enteric fever, all about the third or fourth week in the disease, that are suffi- ciently uncommon to merit only a word in passing. Cystitis and pyelitis may occur from infection of the urinary tract by the B. typhosus. The prognosis in both these conditions is generally favourable, since we are dealing with an in- fection upon which Nature has put a more or less definite limit. Some blood may be present in the urine in association M'ith the pyelitis, but an acute nephritis is seldom seen, al- though albuminuria of a "febrile" and transitory kind is frequently present. Pleurisy is met with fairly often, some- times accompanied by sero-sanguinolent fluid effusion, and occasionally resulting in empyevia, which may or n\ay not be due to the B. typhosus. A some- what rare but alarming complication is hcemorrhagic infarction of the lung, due probably to throm- bosis occurring in the right heart with subsequent embolism, or to the formation of a large thrombus in the pulmonary artery. It may also be due to an embolus carried from a thrombosed vein in the leg or elsewhere. The infarction is accompanied by more or less sero-sanguinolent effusion into the pleural sac, and has been known to result in an empyema. The signs of the infarction are sudden pain in the chest or referred to the abdomen, limitation of thoracic breathing, some dullness on percussion over the affected area, with diminution in the volume of the respiratory murmur, and, very soon after the occurrence, the auscultatory signs of pleurisy and some fine intrapulmonary crepitus with distantly tubular breath- sounds are evident. Sooner or later after the occurrence of the Enteric Fever. 23 infarction, the sputum is tinged witli })lo()c], sometimes in con- siderable quantity, but I have been struck, in the four cases wbich I have seen, by the small quantity of blood present and tbe delay in its appearance. In one case no blood appeared in the sputum until some five days had elapsed after the in- farction had occurred. Of the four cases under my own observation two died, one having been operated on in mistake for perforation of the intestine, the other after the occurrence of an empyema from which pure cultures of the B. typhosus were obtained. The other two cases made a good recovery. Peripheral Neuritis is sometimes met with, usually in- dicated only by persistent pain in the heels or toes whicli may last until tlie patient has completely recovered in other respects. The '"tender toes of typhoid" are familiar and troublesome results of the fever and appear late in the period of declension or during convalescence. Peripheral neuritis of a more serious kind is occasionally met with, resulting in "dropped wrist'' or "dropped ankle," and once, in the case of a medical man, I have seen a double ulnar palsy which per- sisted for months. Endocarditis is a very rare complication, but it does sometimes occur and may be followed by infarction of the kidney or spleen. Sequelae. — The sequelae of enteric fever are such as might be expected from a long febrile illness associated with a Special lesion of the intestine. It is common for the patient to complain for many months after his illness, of distension of the abdomen and flatulence, associated with some pain in the right iliac region. Combined with or apart from this he often gives evidence of marked neurasthenia long after con- valescence has been thoroughly established. He is physically weak, and easily tired mentally. He shirks his work, avoids meeting people, is afraid of various things, and may show a tendency to melancholia. In a few cases which I have seen, this neurasthenic condi- tion combined with considerable abdominal discomfort has led the patient to resort to alcohol and drugs to relieve his depres- sion, with the result that a previously temperate man has 24 Chaper 11. become a confirmed alcoholic or drug-maniac. Post-enteric neurasthenia is confined to no particular age or sex. Chil- dren, adolescents, and adults of all ages, male or female, may- fall a victim to this extremely troublesome disorder. Typhoid Spine. — This condition is comparatively un- common, and was described by Gibney in 1889 as a painful affection of the spine with exaggerated knee-reflexes, ap- pearing towards the end of an attack of enteric fever or during convalescence. Pain is the most prominent symptom, and is felt in the lower dorsal and lumbar region, extending, in some cases, round the body and down the legs. It is often associated with tenderness over one or two vertebral spines, and some swelling of the adjacent soft tissues is not uncommon. In one case, reported by Ogilvy in the Journal of the American Medical Association, vol. li, p. 406, the swelling and tenderness ex-* tended on both sides of the spine over practically the whole of the dorsal region. Areas of hypertesthesia are frequently met with on one or other side of the tender spot. Kyphosis and scoliosis have both been observed in con- nection with this condition. Walking is difiicult and increases the pain. Paresis of the legs is sometimes met with, and the patient may suffer from spasm and cramp and even wasting of the leg muscles. The spine is sometimes fixed and rigid, and in some cases the slightest movement of the patient, and even of his bed, will induce a severe attack of pain in the back. Slight fever is frequently present when the condition makes its appearance during convalescence. The patient who suffers from typhoid spine is often the subject of a general neurosis, and may be hysterical, imagina- tive, and uncontrolled in many ways, even though his pre- vious history has not shown any indication of a neurasthenic habit. In some cases, of course, the patients have always been neurotic and fanciful. The onset of the condition is usually during convalescence, being seldom delayed longer than three months after the attack of enteric fever has subsided, and most commonly Enteric Fever. 25' appearing just as tlie patient beg'ins to move about. The dura- tion varies from a week or two to many months, but recovery is practically invariable. The cause of typhoid spine is probably not always tlie same. In certain cases described by Osier it would appear to be the result of a neurosis, and in such cases the temperature and pulse are not abnormal, and paraplegia of a definitely Hys- terical type may be present; fleeting disturbances of sensation, and pain in tbe back, without any indication of gross spinal lesion or disease of the vertebral column, are observed, while- signs of a general neurotic or neurasthenic state may be apparent. In another group of cases there is definite evidence of perispondylitis and spondylitis, evidenced by kyphosis or scoliosis, tenderness and pain over one or more vertebrae, and swelling of the soft parts in their neighbourhood. In some cases a definite formation of new bone has been observed in connection with the spondylitis. Typhoid spine, therefore, would appear, from the writings of Gibney, Osier, McCrae and others, to be a name given to a set of symptoms in variable combination, of which the most constant is pain in the back, usually associated with some weakness in the legs, stiffness in the back, and exaggerated knee-reflexes, due either to the post-enteric neurasthenic state or to a definite perispondylitis or spondylitis in the lower dorsal and lumbar regions. Care must be taken in arriving at a diagnosis of typhoid spine to exclude the even rarer conditions of focal myelitis- and spinal ineningitis which may be associated with exaggera- tion of the knee-reflexes and a plantar reflex of the extensor type, without there being any affection of the sphincters of the bladder and rectum. It must be remembered, also, that an insular sclerosis has, in one or two cases, followed on an attack of enteric fever. Diagnosis. — The diseases most likely, from their general symptomatology and course, to be confounded with enteric fever are abdominal and general tvherculosis, tuberculous meningitis, irregular forms of malaria, low forms of broncho- 26 Chapter II. 'pneuTTionia, acute pneumonia of the upper lobe, typhus fever, influenza, and paratyphoid fever. It is only during tlie first week or ten daj's that acute lobar pneumonia with concealed physical signs is likely to give rise to a suspicion of enteric fever, and then the mistake in diagnosis is usually made more from insufficient examination of the chest than from any real simulation of enteric fever bj^ the pneumonia. The differential diagnosis between typhus and enteric is often difficult during the first ten days of acute illness, but as a rule the types of the disease are distinct and separate, the flushed dusky face with blood-shot eyes of the typhus patient contrasting strongly wdth the pale face, malar flush and clear eye of enteric fever. But in enteric fever the face may be sometimes flushed and dusky at an early stage, the delirium may simu- late that of typhus, the eye may be bloodshot and suffused rather than clear, and the differential diagnosis may depend on one or other of the special methods available for the diag- nosis of enteric fever. Careful examination of the blood will usually exclude malaria, as it is rare to have a case of ague, however aberrant the type may be, in which the infecting organism cannot be discovered by those to whom the technique of examination is familiar. For the differentiation of enteric fever from tuberculous affections one depends clinically on the development and the course of the disease, on the occurrence of definite special symptoms and the application of certain tests. The occur- rence of squint or other evidence of palsy of the external muscles of the eye, double vision, or failing sight will often make it clear that a doubtful case has been a somewhat obscure example of tuberculous meningitis. Enlargement of the abdomen with, perhaps, signs of fluid or a "doughy" feeling on manipulation or with deflnite distension of the ab- dominal veins, will indicate a tuberculous laeritonitis, and the discovery of tubercle bacilli in the sputum will lead to the diagnosis of pulmonary phthisis, especially if the patient has not been in very good health before the onset of the symptoms which have led to his coming under observation. Of course, Enteric Fever. 27 it is possible that a patient suffering from phthisis may con- tract enteric fever, and it is therefore wise to make special examination of the blood for signs of enteric fever in all cases Avhere the diagnosis is doubtful, a))d, wliere there seems to be a possibility of some tuberculous mischief being present, to perform Calmette's or von Pirquet's tests, or give a test injec- tion of tuberculin. Paratyphoid fever is practically similar in its manifesta- tions to a mild attack of enteric fever, and a purely clinical differentiation is impossible. Its diagnosis must depend on the absence of an agglutinative reaction with the B, typhosus and the presence of an agglutinative reaction with the B. paratyphosus, or on the recovery of the B. paratyphosus from the blood. The methods of cultivating the B. paratyphosus are similar to those employed in the cultivation of the B. typhosus, and the differences in the two organisms are brought out by subculture on various media, as will afterwards be described. The bacilli can also be tested with serum which is known to have the power of agglutinating the B. typhosus. llie blood in enteric fever shows as a rule a fall in the number of white cells to below the normal. On the occurrence of perforation or general peritonitis from any cause a poly- morphoneuclear leukocytosis often occurs, but not invariably, while a leukocytosis may occur in connection with a pleurisy with effusion, an empyema, or any suppurative condition. The special diagnostic methods of greatest service in the diagnosis of enteric fever are the bacteriological examination of the blood and Widal's agglutination test. WidaVs re- action depends on the power of the blood-serum of a patient suffering from enteric fever to agglutinate living motile cul- tures of the B. typhosus in large dilution and in a short time. The degree of dilution of the serum is important, as in cer- tain other diseases the serum from the patient will agglutinate cultures of the B. typhosus if the dilution is small and the serum be left in contact with the bacilli for a long time. It is my practice to perform the test with blood-serum diluted 60-100 times with an emulsion of a young culture of B. typhosus in sterile salt solution, and if satisfactory clumping does not take place within forty-five minutes 28 Chapter II. to an hour, to coiisidei' the reaction negative. With these precautions the test is often of the greatest service, but it is to be remembered that an agglutina- tive reaction is seldom obtained earlier than the eighth or tenth day and may not appear until convalescence is well established, so that a negative result cannot of itself exclude enteric fever. As a rule, however, the reaction can be obtained after the first eight or ten days of the disease. Other diseases in which Widal's reaction may be obtained are general tuberculosis and typhus, and occasionally the reaction is present in these diseases even after the serum has been well diluted. It is unfortunate that these are two of the verv diseases which are frequently difficult to distinguish from enteric fever. Of far greater value in the early diagnosis of enteric fever is the making of a culture from the blood. 10-20 c.c. of blood is drawn from a vein with proper aseptic pre- cautions, citrated, placed in peptone bouillon after long cen- trifugalisation in sterile tubes, and incubated at 37° C, and the resulting growth examined for the B. typhosus. If an organism is present which has the morphological characters of the B. typhosus, subcultures must be made on differentiating media to make sure that it is the B. typhosus and not the B. paratyphosus. Media containing glucose or dulcite coloured with neutral red, and milk containing litmus are of most service. The B. typhosus forms acid without gas with glucose; the B. paratyphosus forms both acid and gas. With dulcite, the B. typhosus forms neither acid nor gas; the B. paratyphosus forms both. After three days' incuba- tion at 37° C. in litmus milk, the B. typhosus shows the pro- duction of acidity, and the B. paratyphosus the development of alkalinity. The results are conveniently shown in the form of a table : — Glucose. Dulcite. Litmus Milk. 3 days. B. Typhosus I Acid. — Acidity. B. Pabatyphqsus Acid & Gas. Acid & Gas. ; Alkalinity. Enteric Fever. 29 This differentiation can be done by any one who has had a good bacteriological training and possesses an incubator, but both the blood culture and Widal's test are better done by a bacteriologist in connection with the Public Health adminis- tration of the district or one of the large Clinical Laboratories. In many places such examinations are made by the municipal bacteriologist. The diazo-reaction of Ehrlich is of little value in the differential diagnosis, and is but rarely used now. Puncture of the spleen for the recovery of the B. typhosus has been done occasionally, but this procedure is not to be recommended, as the typhoid spleen is soft and the re- sulting haemorrhage may be severe, and even fatal. The operation, too, is painful and may induce shock. RelaiJses are very common in enteric fever. The temperature may run a typical course, with a fasti- gium of average or more than average length, and a lysis of considerable duration, yet after it has remained normal for periods varying from one to ten or twelve days it may again rise gradually and the patient embarks on what is practically a second attack of the fever, including the eruption of rose- spots. E-elapse may occur after a primary attack of great severity and long duration, and also after an attack which has been very mild indeed. As a general rule a relapse is milder than the primary attack, but to this rule there are many exceptions, and a severe, and even fatal, relapse may follow a primary attack so mild as to be almost "ambulatory" in type. It is unusual to meet with any of the graver com- plications of enteric fever in the course of a relapse, but they do occur, particularly where the primary attack has been mild and the subsequent relapse severe. Sometimes several re- lapses follow the primary attack, and the severity of each of these is usually much less than its predecessor. Four relapses is the greatest number which I have seen, but more have been recorded. Each relapse is separated from its successor by at least a few days of normal temperature. The term recrude!^- cence is used to describe the condition when the temperature begins to rise again after the lysis has commenced, but where 30 Chapter 11. the curve has not reached normal. The distinction between relapse and recrudescence is purely arbitrary. Treatment. — In considering the treatment of enteric lever ■ we must remember that we are dealing with a prolonged febrile disease in which wasting is a prominent feature, in which the fever often runs high, which may be attended with profound toxtemia, and which may show various complications that call for special treatment. In no acute fever, save, perhaps, pneumonia and diph- theria, is the necessity for absolute physical and mental rest so urgent as in enteric fever, not only from the necessity for husbanding in every way the patient's strength, but also because movement may prejudice the local lesion in the in- testine and encourage haemorrhage or perforation. It is the custom in this country to insist on the use of the bed-pan and bed-urinal, although in mild constipated cases it may be no disadvantage to allow the patient to get up to stool if the night-chair is placed close to the bed and he is not allowed to walk. If constipation is present, the bowels should be moved at least every second day by soap and water enemata, unless the calomel treatment is adopted, and flatulent distension may be greatly relieved by an injection of olive oil and turpen- tine. Where flatulent distension is troublesome, the applica- tion of tepid compresses to the abdomen every four hours or oftener, for fifteen minutes at a time, may give great relief. Frequent and troublesome diarrhoea is often controlled by the introduction of a long colon-tube and gentle but free in'i- gation of the lower bowel with warm water. The patient should be washed all over daily with soap and water. The skin of the back, especially over the buttocks and sacrum, should be sponged several times in the day with methylated spirit and carefully powdered with a dusting- mixture of equal parts of powdered starch, boric acid and lycopodium, to prevent the occurrence of bed-sores which should never be seen in a carefully tended patient. Great care should be taken to change the position of the patient fre- quently, both to avoid bed-sores and to prevent as far as possible the development of hypostatic congestion of the lungs. Enteric Fever. 31 In profoundly toxic cases the injection of a pint of hot sterile salt solution into the subcutaneous areolar tissue is often productive of good results. Headache may be relieved by the application to the fore- head of cloths dipped in cold water and vinegar. It is best to avoid giving phenacetin as it is rather depressing, but the citrate of calfein is effective in doses of five grains repeated every few hours, and the use of the bromides is often followed by excellent results. Delirium and restlessness, even apart from excessive fever, are best treated by cold applications to the skin, either by means of sponging, compresses or baths, but it may be necessary to use opium or other hypnotics to quiet the patient and induce sleep. It must be remembered that patients suf- fering from enteric fever bear opium badly, and that even in moderate doses it tends to induce meteorism. If it is used at all, it should be given in small doses, 5-10 minims of Battley's solution or ISTepenthe by the mouth, combined, it may be, with five grains of chloral hydrate or3ss of the Syrup of Chloral, or the hypodermic injection of morphine, gr. \, may be em- ployed. Such doses of opium, alone or in combination, may be repeated every three or four hours until the patient is quiet or until it is evident, after some half-dozen doses, that the treatment is of no avail. Veronal, trional, or sulphonal in doses of ten grains in ^ss-^i of whisky with hot water and a little sugar sometimes act very well and induce sleep after two or three doses at intervals of two hours have been given. Occasionally I have seen sleep produced and violent delirium quieted by paraldehyde in doses of 90 minims re- peated at intervals of an hour till three doses have been taken. Sometimes §i or §ii of whisky with hot water and sugar given in the evening will induce sleep in a patient who is just beginning to show signs of restlessness and who has not been relieved by cold or tepid sponging. It may be necessary to reduce the temperature if it be at all high, say above 103^ F., and the patient is restless and uncomfortable. No antipyretic drugs should be used for this purpose, but the temperature can often be reduced by 2° F. or more by cold sponging, by a cold compress applied to the 32 Chapter II. front of the body from neck to knees and changed every two or three minutes; by rubbing the surface of the body with a block of ice; or by the use of the cold or tepid bath. The bath is excellent for Hospital use, but is almost impracticable in private practice, as a large portable bath, capable of hold- ing an adult patient stretched at full length, is necessary. This inconvenience is the only valid argument against the in- telligent use of the bath, which should be kept at a tempera- ture of about 80°-90° E. during the immersion. In careful hands no harm should result from the manipulation of the patient, and fever and restlessness which have not yielded to any other form of treatment may yield to this. But in private practice nearly as good results are obtained from the use of the cold compress applied from neck to knees, changed every minute or two and repeated until a fall of temperature of, say, 2° F. has been produced. If this fails, it is com- forting to remember that in certain cases the fever will not yield even to repeated cold baths, but continues to rise, or at least to remain stationary at a very high level, in spite of all the efforts of the physician. When this occurs it is plain that we are dealing with a peculiarly virulent form of the disease, probably a fulminant type that will kill whatever 'endeavours we may make towards its cure. It is interesting to observe that a great reduction of temperature is not neces- sary to ensure marked improvement in the patient's condition. 'The reduction of the temperature by 1° or 2° F. is usually suffi- cient to produce a feeling of comfort and quiet in the patient -and to induce sleep, even if only for a short time. It is not wise by prolonged exposure to cold applications to reduce the temperature to the neighbourhood of normal at the expense of "the patient's comfort and strength, as is so often done. To put it broadly, the temperature should be reduced as little as possible, compatible with the comfort of the patient, save when grave hyperpyrexia is present. A fall of 2° F. accom- panied with comfort is better than a fall of 4° F. accompanied by a feeling of prostration and faintness on the patient's part. The relief from high fever is only temporary and the cold ap- plications may have to be frequently repeated before the general course of the temperature returns to moderate levels. Enteric Fever. 3.3 The "swinging" type of temperature vvliich is often met with at the period of declension is sometimes attended by rigors while the temperature is rising and collapse when the temperature falls. The patient must be kept warm under these conditions; hot bottles or sand-bags should be placed at the feet and along the sides, and hot cloths applied over the heart. Quinine in doses of 10 grains is said by some to influence this type of fever, but I have never seen any good come of its use. Strychnine is sometimes of service when there is a tendency to meteorism, and is best given hypodermically in doses of o't)^^^ of ^ grain repeated every four liours. This ma 3' be continued for several days at a time. When the pulse is unduljr rapid and soft, digitalis should be given, and if given at all the dose should be fairly large. I have ob- tained the best results with Nativelle's granules of crystalline digitalin, giving one every three or four hours, but 10 minims of a reliable tincture given every two hours until an effect on the heart is produced or nausea and diarrhoea occur is less ex- pensive and practically as rapid in action. It frequently happens, however, that digitalis has no effect in slowing the pulse, and if any signs of digitalis poisoning appear, it is wise to discontinue the use of the drug, although the effect on the patient of slight poisoning by digitalis has been greatly exaggerated. It has been usual to give alcohol as a stimulant in cases with soft rapid pulses and a tendency to other signs of heart- failure, and it may be of great value in promoting a sense of well-being in the patient, but if given at all it should be used in small doses, Jii-O^^i ^^ ^ time, repeated every two or three hours, and not more than §iv should be given in the day. If it be found that under the influence of small doses of alcohol the pulse-rate does not fall and restlessness is not lessened after twenty-four hours, the advisability of discon- tinuing the treatment should be considered. The use of purgatives in enteric fever has been the sub- ject of much discussion, and it is necessary, in this connection, to consider the stage of the disease at which the patient has arrived. If the disease is in a very early stage, say in the D 34 Cliayter II. first week, when diagnosis is in doubt, it is not wise to with- hold a smart purgative, such as two or three grains of calomel or a table-spoonful of castor oil, or a pill containing Pil. Hydrarg. grs. ii, Pil. Colocynth. et HyOiScyami grs. iii, with Extract. Belladonnas gr. \, followed by a saline aperient draught in the morning, simply on the suspicion that the un- known fever may turn out to be enteric, since at that early stage of the disease a single dose of this kind may be given with advantage even in enteric fever. On the other hand, if the diagnosis of enteric fever has been made, frequent purga- tion by means of salines, Cascara Sagrada, aloes, or powerful mercurials is to be strongly discouraged, as the throwing of the intestine into a considerable degree of peristalsis or greatly increasing the fluidity of the stools by action on the intes- tinal mucous membrane is bad practice in view of the local lesion. But the present habit which most generally prevails, of moving the bowels only by enemata, has become a little too fixed in the practice of many physicians. Small doses of castor oil, repeated, if necessary, more than once in the day, are quite permissible if they do not cause nausea or griping, while I have seen good results from the giving of small doses of calomel continued steadily for some days or even weeks, during the height of the fever. I do not believe that the use of calomel shortens the course of the disease to any great ex- tent, but in cases treated by calomel, meteorism and ab- dominal discomfort are, I think, less common than in cases treated only by enemata. The calomel treatment of enteric fever is best carried out as follows: — Calomel, gr. \, combined with Resin of Podo- phyllin, gr. ^-Vj may be given every hour during the waking time of the day, so that some 2 grains of Calomel and gr. I" of Podophyllin are taken in the twenty-four hours. This should be continued steadily for 3 or 4 days and then be discontinued for tweny-four hours. At the end of each day of calomel treatment tlie lower bowel should be gently irrigated with warm water to ensure its complete emptying. The irriga- tion should be done by means of a douche-can and a soft india- rubber tube with a rubber catheter attached. The patient should lie on the left side and have his hips slightly raised. Enteric Fever. 35 The water must be boiled and should be at a temperature of 112° F. at the commencement of the irrigation, us tepid or cold water is apt to induce collapse. Tlie patient should be put on Chlorate of Potash, grs. 5, every four hours during the resting period, and at the end of twenty-four hours the calomel sliould be recommenced . This method of treatment by calomel seemis to have no evil result on the local lesion (perforation is rather less common in cases treated thus, and haemorrhages are no more common), but it is perhaps wise to give no purgatives, even calomel, if the third week of the disease has been entered upon before the patient comes under observation. I have begun the use of calomel in small doses in the third week without any untoward result, but I do not recommend the practice. No other purgative should be given in the third week. The effect of the repeated small doses of calomel is to in- duce without pain free and frequent movement of the bowels, 4-5 stools in the day at the end of the first two days treat- ment being common, with a reduction to two or three later on. The tongue grows cleaner, and there is seldom any ab- dominal discomfort or distension in patients treated in this way, and I believe that under this treatment patients assimi- late better, relapses are less frequent, and convalescence more rapid and complete, than when the bowels are moved merely by enemata. Diet. — This should at first, until the fastigium is prac- tically over, be absolutely fluid, save in certain cases which I shall mention later. Water should be given freely, in small quantities of §ii or §iii at a time, frequently repeated. Milk, plain, flavoured with coffee or tea and sweetened, or diluted with warm water or barley water and slightly salted, should form the staple diet. But it is well to give some clear soup in addition, to the extent of a pint in the twenty-four hours, and if thirst is excessive, water with a few minims of dilute Nitro- hydrochloric acid and flavoured with lemon is sometimes of great service. If there is a tendency for curd to be passed in the stools. Sodium Citrate should be added to the milk to the amount of 5 grs. to the ounce. This "citrated milk" often D '2 36 Chapter II. makes milk feeding well borne by patients who have been previously intolerant of it. A raw egg switched into milk is a useful addition to the day's food, and is to be recommended in prolonged cases with much wasting and loss of strength. Milk sugar or fine white cane sugar may be added to the milk- feeds in such quantities as may be most pleasant for the patient. The importance of an adequate amount of carbohy- drate in the dietary of the enteric patient cannot be too much emphasised. If the fastigium be well advanced and the patient is really hungry and shows no untoward symptoms, small quantities of a well-cooked pudding of milk and rice, or milk and arrowroot, may be given twice in the day. This pudding must be cooked slowly for at least three hours. The detritus from such food is practically negligible and is not likely to give rise to any accident. If, however, it be found that such food tends to produce gastric discomfort or ab- dominal distension it should be discontinued for a day or two and then tried again. A semi-solid diet of this kind is satisfying to the patient and helps to keep the mouth clean. If a patient can be trusted to masticate thoroughly, the ad- dition of a piece of dry bread daily to his diet during the period of declension is not at all dangerous, but few patients will take the trouble to chew it almost to a liquid before swallowing it, and it is, therefore, wisely avoided in most cases. Benger's food, Mellin's food, "AUenbury's Diet," Soma- tose and Sanatogen, are all useful in the period of declension when no complication has interrupted the course of the disease, but I greatly prefer the first three to the more purely nitro- genous preparations. In a normal uncomplicated case a piece of dry bread may be given after the temperature has been normal for seven days. It has often been urged that this is too early a date to begin feeding as it so often happens that a relapse follows on the giving of food on the Tth or 8th day of normal temperature, but I have noticed that relapses beginning on the 7th or 8th day are just as common when I have been starving patients till the 14th day as when I have been feeding them on a semi- solid diet through the period of declension, and allowed them Enteric Fever. 37 to have bread on the 8th day, the fact being that a relapse occurs naturally about that time with great frequency. It is often wise, if the patient is hungry and there is little abdomi- nal distension, to feed through a mild relapse with semi-solid food, especially if the primary attack has been of long dura- tion and the nutrition of the patient is low. After the patient has been for two days on bread, a little steamed white fish may be given, by preference whiting; and custard, bread and butter pudding, toast and butter, boiled, poached or scrambled eggs, may be added gradually during the next week and at the end of that time chicken, or pheasant if it is in season, may be given, followed in a day or two by a lightly-grilled chop. After the temperature has remained normal for three weeks the patient may be permitted to get up for a short time if his strength permit, and an ordinary light mixed dietary gradually resumed. Alcohol should on no account be allowed to a convalescent from enteric fever. The treatment of Complications needs some consideration. Perforation, rupture of a suppurating Tnesenteric gland, appendicitis and general peritonitis from any cause demand immediate operative interference. As an example of the results afforded now-a-days by laparotomy in general peri- tonitis, I append the details of operations performed by Mr. Farquhar Macrae, during the last ten years, in the Fever Hos- pitals in Glasgow, and furnished to me by him. In con- sidering these, it is to be remembered that in earlier days these complications practically always ended fatally, and, with improved operative technique and after-treatment, especially since the introduction of the semi-upright position, and the stimulus which successful operation has given to early diag- nosis, the results are steadily improving. It is as wrong to delay operation when such conditions are suspected as it is to treat diphtheria without antitoxin. The importance of early diagnosis on the part of the physician cannot be too greatly emphasised, as everv hour's delay lessens the chance of successful operation. Where the general mortality-rate of an outbreak is high, the death-rate in cases of perforation will be proportionately as 38 Chapter 11. liig-li or even higher, so that a bad run of cases in a severe epidemic must not prejudice either physicians or surgeons against operation. The following table shows the results of Macrae's opera- tions in general peritonitis complicating enteric fever, up to the middle of December, 1910 : — Cases, Recoveries. Without perforation or rupture of abscess 10 3 With rupture of mesenteric gland-abscess 2 1 With rupture of an abscess in the spleen 1 1 With perforation of the intestine 53 12 Total 66 17 In all thei fatal cases of general peritonitis occur- ring without perforation or rupture of an abscess, the diagnosis was confirmed by post-mortem examination, ex- cept in one case, when permission to make an examination was refused. Abscesses in the subcutaneous and inter Tnuscular areolar tissue must be opened and dressed antiseptically. They heal, as a rule, slowly, and occasionally occur in cases which ulti- mately die of asthenia. Particular attention must be paid to the general condition of patients suffering from these abscesses. HceTnorrhage jroitn the bowel sufficiently severe to render treatment other than simple rest a necessity is best treated by the judicious use of small doses of opium, by the mouth or hypodermically, by the hypodermic injection of repeated small doses of strychnine, by the application of tepid compresses to the abdomen and the injection of a pint of physiological salt-solution into the subcutaneous areolar tissue. I have never seen any good come of the use of lead, tannic acid, or the so-called astringents, or of the administra- tion of ergot, ergotin, or suprarenal extract. Opium, even though it may have no direct effect on the haemorrhage, is of value in inducing rest and sleep and in lessening peristalsis and the absorption of the products of intestinal fermentation. If given with strychnine it does not unduly relax the intestine Enteric Fever. 39 and induce ineteorism, wliicli one particularly wishes U) avoid in such cases. Tepid compresses on the abdomen seem to have some action in restoring- the tone of the gut, and are better than any cold applications, since the surface temperature is lowered and a patient feels chilly if a hemorrhage is at all large. The injection of a pint of physiological salt-solution into the subcutaneous areolar tissue is of service in two ways, it dilutes tlie toxins and supplies fluid to the blood to replace that lost by the intestine. The injection may be repeated several times if thought necessary. The physiological salt solution should be carefully sterilised fund allowed to run in by siphon action at a temperature of 110° F. Venous tlirowljosis, as commonly met with in the leg, necessitates rest of the part affected and of the patient generally. The limb should be elevated, wrapped in gamgee or cottonwool after the skin has been carefully cleansed with soap and water, washed with spirit and powdered with a dusting-mix- ture of starch, lycopodium and boric acid, in equal parts, and lightly bandaged from foot to hip. Pain should be relieved by opium, either 10-15 minims of Nepenthe or Battley's solu- tion by the mouth, or \ gr. of morphine hypodermically repeated every two hours until relief is obtained. Lymphangitis of the thigh or leg must be treated by rest and warmth, and by the painting of the skin over the in- guinal glands with tincture of iodine. Pain may be relieved by the application to the limb of hot compresses spread with the glycerine of belladonna, and by the administration every hour of one or two minims of Battley's solution and tincture of belladonna by the mouth. Cystitis and Pyelitis due to the B. typhosus rarely give rise to much pain or discomfort. The patient should be made to drink large quantities of fluid, and TTrotropin in doses of 5 grs. every three or four hours may be given with advantage, while 1 minim doses of Tinct. Bella- donnae every hour will lessen pain and spasm. 40 Chapter 11. Pleurisy and Ilcvmorrhagic Infarction of tlie Lung are both productive of discomfort on account of the embarrass- ment to respiration, and are frequently associated with severe pain. Opium by the moiith, or the hypodermic injection of mor- phine should be used, and hot fomentations to the chest wall either simple or having 3^ ^^ Glycerine of Belladonna or of Tinct. Opii spread on their surface are often helpful. The felt- like tissue called spongio-piline steeped in hot water makes an excellent fomentation, but simple flannel, folded several times > does very well. I have used a mixture containing Liq. Morph. Hydrochlor. Tl\ii and Tinct, Belladonnse n\ii with advantage in both conditions, repeating the dose every two hours until sleep was induced. On one occasion I produced marked poisoning with belladonna in a case of hsemorrhagic infarction of the lung, after six doses of this mixture, but the occurrence fortunately had no bad influence on the patient's progress. Ew,pyema may follow on either a simple pleurisy or a hajmorrhagic infarction, and must be dealt with surgically. Peripheral iieuritis is best treated during the acute stage b}^ rest and a simple alkaline mixture, such as Liq. Ammon. Acet. 3ij Potass. Acet. grs. 10 and Potass. Citrate grs. 101 After the acute stage has passed off, mild Galvanism and massage are usually effective. Typhoid spine must be treated according to the severity of the symptoms and according to its cause. If a definite perispondylitis is present, absolute rest is essential, and the immobility of the patient should be secured by making him lie between sandbags or on a plaster of paris bed. Pain may be further relieved by opiates. It may be necessary for him to wear a supporting jacket for some weeks after he is allowed up. If the condition is secondary to a neurasthenic state, the patient must be treated on general lines, and rest, massage and careful dieting will do much towards a cure. Opium should on no account be used, but counter-irritation by mustard- leaves, blisters, or the actual cautery, will usually reduce the pain. Enteric Fecer. 41 Post-enteric neurasthenia is often very troublesome. The patient should be taken away from work, but, havinf^ recently undergone a long period of rest in bed during his attack of fever, it is difficult to persuade him to rest properly. In spite of the fact that he has so recently spent many weeks in bed, it is best at first to send him back to bed for a week or two, feed him carefully and well, and have him massaged. But it is necessary to be careful that the masseur is not too energetic in his manipulation of the legs, as rough treatment may induce a lymphangitis or a phlebitis with consequent thrombosis, and thus delay cure. After a preliminary rest of this kind it is wise to insist on the patient's going away from his usual sur- roundings for a time, to some pleasant sea-side resort either at home or abroad, where he may have a climate which per- mits him to be much in the open air at any season of the year. He should not be sent away alone, but should be accompanied by some congenial and cheerful companion who is willing to give liim a great deal of attention, and see that he takes exer- cise well within the limits of fatigue. For people who like Iho sea, a voyage in sunny latitudes is often very beneficial, but it is unwise to send a patient to sea if there is any marked 5nelancholia, as the opportunities for suicide on ship-board are greater than on land. If restlessness or any "phobia" be present, a mixture con- taining Sod. Bromid. grs. 10, and Tinct. Belladonnse Tl|5, is often of assistance, and in sleepless cases it is wiser to be content with what sedative action can be obtained from the bromides combined with suggestion, than to use any more powerful hypnotic drug, since the drug-habit is easily formed in these cases. ISTo alcohol should be permitted, for similar reasons. Vaccines have been used recently in the treatment of enteric fever, but as yet this practice has not become at all general. The results are, however, sufficiently interesting to encourage a thorough trial of this form of treatment, at least in Hospital. As a remedy for the "typhoid-carrier" or for any long-continued inflammatory process due to the B. typhosus which persists after the fever has terminated, vaccine-treatment offers many possibilities. 42 Chapter II. Anti-typhoid serum has been prepared by Chantemesse, and according to liis results lias made some difference in the course and mortality of the disease, but as the serum is not in circulation in this country it is useless to us. Other serums have been prepared, but have not given very encouraging results. The early invasion of the blood-stream in enteric fever may account for this, the serums prepared being mainly anti-toxic and only slightly bactericidal, while the mixed character of the infection may also account for the lack of success of this form of treatment. Epidemiology. — Enteric fever may be said to be en- demic in the British Isles saving in some rural and sparsely populated districts. But it is subject, especially in large urban centres, to definite and periodic epidemic variations. The spring and autumn are the periods of its maximum incidence, the autumn shewing by far the greater rise. Localised epidemics have occurred in connection Avith the supply and distribution of milk, while water-borne epidemics have been observed even recently in this country. Second attacks are not very common, but do occur, not usually within two years of the first attack. Method of Infection. — Ground saturated with the excreta of infected persons may retain its infectivity for long periods and may, in the form of dust, spread the infection throughout a whole neighbourhood. It is to be remembered that both the xirine and dejecta of typhoid patients are highly infective, and contact with either of them, direct or indirect, must be guarded against. It is often very difficult to avoid infection from the small liquid stools' which are frequently passed and are apt to soil the bedclothes to such a slight degree as to be almost unobserved, but which, when dried, are capable of spreading the infection eve a beyond the immediate attendants. Period of Infectivity. — The period of infectivity of a case of enteric fever is variable. Usually it has terminated by the time a patient is able to go about again, but it is possible that many Enteric Fever. 43 persons may be infective for longer periods, either for a short time through the urine, or for longer periods through the in- testinal canal. Cases have been known where a chronic in- flammation of gall-bladder, quite without symptoms, or a mild chronic intestinal catarrh, or a slight cystitis have been found to be due to the B. typhosus and have been the means of ren- dering a person infectious for months or even years after the termination of the original attack. "Typhoid-carriers," as such persons are called, are obviously a danger to the com- munity, and, from iheir difficulty of recognition, are often the means of infecting very many people with whom they have been in contact. Such a person may be in the service of a "dairyman or farmer and may be the mysterious cause of his milk being the origin of an epidemic which, may attain wide proportions. The recognition of a "typhoid-carrier" is often difficult. The only certain method is by the isolation of the B. typhosus fi'om the stools, the gall-bladder being the most frequent seat of a concealed infection, or from the urine. Repeated examinations must be made before a negative finding can be of any value, as the presence of the organism in the stools or urine seems to be variable and may be only occa- sional. Widal's test is a very uncertain method of recog- nising a typhoid-carrier, since the agglutinating power of the serum in such cases is very capricious, and may be absent for months at a time. The history of persons who are suspected of being typhoid carriers should be carefuUjr worked out, to discover if they haA^e had any illness that may have been enteric fever, but it must be remembered that certain people are capable of har- bouring virulent typhoid organisms, although they them- selves are not suffering, and never have suffered, from an attack of enteric fever. Death Rate.— The death-rate of enteric fever varies very much in different epidemics, tending to be higher at the beginning and lower as the curve of the epidemic increases. It is greater among the poorer classes of the community, partly from the state of their nutrition and their alcoholic habits, and 44 Chapter II. partly from the fact that the labouring and artisan class struggle on till the last moment, and even when laid up at home, rarely remain completely at rest during the early stages of the disease, and are extremely uncontrolled in the matter of diet. So that a death-rate of 26 per cent, has been noted within recent years in the fever hospital of a large urban dis- trict during an autumn epidemic rise. In private practice among better-class patients the death-rate is much low^er, and taking it all round, froim 7 to 18 per cent, may be said to be a fair average, though the death-rate varies greatly from year to year. Home Prophylaxis. — A patient suffering fronv enteric fever can be treated at home only when the house is capable of complete isolation from other houses. In certain flats in the poorer districts of town or country there is no separate W.C. accommodation for each family, but three or four families may share a com- mon latrine. Under these circumstances it is impossible to permit an enteric patient to remain in his own house, and he must be removed to Hospital, if necessary on a warrant. The same rule applies when the patient is staying in an hotel. Where each family is provided with a separate W.C. it is necessary to insist on removal to Hospital only where it is impossible for the patient to occupy a room which is reserved solel}' for his own use. But it is advisable to remove all patients to Hospital who live in flats, or who inhabit houses where the dejecta are disposed of by means of earth closets, and in most cases it is well, not only for the patient, but for the other inmates of the household, to remove him to Hos- pital when the accommodation of the house does not permit of a AV.C. being reserved solely for the disposal of the dejecta of the patient and his immediate attendants. Isolation of the patient must be strict, as, although enteric fever is not so easily infectious as measles or scarlet fever, the drying of the dejecta or urine on the bed-clothes makes the dissemination of the B. typhosus throughout the sick-room an easy matter. The sick-room should be arranged as for any other infectious fever, and all the usual precautions Enteric Fever. 45 must be observed. Special care must be taken in tlie t^isinfection of the motions and the urine. ^^^^J should be mixed at once with equal parts oi a crude carbolic liquid, and allowed to stand for an hour or at least half-an-hour before beinj^ permitted to pass into the drains. Public Health Administration. — This resolves itself, as in the case of all infectious fevers, into the strict isolation of the sufferers, that they may be as little as possible a source of danger to the community. Care- ful enquiry must be made into the history of the illness, and all those who liaA'e been in close contact with the sick person be- fore and during the period of incubation must be seen, as it is in this way that ambulatory or mild, unrecognised cases and "typhoid-carriers" are sometimes discovered. The milk and food supply of the household must be noted and investigated, as one or two cases having the same milk supply occurring in a district throws suspicion on the dairy or the milk-shop. A frequent cause of a milk-epidemic is that one of the assistants in a dairy-farm or milk-shop may be suffering from an unrecognised attack of enteric fever, or may be in close attendance, when not at work, on a relative who is suffering from a disease which turns out to be enteric fever, although this diagnosis may not have been made until the occurrence of other cases. The drainage of the patient's house and the hygienic conditions obtaining at his place of work must be in- vestigated and necessary alterations made. The bed-clothes and mattresses, and everything portable which has been in contact with the patient and his attendants must be disin- fected after the convalescence of the patient, and the sick- room should be washed over with formalin and re-papered. Cotton and linen stuffs and blankets should be boiled, mat- tresses treated by steam, and furniture, if stuffed, subjected to a formalin-spray, while it may be sufficient in the case of books and papers to use vapour of formalin, taking care that they are so placed that the vapour can reach every part. The improvement of sewage-disposal, the opening up of congested districts, the paving of back-courts with imper- meable material, the inspection of W.C.'s to see that they are 46 Chapter II. kept clean and in good order, the insistence on public cleanli- ness on the part of everybody and the constant urging on them of personal cleanliness, are all points to which the Health Autliority of a district must pay attention if their work is to have any good result in lessening the incidence of enteric fever. t^"'' ' '"■■'■■:',. 1-- 1.J ' 1 ■■ -^" ■■■■-i ^7;^— 1 ! 1 i ■"■" ■■■-# ■i;-',-.-. -■j ■::, , rt- ■ :M+-L- •n ::.!!-:' fLU^^JTi-fj^: iji.LhfrryW ^U^.iiU4-i-\ 1 ' 1 1 M 11 1 ^:l^^l-^^i-L ^ Ij; I --I h H ( 47 ) Chapter III, DIPHTHERIA. Synonyms. — Membranous Croup. Fr. : Diphtherie, Ger. : Diphtheric. Definition. — An acute infectious fever characterised by a local lesion of the fauces, tonsils, and the air-passages generally, associated with a prolonged and severe toxaemia, with frequent paralytic manifestations. The disease is due to an invasion of the fauces and air passages by the Bacillus Diphtherise, discovered by Klebs in 1883. Incubation Period. — The incubation period is usually described as from one to seven days, but it is ex- tremely difficult to fix the maximum. I have known of a child who having been exposed to infection was observed for a fort- night after the B , diph theriae was isolated from his throat, and during the fortnight he remained quite well. After that time, however, he developed a typical attack of diphtheria under the eyes of his father, who was a medical man, and whose zeal for observing the behaviour of the bacillus outran the dis- cretion which he should have displayed for his child's sake. Rash. — No rash has been observed as typical of the disease. Period of Invasion. — This is usually very short, amounting only to a few hours. The patient feels slightly chilly, depressed and languid, may suffer from some headache and nausea and is almost at once conscious of sore-throat. The depression is often severe, and the patient may be quite 48 Chapter III. 13rostrated within an hour of the iirst feeling of malaise. The pulse is frequently rapid out of all proportion to the tem- perature, but may be slow, and tends to be very soft. The face is rarely much flushed, and the fever is usually moderate, 100°-102o F. Clinical Types. — From tlie beginning of the appear- ance of symptoms the local lesion is apparent either in the nose, fauces or larynx, and according as one or other of these parts is the primary seat of the local lesion, the attack of diphtheria is called "nasal," ^'faucial" or "laryngeal." The faucial type is by far the most common. The local lesion is characterised by the formation of a "false membrane" on the parts affected. This " false membrane " is produced by the degeneration, necrosis and desquamation of the epithelial layer of the mucus mem- brane with exudation of fibrin, the result of the local action of the toxins of the B. diphtherias. Microscopically it is seen to consist of a net-work of fibrin with some red blood cells and leukocytes entangled in it, with much epithe- lial cUhris and numerous clumps of bacteria, the B. diph- therise, non-pathogenic bacteria of the mouth and, fre- quently, the staphylococcus albus or aureus and masses of streptococci. In striking contrast to enteric lever, the invasion of the blood-stream by the bacillus diph- therise is not at all common, and while occasionally the bacillus has been found in the spleen and kidney, the wide- spread lesions met Avith in diphtheria are due to the action of toxins circulating in the blood-stream and manufactured by bacilli which occupy a superficial situation. Faucial Diphtheria. — The usual site for the membrane is on one or both tonsils, the uvula, the posterior pillar of the fauces, the soft palate or, rarely, on the posterior pharyngeal wall. On examining the throat, the fauces are found to be congested and reddened and in the neighbourhood of the mem- brane especially the parts are swelled and angry-looking. If the membrane be situated on the tonsil, the tonsil is dis- tinctly enlarged, and tender to pressure from outside. The appearance of the membrane on the first day of illness varies Diyhthevia. 49 very much in diil'erent individuals. In some it may appear only as a faint whitish semi-transparent film on the inflamed mucous membrane, in others it appears as a thick white opaque firm-looking growth, like the outer skin of a mush- room. As days go on it grows yellower and thicker, while the central portions of the growth become dark and the peri- pheral parts tend to curl up like carelessly dried wash-leather. If left unchecked the membrane may spread all over both ton- sils, the uvula, the pillars of the fauces, the soft palate and posterior pharyngeal wall, extending upwards into the naso- pharynx and downwards into the larynx and bronchi. Such wide spreading of the membrane is seldom seen at the present time, unless the child has been kept at home without seeing a physician for many days after the onset of symptoms. The membrane may appear at first as only one patch which spreads, or it may show itself as numerous small dots of yel- lowish grey, not unlike the exudate in follicular tonsilitis, Avliich afterwards coalesce to form a plaque. If any exudate resembling the above descriptions be present on a tonsil it is wise to strip a little of it off for purposes of diagnosis. If the surface from which it has been stripped is raw and bleeds, the presumption is that the condition is diphtheritic. The general appearance of the patient is not like one suffering from an acute fever. There is seldom any flushing of the face, which is usually pale and presents an expression of exhaustion and languor. The lips may be a little livid, apart from any laryngeal obstruction, and in profoundly toxic cases, the pupils are much contracted. The whole appearance and attitude of the patient is one of extreme exhaustion and relaxation, and it is always a surprise to the student, on seeing his first case of severe diphtheria, to realise that the pallid cachectic patient before him may have been in appar- ently good health less than twenty-four hours before. The temperature is very moderate, except wlien the local lesion is complicated by much pyogenic infection, but the pulse is usually rapid and weak. Sometimes the temperature may not rise above 100° F. I have seen this in rapidly fatal cases, and it is well to realise that the gravity of an attack of diphtheria cannot be measured E 60 Cliaijter 111. in the least degree by the height of the fever. There is very frequently enlargement of lymphatic glands in the neck, and pressure over these glands usually produces some pain. The progress of the case now-a-days depends very much on how long the disease has lasted before its recognition by a physician, because it is now, or should be, the ordinary prac- tice, immediately after recognising a case as diphtheria, to give an adequate dose of antitoxin, and in some 12-24 hours after giving the antitoxin the condition of the patient shows a marked change for the better if treatment has been begun within the first forty-eight hours after the appearance of symp- toms. The patient grows more alert in appearance, the pallor lessens, the pulse slows somewhat and the temperature begins to fall, while the appearance of the membrane undergoes a change. It becomes more translucent and less solid in ap- pearance, and there is a distinct diminution in the surrounding inflammation. Pain is lessened and the tenderness over the cervical glands diminishes. Within three or four days the membrane disappears and the patient begins slowly to recover strength, although in many instances it may be weeks before he ceases to suffer from a feeling of great prostration, and he may continue to be easily tired for months. In children it is noticeable that even after a mild attack of short duration their convalescence is slow, they may remain pallid and list- less for weeks, and exhibit a feebleness in walking out of all proportion to the apparent severity of the attack, even though there have been no paralytic manifestations. The membrane may separate in a mass and be coughed up in fairly large pieces, but it is more common, where due atten- tion is paid to the care of the mouth, to find that it gradually fades, becoming less thick and opaque until it appears as a slight semi-transparent film on the surface of the mucous membrane similar to its appearance at a very early stage in the disease. It is sometimes difficult to say exactly on what day the membrane disappears when it fades in this way and does not separate en bloc. When, however, several days have elapsed between the onset of the illness and the giving of antitoxin in adequate doses, the course of the disease is not so mild and uneventful. Diphtheria. 51 even when the type is simply faucial. It is not uncommon among- the poorer and more ignorant classes o£ the community to find that the initial sore throat is disregarded by the parents and it is only when after four or five days' illness the child's condition becomes alarming that the physician is called in. Under these circumstances we have to deal with a con- dition not much less alarming than diphtheria used to be in the pre- antitoxin days, since much of the toxin has become fixed by the tissue-cells and is beyond the reach of any anti- toxic serum. It is still no uncommon thing to find such a patient in a state of the gravest asthenia, with a membrane spread widely over the fauces and tonsils, presenting an ugly greyish appearance with dark central areas and associated with a great deal of oral sepsis, foul tongue and sordes on the lips and teeth. The pulse is rapid, extremely soft, and often irregular ; the urinary output may be low ; the child may have a tendency to vomit ; the pupils are contracted ; and the whole aspect of the patient indicates an extremely grave toxaemia. Even though antitoxin, in full doses, may be given at once or within a few hours, the progress of the case may be quite unsatisfactory. Despite all efforts, the membrane, while per- haps showing no sign of further spreading, may persist for many days and the child may die of toxaemia within a week. It is in this class of case that slow cardiac failure occurs. The heart grows gradually weaker, the extremities tend to be- come cold, the capacity for taking even the lightest form of food grows less and vomiting may be frequent. Death may en- sue suddenly as the result of cardiac failure due to the strain of vomiting, or the heart may grow gradually more feeble. and rapid until death occurs from asthenia. Some cases may linger in this toxaemic condition for a fortnight or more and may display paralytic manifestations either of the heart or of other muscles, or may develop a low form of broncho-pneu- monia and ultimately die. If recovery does take place, it is only after a long and tedious convalescence. Nasal diphtheria. — This has always been recognised as a particularly dangerous type of the disease and it is easy to understand why it should tend to be more serious and more XJ *J 52 Chai)tcr 111. fatal than the ordinary faucial type. The nasal cavities are inaccessible and difficult to see properly, and they are also difficult to clean by direct applications. Thus a nasal diph- theria may proceed far without recognition, and concomitant pyogenic infection is usual and not easy to deal with. Unless, by some fortunate chance, membrane forms just within the nostril and is visible on superficial examination, there is nothing to make a physician suspect that this somewhat severe nasal catarrh with rather profound constitutional symptoms of depression is due to the B. diphtheriaj. It is only when the extreme prostration of the patient and the sanio-sauguinolent nature of the nasal discharge makes it evident that something out of the ordinary is happening, that the physician suspects a nasal diphtheria and makes a culture from the nose for diag- nostic purposes, unless it is known that the patient has been jDreviously in contact with a case of diphtheria. Unless the physician has had some experience of diphtheria, it is fre- quently the case that the discharge of a piece of membrane is the first sign which makes him suspicious. By this time, of course, the disease has been in progress for many days and the toxaemia is profound. Beyond this difficulty in recog- nising the condition early, I do not see that a nasal infection is worse than a faucial one, but from what has been said before it will be seen that every day lost in making a diag- nosis and beginning antitoxin treatment means greatly in- creased risk to the patient, and it is this delay in diagnosis that makes nasal cases appear to be so malignant. Laryngeal diphtheria. — Similarly, in the case of the laryn- geal type of the dit^ease, on account of the impossibility of view- ing the larynx by ordinary means, diphtheria is naturally not suspected until the exudate in the neighbourhood of the cords is sufficient to cause some degree of stenosis, and even then time may be lost because a simple croup may be diagnosed in the first instance, and thus a dangerous delay in beginning treat- ment is incurred. But besides this danger, which is common both to the nasal and lar^mgeal types of the disease, there exists the danger of laryngeal obstruction with all the strain and loss of aeration which follows and which calls for special treatment. The laryngeal form may be secondary to Diphtheria. 53 a primary faucial diphtheria either by direct extension of the membrane downwards, or to a secondary infection of the larynx without there being actual continuity between the membrane on the fauces and in the larynx. The signs which are suggestive of laryngeal diphtlieria are those of a greater or less degree of laryngeal obstruction, combined with the usual toxaemia of the disease, and it is on this combination that the great danger of this type of the disease depends. We shall see under the section on treatment how not only the degree of laryngeal obstruction but the effect of that obstruction on a poisoned body has to be taken into consideration, so that in some cases where the laryngeal obstruction may be at the moment comparatively slight but the toxaemia severe, immediate tracheotomy is called for, while in other cases w^ith a great degree of laryngeal obstruction the toxaemia may be comparatively slight and tracheotomy may be delayed wdth safety. It is a good rule to be anxious about those cases with diphtheria of the larynx who, while showing signs of laryngeal obstruction, have a pale face, a soft and rapid pulse, perhaps a little irregular, and contracted pupils and who are quiet and feeble-looking. A great degree of cyanosis in a child even with marked signs of laryngeal ob- struction need not cause the same anxiety if he seems capable of effort and has a strong, regular pulse, albeit rapid. The amount of retraction of the lower intercostal spaces, the lower ribs and the lower end of the sternum during in- spiration gives, in a child, a fair indication of the degree of laryngeal obstruction. Another danger in connection with larjmgeal diph- theria is the tendency for broncho-pneumonia and catarrh of the smaller bronchi to occur, either due to invasion by the B. diphtherias or to a secondary pyogenic in- fection. Sometimes the trachea, bronchi and even bronchioles are found post morteTn to be covered with the typical " false membrane," and occasionally a complete cast of trachea and bronchi is coughed up during life as the membrane separates. Such happenings are rarer now that the use of antitoxin has become more general. The separation of a large piece of membrane in the trachea or larynx or the inhalation of a 54 Chapter 111. large piece of membrane separated from the fauces may some- times give rise to laryngeal obstruction, and necessitate im- inediate tracheotomy. Aberrant types of Diphtheria. — The primary local lesion ipay sometimes be found not in the air-passage or fauces but on the vulva, the conjunctivae, the lip or on some wounded surface. In these situations the general symptoms are usually slight, and the disease is troublesome mainly because others may acquire diphtheria of the faucial, nasal or laryngeal types from such conditions while undiagnosed. Differential Diagnosis. — The diseases most likely to be confused with diphtheria are acute tonsillitis, scarlatina^ -measles, simple catarrhal laryngitis, and some cases of croup. In acute tonsillitis the pain is much more severe than is common in diphtheria, where pain is usually moderate and may be absent. Acute tonsillitis, too, is commonly accompanied by high temperature, a flushed face, a full bounding pulse and all the common signs of fever. As in diphtheria, however, the cervical glands are apt to be enlarged, but are usually much more tender. The follicular exudate may simulate very closely the diphtheritic membrane in its early stage and an exudate firmly adherent over a portion of the surface of the tonsil or posterior faucial pillar or a superficial slough, may also: present a very suggestive appearance; but exudate can usually be easily removed by swabbing the throat, leaving no bleeding surface behind, while a superficial slough is not so easily stripped oft as the false membrane, and when easily separated, seldom leaves the raw bleeding surface which is seen on stripping the membrane in the early stages of diphtheria. But in many cases the differential diagnosis apart from bacteriological examination is practically impossible. Similarly, a case of scarlet fever in which the rash has been so slight as to escape observation and where desquama- tion has not yet begun may be difficult to differentiate without a bacteriological examination. The character of the tongue may help, as a "strawberry tongue" is not met with in diph- theria, but the superficial ulceration covered with exudate which so commonly appears on the tonsils may closely simulate Diiyluhe.ria. ■' 66 the false membrane. It is best in all cases of doubt to have a swab from the throat examined by culture before a diagnosis is arrived at, but where there is a reasonable possibility that the disease is diphtheria it is advisable to give antitoxin on suspicion. Measles may in the early catarrhal stage simulate laryn- geal diphtheria through the occurrence of a laryngitis with signs of obstruction, but the facies of the patients are very dis- similar. In measles there is usually a flushed, bloated face with coryza and lachrymation, and "Eoplik's spots" are a help towards differentiation. For bacteriological diagnosis a swab of the suspected part must be taken with sterilised cotton-wool and placed in a sterile test-tube stopped with sterile cotton-wool for examina- tion by culture. In taking the swab, great care must be taken to avoid touching the tongue and the teeth. At the same time a smear should be made on a glass slide from the suspected part, dried, and sent with the swab for examination by a com- petent authority. At the present time, practically all Medical Officers of Health are accustomed to carrj^ out such examinations, or have a bacteriologist connected with their department whose duty it is to aid the practitioner in this way, so that practitioners working even among the poorest classes of the community have little reason to be long in doubt in these cases. A test tube can be roughly sterilised by a few minutes boiling, and cotton wool pulled out from the centre of a roll with hands that are surgically clean will be sufficiently sterile to be used as swab and stopper, in such districts where suit- able apparatus is not supplied gratis by the Local Authority. Where it is impossible to have such an examination done in reasonable time by the Local Authority, a smear from the suspected throat should be taken on a glass slide and stained by Neisser's method, which roughly differentiates the B. diphtherise from the pseudo-diphtheria group of organisms which are found both in health and disease in the throat, nose and conjunctival sac. Staining with ordinary methylene blue or other aniline stains is not sufficiently accurate, even for an approximate diagnosis. 56 Chapter III. Complications. — The complications of diphtlieria most, commonly met with are seco7idary pyogenic infection of the throat, otitis media, nephritis, bronchial catarrh y and broncho-pneumonia. The multiple neuritis so frequently met with at all stages of the illness can hardly be called a complication or a sequel, and will be described under the heading of diphtheritic palsies. Secondary pyogenic infection of the throat is often a troublesome complication and adds danger to an already dan- gerous condition, since the toxins elaborated by pyogenic or- ganisms are not influenced in any way by the antitoxin, and throw an extra burden on the overtaxed sj'stem. The pyogenic infection often causes extensive sloughing of the tonsils and soft palate and may be associated with acute otitis media and inflammation of the cervical glands, and, possibly,' suppuration of these glands. Otitis Tnedia may occur apart from any marked secon- dary infection of the throat and may be due to the B. diph- therise itself, although it is usually associated with the Diplo- coccus of Fraenkel or one of the ordinary pyogenic cocci. It is not accompanied, as a rule, by the same amount of pain as is met with in a similar condition arising in association with scarlet fever or quinsy, and usually clears up without the necessity for operation. Nephritis is not a common complication. A slight al- buminuria is very frequently met with, but is of a "toxic'* type, comparable with the ordinary "febrile albuminuria," and is not associated with any grave lesion of the kidney. In such cases casts are seldom seen in the urinary sediment. Occasionally, however, a profuse albuminuria occurs, with numbers of casts and perhaps a little blood, and in these cases it is reasonable to suppose that either the kidney, as does happen sometimes, is invaded by the B. diphtherise, or' that the toxremia is sufficient to produce a serious degenera- tion of the renal epithelium. Slight broncliial catarrh is quite common in diph- theria, but if the case has been brought under treatment early it does not as a rule give much trouble. If, however, treatment^ Diphtheria. 57 lias been instituted late, bronchial catarrh and a low tyj)e of broncho-pneumonia are often troublesome and dan- gerous complications, and are particularly dangerous in cases where tracheotomy has been performed. This may be due to an infection by B. diplitheriae, or to a secondary infection by the pneumococcus or one of the pyogenic cocci. Vomiting induced by taking food is sometimes a very dangerous complication, not only because of the inanition which results from insufficient feeding, but also on account of the severe cardiac strain induced by the effort. In some cases vomiting follows on any attempt to swallow even liquids, and so immediately does it follow the act of swallowing that it has been thought that it is due to the irritation of food passing the fauces. This idea is supported by the fact that feeding by the nasal tube may result in a cessation of the vomiting, and that when it is discontinued the vomiting returns. Sequelae. — Besides the various paralytic manifestations, the most common sequelae are cardiac weakness due probably to fatty degeneration of the heart muscle, some degree of ge?ieral muscular erifeeblement and a marked cachexia which may persist for months after an attack of diphtheria. Cardiac iveakness is very common after an attack of diphtheria even of moderate severity, and produces consider- able breathlessness on slight exertion and often a marked degree of palpitation and prsecordial discomfort. It is pos- sible that some of the sudden deaths which have been noted as occurring weeks after the subsidence of all local signs may have been due to heart-failure following on an extensive fatty degeneration of the cardiac muscle. General muscular enfeeblement is, of course, common after all febrile conditions, but it is so much greater and of longer duration after diphtheria than after almost any other of the infectious fevers that it appears worthy of special men- tion. So profound is the effect of the toxins of diphtheria that a patient may be muscularly inert and easily exhausted for many months after the usual period of convalescence. The pallor and anaemia which follow on diphtheria are frequently 58 Chapter 111. obstinate, especially in children of 8-14 or thereabouts. Younger children are not usually affected to the same degree. It has been suggested that ihis cachexia is partly due to the effects of antitoxin, but it is more probable that we see more of the post-diphtheritic cachexia than in pre-antitoxin days because more serious cases survive now than formerly. Diphtheritic palsies. — Palsies of various groups of muscles are common in all stages of the disease after the first few days, and are due to a peri- pheral neuritis caused by the action of the diphtheritic toxins. The most common form is paralysis of the palate, usually unilateral on the same side as the local lesion. The paralysis is of very varying degree, from a slight drooping and immobility of one side, without any alteration in voice or difficulty in swallowing, to a complete paralysis of the whole soft palate with nasal speech and regurgitation of food into the nose on attempting to swallow, A palatal palsy may occur as early as the first week of the disease, especially if the local lesion is extensive and several days have passed before the commencement of treatment, but it may appear at any time up to the third or fourth week. If there be much ten- dency to regurgitation of food into the naso-pharynx it may be necessary to feed for some time by the nasal tube, to avoid the risk of an inhalation-pneumonia. Another early manifestation of diphtheritic palsy is the occurrence of squint, particularly internal squint, due to palsy of the external rectus muscle. This is very often the first in- dication of a paralysis which may in the end affect profoundly many groups of muscles and prolong convalescence for many months beyond the usual period. Of the limb palsies, that of the peroneal group is perhaps the most common, and next to that, palsy of the extensors of the wrist, but the whole limb may be pro- foundly paralysed. On rare occasions a palsy, more or less pro- found, of all four limbs may occur, or, rather less rarely, a paraplegia. In two cases of hemiplegia which I have seen as a result of diphtheria, there was at first, besides a profound palsy of an arm and leg on the same side, a slight but distinct Diphtheria. ■■ 59 loss of power in the arm and leg of the other side, which cleared up in a few days. The multiple neuritis of diphtheria is rarely associated with pain or tenderness in the affected parts. The prognosis is usually good, although in severe cases months may elapse before complete recovery. In a few cases, however, a palsy of the diaphragm has resulted in death, and in many instances a sudden cardiac failure has occurred early in the disease, presumably from paralysis of the vagus. Before such sudden cardiac failure the pulse has been found to have been weak and irregular, and as sudden cardiac failure has in most instances followed on injudicious movement on the part of the patient, any irregularity of pulse in diphtheria should be considered as a grave sign which may be the forerunner of serious accident. Diphtheritic palsies usually occur within four weeks from the onset of the illness, but I have known many cases where no paralysis was observed until six or even eight weeks had elapsed. There is little doubt that the incidence of paralysis has been greatly lessened by the introduction of the antitoxin treatment properly carried out, although in the earlier days of the treatment it was thought by many that slight palsies were even more frequent than formerly. This was probably due to the fact that antitoxin was given in quite inadequate doses, so that, while the death-rate was lowered, the process of cure in many cases w^as comparable with that of the more severe cases which recovered in pre-antitoxin times and was attended with many of the accidents which were then met wdth, so thatj many more grave cases having recovered, the incidence of ac- cidents among all cases treated naturally appeared to be greater. Treatment. — The main points in the treatment of diphtheria are careful and absolute rest in bed during at least the first three weeks of the disease, and the proper use of antitoxin. Absolute rest in bed is most essential until all risk of cardiac failure may reasonably be supposed to be over, that is until three or four weeks have passed. In the first fortnight the patient should be allowed 60 Chapter 111. to do nothing for himself, and the bed pan and the bed urinal sliould be used. He must be watched, and, if old enough, warned, lest any injudicious movement induce an attack of heart-failure. It is unwise to allow a patient to get up until at least three weeks have elapsed, and if the attack has been at all severe it is best to keep him in bed for four weeks. In really bad cases, of course, it may be necessary to keep him in bed much longer, especially if there have been any complications or palsy. But it is in the use of anti-diphtheritic serum that the chief treatment of diphtheria lies, and to be successful one must not only use the serum but use it properly. The serum now used is standardised in "units," and accurate dosage is thus rendered possible. The principle of dosage should be to neutralise the circulating toxins as quickly as possible, so that none may be left over to be fixed by the tissue cells, because when once a toxin molecule is fixed by a cell it cannot be neutralised by an antitpxin either injected or produced in the body. If Ehrlich's theory is to be accepted even as a working hypothesis this must be apparent, and, despite all statements to the contrary by older practitioners, there is no doubt that the minimum dose of antitoxin, even on the first day of the disease, should be from 6,000 to 10,000 units, and if two or three days have elapsed since the onset of illness, from 10,000 to 20,000 units should be injected. It is infinitely better to give only one dose than to give repeated doses at intervals of twenty-four hours, not only because it is not right to allow the toxin to have a greater opportunity of fixing itself than is necessary, but because it is not well to subject the patient to the irritation of repeated injections. The injection is usually made subcutaneously in the flank, and this is a con- venient situation, as it is least subject to friction and pressure while a patient is in bed. This is the objection to the loose tissue between the shoulders as the site for injection. In cases which have been ill for many days before being seen, the practice of intravenous injection has been adopted by some with apparent success. The usual method is to plunge Dipht/ieria. 61 the needle of the syringe directly into a vein in the bend of the elbow. The process is a difficult one in the case of children on account of the small size and thin walls of the veins. 1 know of no untoward result following this practice save in a case of my own, when a boy died suddenly within ten minutes after an intravenous injection had been given. The cause of death in this case is unknown, but I confess that the occurrence made me fight shy of intravenous injections from that time. One interesting point to be remembered in connection with serum treatment is that for some time after injection cer- tain patients become unduly sensitive to horse-serum. This is important in considering the advisability of giving a second dose of serum on the occurrence of a second attack within a few weeks or months of a first, and is also a fact to be recorded against the habit which certain physicians have of giving more serum on the occurrence of a palsy. In the latter instance the giving of serum is probably futile, as considerable fixation of the toxin molecules has already taken place, and it is un- likely that the neutralisation of the small amount of free toxin which possibly remains in circulation will have any effect in arresting the palsy. If a full dose of serum be given to a patient who is hypersensitive, a condition of anaphylaxis is produced; that is to say, certain alterations take place in the behaviour of the ordinary phenomena of " serum-disease " which will be discussed later, and profound constitutional disturbances, collapse and even death may ensue. This condition of hypersensitiveness to horse-serum may tegin about a fortnight after a full dose and continue for some months or even years, so that it is wise not to give a second full dose of serum within these limits without taking certain precautions. It is said that danger from anaphylaxis may be avoided by the giving of a very small dose of 50 or 100 units of antitoxin twelve hours before the full dose, when a patient has shown himself susceptible to serum-disease within a few years previously. Serum disease is the name given to those constitutional and local symptoms which follow the injection of antitoxic ■sera derived from the horse, as in diphtheria and plague. The 62 Chapter III. most common results are the occurrence of an urticarial rash both at the seat of the puncture and on the body generally. The rash is often morbilliform, often scarlatiniform, and, like all other so-called "toxic" rashes, has a tendency to be most marked about the joints. Whether morbilliform or scarlatini- form, it is inclined to appear in blotches and is often in- tolerably itchy. The appearance of the rash is frequently as- sociated with headache, nausea and general malaise, and occa- sionally with some rise in temperature, which, however, is rarely very high unless, as sometimes happens, there is besides the above-mentioned symptoms, some pain in the joints. The joint-pains in serum-disease, associated as they frequently are with fairly high fever and considerable constitutional dis- turbance, may closely simulate an attack of acute rheumatic fever, but they are not commonly so severe and may only exist as a very slight affection indeed. They attack as a rule those joints on which most strain falls in the patient's occupation, and are accompanied by slight swelling which is mainly peri-articular, but in some cases, fairly large effusion into the joint or neighbouring synovial pouches has been ob- served. Serum disease usually appears some 8-14 days after the injection of serum and lasts for about a week or less, but in rare cases relapses occur and repeated outbreaks of rash with fever and joint-pains may be observed, separated by a few days of normal temperature and freedom from symptoms. When a patient has been hypersensitised by a previous in- jection of serum, the phenomena of serum disease appear rapidly, almost without any incubation-period, so that rash, malaise, headache and fever may show themselves within a few hours of the injection. The constitutional symptoms of hypersensitised patients are usually much more severe than in those who have had no serum previously and may, indeed, give cause for grave alarm from the collapse from which the patient suffers. In several instances death has followed an injection of serum when the patient has been in this condition of anaphylaxis. Local treatment of the throat and nasal passages must be carried out with some care, but no attempt ought to be made Diphtheria. 63 to remove the membrane or apply strong disinfectants to the throat, on account of the pain and discomfort which this en- tails on the patient. The fauces may be sprayed frequently Avith a warm solution of Sod. Bicarb, or Sod. Biborate, and the mouth and fauces may be swabbed out several times a day with a mixture of Glycerine of Borax and warm water, but strong carbolic preparations or other powerful local anti- septics should be avoided, unless there be a great deal of secondary pyogenic infection. In a case of laryngeal diphtheria, the possibility of tracheotomy being necessary is always present in the mind of the physician, and the attitude towards this operation has changed very greatly since the introduction of the antitoxin treatment. Formerly, on account of the tendency of the mem- brane to spread to the cut surface, it was only performed as a last resort, and many practitioners, both in hospital and private, had given it up altogether on account of the appalling mortality which attended it. But now, when spreading of the membrane is practically unknown after adequate doses of antitoxin, the operation holds out chances of success which rob it of its terrors, and while its mortality-rate is, naturally, rather high, it is not such as to make a practitioner hesitate in its performance. The question is, when should the operation be performed, and when should a chance be given for the swelling of the cords to subside under the influence of antitoxin and other treatment? It is to be remembered that in many cases the apparent obstruction is increased by spasm, and many of the symptoms are the result of fear on the part of the patient. Unless the obstruction is very marked, as evidenced by much indrawing of the intercostal spaces, and the lower ribs and lower end of the sternum in children, with a great degree of cyanosis or exhaustion on the part of the patient, or unless a fair degree of obstruction is present in association with a very profound toxaemia indicated by a ''pale lividity" of the lips and face, coldness of the skin generally, and contraction of the pupils, it is wise to wait for some hours after giving antitoxin, in the hope that some amelioration of the symptoms will take place. 64 Chapter 111. In the meantime, a dose of 3^-3^'^ °^ whisky, according to the age of the child, in hot water with sugar, or the hypoder- mic injection of a small quantity of morphine, say from i\th to |-th of a grain according to age, will help to reduce the extra obstruction due to spasm and quiet the restlessness of the patient, and the surrounding of the bed with an impro- Tised tent into which steam is led by a funnel from a boiling hettle, will ensure the warm moist atmosphere which is neces- sary for those who suffer from an acute laryngeal inflamma- tion. During this time of waiting the physician should be in close attendance on the patient and all should be in readiness for the performance of the operation, since it is quite usual tor a sudden spasm to occur which may threaten the life of the j)atient should the operation be delayed longer than ten or fifteen minutes. One must remember that in the laryngeal obstruction of diphtheria a child is handicapped for the fight by a toxsemia which has a profoundly depressant effect on the lieart, and he cannot, therefore, endure much struggling. If, after a few hours of palliative treatment, the conditions are no better but rather worse, the operation should be performed without further delay. To those who have had much clinical experience of diph- theria it is comparatively easy to decide when the operation is necessary, but to those whose clinical experience is yet small, I would say that it is better to be too early than too late; it is better to operate sometimes needlessly than to have a patient die with laryngeal obstruction without tracheotomy Iiaving been performed. The instruments necessary for the operation are few. A small scalpel with a keen edge, a couple of artery forceps to retract the edges of the wound, a blunt retractor to pull down the isthmus of the thyroid should it be in the way, some pres- sure forceps to stop excessive bleeding should a large vein be cut, and some sterile ligatures, are all that is necessary. When the child is unconscious no ansesthetic will be required and, indeed, when there is much cyanosis, the sensation of the child is so blunted that the pain of the operation is slight, and the patient can be easily controlled. But when the child is strong Diphtlieria. 65 and struggles much, a small quantity of chloroform is neces- sary to keep it quiet, and the I'isk of accident is so remote that it is quite outweiglied by the additional comfort to the operator and the increased chances of rapid and successful operation. 1 have never seen any evil result from the careful administra- tion of chloroform in small quantity by the "open" method, even in profoundly "toxic" cases, but I have seen a child's heart fail after much struggling where the operator feared the anaesthetic. When the practitioner has had much experi- ence of the operation it is extraordinary how rapidly it may be done even with a struggling child, but when he has had little experience it is wiser to be slow and certain than to attempt rapidity and cut what should not be cut or lose the trachea for a time. I do not propose to describe the operation, but I would say this, that much of its success depends on the in- cision through the skin and subcutaneous tissue being ac- curately in the middle line as, if it has been made a little to one side, the search for the small soft trachea in the fat neck of a child is often irritating and disconcerting. In an adult, tracheotomy is rarely necessary in diphtheria, and should a sudden alarming obstruction occur, it may be rapidly relieved by putting a knife through the crico-thyroid membrane, an operation which can be done in a moment and involves no preparation or anaesthesia. The after-treatment of a tracheotomy is important. Care must be taken to keep the tube moist and free, by covering the opening with a hot moist sponge which should be frequently changed during the first twelve hours after the operation, and secretion should be encouraged by a hot alkaline steam sprayed into the opening of the tube every few hours. The inner tube should be removed and cleaned at least twice in the day, and if loosened membrane gives rise to any obstruc- tion it may be removed by cleaning the outer tube with a feather or sucking it out with a syringe and rubber tube. It may be that the tracheotomy tube will have to be taken out, and if this is the case the wound must be held open by a double retractor, while the trachea is cleaned. At the end of the first day after operation the inner tube should be taken out 66 Chaftcr 111. and tlie end of the outer tube should be covered and trial made of the patient's capacity to breathe through the larynx. Simi- lar trials should be made at intervals of twelve hours, and be- tween two and three days after the operation the tube may be removed and as a rule does not need to be returned. In some cases, however, the patient may have difficulty in breathing again and reintroduction of the tube may be neces- sary for twelve hours. Houghly speaking, the shorter the time the tube remains in the larynx the better, as if it has to remain for a long time troublesome granulations may appear in the trachea and may require special treatment. Sometimes tlie introduction of a larger tube for a day or two is sufficient to check these granulations, but occasionally they require scraping or treatment with "blue-stone." As a general principle, the tube used should be as large as can be introduced into the larynx without distress. The wound should be cleaned twice daily with a saturated solution of boric acid and a piece of boric lint should be placed under the flange of the tube. After the tube is removed, the wound may be covered with sterile gauze, dusted with powdered boric acid crystals, and kept in place by a light gauze bandage. The wound usually heals in about a week after the tube is removed. In a few cases patients have been known to acquire a "tube-habit" and seem unable to give it up for many weeks. I have tried to trick certain of them by removing the tube rapidly during sleep and have noticed that breathing was perfectly easy and natural while they were unconscious, but when they woke and found the tube gone, an attack of laryngeal spasm came on. It is a good thing to make such a patient wear a corked tube for some days before trying to train them to do without it altogether. No trouble results, as a rule, from the contraction of the scar left after the wound heals, but one or two cases have been recorded where a cicatricial stenosis of the larynx has oc- curred. Intubation has been urged by many as a substitute for tracheotomy in many cases. It is possible that in skilled hands and in hospital practice it may be attended with small Diphtheria. 67 risk, but even under these conditions, where the tube, if dis- lodged, can be quickly replaced by the physician in charge, in- tubation has frequently to be followed by tracheotomy. In private practice it is not to be recommended. The operation requires a considerable amount of training and manipulative dexterity, and one cannot expect a nurse to replace a dis- lodged intubation tube, so that the proximity of the practi- tioner is necessary to a degree impossible for one engaged in a practice of any size. After tracheotomy, on the other hand, the tube, if dislodged, can be replaced by any nurse who has had an ordinary training in fevers, and the practitioner is able to do his work properly without the danger of impossible calls on his time. The objections to intubation in this way are very practical, and the operation has not taken hold in this country for these reasons. However, if a practitioner is able to devote the time necessary to one patient, intubation will be found, in a certain number of cases, to obviate the need of tracheotomy, when otherwise the major operation would have to be performed. Treatment of Complications. — Secondary pyogenic infec- tion of the throat with ulceration must be treated as in Scarlet Eever. (q. v.) Otitis Tnedia yields readily, as a rule, to swabbing out the ear with some antiseptic cotton-wool and insufflation of Iboric acid powder. I have never seen mastoid abscess or periostitis following a diphtheritic otitis media. Broncho-pneuTnonia and Bronchial catarrh must be treated on general lines. If there is much embarrassment of breathing, heat over the chest, especially in young children, will often relieve it, and a mixture of Acetate of Ammonia 3ss-3i with Ammon, Carb. grs. i-iv appears to help the condition, the dosage to be calculated according to the child's age. I have not seen belladonna do any good in the pulmonary complications of diphtheria. The question of stimulation arises here as in many other conditions associated with the acute fevers, and I believe that, as in whooping cough and measles, children suffering from broncho-pneumonia and F 2 68 diaper III. broncliial catarrli benefit greatly from either doses of 30 minims of Avliisky every 3 or 4 hours throughout the day or a hii'ger dose of "^ii-lyxv at night. The action of the alcohol is, I think, mainly sedative, and it is the safest hypnotic to give to a child whose heart is poisoned with the toxins of diphtheria. Opium is distinctly counter-indicated. If, when recovery has begun, the process of resolution is slow, the use of Ammonium Iodide in doses of from 2 to 5 grains three or four times in the day will often hasten matters. Inflammation of tlie cervical glands should be dealt with by careful treatment of any septic condition of the throat or mouth, and by the application of dry cotton-wool to the neck. Should suppuration occur, the abscess must be opened and dressed with large moist dressings at least once a day. If nephritis occur, the patient must be kept warm, special attention must be paid to the action of the skin and bowels, large quantities of fluid should be taken, and the use of the alkaline diuretics is to be recommended. The treatment of vomiting is often troublesome. If it follows on cardiac failure, as it frequently does, its treatment must be mainly directed to the heart, but the application of hot fomentations to the epigastrium and the giving of small doses of champagne, frequently repeated, will sometimes help in getting rid of this most troublesome complication, but in association with cardiac failure it is always an ominous sign. Where it is due simply to the passage of food over the fauces, feeding with diluted or predigested milk by the nasal tube, if necessary for many daj'S, has very frequently the effect of stopping the vomiting. Feeding with the nasal tube has the advantage over rectal alimentation in that the child's nutrition suffers less and there is no danger of the occurrence of scurvy should the process have to be continued over a long time. The diphtheritic palsies are treated at first by rest and warmth. A severe palatal palsy will necessitate nasal feeding until recovery is sufficient to allow of swallowing without re- gurgitation of food into the naso-pharynx. Paralysis of a liml) Diphtheria. 69 is best treated, as general convalescence is established, by mas- sage and mild galvanism. Small doses of strychnine, hypoder- mically or by the mouth, are recommended for all forms of diphtheritic palsy. Epidemiology. ^ — Diphtheria is endemic witliin the British Islands, and is liable to no very definite variations. It may make its appearance in epidemic form as the result of a school or milk infection, or in connection with some insanitary spot like an unclean pigsty. It is always a moot point as to whether defective drainage has anything to do with the occurrence of diphtheria in a household, and I think that the result of the defective drainage may be looked upon as a strong predisposing cause, although perhaps not the im- mediate cause, of the disease, from its tendency to produce in the household a lowered vitality and general ill health with faucial inflammations of greater or less severity. It seems likely that the bacillus may remain potentially active in buildings and in soil for long periods, as is instanced by periodic outbreaks of diphtheria in certain hospital wards and in connection with the turning up of ground in the neighbour- hood of dwelling houses. In schools it is easily conveyed from one child to another through the medium of slates, pencils, boots, games, and, among girls, of kissing. It is possible that infected clothing may remain dangerous for a long time. Period of Infeetivity. — The length of time during which a patient who has suffered from diphtheria may remain infec- tious is very variable. The bacillus has been found to be absent from the throat as early as the end of the second week. In view of the uncertainty which attends the recovery of the bacillus from the throat it is well to consider that all patients are infectious for at least six weeks, and no child should be allowed to return to school until eight weeks have elapsed from the beginning of treatment. The death rate in diphtheria varies greatly according to the clinical type of the disease, the age of the patient, and the day of disease on which antitoxin has been given. 70 Chapter III. I append tables of death rates from the City of Glasgow Fever Hospitals showing the effect of treatment and age inci- dence on the mortality-rates. Pre-antitoxin Years : 1871-1894. Antitoxin Years : 1895-1909. Ages. Cases. Deaths. Per cent. of Mortality Cases. Deaths: Per cent, of Mortality 0-1 17 12 70-6 177 73 41-25 1-2 91 61 67-0 475 145 30-5 2-3 85 51 60-0 522 120 22-9 3-4 106 49 46-2 491 70 14-25 4-5 82 38 46-3 424 58 13-6 5-10 233 93 39-9 1127 106 9-4 10-20 93 9 9.6 391 17 4-3 20-30 66 6 9 198 5 2-5 30- 17 101 5 4-9 Total 790 319 40-4 3906 599 15-3 Home Prophylaxis. — Patients nursed at home must be rigidly isolated during the infectious period, and the room prepared in the usual way as a sick room. No patient may remain at home unless the house is of sufficient size to provide a room solely for himself and his attendant. It is well for the practitioner to inject all those of the household with a protec- tive dose of antitoxic serum, say 300-500 units. The discom- fort subsequent on this small dose is slight, as a rule, although, if care be not taken in diet and regulation of the bowels, "serum-disease" is fairly common, and, because of the neg- lect of simple precautions of this kind, "serum arthritis" occurs with greater frequency in persons who have received a protective injection than in those who have been injected for purposes of cure. It is remarkable how the injection of a small amount of antitoxic serum will prevent the spread of diphtheria in a household or in a school. After the recovery Diphtheria. 71 of the patient disinfection must be thorough, and during his illness everything which comes in contact with him must bo steeped in disinfectant and boiled before coming in contact with others. Public Health Administration. — In every case where the accommodation at home is not adequate for suitable isolation, the patient must be removed to Hospital. The Local Authority should provide means for the examination by a com- petent person of swabs from suspected throats, and should supply sterile swabs for the use of the prac- titioner. The question of the supply of antitoxin gratis or at a reduced price is an important one, as many people cannot afford to bear the cost of serum-treatment, even though their houses are quite suitable for the nursing of diph- theria. In some districts this is done, but the practice is not yet general. Similarly, the protective injection with 300-500 units of antitoxic serum of all children in a school when one or two cases have occurred should be undertaken. The drains of a house or school where diphtheria has appeared must be carefully tested, and put right if found to be defective, and schoolrooms as well as living-rooms should be stripped of paper, sprayed with formalin solution and repapered or white- washed. The milk supply of a household where diphtheria has appeared must be carefully investigated. All bedding and clothing which has been in contact with the patient should be steamed, and more perishable furniture and books treated with formalin spray or vapour. ( 72 ) Chapter IV. THE PLAGUE. Synonyms.— Bubonic Plague : Pestis Bubonica. Fr. : La Peste. Ger. : Die Pest : Bubonpest. Definition. — An acute infectious fever associated with enlargement of glands from wliicli, as well as from tlie blood stream and viscera, the causal organism may be recovered — the B. Pestis, discovered, independently, in 1894 by both Kita- sato and Yersin. Incubation Period. — This varies from a few hours to about a fortnight, but the usual period is from three to eight days. Rash. — There is no typical rash in plague as in typhus or scarlet fever, but hsemorrhagic areas varying from small pin-head petechiee to blotches about half-an-inch in diameter are frequently found on the skin over the body, especially on the more exposed parts. During the period of invasion and early stage of fever the skin is usually flushed and dusky and may show a peculiar sub-cuticular mottling such as is seen as a prodromal eruption in typhus and measles. Period of Invasion. — The symptoms of invasion last for a very varying period according to the malignity of the at- tack. In certain cases there may precede the stage of fever a day or two of severe headache, malaise, slight shivering, aching in the limbs, vertigo and great weariness, with some- times drowsiness and sometimes vigilance and evil dreams, and during this time the temperature may be normal or only The Flarjue. 73 very slightly raised. In other cases the disease is ushered in by vomiting, violent lieadache, considerable shivering, and sometimes diarrhosa, with sudden and rapid rise of tempera- ture in a few hours to highly febrile registers, 103*-' to 106° F. being frequently observed. The rise of temperature is not commonly quite so sudden as in malaria, but is more compar- able with typhus. Stage of Fever. — -The pulse and respiration are greatly increased in rate. The face, in white-skinned persons, is of a dusky pallor ^ and looks dull and heavy, as in typhus, but added to this there is a curious anxious expression about the eyes, which is accentuated when the patient is touched. The eyes are blood-shot, and the skin is dry and burning. The tongue is covered with a thick creamy fur which rapidly becomes brown, and sordes form on the lips and teeth. Prostration is extreme and the voice is feeble. The patient may suffer from delirium, usually of a low muttering type, but sometimes violent,. or he may, as is more common, sink rapidly into a typhoid state of stupor and prostration, with picking at the bedclothes, suhsultus tendinum, and retention of urine. Vomiting fre- quently occurs, and either diarrhaia or constipation may be present. The pulse, which for the first few hours may have been full and bounding, becomes soft and intermittent, and the first sound of the heart is weak and almost inaudible. The spleen is enlarged and frequently the liver also. The urine is scanty and high coloured and may contain a small quan- tity of albumin, but anything in the nature of an acute nephritis is rarely met with. Clinical Types. — The severity and duration of the disease vary very much in different epidemics even in the East, and an epidemic of plague in Western and Northern Europe differs greatly from that met with in the warmer climates and the unhygienic surroundings of the native quarters of towns and villages in China, India and Southern America. Among white races living in sanitary dwellings in a tem- perate climate, plague tends to be less virulent and more chronic in its course than is usual in sub-tropical countries. 74 Chapter IV. and the danger of a large epidemic is slight since the winter and spring are too cold to favour the activity of the B. pestis which has, besides, no such nidus of filth as is met with in any Eastern town. But the difference is merely one of degree— plague in Western Europe or in the United States of America is simply plague in Hong Kong watered down — the manifestations are the same, though less severe, and the clinical types are identical. The tendency to chronicity was notable in the Glasgow epidemic, when crisis occurred in one case 18 days after the onset of the disease, and when two of the ultimately fatal cases survived, one to the 40th and another to the 44th day. In nine-tenths of all cases of plague the type is bubonic, i.e., in addition to the conditions described above as belonging to the "stage of fever," visible swelling and inflammation of one or another of the more superficial groups of lymphatic glands occur, forming the typical "bubo." The buboes are most often single, and appear in one groin in a large per- centage of cases, but they may appear on both sides. They may also appear in the axilla, and, chiefly in children, at the lower angle of the jaw. Small buboes have been seen in the root of the neck, the sub-occipital region, and in the bend of the elbow, but buboes in these situations are extremely uncommon. The buboes vary very much in size, from a hazel- nut to the size of one's fist. They are usually reddened on the surface, painful, tender on manipulation, and are often surrounded by a brawny area of infiltration both of skin and connective tissue. The bubo makes its appearance at some time between the first and fifth day of the stage of fever, most commonly during the first day. In faA^ourable cases after a very variable period of fever the symptoms begin to abate and the first indication of better- ment may be the occurrence of a profuse sweating. The tem- perature begins to fall, the pulse to recover its tone, the tongue to clean, and the patient becomes sensible and in- telligent. But the bubo does not subside with the other symptoms. In most instances it softens and suppurates, and, if left to itself discharges through a necrosed area of skin a quantity of very foul smelling pus mixed with sloughs. When The Plague. ' 75 it does not suppurate it may take months to disappear. The healing of a burst or incised bubo is a very tedious process and may prolong convalescence for many weeks. In a small minority of cases convalescence is rapid. If death occurs, it does so usually within the first week of the disease, from beart failure, profound asthenia, and coma, sometimes with convulsions. But in some cases life is prolonged past the subsidence of the more acute manifestations of the disease, and death may occur from asthenia after prolonged sup- puration of one or more buboes. The other clinical types usually recognised are the septiccemic and 'pneumonic forms of the disease. In the typical septiccBTnic form no enlargement of lym- phatic glands is visible during life, and the signs of illness are fever, very often slight, profound exhaustion, delirium, stupor and coma, with, in a fair number of cases, haemorrhages into the skin and from the bowels or other mucous membranes. In these cases the bacilli are found in large numbers in the blood. Diarrhoea is a common feature in the septicsemic form of plague, and an intestinal form of the disease is sometimes described. There is little doubt but that the first cases, which were unrecognised, occurring in the Glasgow epidemic of 1900 belonged to this intestinal variety of the septicsemic form. Death usually occurs in septicEemic plague between the first and third day of the disease, and this form is very dangerous to the community, as unless it occurs in the middle of an epidemic it is seldom recognised as plague, until the occurrence of attacks of the bubonic form among those who have been in contact with the patient makes it plain what his illness has been. There is, however, a somewhat modified form of the sep- ticsemic type which appears particularly in temperate coun- tries and in which, while the bacilli are found in the blood- stream, the attack is characterised by slight enlargement of the superficial lymphatic glands, so that small masses of glands may be seen in the groin, axillse and neck. In this class of case the small buboes are always inultiple. The mor- tality in this somewhat modified form of the septicsemic type 76 Chapter IV. is rather less than in that which shows uo lymphatic enlarge- ment, but is far in excess of the death-rate from the true bubonic variety. Pneumonic pJague is the most directly infectious of all the forms of plague, as the bacilli are discharged in great numbers in the sputum, and it is also an extremely fatal form of the disease, death occurring usually between the third and fifth day of illness. The symptoms of invasion are severe and the tempera- ture rises rapidly to high registers. The patient is short of breath, and troubled by a frequent cough and profuse rather watery blood-stained sputum, not viscid and "rusty" like the sputum in an ordinary acute pneumonia. Signs of con- solidation of the lung are not well marked, but there may be some dullness on percussion at one or both bases behind, with great diminution of the volume of the respiratory murmur and much intra-pulmonary crepitus. Respiration is very rapid. As in the septicsemic form there is great danger to the community in such cases when they occur at the beginning of an epidemic, since there is little to indicate clinically that they are anything more than extremely malig- nant cases of acute pneumonia, and the infection may thus be spread widely before the disease is recognised as plague. Another form which often appears at the beginning or end of an epidemic of true plague, but which has been noted as occurring in great numbers in the course of certain epidemics, is the 'pestis Tninor, or ambulatory form of plague. It is characterised by slight malaise, headache, a little fever, and the occurrence of small buboes which do not suppurate. It is easily seen how such cases anay spread the disease, and their recognition is of the greatest importance. Diagnosis. — The only reliable method of diagnosis is by the recovery of the infecting organism from the bubo, the blood, the stools, or the sputum. Nothing but a bacterio- logical examination can separate plague from adenitis of other kinds associated with fever, when they occur in a dis- trict where plague is common or in the course of an epidemic. The Plague. 11 It will be iiece,ssary to differentiate bubonic swellings of all kinds, whether cervical, axillary or inguinal, when plague is epidemic, and cases of tuberculous adenitis, pyogenic infec- tion of glands and venereal bubo will all be suspected. The puncture of a bubo and the withdrawal of some of the fluid by a syringe with due antiseptic precautions, and the examina- tion of the fluid by staining or culture, is the only method by which plague can be accurately detected. Fortunately the bacillus pestis is large and stains well with the ordinary anilin stains, such as Gentian Violet, and it is usually easily recog- nised from a stained smear-preparation made directly from a bubo. The short thick bacilli, staining with a "cap" at either pole with a clear space between, present a very typical appearance. A culture on peptone-agar should be made at the same time and incubated at 37° C. for 18 hours, but it is to be remarked that in cases which have been ill for some time before examination, especially when the bubo is beginning to soften, a somewhat degenerated and badly- staining organism may be seen in a smear-preparation, but a culture may be sterile. When any doubt remains after examination by culture and staining, inoculation of a rat should be performed. The differential diagnosis of plague, apart from the occurrence of bubonic swellings, is clinically impossible without bacteriological examination. In temperate climates it may be confused with typhus, which is the only one of our common infectious fevers to which it bears any resemblance, unless the type be "intestinal" or "pneumonic." In the Glasgow epidemic of 1900, the early cases which were not sent to the Fever Hospital were "intestinal" in type and were labelled "Zymotic enteritis," while the first three Avhicli were brought to Hospital were certified "Enteric (?) " and had well marked buboes. In Suffolk, during the autumn of 1910, the first cases were pneumonic in type and were, most naturally, not recognised as other than a very virulent pneumonia. It is most unlikely that a severe case of bubonic plague will be mistaken for anything else, but a mild case with bubo in the groin can only be distinguished from a venereal bubo by the discovery of the B. pestis. 78 Chapter IV. Complications. — Tlie complications of plague are not at all numerous. Those wliich do occur are usually in association with pyogenic infections, resulting from the suppuration of the bubo, such as metastatic abscesses and pleurisy. In the Glasgow epidemic of 1900 we observed one case with an axillary bubo where death resulted after the forma- tion of a large abscess under the pectoral muscle from which we recovered the pneumococcus. Sequelae. — Beyond a prolonged and troublesome con- valescence with much anaemia and muscular weakness, the sequelae of plague are unimportant. Treatment. — The treatment of plague apart from the use of antitoxic serum consists mainly in the main- tenance of strength by rest and judicious stimulation with alcohol and strychnine and the procuring of sleep and relief from pain by the use of small doses of opium, either hypoder- mically in doses of ^ gr. of morphine, or by the mouth in the form of Battley's solution in doses of 5 min. every two or three hours until quiet is induced. The bubo must be carefully tended ; the skin over it should be gently cleansed with soap and water, sponged with spirit each day, and covered with a layer of Gamgee's tissue after powdering. When softening occurs and a necrotic area of skin appears, it is well to open the swelling freely to allow of sufficient drainage, and a discharging bubo must be dressed with the strictest antiseptic precautions. Antitoxic Serum has been prepared by Yersin, Calmette and Borrel, but the effectiveness of these has not been proved in India and China, except when Tersin's serum was first used in Hong Kong. On that occasion twenty-four out of twenty- six treated cases recovered. It is possible, however, that in temperate climates anti- toxic serum may prove effective, if a more powerful and pro- perly standardised serum is prepared. Apart from serum treatment one feels very powerless in the presence of a disease so virulent and rapid in its course as plague, and all other The Playue. 79 treatment is frankly palliative and unsatisfactory. Our cases in Glasgow were too few to make our observations on the effect of serumtherapy of mucli value, but our impression was that in cases where we had a little time afforded us it was an aid to recovery, and that after the use of Yersin's serum tlie patients rallied somewhat and were more comfortable, the most reliable happenings being that the pain of the bubo became less and profuse sweating often followed the injection. The best results undoubtedly followed the giving of 40 ccm. of serum intravenously, and this dose may probably be in- creased with advantage. Epidemiology. — Plague is endemic in India, China and Uganda. It has aj)peared in epidemic form in Russia, Egypt, Turkestan, Japan, the Philippines, Madagascar, South Africa, South America, San Francisco, and Australia. With the exception of the limited epidemics at Oporto in 1899, Glasgow in 1900 and 1901, and Suffolk in 1910, plague has not appeared in Western Europe for long, save for the occur- rence of a few cases here and there, mostly imported, in the great seaport towns. On the whole, plague is favoured by a tem- perature that is neither extremely hot nor extremely cold. In Arabia, epidemics tend to decline during the hot and dry summer, and in temperate climates the disease usually dies down in the winter, to reappear, may be, lat-e in the following summer. In Glasgow, the disease appeared both in 1900 and in 1901 during the month of August. On the other hand, the plague has raged through the extreme heat of a Hong Kong summer, and has survived the rigours of a Russian winter. Method of Infection. — While undoubtedly directly infec- tious, plague is not nearly so much so as scarlet fever, measles, or smallpox, and it is extremely rare that the attendants in a clean and well-ventilated hospital acquire the disease from the patients unless they are dealing with the pneumonic variety. Unfortunately cases of laboratory infec- tion have, however, been known both abroad and in England. Where attendants on the sick have contracted the disease, it has usually been when they have visited the patients in squalid and verminous homes, or when the patients have been so Chapter IV. allowed to wear their dirty and probably flea-infested clothing in hospital, or when the attendants have been careless about abrasions and cuts on their own hands or faces. Apaj't from contact with infected bedding, clothing or furniture, where irom the collection of filth the virus has been unusually con- centrated, it seems beyond doubt, after the work done by Lamb at Kassauli, that plague is spread from patient to patient by means of fleas and other vermin, and the disease is carried on by rats and spreads from them to human beings, •once more by the agency of fleas. It has been remarked in "the East that plague among rats has preceded an epidemic among human beings, and that the surviving rats will leave a district in which other rats have died in great numbers from "the disease, some of them doubtless carrying infection with "them. In temperate climates at the present day, plague must be imported from some place where it is either endemic •or epidemic at the time, but the mode of entry of the disease is not always plain. The two small outbreaks in Glasgow in 1900 and 1901 are of extreme interest, because no definite case of plague Avas imported at the beginning of the first out- break, nor were any of the patients known to have been in direct contact w^ith foreign shipping. The disease arose in a squalid part of the town from no definite source of infection, as it might do in any other large city, despite all the precau- tions of modern health administration. The second outbreak in the following year arose in the largest Hotel in the city and was traced readily to rats who frequented an old disused sewer. 'The rats were found to have plague amongst them to a very considerable extent, and it is likely that the rats were first in- fected during the epidemic of the previous year, while that first epidemic may well have been due to rats infected with plague by other rats who had come from abroad on board ship. Period of Infectivity. — While in a few cases the B. pestis has been found to have disappeared from patients after the lapse of a fortnight from the commencement of the illness, it has been found in others as late as the fifth or sixth week. It is, therefore, wise to consider that patients who have had plague are infectious for at least six weeks, and they •should be isolated for that period. The IHagne. 81 Death Rate. — The death-rate varies greatly in ditterent epidemics, even in the East, and while one epidemic may show a death-rate of 90 per cent, among those attacked, another may show a death-rate of only 50 per cent. It is astonishing to note the effect of nationality on death-rate in the East. Manson quotes in this connection the figures of an epidemic in Hong Kong in which, while "the mortality among the indifferently fed, overcrowded, unwashed and almost unnursed Chinese amounted to 93.4 per cent., it was only 77 per cent, among the Indians, 60 per cent, among the Japanese and 18-2 per cent, among the Europeans, a grada- tix)U in general correspondence with the social and hygienic conditions of these different nationalities." In the Glasgow epidemic of 1900, when plague appeared among the lowest of the Irish population, the hospital death-rate was 28"5 per cent., while the death-rate among all cases at home and in hospital was rather over 40 per cent. Personal Prophylaxis. — As no patient suft'ering from plague can be treated at home with any safety to the com- munity, the question of " home prophylaxis " does not arise. But something falls to be said about the precautions to be taken by those whose work it is to tend the patients, to investigate suspicious cases and to work in the infected area. Nurses and physicians must hang over the patients as little as possible, and must take the greatest care to protect any cut or abrasion of the skin with an impervious dressing of collo- dion or " New-skin." The hands should be washed very frequently, particular care being taken with regard to the cleanliness of the nails, and after washing, the hands should be immersed for a few minutes in a fairly strong solution of permanganate of potash. Stronger antiseptics are not desirable as they encourage the formation of cracks in the skin, and expose the attendant to the risk of infection through an in- jured epidermis. The nurse should see that the patient, if verminous, is freed as soon as possible from his parasites, since infection by them is a dangerous possibility. No food must be eaten in the ward, and frequent bathing and changing of garments is essential. 82 Chapter IV. Those who are engaged iu work iu an infected district > either as physicians, inspectors, or on the disinfecting staff, ought to wear leggings, as the legs below the knee are the most easily accessible portions of the body to fleas, and the hands should be washed frequently as in hospital. Rat-catchers should wear gauntlets. Public Health Administration. — In dealing with plague, as with smallpox, it is necessary not only to isolate all persons who have fallen victims to the disease, but to segregate carefully all " contacts " until the maximum in- cubation-period of a fortnight has elapsed. In Glasgow, the patients were taken to the Fever Hospital, and all the " con- tacts " were isolated in Reception Houses where they were under constant supervision by a trained staff of nurses and visited twice daily by a physician. Their temperature was recorded night and morning, and the slightest variation from normal health was reported by the nurse to the visiting phy- sician at any time of the day. I may take the administration methods of the Glasgow Sanitary Office, carried out under the supervision of Dr. A. K. Chalmers, as being applicable to any western country attacked by plague, and, instead of stating what ought to be done, I shall state what was done in 1900 as being as effective as possible. The following routine was followed during the epidemic : 1. Within the infected area ashpits were emptied thrice weekly and washed once a week with chloride of lime solution. 2. Back courts were hosed every night with chloride of lime solution. 3. A special inspection of the district was undertaken for the detection of dirty houses, entries, &c., and for the overcrowding of houses. 4. Medical inspection of the district was carried out and the inhabitants of infected buildings and all " contacts " were offered injection with Tersin's serum or Haffkine's vaccine, while all suspected cases were visited with their own medical attendants. Tlie FUujue. 83 5. Handbills were distributed offering tlie service oi' the medical staff at any time. 6. The crews of all ships were inspected on arrival in port. 7. Fumigation of infected liouses was carried out by liquified SO 2 for twelve or twenty-four hours, after which the house was entered and all articles of bedding, clothing, &c., were wetted with a 2 per cent, solution of formalin (1 gallon of a 40 per cent, solution of formaldehyde to 50 gallons of water), removed to the Sanitary Wash-house, and then boiled or steamed. All articles which could not be boiled or steamed were burned. 8. All houses where cases had occurred or from which con- tacts were removed were sprayed with the formalin solution, as were also the lobbies and entries. 9. Clinical demonstrations Avere given daily to medical practitioners at the hospital. 10. A pamphlet descriptive of the varieties of the disease was distributed among the medical practitioners of the city. 11. Physicians to out-patients at the various hospitals were specially circularised. 12. A campaign against rats was entered upon; rat-catchers were engaged and the bodies of rats were investigated for the signs of plague. The sewers of the hospital were treated with liquified SO2, and the rats driven from the hospital by this method. 13. The bodies of those who died from plague were drenched with formalin and enclosed in an air-tight leaden shell before burial. 14. As the epidemic arose among the Irish Catholic popula- tion, the holding of wakes over any dead bodies was prohibited, thus repeating one of the old precautions taken at the time of the great ravages of the plague in Glasgow in 1646, when it was ordained "that ther be na meiting at lykwakes nor efter burrials, and that this be intimat by touk of drume." G 2 ( 84 ) Chapter V. CHOLERA. Synonyms. — Cholera morbus, Asiatic Cholera, Epi- demic Cholera. Fr. : Cholera. Ger. : Cholera. Definition. — An acute speciiic disease, characterised by violent gastro-intestinal symptoms, propagated by water, running a short course and occurring in epidemics, associated with an organism found in the stools, the Cholera Vibrio, or Comma bacillus, discovered by Koch in 1883. Incubation Period. — This varies from a few hours to ten days, and three to six days is given as the usual incu- bation period. Rash. — No rash has been observed as typical of the disease, but a patchy scarlatiniform eruption is occasionally seen during the stage of reaction. Clinical Types. — Cholera may attack a patient with great suddenness, or may be preceded by certain pro- dromal symptoms. The most common of these is the "pre- monitory diarrhoea," but it is open to doubt whether this is really due to the cholera infection, or whether it is not due- to a simple intestinal catarrh which renders the bowel more •s'uluerable to the attack of the cholera germ. Occasionally a short period of languor and depression with headache and noises in the ears, precedes the true onset of the disease. The first symptom of cholera is the passage of very frequent, copious, watery stools, which is not accompanied by any pain or griping. The stools very quickly lose their fsecal character Cholera. 8 5 and take on the "rice-water" appearance so typical of the disease, i.e., they are like very thin rice-water containing abundant small white flakes. Violent v^omiting soon appears, at first of food taken and bile-stained mucous material, but very quickly of the same "rice-water" material as is passed by the bowel. The patient now presents all the appearance of profound collapse — he looks shrunken and pinched, the eyes are sunken and the fingers look shrivelled, while the skin generally is cold and covered with a clammy sweat, respiration is rapid and shallow and the pulse is weak and fluttering or may be altogether absent. The urine is completely sup- pressed. The temperature in the axilla and mouth is sub- normal, sometimes as low as 93° or 94° F., but at the same time the rectal temperature may be as high as 104° F. The patient is restless, complains of intense thirst, and suffers ex- cruciatingly from cramps in the abdomen and extremities. His mind may be clear although apathetic, or he may sink rapidly into a mild delirium followed by coma. This stage has been called the " stage of collapse " or " algide stage," and may terminate in death, in rapid convalescence, or in the stage of " febrile reaction." When death occurs in the stage of collapse, it usually does so within twenty-four hours of the onset of symptoms, and may occur after an illness of only two or three hours. Sometimes after the stage of collapse having lasted for about a day, the purging gradually ceases, the body becomes warm again, the pulse is stronger, the urinary flow returns, bile appears in the motions, and in a few days the patient is well again. Much more commonly, however, the " algide stage " merges into the " stage of reaction. " As this stage is entered upon, the patient becomes warmer, the shrivelled, shrunken look disappears, he grows less restless, ceases to suffer pain, and the pulse grows stronger, while the bowels move less frequently, and the motions begin to show bile- staininff. At the same time a certain amount of fever makes its appearance, of variable degree, rarely rising to very high registers. In some cases this "febrile reaction" lasts onlv for a few hours, at the end of which the fever subsides and convalescence begins. But in more severe cases the stage of 86 Cha'pter Y. reaction may last for four or five days to rather over a fort- niglit, during which the patient may be highly febrile and resemble a case of enteric fever, the resemblance having struck some observers so much that the name "cholera typhoid" has been given to this stage of the disease. The patient's face is flushed, and the fever may rise even to hyperpyretic registers. The tongue is brown and dry, low delirium, with some tremor, and suhsultus tendinuTn, may be present, or the patient may sink into a state of profound stupor. The stools are like the later stools in enteric fever, greenish or " pea- soup " in character, containing, perhaps, a little blood, and are commonly very offensive. The urine may remain sup- pressed for some days, even as long as six, and when the flow is re-established it is usually scanty, high-coloured and may be highly albuminous, containing abundant casts. In favourable cases the symptoms gradually subside in about a week, the urine becomes copious and less albuminous, and the patient becomes convalescent. In cases which prove fatal during this period, death often results from a profound asthenia or a low form of pneumonia. Diarrhoea may again become urgent, and the patient may die with all the indications of a very acute enteritis. Death may also occur after convul- sions, or profound coma, which usually occur when there has been delay in the re-establishment of the urinary flow, or when the urine has remained very scanty and albuminous. Cholera sicca is the name which has been given to a very fatal class of case in which collapse sets in with great rapidity and in which there is almost no diarrhoea or vomiting, and no passage of "rice-water" stools. In such cases 'post-mortem examination reveals the presence of large quantities of rice- water material in the bowel, although none has been passed during life. Mild forms of Cholera. — In all epidemics mild cases are found, in which there is diarrhoea and malaise without com- plete suppression of urine or the occurrence of " rice-water " stools, and in which the diarrhoea is not accompanied by cramps. In other cases the typical rice-water stools may be present, but are not accompanied by suppression of urine, Cholera. 87 while the cramps may be not at all severe. In these mild forms the attack subsides quickly, and is not followed by any " stage of re-actiori." Kelapse in Cholera. — In a certain number of cases after the patient begins to show signs of " reaction " a relapse occurs, and the patient sinks again into a state of collapse and purging. Such relapses are generally fatal. Diagnosis. — The diagnosis of cholera, especially at the beginning of an epidemic, is not always an easy matter. Pungus-poisoning, ptomaine-poisoning, zymotic enteritis, and the early stage of trichinosis, may present symptoms ex- tremely like Asiatic cholera, and may occur in more or less epidemic form. These diseases are accompanied by diar- rhoea and vomiting, with a tendency to collapse, and the stools may resemble very closely the "rice-water" evacuations. It is very unusual, however, that the stools are as deficient in bile as in a severe case of cholera, and " rice-water " vomiting is never seen in other diseases, while in fungus-poisoning por- tions of the fungus eaten may be seen in the stools, and micro- scopic examination of the dejecta in a case of trichinosis will reveal the presence of the adult worm. The great difficulty in differential diagnosis in temperate climates is between zymotic enteritis or acute gastro-enteritis and cholera, and here we must depend largely on the results of a bacteriological examination of the dejecta. Films may be made directly from the stools, but it is best to make cultures from one of the flakes floating in the liquid stool. After placing such a flake in a test tube of Dunham's solution of 1 per cent, peptone and •50 per cent, sodium chloride, and incubating for some 6-10 hours at 37° C, the upper strata of the fluid will be found, in most cases of cholera, to show an abundant growth of the characteristic vibrio, or comma bacillus. But, as the bacillus of Tinkler and Prior and Deneke's vibrio are morphologically practically identical with the vibrio of cholera, it will be necessary in addition to try to get the " cholera-red " reaction, which is obtained by adding a few drops of sulphuric acid directly to the culture. In view of the necessity for accurate differentiation of the cholera vibrio, it is wise to leave the bacteriological examination in 88 Chapter V, the liaiuls of a skilled bacteriologist, although it is a good thing for the practitioner to make a film from the suspected dejecta and search directly for the vibrio after staining with fuchsin. The presence of any vibrio in the dejecta makes it necessary'- to have a further examination made. It is to be remembered that in a few cases of cliolera the vibrio may not be discovered, just as in a certain number of cases of pul- monary phthisis careful search has failed to reveal the pres- ence of the bacillus of tubercle in the sputum during life, so that the negative result of a bacteriological examination must not be taken absolutely to mean that a patient does not suffer from cholera. Complications. — The complications of cholera are not numerous, but may be severe. Occasionally during the second week pneumonia, bronchitis or pleurisy occurs, or some sloughing of the fauces, bladder, or sexual organs, or, it may be, actual gangrene of fingers, toes, ears or nose takes place, while bed-sores are apt to occur. A troublesome com- plication is ulcer of the cornea, which may occur early in the "stage of reaction." The lower part of the cornea is that which is usually affected, and the beginning of the process is characterised by a cloudy opacity in the cornea, covered, per- haps, with some exuded lymph. Ulceration quickly follows, and perforation may result, and as a rule, if the patient re- covers, the eye is destroyed. Sometimes during the second or third week an acute suppurative parotitis occurs which seri- oasiy interferes with the patient's taking food, and is always an ominous sign. Sequelae. — The common sequelae of cholera are anaemia, mental and physical weakness, insomnia, enteritis, coli- tis, and nephritis. In most cases which have recovered after passing through a severe "stage of reaction" con- valescence is protracted and many months may elapse before the patient recovers his ordinary strength. Treatment. — So far, as the death-rate shows, the treat- ment of cholera has been most unsatisfactory. It is purely symptomatic, as no anti-cholera serum or vaccine has been discovered for curative purposes. In the stage of Cholera. 89» premonitory diarrlioea, or very early in the stage of " rice- water" purging-, opium, given as laudanum or chlorodyrie in large doses combined with brandy, is often very efficacious in checking the loss of fluid, and even in tHe " stage of collapse" the use of morphine hypodermically in doses of J-| of a grain is not to be discouraged. But where the " stage of collapse " or " algide stage" is fully established, the treatment first recommended by Cox of Woosung, and modified by Leonard Eogers of Calcutta, is worthy of serious trial. In view of the fact that many of the most dangerous symptoms in cholera are due to the loss of fluid by the bowel. Cox recommended the continuous slow intravenous injection of normal saline solution, allowing the fluid to flow by gravity from a vessel placed about a couple of feet above the level of the point of injection, continuing the process so long as any danger of col- lapse was present. Leonard Rogers published his results of intravenous saline injections in the British Medical Journal of Sept, 24th, 1910. He uses a " hypertonic " saline solution, consisting of 120 grains of sodium chloride, 6 grains of potassium chloride and 4 grains of calcium chloride to a pint of sterile water. Soluble tablets for the making of this solution may be obtained from both Messrs. Burroughs, Wellcome and Co., and Parke, Davis and Co. Where the rectal temperature is hyperpyretie the solution should be injected at a temperature not exceeding- 98-4°, or even somewhat lower. When collapse is marked,, three or four pints may be given at the rate of four ounces per minute, and the rate should be slowed to one ounce per minute if the patient complains of headache or other distress. The specific gravity of the blood should be taken before the commencement of this treatment, as the amount of fluid in- jected ought to be regulated by the height of the specific gravity, as collapse, simulating cholera, but without a high specific gravity of the blood, will not be helped by intra- venous injections, but the reverse. Rogers found that his- results with intravenous injections were better than with in- tracellular and rectal injections, but has found that he has obtained his best results by a combination of intravenous- " hypertonic " injections and the giving of permanganates by 90 Chapter V. the mouth. He gives permanganate of calcium in solution, (^-1 grain to the pint of water, increased rapidly by 4-6 grains to the pint) and encourages the patient to drink as much as possible in the day. Vomiting is seldom induced by this treatment and, indeed, is often checked by it. In other cases he has given the permanganate of potash in doses of 2 grains in the form of a pill made up with as little kaolin and vaseline as possible and coated with a varnish composed of one part of Salol and five parts of Sandarach varnish. The pills must be absolutely fresh. One pill should be given every quarter of an hour for the first two hours, and then every half hour until the stools are green and less copious, which, Rogers states, occurs in about twelve hours. At the beginning of the second day eight more pills should be given with the same intervals, and, in severe cases, eight more at the beginning of the third day, to prevent relapse. Barley water may be given to the patient during treatment with the permanganate pills. Vomiting may be relieved by sips of iced water or small quantities of iced champagne. The cramps can often be alleviated by friction by the hand with some A. B.C. Liniment or other mild rubefacient, or, if unrelieved by such treat- ment, may demand the hypodermic injection of morphine, or even the inhalation of chloroform. The patient must be kept warm and absolutely at rest; the use of a warmed bed pan must be insisted on, since the exertion of rising to go to stool is most dangerous. Calomel in small doses, as in enteric fever, has been re- commended by some, and the whole gamut of astringents has been tried, but it is plain that in large numbers of cases of cholera vomiting prevents the employment of either oral medication or alimentation. In the same way the profuse diarrhoea makes any attempt at rectal medication equally im- possible, so that hypodermic, intracellular, and intravenous methods will be found in many instances to be the only ones possible. If the pulse fail at the wrist, the hypodermic injection of alcohol or ether may spur it on for a little, and a single in- travenous or intracellular injection of a pint of saline solution > Cholera. 91 may bring temporary improvement, but if the saline injec- tions are to be eifective they ought to be given slowly and con- tinuously and not intermittently, and it is better to try to prevent the occurrence of serious cardiac failure by beginning such injections early in the disease than to institute them when failure of the heart has begun already to render absorp- tion even from the lymph-spaces extremely slow and difficult. If the urine be suppressed after the first day of the stage of reaction, it is viell to stimulate its secretion by hot appli- cations to the loins, or by the application of dry cups to the lumbar region followed by a hot poultice or fomentation. Careful examination should be made for distended bladder, as sometimes after a period of suppression of urine it is retained by an atonic and insensitive bladder after the re-establish- ment of secretion. Should the bladder be found distended, the catheter should be used at once. If in the stage of reaction there should still be much purging, large doses of the salicylate of bismuth should be given with a little powdered opium. The rectal injection of large quantities of tannin in mucilage is sometimes of ser- vice in obstinate diarrhcea, and, as in enteric fever, the care- ful irrigation of the lower bowel with hot water, using a soft tube, may cure the condition. Should the patient be con- stipated, no purgatives should be given, but movement of the bowels should be secured by the rectal injection of soap and water. When corneal ulcer occurs, the eye should be bathed fre- quently with warm soda-bicarbonate solution or treated with some of the albuminous salts of silver, while touching the edge of the ulcer with the galvano-cautery may stay the pro- cess. Sloughing of the fauces should be treated by careful spray- ing of the throat with some mild antiseptic, and sloughing of the bladder by rest and bland diuretics in combination with small doses of tincture of belladonna, 1 or 2 minims, every hour. Gangrene and parotitis fall to be dealt with sur- gically. The treatment during convalescence is mainly dietetic, but persistent ansemia will be helped by the use of iron and arsenic, nervous symptoms by rest and change of 92 Chapter V. scene and the use of the bi-omides combined with belladonna and mix vomica, while enterocolitis may be relieved by a bland dietary or the giving of powdered ipecacuanha with very small- doses of calomel and regular irrigation of the lower bowel. The treatment of nephritis is too well known to need comment. Diet. — During the algide stage, all food should be withheld. Thirst may be quenched by sips of iced water if vomiting is not induced by small quantities of fluid taken by the mouth, but the use of saline by continuous intravenous or intracellular injections Avill be found to quench thirst almost as well as sips of water by the mouth, and insures at the same time a replacing of some, at least, of the fluid lost by the bowel. During the " stage of reaction " and in " cholera typhoid " the diet must be fluid and extremely bland. Milk diluted with barley-water or rice-water, with a little clear soup or meat-juice, should form the entire diet of the patient during these periods, since errors in diet may induce relapse, or at least a very troublesome diarrhoea. During the estab- lishment of convalescence a mixed diet should be quite as carefully resumed as in enteric fever, and, indeed, the resump- tion may be Math advantage even more gradual, as the future health of the intestine depends largely on careful feeding during convalescence. Epidemiology. — As a rule cholera appears in temper- ate climates during the summer months and disappears as winter advances, but it has been known to survive the cold of a Russian winter. In Europe the later epidemics have been definitely spread by water-supply, as is instanced by the epidemic in Hamburg in 1892-93, and the Naples epi- demic of 1883. The danger of an impure water-supply was very well exemplified in the Hamburg epidemic. Hamburg and Altona are practically one town (in one part the boundary between the two is simply a street), but at the time of the epidemic Hamburg was more or less an independent town, ■while Altona was Prussian. Both drew their water-supply from the Elbe, but, while Altona had an elaborate system of filter beds, Hamburg had none, and the water was pumped Cholera. 93 straight into the main from the river. T}ie result was that Hamburg suffered severely, while the cases in Altona were lew, showing that tlie disease was definitely water-borne, since the communication between the two towns both commercially and socially is considerable, and, had the disease been com- municated chiefly by contact and aerial convection like small- pox, the two towns would not have suffered so dispropor- tionately. The causal agent is in the stools, and patients may of course, infect those surrounding them by the dejecta, and defectiA^e drainage may spread the disease through a limited area, but when the water supply is good and free from all risk of contamination, it is not probable that an epidemic will attain any very great proportions. There is no doubt that the cholera vibrio is at least a necessary adjunct to the ac- quirement of the disease, but from laboratory experiments it has been shown that large quantities of the vibrio in culture may be swallowed with impunity. But the laboratory pure culture may be a very different thing to the bacillus in the ground, and we do not know what symbiotic influence may be required for the acquirement of a virulence necessary for the production of an epidemic. That such a virulence must be acquired outside the body is shown by the fact that at the beginning of an epidemic the cases tend to be acute, short and fatal, while as the epidemic proceeds the attacks tend to be milder and of longer duration. Among the causes which contribute to an attack of cholera must be mentioned chill, irregular living, errors in diet, and fear. The last is no mere Action of the imagination. I have heard the same story re- jaeatedly from men who have seen service in the East, both physicians and others, that, in their experience, fear is one of the most powerful predisposing causes of an attack of cholera, and when it is remembered how fear and worry tend to lower vitality, it is not surprising that this should be the case. Period of Infeetivity. — The discharges of a patient w4io has had cholera may remain infectious up to about seven weeks from the onset of the illness, althousrh in mild cases they may be free from the vibrio in two or three weeks, and it is wise to consider a patient infectious until the vibrio can be no longer discovered in the stools. 94 Chapter V. Death-Rate. — The average death-rate in all epidemics is calculated at about 50 per cent, of cases attacked, but it is much higher in some epidemics, while in others it is considerably less. Much depends on the condition of those attacked. The old, the very young, pregnant women, those who suffer from disease of the heart, liver or kidneys, the naturally feeble, the poorly fed, and the alcoholic, die in great numbers. Personal Prophylaxis. — As in plague, no patient ought, in civilised western countries, to be nursed at home, whatever be his social position, so that discussion of " home prophylaxis " does not fall to be made. Those in attendance on the sick should take the same precautions as in enteric fever, and the same scrupulous care should be adopted in the disinfection of the dejecta, vomited material, and all vessels and clothing which have been in contact with the patient. Food must never be eaten in the ward, and the hands should be most carefully cleaned after touching the patient. Those living in a district in which cholera has ap- peared should pay the strictest attention to personal and household cleanliness, and must live most carefully in every way. Fruit and cucumber which has travelled at all should not be eaten, as the possibility of " carried " fruit causing diarrhoea is well known, and anything which encourages gastro-intestinal catarrh predisposes to cholera. The domestic water-supply must be enquired into, and it is better during an epidemic of cholera to drink no fluid which has not been thor- oughly boiled. Manson most sensibly recommends that during an epidemic the drink of a household should consist of weak tea and decoction of lemon, for both of which boiling water is necessary. Aerated waters should be avoided except such as are manufactured, like those of the " Salutaris" company, from distilled water. If aerated waters are manufactured with a basis of distilled water and in hygienic surroundings, they are quite incapable of conveying infection so long as the syphons and their fittings are cleaned both inside and out with steam, under pressure, before being refilled. Public Health Administration. — All persons must be isolated in a suitable Hospital or camp, according to district Cholera. 95 uiid climate, and all " contacts " if not segregated in Reception Houses ought, at least, to be kept under the strictest medical supervision in their own homes. The dis- trict in which the outbreak has occurred should be subjected to the most rigorous scrutiny, and its water-supply, drainage, and general cleanliness promptly attended to if in any way defective. There are few towns in Great Britain where, from the condition of water-supply, a large water-borne epidemic is likely to break out, since when the supply is from an ad- jacent river the water is filtered before it is distributed to the mains. The only exception which occurs to me at the moment is the town of Montrose, in Scotland, where the inhabitants still use an unfiltered water-supply from the river. But while the source of the water-supply itself may be pure, there is always the danger in an epidemic of cholera of one or other of the mains being contaminated, and the greatest care must be taken to avoid contamination of ground either directly or through a defective drainage-system. In moist soil the vibrio of cholera is capable of preserving its virulence for a long time. The condition of the source and distribution of the food-supply must be most carefully enquired into, as any contamination of milk or other food may do much to spread the disease. The methods of dealing with the infected area and infected houses should be similar to those adopted in the case of plague (q. v.), save that there is no need to inaugurate a campaign against rats. The infected area should be visited constantly by medical men, who, besides looking for suspicious cases, ought to en- deavour to infuse a spirit of cheerfulness and hope among the inhabitants, and drive out that fear which is, in cholera, such a powerfully predisposing cause of the disease. The people should be warned against the drinking of unboiled water. Filters of all kinds should be discouraged, as the only ones which are at all effective are those of the Pasteur-Chamber- land type, and the ordinary charcoal filters are not onh^ no protection, but a positive source of danger. The question as to how far people coming from infected districts should be limited in their movements in non-infected areas is always a matter of discussion. In continental countries- 96 Chayter V. ships coming from an infected country are strictly quar- antined, and passengers are detained at frontier towns, roughly disinfected, and herded in ridiculous discomfort for some days, in the hope of checking the spread of cholera by these means. Such rigorous quarantine regulations disorder the trade of the infected country and lead to attempts being made to conceal the existence of cholera cases. The habit in Great Britain has been to examine all ships coming from in- fected ports, to isolate any persons who appear to be ill, and supervise the goings and comings of the other passengers until such time as there is no further risk of their developing cholera. The ships are thoroughly disinfected and cleaned before another crew is allowed on board. By means of these milder regulations business is not disorganised, and there is less likelihood of cases being concealed. The importance of not having cases concealed is obvious, and it is better for a district to have a dozen declared cases of a disease in its midst than one unknown or concealed case. Prophylactic inoculations of graded strength have been practised by HafEkme, and in the course of an epidemic tending to grow at all large in one of our western cities this might well be tried as one of the means of protecting those at work among the sick, and of helping to limit the spread of the disease. ( 'J7 ) Chapter VI. RELAPSING FEVER Synonyms. — Febris recurreris ; Febris reeidiva; Bilious remittent fever; Famine fever. Fr. : Fievre a rechutes. Ger. : Riickfalls fieber; Hungertyphus. Definition. — An acute infectious disease charac- terised by a sudden febrile onset, short course and rapid subsidence, followed at an interval of from 1-7 days by a re- lapse, which, with a similar intervening period, may be re- peated an indefinite number of times. It is associated with the presence in the blood and tissues of spirochsetse, one of which was discovered by Obermeier in 1873, and another, usually called the Sp. Duttoni, by Ross and Milne, in Uganda, and Dutton and Todd, in the Congo, quite independently of one another. Carter described a spirochseta similar, apparently, to the Sp. recurrentis of Obermeier as oc- curring in the "relapsing fever" met with in India. Incubation Period. — The incubation period is usually from two to six days, but may be prolonged to fourteen days. Rash. — No rash is described as typical of the disease, but a roseolar eruption in character something between measles and typhus has been seen in rare instances. Clinical Types. — It would seem that the type of relaps- ing fever as met with in Europe and India differs in certain particulars from that met with in Africa, and from this fact and because there are certain notable differences in 98 Chapter VI. morphology between the spirochseta recurrentis of Obermeier and Carter and the spirochsEitaDuttoni, one is justified in saying that relapsing fever in Africa is a different disease from that met with in Europe and India, although both types are due to infection by a spirochseta, and in general resemble each other Tery closely. The experiments of Todd and Brei support this view, as they show that immunisation against the spirochseta of the Indian form of relapsing fever does not protect against the Sp. Duttoni. European and Indian Type. — The onset is sudden, heralded by chill, rigors, giddiness, severe headache, nausea and vomiting. The temperature rises at once into high regis- ters, 104° and 105° F. being quite usual readings, and it may even rise to 107° or 108° F. The pulse and respiration are notably increased in rate, but the respiration-rate is not in- creased proportionately to the pulse. Delirium may be present if the fever is high. The skin is dry and burning. As compared with typhus, the prostration is not marked, and the patient may walk to consult a doctor even in the second or third day of his illness, but giddiness is a very striking symptom. The face is flushed but not dusky and heavy-look- ing as in typhus. The tongue is moist, covered with a thick white fur, and thirst is usually extreme. Appetite is very variable, being in some cases entirely lost, and in others quite unimpaired. There is sometimes considerable pain and tenderness in the epigastrium, and the spleen is always en- larged, with marked tenderness on pressure over the area of splenic dulness. The liver also is most usually enlarged. A Blight icteric tinting of the conjunctivae is very commonly present, and in a fair proportion of cases generalised jaundice appears about the third day of the fever. In such cases the urine is bile-stained, but the stools remain dark in colour. The fever usually remains high for some five to seven days, showing no great degree of oscillation ; the pulse varies with the temperature, and may be very rapid indeed. The patient siiffers much from headache and pains in the back and limbs. Sleeplessness is almost always a source of trouble, and the mind usually remains clear although some delirium may be present. On the fifth, sixth or seventh day the fever falls Relapsing Fever. 99 rapidly by crisis, and it is common to have, just before the crisis, a rise of temperature even of several degrees, while with the pre-critical rise violent delirium and restlessness may set in for a short time. The fall of temperature to normal or subnormal registers is very rapid — a fall of 8° or 10° F. in a few hours being quite common. Murchison records in one case a fall of 13° F. in six hours, and in another a fall of 14*4° F. in twelve hours. The crisis is usually accompanied by profuse sweating, and sometimes diarrhoea and epistaxis occur. As in all diseases where fever terminates by crisis, the sudden fall of temperature may be attended by dangerous and even fatal collapse. In aged and feeble patients death may occur with coma before the end of the first paroxysm. After the first crisis, there is an interval of apyrexia which lasts for a variable time, usually for five or seven days, but intervals as short as two and as long as twenty-five days have been re- corded. During the apyretic interval the patient feels well and will, perhaps, be with difiiculty restrained in Hospital, but at its termination he is suddenly seized with the same acute symptoms and rise in temperature as ushered in his first paroxysm. This first relapse may last as long as the first paroxysm, but is usually somewhat shorter and may last only for a couple of days. It terminates by crisis, as did the first paroxysm, and this may end the attack. But in some patients, after a short second period of apyrexia a second relapse occurs, which is usually milder than the preceding, and of short duration, rarely exceeding three days After its termination the attack is in most cases finished, but more rarely a third, fourth or even fifth relapse may occur. After the termination of the last relapse, convalescence is often a little tedious, and the patient does not recuperate with the same rapidity as after typhus, and his recovery may be de- layed by certain troublesome complications and sequelae. Throughout the attack, save at the time of the crisis, the bowels tend to be constipated. The tj^pical course of the disease is not always followed. In some cases there is no relapse after the first crisis, while in others there is no definite crisis at the end of the first paroxysm, but the temperature after an incomplete B 2 100 Chapter VI . fall tends to rise again and tlie patient drifts into a typhoid state in which he may die from asthenia, sudden cardiac failure, or suppression of urine with violent symptoms of uriemia. vSuch " typhoid " cases are commonly deeply jaun- diced and vomit dark bilious material, while they sometimes have numerous haemorrhages into the skin and from mucous surfaces, presenting a " liaBmorrhagic" form of the disease. African Type. — The '' African " type of relapsing fever diifers in many respects from the "Indo-European" type, although in general the manifestations are very similar. There is the same sudden onset and abrupt termination of the initial paroxysm and the same tendency to relapse after irregular periods of apyrexia. The initial paroxysm, however, is shorter than in the European type, and terminates in most cases about the end of the third day. The intervals of apyrexia are of very irregular duration, varying from one day to nearly three weeks, and the number of relapses is usually greater than in the "European" type, five or six relapses being the rule, and as many as eleven having been observed. The fever is shorter in the relapses than in the initial paroxysm, but rises quite as high. The intervals of apyrexia become longer as the attack proceeds. Another point of dif- ference between the types is that in the "African" form diarrhoea and dysenteric manifestations are fairly common. Diagnosis. — The diseases most likely to be confused with relapsing fever are malaria, enteric fever, typhus fever and influenza, but, although at the beginning of the attack there is little to distinguish it from typhus or enteric fever with a sudden and severe onset, the course of the disease, showing as it does a definite "relapsing" character, the first relapse occurring about fourteen days from the onset of symp- toms, makes differentiation comparatively easy. The dura- tion of the paroxysms distinguishes it from malaria. It is during the first paroxysm that differentiation from other fevers may be difficult, but the clear, vigilant look in the eyes and the absence of a dusky flush on the face will help to differen- tiate it from typhus, and the early enlargement of the spleen is unlike that seen in enteric fever. For accurate Relapsing Fever. 101 diagnosis, however, we must depend on the micioscoi)ic!iJ ex- amination of the blood and the detection of spirochsetse. The spirochsetse stain well with ordinary basic anilin dyes, ;ind gentian violet is a convenient stain to use for the purpose after drying the film made from the blood and fixing it with absolute alcohol. Jenner's and Leishman's stains give very pretty results. The sp. recurrentis of Obermeier is a delicate spiral thread from T />l — 9 /i long, while the sp. Duttoni of the "African type" measures some 16 fx in length, or about twice as long as the sp. recurrentis. The sp. Duttoni tends to form loops and coils of a " figure-of-eight " sbape. In the " European " type of the disease, the spirochgetae are found in great numbers in the peripheral blood stream during a paroxysm, but in the " African " type they are apt to be scanty and difficult to find except after repeated examinations. It would seem to be quite possible that in various parts of tlie world *' relapsing fever " may occur which is caused by spirochsetse differing in some degree from those described, but on this point further evidence is needed before any definite statement as to their occurrence can be made. Complications. — These are not numerous, and the most serious, lobar pneumonia, is one of the rarest. Pneumonia has been fairly frequent in certain European epidemics, but quite uncommon in Great Britain. Sometimes the pneumonic consolidation breaks down and results in gangrene of the lung. Bronchitis is very common, but is seldom more than a very slight catarrh of the larger bronchi. Diarrhoea and a form of dysentery have been troublesome complications during certain epidemics, and rupture of the spleen and the breaJdng- down of a splenic einbolus have occasionally been noted as a cause of death, the former resulting in Aaolent hfemorrhag'^, and the latter in general peritonitis. Parotitis and inguinal bubo sometimes occur, and have been, in some epidemics, a most unfavourable sign, but in Great Britain they seem to have occurred most frequently in cases which ultimately re- covered. Pregnant women near always abort, but the abor- tion is not uncommonly delayed till the relapse. When abor- tion does occur it is frequently fatal, and the child is still-born or dies within a few hours. 102 Chapter VI. SequelcB. — Multi'ple 7ieuritu, synovitis, associated with severe articular pain and sometimes with effusion into the knees or anlcles, nephritis and a form of ophthalmia have all been observed as sequelse of relapsing fever. The ophthalmia occurs first as an affection only of the retina and choroid, but involves secondarily the more supercificial struc- tures, and is then associated with severe pain. Only one eye is commonly involved, but recovery is always tedious, while in a certain proportion of cases vision is lost. Treatment. — No drug treatment has yet been intro- duced which has been successful in cutting short the course of the disease, and treatment, in the absence of serumtherapy, must be palliative and symptomatic. Where the bowels tend to be constipated, a mild aperient should be given throughout the attack. The patient may be made more comfortable by cold or tepid sponging, and by the application of cold to the head, either by cloths dipped in iced water or by means of a Leiter's coil. When epigastric or hypochondriac pain is severe the giving of an emetic, followed by the application of tepid compresses to the abdomen may afford relief. It is wise to give a simple diuretic or diaphoretic mixture consisting of Liq. Ammon. Acet. ^i, Potass. Acet, grs. x, and Spr. Aetheris Nitrosi TT^xv, at three-hourly intervals throughout the attack, as one of the dangers of the disease is scanty urinary output with symptoms of uraemia. Should ursemia be seriously threatening, it is well to give an intracellular injection of hot saline solution, and bleeding may be resorted to in addition. Opium may be of service in the relief of pain and sleepless- ness, either alone in the form of Battley's solution or in com- bination with a small dose of chloral hydrate, while powdered opium either alone or in the form of Dover's Powder may be helpful when there is much diarrhcea, or when there is a tendency for the stools to be dysenteric. Alcohol may be used with advantage at the time of crisis, in small, frequently repeated doses. Diet. — The diet should be fluid, consisting oi milk, barley water and beef -tea or some clear soup, during the periods of fever, and after the fever lias declined, a semi-solid Relapsing Fever. 103 diet may be given at once, if there is no diarrlu/ja or neph- ritis present. During convah;scence a mixed diet may be rapidly resumed according to the patient's wishes and capacity. Epidemiology. — li-elapsing fever has not occurred in Great Britain in any considerable epidemic since 1870. One death occurred in Glasgow in 1879, and three in Ireland in 1890, but since then no cases have been observed in the British Isles. It is still met with, however, in Eastern Europe and in Asia, and the "African" type is common in the region of the Great Lakes and on the Congo. Relapsing fever is usually associated with unusual poverty and squalor, with consequent enfeeblement of health, so much so that in many of the epidemics which appeared in the large towns of Great Britain, the vast majority of the cases were destitute Irish people who had just left their native country, while the English and Scottish inhabitants were attacked in small num- bers. But it is quite conceivable that with the practically un- restricted alien immigration which is usual in this country, the disease may once more gain entry to British towns, and the great mass of filthy and destitute people, and the dirty and insanitary condition of certain portions of our towns would form a very suitable nidus for a severe epidemic. Death Rate. — This is low as compared ■'vith most of the infectious fevers, from 4 to 6 per cent, being usually given as the average mortality in an epidemic. Method of Infection. — There seems to be little reason to doubt that the "European" type of the disease is conveyed from person to person by vermin, particularly by bed-bugs and body-lice, and it seems probable that the apparent spread of the disease by clothing and bedding has really been due to the fact that such clothing or bedding has been the habitat of some of these parasites. In the "African" type, the infection is spread by a form of tick, the ornitho- dorus mouhata. Home Prophylaxis. — The strictest cleanliness of house and person must be observed, in view of the possibilitv 104 Chapter VI. of the transmission of the disease by vermin. Those in con- tact with the patient should avoid contamination by the dis- charges as far as possible, especially if the case be complicated with pneumonia or be of the hsemorrhagic type. Abrasions of the skin should be carefully cleaned and sealed up with collodion or " new skin." Patients in the poorer localities of an infected district should not be kept at home, as the dilapi- dated plaster and wood-work in such districts harbour vermin in large numbers and proper isolation is impossible. In Africa, the traveller should avoid as far as possible old camping-grounds and native villages, and should use a mos- quito-net and a bed elevated some distance above the ground. A night-light is also an advantage, as the ornitho- donis mouhata makes its attacks usually in the darkness and may be deterred by light. Public Health Administration. — As in cholera and plague, the duty of the Health Office is to see to the strict isolation of all affected patients, to remove to hospital all those attacked who are living in squalid and crowded districts, to thoroughly cleanse and disinfect all houses where cases have occurred, and all articles which have been in contact with a patient. Strict supervision of contacts and suspected cases must be exercised, and opportunity afforded to practitioners for bac- teriological diagnosis, either by the examination of. blood-films alone, or by animal inoculations. ( 105 ) Chapteii VTI. MALARIA. Synonyms. — Ague, Intermittent Fever, Marsh Fever. Fr. : Malaria, Fievre intermittente, Fievre Palustre, Gev. : Malaria, Wechsel Fieber, Sumpffieber. Definition. — An acute disease characterised by attacks of fever, usually of a periodic character, separated by variable intervals of more or less complete apyrexia, due to the presence in the blood and viscera of a specific sporozoon discovered by Laveran in 1880. The host of this sporozoon is the mosquito, by which it is conveyed to man. Incubation Period. — The incubation period for malaria seems to vary from about twenty-four hours to several weeks. Instances have been recorded of patients developing the disease within twenty-four hours of their arrival in a malarious district, and, on the other hand, I recollect a patient, who had never previously suffered from malaria, but who, after staying a week in New Orleans during September, sailing from there in a tramp steamer to the Netherlands and Germany, and afterwards coming by easy stages to Liverpool and Glasgow, developed malaria after he had been ashore and exposed to the chills of a Scottish December for a fortnight. His attack was a benign tertian. Rash. — No typical eruption has been observed in malaria. Clinical Type. — The three main types of malarial fev^r are the Tertian, the Quartan, and the Aestivo-Autumnal or Malignant Malaria. 1. Tertian MaJaria is so called because the febrile paroxysm occurs on every alternate day. (See Chart 1.) 106 Chapter VII. The febrile paroxysm is clinically divided into three stages, the '' cold stage," the " hot stage " and the " sweating stage." At or about the same time in each day on which a paroxysm occurs, the attack is ushered in by the development of the cold stage, in which the patient is seized with a feeling of chill and shivering, and almost always has a marked rigor, which is sometimes so severe as to make standing upright im- possible without support and to shake the bed or couch on which he lies. The " cold stage " is sometimes preceded by some hours of general discomfort and lassitude, with subjec- tive sensations of nausea, slight headache, pain in the bones and a feeling of cold water trickling down the spine. During the stage of premonitory symptoms the temperature often rises slightly. In some instances the premonitory symptoms pass off without being followed by a properly developed paroxysm of the disease, but usually after a few hours they are followed by the chill and rigor which characterise the onset of the " cold stage." The feeling of chill is purely sub- jective, as although the hands and feet are cold to the touch, the temperature in the axilla and rectum is seen to rise during the whole period of chill and rigor. At the same time the patient suffers acutely from headache and nausea and may vomit severely. His face is pinched and pallid, with some cyanosis of the lips and ears, and he heaps coverings on him- self in the endeavour to get warm. In young children the rigor is sometimes accompanied by convulsive seizures. After the "cold stage '^ has lasted for about an hour, the Jtot stage begins, in which the patient begins to feel warmer, and the feeling of warmth rapidly increases, alternating some- times with chilliness for a short time, until within an hour he suffers from burning heat and discards the coverings which he has heaped on himself during the "cold stage." During this period the temperature rises still further until it may reach very high levels indeed, temperatures of 106° F. being frequently recorded. The face is flushed, the skin dry and burning, headache is severe, and vomiting may be distressing. The pulse is full and bounding and respirations are rapid. After one or two hours of acute discomfort, the final or sweating stage of the paroxysm is reached. The patient Malaria. 107 breaks into a profuse perspiration, tlie feeling of heat passes away, the fever declines, headache and nausea disappear, and the pulse and respiration become quiet. The sweating lasts one or two hours, and when it ceases the patient feels tranquil and languid, and in a few hours he may feel well enough to go about his work again. The whole paroxysm thus lasts for about six hours, and in the tertian type is not repeated on the following day, but is repeated on the day after, in all its stages, at or about the same hour as it occurred two days earlier. The spleen enlarges during the paroxysm and recedes at first during the apyretic interval, but after several paroxysms the spleen remains enlarged during the interval, still tending to increase somewhat during the paroxysm. The urine is passed frequently during the cold stage, and at this period is actually increased in quantity above the nor- mal. The excretion of urea is also increased during the paroxysm, and for some hours afterwards. It is possible to h^'ve two attacks of tertian ague running at the same time, so that each daj may be occupied by a paroxysm, and a quotidian character given to the fever. The clinical manifestations often bear evidence of this apart from microscopical examination of the blood, inasmuch as the attacks on two consecutive days may vary greatly in severity and may reach their height at quite different times. (See Chart 2.) This is not always the case. Two tertian infections may mature at about the same time each day, and present a picture of a quotidian ague having its maximum swing about the same hour. But the infecting organism presents no difference from that found in an infec- tion with regular tertian manifestations, so that even when the quotidian paroxysms appear at or about the same hour each day, we are bound to consider the attack to be a double tertian, due to two infections by the parasite of tertian malaria, which mature on different days. 2. Quartan Malaria : In the quartan type of the disease the paroxysms are separated by an interval of two days of apyrexia (see Chart 3), but are made up of the same three 108 Chapter VII. stages of cold, heat and sweating as in the tertian type of the disease, and have a similar duration. A double or triple in- fection by the quartan parasite may take place, so that two consecutive days may show a paroxysm, followed by a day of apyrexia, or the paroxysms may occur daily. 3. Aestivo- Autumnal or Malignant Malaria. — In this type of the disease the paroxysms are not quite the same as in the benign tertian and quartan fevers. In certain cases, they follow a regular type, and are separated from each other by a definite period of apj-rexia. (See Chart 4.) In such cases the rigor may be much less severe than in the benign types, but the hot stage lasts longer, sometimes occupying twenty-four hours. It is not uncommon in this type of infec- tion to have a fall of some degrees of temperature, or pseudo- crisis, some hours before the real termination of the paroxysm. In other cases of malignant infection the paroxysms are well defined, of short duration and occur dail}^ and tliere seems reason to believe that many of the quotidian types of ague, apart from the double infection by the tertian parasite, may be due to a separate organism, which has not yet been fully studied and described. Another type due to a malignant in- fection is the remittent (see Chart 5), where no period of apjTexia separates ihe paroxysms, but where the termination of one is not complete before another begins. In such cases the stages of the paroxysms are usually not well marked ; rigor may be replaced by a sensation of chill, and sweating* may be no marked feature during the decline of the fever. In other cases the febrile movement may be very slight and quite irregular. Part of the irregularity in the manifesta- tions is, doubtless, frequently due to previous dosing with quinine, as it is quite uncommon to find Europeans who have been in a malarious district for any length of time who have not used quinine for prophylactic purposes. At the same time, apart from the administration of quinine, the mani- festations of a malignant infection, especially if the infection has been repeated several times, tends to be accompanied by febrile movements which may be slight and atypical, although the other constitutional disturbances may be grave. (See Chart 6.) A malignant infection may be accompanied by Malaria. 109 jaundice, with much vomiting (the hilious remittent type of tlie disease), and in some cases may be speedily followed by cerebral symptoms, siicli as stupor, convulsions and coma. In such attacks the temperature may rise to very hi^li registers, iind death may occur with a hyperpyrexia of 109° or 110° F. Yet another form of the disease may be developed by a malignant infection — the ahjide form, characterised by col- Lvpse, coldness of the surface of the body and a tendency \a) syncopal attacks. A'^omiting may be present, or profuse watery diarrhoea with collapse closely simulating cholera, or haemorr- hage from the bowel or stomacli. In other cases, particularly in such as show signs of cachexia, the sweating stage may be dissociated with a proneness to sudden cardiac failure, which may be induced by an injudicious movement on the patient's part. It is cases of this kind that shoAv how important it is that an early and accurate diagnosis of the particular infecting organism should be made. Mixed Infections. — In certain cases of malaria more than one kind of infecting organism may be present, and in these cases the disease may show most irregular manifestations, due to a blending of the benign types of tertian and quartan malaria, or to a mixture of the benign and the malignant in- fections. Such cases can only be elucidated by the careful and systematic examination of the blood, and the recognition of the various infecting organisms. Mild types. — In many instances, a person living in a malarious district suffers from headache, nausea and general malaise for some hours without the occurrence of rigor, heat or sweating, and this attack may be repeated, with intermis- sions of varying length, several times, and in some such cases a typical attack of malaria develops out of the attack. In others, however, the symptoms are apparently not prodromal to an attack of true malaria, but constitute in themselves an abortive attack of the disease, ultimately disappearing without the development of a febrile paroxysm. Diagnosis. — The only accurate means of diagnosis in malaria is the microscopical examination of the blood and the detection of one or other of the forms of the malarial parasite. 110 , Chafer VII. The three parasites usually described are the tertian, quartan, and vialignant. For those who have not had great experience in malaria it is wise to examine dried films of blood which have been stained by the Romanowsky method or one of its modi- fications. Personally, I prefer to use Jenner's or Leishman's stains as being both simple to manipulate and effective in action. When stained by these methods the red blood cor- puscles appear brownish-red, nuclei appear blue and the parasite shows a blue protoplasm with red chromatin. The benign tertian parasite when stained appears in :i red blood corpuscle as a small blue ring, with one part of its circumference slightly thicker than the other, containing a bright red spot of chromatin. As it grows it is seen as a more or less regularly-stained blue mass of protoplasm, containing fine granules of pigment which it has acquired from the red blood corpuscles. The red blood corpuscle enlarges with the growth of the parasite, assuming the appearance of a large megalocyte, and is occupied almost entirely by the parasite when it has reached maturity. The parasite matures both as a sexual and an asexual form. The sexual form is practically undistinguishable from a full grown asexual parasite before sporulation has taken place, i.e., it appears as a large more or less homogeneous protoplasmic mass stained blue, containing numerous pigment-granules and irregularly distributed chromatin. In the asexual form, which is proceeding to spore- formation, the pigment collects itself, as the parasite grows, into two small masses at the centre, while the chromatin gathers at the periphery. Radial segmentation of the organism occurs, and the result is a grouping of some fifteen to twenty- six oval spores, each containing a red dot of chromatin, like a bunch of grapes round one or two central masses of coarse brown pigment. The remains of the red blood corpuscle, at least from the time that the organism is half -grown, show, in deeply stained specimens, an appearance of granules to w^hich has been given the name of " Schxiffner's dots." Imme- diately before the occurrence of a febrile paroxysm, the cor- puscle ruptures and the spores are set free in the blood-stream. Malaria. Ill The spores may invade other red blood corpuscles and be the starting point of another cycle. The sexual forms, or " gametocytes," do not develop fully m the human blood, but when removed from the body certain of them remain as large roughly spherical bodies, with a faint appearance of seg- mentation in the j^rotoplasm. These are the female forms or " macrogametes." Others produce pseudopodia, which con- stitute the male element of the parasite, and become detached, appearing as elongated motile bodies, the " microgametes," which effect conjunction with the female macrogamete. Pseudopodia are never seen in the circulating blood, but the formation of flagellate forms are frequently seen during the examination of fresh specimens of malarious blood under the microscope, especially when a hot stage is used. I have seen one such flagellate organism under a high power, surrounded by three large polymorpho-neuclear leukocytes who ulti- mately consumed it, and went off with pigment in their interiors. The quartan iiarasite is much smaller than the tertian, and does not grow beyond the size of a red blood-corpuscle. In its early or " ring-form " stage it is quite indistinguishable from the tertian parasite, but the fact that it does not cause enlargement of the red blood corpuscle as it reaches full growth, and that the protoplasm of the red blood-corpuscle does not show " Schiiffner's dots" ar© notable points of differ- ence. The quartan sporulating form is much smaller than the tertian, and the segments, some eight or ten in number, are arranged in characteristically regular, " daisy-like " formation round a central dense mass of very dark pigment. Microgametes and macrogametes are formed as in the tertiao parasite. The " Tnalignant parasite " is still smaller than the quartan, and, indeed, to those unskilled in the examination of the blood for the malarial parasite it may, even in stained specimens, readily escape notice in its early or "ring" form. The blue ring is often of hair-like thinness, even under an oil- immersion lens, and the chromatin-dot is very small indeed. This makes the detection of the parasite in many cases a matter of extreme difficulty, as it is very uncommon to find 112 Chapter VII. sporulation forms of the " malignant " parasite in the peri- plieral blood-stream, although it has been observed in certain cases, and one is usually dependent on the detection of the " ring-form " for the formation of a diagnosis. The sexual form "of the parasite is, however, very characteristic. It appears as a crescent-shaped body, to the concavity of which is usually seen adhering a fragment of a red blood-corpuscle. The crescent-body stains a pale violet and shows in its centre an agglomeration of fine granules of pigment. This form is rarely visible during a febrile movement. The sporulating forms are very small, and show an irregular heap of from six to twelve spores. The blood-corpuscle which has been invaded l)y the malignant parasite frequently shrinks, becomes darker in colour than the normal, and tends to show a crenated margin. While this description applies generally to all the forms of malignant parasite, it is only right to say that Manson, following Italian observers, recognises three malignant para- sites, viz. : — (1) the ordinarily-described parasite of malignant tertian ague, Laverania malarioe, which displays a fine pig- ment; (2) a pigmented quotidian parasite, Laverania jjrcecox; and (3) an unpigmented quotidian parasite, Laverania iTmnaculata. Of the two pigmented forms, Laverania Tnalaricc is the larger, being about ^-f the size of a red blood- corpuscle, while Laverania "prcecox is just one half of that ■size. In both of these parasites, pigment can be seen scattered through the partly matured forms and collected in small irregular masses in the centre of the sporulation and crescent forms . The hloocl in malaria presents certain characteristics apart from the presence of the parasite, which may arouse a suspicion in the mind of the physician that the case is one of ague. Some degree of ansemia is always present, and in malignant cases the red corpuscles tend to show a diminution in size, a density greater than normal, and a crenation of their edges. The presence of pigment in the leukocytes or free in the blood-stream should always suggest the possibility of an otherwise unexplained pyrexia being of malarial origin if ihere is any possibility of the patient having acquired the in- fection, even some years previously. Malaria. 113 The accurate diagnosis of tlie malarial parasite is a matter of great importance botli as regards prognosis and treatment, as the possible effects of a benign and malignant quotidian or tertian fever are widely different in range and severity. It is not likely that a tertian or quartan malaria will be mistaken for any other disease, the regular periodicity is so striking and characteristic, but in malaria of the quoti- dian, remittent, or irregular types, while the association of the fever with splenic enlargement and previous residence in malarious districts may arouse suspicion although the patient falls ill in a non-malarious country, accurate diagnosis is im- possible without the detection of the infecting parasite. Even the test of quinine-treatment by the mouth will fail in certain obstinate cases. It is to be remembered that the acquiring of some other infectious fever may in some cases arouse even a long-dormant malaria, and the difHculties in diagnosis pre- sented by an attack of enteric fever complicated by a con- current attack of malaria have given rise to the name " typho- malarial fever," which has been frequently given to such cases. Only careful examination of the blood by the making of cultures, by the performance of Widal's test, and by the discovery of the malarial parasite on microscopical examina- tion will definitely reveal the true character of the illness. Complications. — In certain cases of intermittent malaria of a "low" or "adynamic" type, profound nervous depression, rapid blood-destruction, hsemorrhages from various mucous membranes, and local gangrene may supervene as complications. The hyperpyrexia, cardiac failure, convul- sions and loss of power which occur in some malignant infec- tions, are so much a part of the algide and cerebral types of the disease that they cannot well be classed as "complications." Sequelae. — The sequelse of repeated attacks of malaria are best described as forming a part of the "malarial cachexia," a general deterioration of health associated with anaemia, enlargement of the spleen and, most usually, with a tendency to irregular febrile attacks, especially following chill or any unusual mental or physical strain. The patient 114 Chapter VII. is pallid and anaemic looking, with a peculiar dull yellowish colour of the skin and very frequently some yellow tinting of the sclerotics. This condition of cachexia, while usually fol- lowing on repeated attacks, may be established b}^ one very severe attack of the disease, and may even result from pro- longed residence in a malarious district without the patient having had any recognisable malarial paroxysm. The cachexia may be present without fever, although this is not usual. Splenic enlargement is sometimes enormous, and al- though the " ague-cake " is frequently firm and even hard on palpation, rupture from very slight violence of a chronically enlarged spleen the result of malarial infection is quite com- mon. This is one of the reasons v/hy "kicking a nigger" is discouraged by European administrations in Africa and India, while among natives of malarious countries a blow over the spleen is a favourite w^ay of getting rid of an enemy. In very malarious districts splenic enlargement is often found ia young children, and it is even said that infants are sometimes born with an enlarged spleen as the result of chronic malarial poisoning of the mothers. Sometimes when malarial cachexia appears in childhood, development is greatly retarded, so that a person of twenty- five years of age may look like a child of eleven or twelve. Malarial cachectics are often very prone to severe haemorr- hages. In such cases a very slight operation, such as a tooth - extraction, may give rise to a profuse haemorrhage which may be difficult to control, and the greatest care must be taken, in this class of patient, in advising or performing any operation even of the most trivial description. Epistaxis, hsematemesis, haematuria, retinal haemorrhages, and purpura may occur without any operative interference, and such occurrences are of grave import, indicating, as they do, a very profound degree of cachexia. Neuroses of various kinds have been observed in connec- tion with the malarial cachexia, and the striking point about them is that they may be definitely periodic in their occur- rence. We may see quotidian^ tertian and quartan attacks of neuralgia, pain in the epigastrium, vomiting, headache, and even diarrhoea, or attacks of sneezing and palpitation. Herpes, Malaria. 115 erythema nodosuTu, urticaria, und eczema. Lave been observed, and in a few instances synovitis Jias been noted, all sliowing a periodic tendency to exacerbation and improvin*^ under treat- ment by quinine. Perijilieral neuritis has been observed associated with tlie presence of the malignant parasite in the blood. Organic changes of a fibrotic kind in heart, kidney, liver and spleen are frequently met with in cases of long continued cachexia, and cachectics are very liable to hroncliial catarrh and hroncho-fmeumonia as a result of chill. Blackwater fever. — It is perhaps against the convictions of many to place blackwater fever in the list of malarial sequelae, but it is, I think, more unreasonable to class it as one of the dangers of the quinine treatment of malaria. The hsemoglobinuria which follows so rarely on the taking of large doses of quinine disappears when the drug is withdrawn, and this is very far from being the case in blackwater fever. Manson chooses, with considerable reason, to class it as a separate disease pending further information. But there is no doubt that blackwater fever occurs habitually in malarious districts and usually attacks a patient who has been the sub- ject of some degree of malarial infection, the manifestations of which may have been obscured by the use of quinine. The fact that it has become apparently more common in recent years in the West Coast of Africa and in British Central Africa may be due, as Crosse suggested, to its having been only recently separated clinically from the "bilious remit- tent" type of malaria. Its onset and course are similar, and it is not always easy, save by appropriate chemical tests, to distinguish a very deeply bile-stained urine from haemoglobi- nuria. But the evidence of careful observers in British Cen- tral Africa and British East Africa goes to show that it is at least very frequently associated with the presence in the blood of the malignant parasite of malaria, and that it tends to yield to quinine suitably administered. It would seem that this hsemorrhagic type of malaria is influenced by certain local conditions, as it tends to appear almost in epidemic form in certain districts in Africa which, after the I 2 116 Chapter VII. occurrence of numerous cases during one year, may be prac- tically free of blackwater fever for several seasons. But this is no argument against its being of malarial origin, as anyone who has liad experience of smallpox will remember how in cer- tain epidemics the hsemorrhagic type of the disease is scarcely seen, while in others it appears with uncomfortable frequency. It is possible that certain cases of blackwater fever may be due to an infection other than malarial and may bear the same relation to some tick-borne fever as others bear to malaria, but at present due consideration must be given to the opinion expressed by Crosse and other observers in Africa, that in the majority of cases it is due to an infection by a malarial parasite and will yield to quinine, since their ex- perience of the condition as met with in Africa must far out- weigh that of Koch and others who were mere visitors to the districts. Certainly in the one case which I have seen, the condition appeared in a man, who had been previously the subject of a malignant malarial infection, several months after he had landed in Great Britain, during which time he had not used quinine. The malignant parasite was present in his peripheral blood in very small numbers, extremely diffi- cult to detect, and the condition yielded in a day or two to intramuscular injections of quinine. It seems, on the other hand, to be certain that in some cases quinine does not cure, even when given properly, but the objection to quinine in the treatment of blackwater fever by those who have given it only by the mouth must not be taken too seriously. Treatment. — During a paroxysm, the patient ought to go to bed as soon after the commencement of the rigor as possible, and remain there until the sweating stage is over. Durinff the cold sta^e he should have hot drinks and be covered warmly. In the hot stage, his discomfort may bo alleviated by tepid or cold sponging, and headache may be relieved by the application of cold cloths to the forehead. Should vomiting be severe, the application of a mustard poultice or mustard leaves to the abdomen will often help to check it. During the sweating stage, when the fever is de- clining, his clothes should be changed rapidly and the sur- face of the body dried as occasion needs, and any tendency to Malaria. 117 collapse may be met by hot applications over tlie lieait and the hypodermic injection of strychnine and ether, while small doses of alcohol by the snouth or rectum may be called for. In the intervals between the paroxysms, should the attack be tertian or quartan, the patient may be allowed greater liberty, but it is well to discourage any great physical or mental activity until the attack has been subdued by quinine. In the vast majority of cases, quinine, properly used, will cut short the attack, so that only one or two paroxysms may occur. When the attack is of the tertian or quartan type, it is well to withhold quinine until the paroxysm is over, and then to give it in solution in one or two ways. It is to be remembered that the commencement of the paroxysm coincides with the maturation and rupture of the sporulating forms of the parasite, so that to be effective in checking the onset of the day's paroxysm, quinine must be given before such matura- tion can occur, thus preventing the liberation of the spores, both to anticipate the paroxysm and to prevent the formation of a new brood of the parasite. As it is thought that the parasite is most vulnerable between its half-grown and its mature stage, it is the practice of many physicians to begin treatment with quinine by giving one large dose of 20-25 grains each day an hour or two before the time at which the paroxysm is expected to occur, and this method, which is the one used largely by British physicians in Spain, is certainly very effective, and tends less to the saturation of the tissues by the drug than the employment of repeated small doses ap- proved of by others. It has one disadvantage, in so far as it may, in susceptible persons, produce the uncomfortable S3'mp- toms of cinchonism — deafness, ringing in the ears, headache, vomiting and an intolerable urticaria, but such susceptible people are comparatively rareh^ met with, and if the patient is at rest during the time of treatment, severe cinchonism is not very likely to occur. Those who prefer to use quinine in smaller quantities frequently repeated, give doses of 5 grains at intervals during the day, beginning just after the sweating stage is ended, until 30 grains have been given. Another method of administration is to give 10 grain doses at 5 a.m., 8 a.m. and 11 a.m. and this has the advantage over the large 118 Chapter VII. single dose of lessening- the risk of producing cinclionism. Where the large single dose is used, it should be repeated daily for some four or five days. The dose should then be reduced by one half and given for a week, when it should be further reduced by one half and continued for ten days or a fortnight. When the smaller repeated doses are employed, they should be continued regularly for a week, and for a week thereafter they should be reduced in frequency so that 15 grains are taken in the twenty-four hours, while for yet another fort- night 10 grains should be given each day. In the treatment of a quartan ague, it is well to wait, as in the case of a tertian, until the paroxysm has subsided before giving quinine, and if the large single doses are used they must be continued for a week, and reduced in a corres- pondingly more gradual way as compared with a tertian at- tack. When the small repeated doses are used the initial number should be continued for ten days, while 15 grains daily should be continued for ten days, and 10 grains daily for another fortnight. The different types of malaria behave very differently under treatment. A benign quartan attack is more easily checked by small doses of quinine than a benign tertian, but shows a much greater liability to relapse — while its manifestations are very easily subdued, it is difficult to eradicate. A benign tertian, on the other hand, while some- times rather difficult to check, shows much less tendency to relapse after reasonable treatment. K malignant infection is the 'most troublesome of all, not only because of its comparatively refractory behaviour towards quinine, but on account of its tendency to be accompanied by the more pernicious symptoms of the disease and its liability to induce cachexia. It is not necessary to give quinine other- wise than by the mouth during the early stages of a mild malignant infection, but it should be given as soon as the diagnosis is made, irrespective of the presence of fever at the time. On the slightest hint of the onset of nervous symptoms as indicated by drowsiness or coma, restlessness or delirium, it should at once be given intramuscularly, as any delay in g'itting the patient thoroughly under the influence of quinine Malaria. 119 may result in his deatli. Similarly, on the occurrence of any of the so-called " alg'ide " symptoms, quiiiirio must be given intramuscularly or intravenously Avitbout delay. If quinine is being given by the mouth and the malignant attack con- tinues, even with slight febrile manifestations or periodic neurotic symptoms, for more than a few days, it is well to resort to intramuscular or intravenous injections, as the danger of a severe cachexia following on a prolonged malig- nant infection is considerable. To many, these recommen- dations may appear to be signs of over-anxiousness, but most people who have seen the sudden occurrence of nervous symp- toms which have ushered in a fatal termination, during a rather prolonged but apparently mild attack of malignant malaria, will agree that it is well to prevent such symptoms rather than to be compelled to treat them. It is impossible to foretell the occurrence of cerebral or algide symptoms, and it is necessary to realise that they may appear during the course of any malignant infection, however apparently mild its manifestations may be. Those who have worked in inalarious districts seem to acquire, to a certain extent, that contempt of mild attacks which is born of over-familiarity, but it may be taken as true that many deaths from malaria, and many cases of malarial cachexia, are absolutely prevent- able if the patient is able to take sufficient care and the phy- feician is alive to the importance of accurate diagnosis and prompt and efficient treatment. Quinine should never be given by the mouth in powder or pill, but in solution, and the most convenient salt to use is the bi-hydrochloride, which has a solubility in water of 1 in I. This salt is less irritating to the stomach than the sulphate, and its solubility lessens the possibility of the quinine not being absorbed. It is most probable that much of the enormous doses of the sulphate of quinine in powder, said to have been taken either for curative or prophylactic purposes, never dissolved at all, but passed through the body pretty much as it was ingested. The same salt is convenient for intramuscular injection, and should be gi^'en in doses of from T-10 grains dissolved in 30-60 minims of water repeated in severe cases two or three times in the day. Intramuscular injections should be con- 120 Chaper VII. tinned for a m eek, the best site for injection being' the gluteal region, care being taken to aToid large nerves. Bacelli, one of the best known of Italian physicians, uses the bi-hydrochloride of quinine 1 gramme, sodium chloride 75 centigrammes, with distilled water 10 grammes, as a solution for intravenous injection in malaria of a pernicious comatose remittent type. He injects into a vein from 5-7 grammes of the solution at a time, and states that he has reduced his death-rate in such cases to 6 per cent., as against the death- rate of 17 per cent, which he had when he employed the intra- muscular injection. Calomel should be given in doses of 3-5 grains at the com- mencement of treatment, and, as in all fevers, free movement of the bowels at the beginning of an attack is good practice. In all cases of malaria, when a few hours' delay in the beginning of treatment with quinine is at all justifiable, it is well to give calomel or blue-pill, followed hj a saline aperient, before giving quinine. In this way, the risk of the occurrence of cinchonism is greatly lessened. Algide and dysenteric syvi'ptoms require the use of small doses of opium as well as quinine. Hyiierpyi'e.via should be treated by prolonged immersion in a tepid or cold bath while ice is applied to the head. Malarial Cachexia. — The treatment of malarial cachexia resolves itself into attacking the malarial parasite with quinine if it be present, preferably by intramuscular injec- tions, and dealing with the anaemia by the use of arsenic and iron, while special conditions may call for special treatment. Malarial cachectics should leave malarious districts and spend at least one year in a temperate, non -malarious country. They should scrupulously avoid chill and damp, and ought to clothe themselves warmly and pay particular attention to wet feet. Quinine should be taken for two or three months after leaving malarious districts. The enlarged spleen is best treated by counter-irritation, using either Jinimentum iodi or unguentum hydrargyri biniodidi, or a more heroic practice may be resorted to, which is sometimes very successful, the injection of 20-30 minims of turpentine subcutaneously into the abdominal wall overlying Malaria. 121 iU the splenic enlargement. This produces a species of abscess- formation, and is frecjuently followed by a reduction in the size of the organ. Hepatic enlargement and congestion are best dealt witli by a course of treatment at Carlsbad, Kissingen, Vittel, or Harrogate, but when this is not possible, it is well to gi\e the patient systematic treatment by saline aperients in the morn- ing for several weeks. The treatment of blackwater fever is, as has been already seen, a very vexed question. Where the belief is held, as in the case of Koch, that blackwater fever is definitely" due to previous treatment by quinine, that drug will naturally be withheld, and treatment by arsenic or other drugs sub- stituted. Where, however, its origin is believed to be mainly malarial, especially if even a very few parasites are discovered in the blood, quinine will be employed. The results obtained by many physicians in British Central Africa certainly justify the serious trial of quinine, but the quinine must be giveu intramuscularly and in a similar dosage as is employed in a. severe remittent case of malignant malaria, or Bacelli's intra- venous method may be employed. At the same time it is best to withhold all food by the mouth and give alcohol by the- rectum, alternating with small rectal injections of physio- logical salt solution. Diet. — During the febrile stage of the disease, whether the infection be benign or malignant, the diet should consist of clear soups and milk diluted with barley-water or rice- water, and during the earlier stages of treatment by quinine* a very light diet consisting as far as possible of carbohydrates, fish, eggs and chicken should be employed. While there is. no reason, in most cases of malarial cachexia, why meat, should be Avithheld, it should be given very plainly cooked, grilled for preference, and in moderate quantities. In cer- tain cases of cachexia, especially those associated with organic disease of the kidneys and liver, the diet must be restricted as in the earlier stages of treatment by quinine, while in others, the extreme irritability of the stomach will prevent any diet other than milk and milk-foods being tolerated. When con- valescence is thoroughly established as full and generous a i22 Chapter VII . diet as is within the patient's toleration should be given. It may be necessary in cases Math obstinate vomiting to give the stomach absolute rest while the vomiting is present, and feed the patient entirely by the bowel. Epidemiology. — Malaria is endemic in most parts of the Avorld to-day save in the very cold latitudes, but is more prevalent in warm than in temperate climates and more prevalent in sub-tropical and tropical countries than in the merely warm. Tertian malaria has a practically universal distribution, but the other two types, the quartan and malig- nant, are not so universally distributed, the quartan being commoner in temperate and fairly warm countries, while the malignant is more prevalent in sub-tropical and tropical dis- tricts. In those warm countries, not sub-tropical, in which malignant malaria appears, as in Spain and Italy and parts of the United States of America, its prevalence is governed to some extent by the season of the year, first cases tending to appear in late summer and early autumn, and for this reason the name " Aestivo- Autumnal " has been given to the type. Malaria is much less prevalent in Europe than it used to be, on account of the improved drainage and sanitation which has been introduced into most Western countries during the past century. Chill is a predisposing element in the pro- duction of an attack, and while in merely warm countries a first attack of malignant malaria may be acquired in summer or autumn, the chills of winter and spring may induce a second attack when the infection is latent, and in those who come to cold or temperate climates after residence in malarious districts the determining factor in the production of another attack may be the arrival in England or the Northern parts of America during the cold weather. In temperate climates malaria is frequently associated with the presence of swamps, but in warmer regions this is not so marked, although the existence of pools of still water are absolutely necessary to the breeding of the mosquito with which malaria is so closely connected. In some districts the rainy seasons are malarious, in others malaria is less during the rains. This, as Manson points out, is simply due to the fact that in some districts the rains wash out the local Malaria. 123 mosquito-pools and in others are just sufficknit to fi]l tlicrn. I'Ik; disturbance of soil in malarious districts is often productive of a marked outbreak of the disease. The reason for this is not at first apparent, Init to quote Manson again, " soil dis- *'turbance usually means tlie formation of holes; holes imply " puddles, and puddles imply mosquitoes. Workmen from ^' many districts, some of them malarious, are assembled in *' crowded lodgings; one infected workman suffices to start " the epidemic. Method of Infection. — The work of Manson and of Ross has placed it beyond argument that the mosquito is an essential factor in the infection of man by the malarial para- site. The mosquitoes whicli have been found to act as inter- mediary hosts of the parasite belong to the group Anophelinse, and, so far, no other group of the mosquito-family has been found to be capable of carrying the malarial parasite. When a mosquito sucks infected blood into its stomach the sexual forms of the malarial parasite appear as hyaline or male, and granular or female, spheres. The male spheres exflagellate and the detached flagella, or iidcro gametes, penetrate a granu- lar sphere or macro gamete. The conjugation of these two bodies results in the formation of a lanceolate form capable of movement, which penetrates the wall of the mosquito's stomach and comes to rest between the longitudinal and transverse muscular fibres. The parasite then acquires a cap- sule, and develops in its interior a great number of spindle- shaped bodies, which after the rupture of the capsule are set free in the body of the mosquito. From there they pass, probably by the blood-stream, into the salivary glands which communicate with the base of the mosquito's proboscis by a long duct. The spindle-shaped bodies, or sporozoites, are in- troduced into tlie blood of a patient through the duct and proboscis by the action of the mosquito in biting, and then penetrate the red blood corpuscles and develop into one or ether of the malarial parasites of the tj^pes already described. Home Prophylaxis. — This consists, in the main, in house- hold and personal cleanliness, in seeing that there is no standing water in the neighbourhood of the house, either on the ground or in vessels, and in the scrupulous use of 124 Chapter VII. mosquito-uettiug and avoidance of infected areas — in otlier words, in doing everything to avoid being bitten by mosquitoe* and to- prevent the breeding of mosquitoes near the house. The native quarters of insanitary towns and in the country should be avoided, especially in the dusk and dark, as the mosquito is most active at these times. Houses made mosquito-proof by having mosquito-netting over doors and windows, are being frequently used in malarious districts, and steamships are being rendered proof in a similar way. At the same time, residents in malarious districts are well advised to avoid the evening and morning chill, which is a predisposing cause iii malarial infection, and the use of quinine as a prophylactic is to be encouraged. From three to five grains of the bi- hydrochloride should be taken daily in the morning, or ten grains twice a week, or fifteen grains every ten or eleven days. Each method has its advocates, but the small daily dose is probably the best. People who show intolerance of quinine should not go to malarious countries. Public Health Administration.— The duties of the medical oificer in malarious districts are to educate his people in the " mosquito-malarial theory," to distribute quinine among those too poor to buy it and to take measures to eradi- cate the mosquito. Each one of these duties is important. It has been shown in British Colonies that the belief in the mos- quito-malarial theory on the part of the governor has been half the battle in freeing a district from malaria, while an obstinate and unbelieving set of ofl&cials have made the efforts of the medical officer of no avail. The distribution of quinine among the poorer people tends to lessen the field of infection for the mosquito, which is a result of some value. The war against the mosquito resolves itself into draining swamps as far as possible, either directly, or by planting large trees of tho "blue -gum " type, and in removing all pools and standing water collected in such disused vessels as tins, broken pots, &c. When pools cannot be drained and filled up, as in the residual pools in river-beds, it is enough to cover their sur- face weekly with petroleum, which prevents the mosquito from settling to deposit the ova, and asphyxiates the larvae which have already hatched in the pools and which must come to the surface to breathe. Biffl lHI liiEE!dSg ( 125 ) Chapter VIII. EPIDEMIC CEREBROSPINAL MENINGITIS. Synonyms. — Spotted fever ; Epidemic cerebro-spinal fever. Fr. : Mening'ite cerebro-spinale epidemique. Ger. : Epidemisclie Genickstarre. Definition. — An acute infectious fever, associated with an inflammation of the cerebral and spinal meninges due to an infection by the Diplococcus rneningitidis intracellularis discovered by Weichselbaum in 1888. Incubation Period. — The incubation period seems to vary from one to twenty-eight days, but the usual latent period is apparently about two to ten days, although it is extremely difficult to be accurate on this point. Rash. — Although the name " spotted fever " has been given to epidemic cerebro-spinal meningitis, the hsemorr- hagic eruption which apparently gave rise to the name has been seen comparatively infrequently during recent epidemics. Billings of New York states that it occurred in only 10 per cent, of the cases which he analysed, Claude Baker gives 22 as his percentage, Avhile in Glasgow, during 1906 and 190T the percentage of cases in which the petechial rash appeared was 10.9 in 1906 and 21 in 1907, giving an average percentage of 15.95. The eruption appears usually somewhere between tbe first and fifth days of illness, most commonly on the third or fourth. Its duration is short, only three or four days elapsing between the appearance of the petechia? and their 126 Cha2)te,r:VIII. fading. Tlie rash lias a very generalised distribution, but may be more profuse over the lower part of the abdomen, and inner side of the thighs. It is composed of small haemorr- hages into the skin, of a bright purple colour, varying in size usually between a pin's head and ^ of an inch in diameter, although it is not uncommon to find spots of the size of a shilling and even larger. Haemorrhages into the conjunc- tivae are occasionally seen. A similar eruption to this appears sometimes just before death. The occurrence of a haemorrhagic eruption is a very ominous sign. During the Glasgow epidemic of 1906 and 1907 only one case which had haemorrhages into the skin re- covered, and in this case fever lasted for 160 days, while recovery took place with complete deafness. In a few cases a mottling of the skin like the subcuticular mottling of typhus has been noted, both apart from and in conjunction with the petechial rash. An herpetic eruption distributed about the angles of the mouth, on the cheek, the ears, or alae of the nose, appears with just about the same frequency as the petechial rash with which it is sometimes associated. It usually makes its ap- pearance on the second or third day of illness, but may be deferred until the second week. In some cases it makes its first appearance at the beginning of a relapse, and in others when it has appeared at the beginning of the attack it re- appears when a relapse occurs. A blotchy erythematous eruption of quite irregular distribution is sometimes met with, and Osier mentions a deep livid erythema accompanied by blood-filled vesicles as occurring occasionally on the ex- tremities. Clinical Types. — The onset of the disease is sudden, and in most cases the attack is ushered in by the sudden occur- rence of headache and vomiting, sometimes accompanied by rig-or, or in children by convulsions. Extreme vertigo has been observed as a symptom of onset. In some cases the acute symptoms may be preceded by a few days of general malaise, or sore throat, or, very occasionally, of nasal catarrh. Shortly after the occurrence of the initial symptoms the patient may complain of stiffness and pain in the neck, and retraction of Ejndeviic Ccrebro-Spinal Meningitis. 127 the liead may be noticed even in patients who are still able to walk about. The teiwperatura is usually elevated from the start, but may fall to normal within the first day, although it is common to have a certain amount of fever present through- out the attack. It follows no regular curve, and the height of the fever is no measure of the severity of the attack. In some cases it rises rapidly to 105° F. or more just before death, but in many of the most acute cases death occurs during the first week with a normal or subnormal tempera- ture. In a large number of cases the fever tends to be high during the first week and " continued " in type, while during the second week it takes on a marked remittent type which may end abruptly, or gradually terminate by a prolonged lysis. The pulse is usually increased in frequency, but in some cases its rate may be as low as 40 or 50 per minute, and it is common to have extraordinary daily varia- tions in the same patient, having little apparent connection with variations in the temperature. Before death the pulse becomes rapid and feeble and may be very irregular, and in the more chronic cases it is usually rapid, irregular and indi- cative of low pressure. In general, the disease presents acute, chronic and mild types. The acute type is characterised by severe initial symp- toms. Pain in the head, neck and back is complained of, especially on movement, Kernig's sign is frequently present and delirium, with more or less coma, develops within the first twenty-four hours. The face is flushed and may be very dusky, with suffusion of the conjunctivae, w^hile the patient has an anxious, suffering look. In young children there is frequently a tendency to slight aching in the back, but pronounced opisthotonos is not seen until the more chronic stage is reached. The knee-jerks are frequently exaggerated before the onset of coma, and the plantar reflex is exaggerated but definitely flexor in type. The patient is often markedly hypersesthetic, shrinks and becomes restless on even light handling, while photophobia is often present. The condition of the pupils is very variable. If delirium is present they are usually contracted, if coma. 128 Chopter VIII. dilated. They are frequently irregular, and a degree of hip pus is sometimes present. A variable degree of squint is very common. In acute cases death occurs within the first fourteen days, not uncommonly on the fourth or fifth day. The chronic type has an onset and early course similar to the acute, but death does not occur during the first fortnight. Instead, there comes an abatement of the more acute symp- toms of pain, delirium and coma, but convalescence does not begin. There may be no fever, and when it is present it is iisuall}' verj?- irregular in type. Opisthotonos may be marked, and a progressive wasting sets in. In some cases the degree •of emaciation is quite extraordinary, and this remarkable ■degree of wasting is one of the most notable features in all •cases which belong to the chronic type. E-igidity of the limbs is a very common symptom, and may be either transient or persistent. Vomiting is another symptom that is at times very distressing, although it may not interfere with appe- tite, which is usually good. Twitching of the face and limbs, and marked muscular tremor are often observed. The patient may become com- pletely deaf, and there may be some otitis media. A hypersemia of the optic disc has been observed in certain cases, but none of those which recoA^ered during the Glasgow •epidemics were blind. As the disease proceeds the patient .after a tedious period of wasting and enfeeblement may slowly recover, gradually losing his headache and rigidity and ten- dency to vomit, but after the passing away of all symptoms he may be unable to walk for weeks. His mental condition is often much enfeebled, and many who recover are permanently deaf. Many suffer for long from paresis of various groups of muscles. Death may occur after a prolonged illness of many weeks from sheer asthenia and progressive wasting, or it may be ushered in by the occurrence of violent convulsions. The mild type of the disease is one where the onset is •quite characteristic, but where there is no delirium or coma, although retraction of the head and even opisthotonos may be present. Such cases usually recover after a more or less chronic course without any of the more serious occurrences, such as wasting, deafness or paresis. Epidemic Cerehro-Spinal Meningitis. 129 The abortive type is a name which may be given to a class of case where, although the onset is severe and acute, the disease terminates favourably within the first week or ten days, with rapid subsidence of all the symptoms and none of the dreary happenings of the chronic type. Relapses are not uncommon, and may be very numerous, as many as a dozen having been observed. The relapses are not usually as severe as the initial attack, and each succeed- ing relapse tends to be milder than its predecessor. Complications. — The only occurrence during the course of cerebro-spinal fever which may be classed as a complication is the occurrence of chronic hydrocephalus. This is met with not infrequently, appearing somewhere about the third week. The condition is indicated by an enlargement of the head, all the more striking when compared with the emaciated face. The eyes have a fixed staring look, and there is a ten- dency to retractation of the upper eye-lid. Nystagmus and hippus may be present, and optic neuritis is always found. The hypostatic congestion of the lungs which sometimes occurs in chronic cases can scarcely be described as a com- plication, as it is due to the failure of the heart which is so marked a feature in such cases. Sequelae. — Many of the cases which recover are deaf and mentally deficient. The mental deficiency may in some in- stances become less noticeable as health is established, but the deafness is always permanent. A very marked degree of muscular weakness is present for a long time in such cases as survive a chronic attack, but this is not a marked feature in those whose attack has been abortive. Diagnosis. — Apart from association and the occurrence of the petechial rash there is nothing to distinguish an at- tack of epidemic cerebro-spinal meningitis from any other acute meningitis affecting the posterior basal region and the spinal cord, and only the course of the case may arouse sus- picion. A fulminant case of typhus may closely simulate a case of cerebro-spinal meningitis, although it is unusual to have headache persisting through delirium in any condition other than a meningeal inflammation. x\ccurate and early K 130 diaper Vlll. diagnosis must depend on the result of the examination of the cerebro-spinal fluid, and the importance of this examination cannot be too much emphasised, especially as in the early stages treatment by serum may offer some hope. In every case in which meningitis is suspected, the cerebro-spinal fluid should be examined by lumbar puncture without delay. Punc- ture is usually made in the space between the third and fourth or between the fourth and fifth lumbar vertebrse, the land- mark being the line drawn between the summits of the crests of the iliac bones. In this region nothing is likely to be in- jured by the needle save a cord of the cauda equina. A. needle of some four or five inches long with a large bore similar to those used with serum syringes should be used for the purpose. The patient may sit up, if he is able, or he may lie on his side. The back should be flexed as much as pos- sible, and if the patient is delirious it may be necessary to have the assistance of two or three attendants to hold him in position. Lumbar puncture in cases of tabes dorsalis and general paralysis is performed easily after freezing the part to be punctured by means of the ethyl-chloride spray, but on account of the hypersesthesia present in cerebro-spinal menin- gitis the process of freezing is usually as painful as puncture, and it may be necessary to give a general anaesthetic before the operation can be performed with safety. A little chloro- form is well borne. In the case of an adult who is not very restless, it may be enough to administer \ gr. of morphine hypodermically a short time before puncture is made. In young children the interspace selected may be punctured in the middle line, but in older children and in adults it is best to introduce the needle about f in. to \ in. to the right or left of the middle line, between the laminae, and give the needle an inward and upward inclination. The needle should be introduced firmly and slowly, carefully avoiding bone, until the fluid flows. The depth to which the needle must penetrate varies from 1\ inches in a young child to some three or four inches in an adult. In cerebro-spinal meningitis ths fluid most commonly spurts out with considerable force, on account of increased pressure in the subarachnoid space, but it may flow only in drops. The fluid should be caught in a Epidemic Cerebro-Spinal Meninf/itis. 131 sterile tube stoppered by sterile cotton-wool, and set aside for future examination. The needle should then be withdrawn, and the puncture sealed with a little sterile g-auze and collodion. The skin should be carefully cleaned and the needle boiled be- fore puncture. Soap and water followed by an application of acetone may be used to cleanse the skin. A very purulent and sticky exudate may refuse to flow through the needle even when it is undoubtedly in the subarachnoid space, and when fluid does flow, the quantity obtainable varies very much. Sometimes a few cubic centimetres is all that can be obtained, while at others as much as 50 or 60 cubic centi- metres are obtained with ease. A very few cubic centimetres is enough for bacteriological examination, and it is only when lumbar puncture is used for therapeutic as well as diagnostic purposes that a large amount is withdrawn. The fluid during the acute stage of an attack is always more or less turbid, but this turbidity varies from a mere cloudiness to a thick purulent exudate. For bacterio- logical examination the fluid should be centrifugalised and smear-preparations and cultures on ascitic agar made from the sediment. The smear-preparations should be stained by Jenner's method and examined microscopically. The cellu- lar elements in the cerebro-spinal fluid in a case of epidemic cerebro-spinal meningitis are mainly polj'-morphoneuclear, as in the acute stage of all meningitis, whether of tubercular or pyogenic origin, and the differentiation depends on the recog- nition of Weichselbaum's diplococcus intracelluloris . As the name implies, this diplococcus is found in the protoplasm of the polymorphoneuclear leukocytes, but it is also found in considerable numbers free in the fluid. Morphologically it presents the appearance of two small bean-like cocci lying- with their concave sides towards each other, closely resem- bling the gonococcus. The polymorphoneuclear leukocytes are usually somewhat degenerated and may show marked vacuolation. When puncture is made during the chronic stage, the fluid may be quite clear, but in contrast to the clear fluid obtained in cases of tuberculous meningitis, the cellular elements continue to be polymorphic and not lym- phocytic. K 2 132 Chapter VIII. Ag glutination of the diplococcus intra cellularis from cul- ture by the blood serum of a patient suffering from cerebro- spinal meningitis lias been shown to take place, but this re- action is not always present and, indeed, is seldom present in the very early days of the disease, so that its use is confined to the recognition of cases which come under observation after having been ill for some time. A disadvantage of the re- action as a test is that it is obtained with great variability in even moderately high dilutions, and a dilution of only 1-3 or 1-5 must be employed to obtain it with any certainty. The opsonic index of the patient to the diplococcus intra- cellularis is usually raised and may be very high. Treatment. — Apart from the giving of antitoxic serum, the treatment of cerebro-spinal meningitis must be purely symptomatic and palliative. It will be necessary to relieve pain, lessen restlessness and control delirium during the acute manifestations and to maintain strength during the chronic stage. Morphine in small doses hypodermically will quiet restlessness, relieve pain and induce sleep, but it has been observed that after its use patients tend to become comatose, and many physicians prefer to use small doses of chloral hydrate in combination with sodium bromide, repeated at frequent intervals, to quiet the patient, and to rely on other methods for the relief of pain. Cold applications to the neck and spine have been advocated when pain is severe, but the majority of cases so resent cold that the applications can be made only for very short periods and are quite ineffectual. Claude Ker, of Edinburgh, advocates the use of a hot bath when patients are restless and in pain, and his experience is that after a bath a patient may get some hours' sleep and freedom from pain. This method of treatment is possible in a private house as in hospital. Several baths should be given in the course of the day, and each bath should be of about half-an-hour's duration. But the death-rate shows how futile palliative treatment is in the case of cerebro-spinal meningitis, and one must look to some form of serum-therapy to make treatment at all hope- ful. Anti-meningococcal serum has been made by KoUe and Wassermann, Ruppel, and Burroughs, Wellcome & Co., and Epidemic Cerehro-Sjnnal Meningitis. 133 all these sera were used in ]}elvidere llospita], Glasgow, between May, 1906, and May, 1908, and the result of treatment recorded by Curri© and Macgregor in " The Lancet " in October, 1908. The sera were given subcutaneously, intra- venously and intrathecally, but the results following on their use were not very encouraging, the death-rate all over being 74.8 per cent. Gardiner Robb published in 1909 tlie results of his experience Avitli Flexner's serum in Belfast, and the apparent reduction of the death-rate in that city from 70 to 30 per cent, would seem to offer some hope that serum-therapy properly used may afford a weapon of some power to fight this most deadly disease. But it must be remembered in comparing the results of on© man in one place with those of another man in a different place, that the type of epidemic in the first place may have been quite different from that in the second, and it is only after the careful study of the results obtained by the same serum in many different epidemics that we can properly arrive at its true value. Serum ought always to be given intrathecally. Lumbar puncture should be made, as much fluid with- drawn as will flow naturally, and at least as much serum injected. When the fluid is thick and purulent it is well to wash the cavity with sterile saline solution to remove as much pus as possible before the introduction of the serum. As much as 40 cubic centimetres may be injected at a time, unless great restlessness and headache on the part of the patient shows that the pressure in the subarachnoid space is too high. The injection may be repeated daily or even oftener until the subsidence of symptoms. McKenzie and Martin published in the Journal of Pathology and Bacteriology, 1908, the results of their investi- gations on the cerebro-spinal fluid. They showed that the cerebro-spinal fluid did not contain certain substances which were bactericidal to the meningococcus outside the body, although such substances were present in the blood-serum of the same patient. They accordingly injected into the sub- arachnoid space serum from the blood of other patients or, in some cases, of the patient himself, to supply the deficiency, and the results seem to warrant the employment of such 134 Chapter VI IL •treatment, at least where there is difficulty or delay in the pro- curing- of a suitable antitoxic serum. The mere aspiration of cerebro-spinal fluid is at times attended by temporary relief to the patient, and continuous drainage of the subarachnoid space has been tried in some eases, but the results of any form of treatment other than serum therapy offer but little hope for the amelioration or cure of the disease. Treatment of Sequelae. — The troublesome muscular weak- ness which is so usually present in cases who recover from cerebro-spinal meningitis is best treated by massage and mild galvanism, while the general condition of the patient may be improved by the use of iron, arsenic and strychnine. A good combination for older children and adults is that of Ferri et Amnion. Cit. grs. v-x, Liquor, Arsenicalis m. ii-v, and Liquor. Strychnini m. iii-v, given thrice daily after food. In young children, nothing is better than Extract of Malt and Syr. Ferri Phosph. Co. in suitable doses according to the patient's age. In cases who have become convalescent, the greatest care must be taken in allowing them to resume work after their illness. It is wise to forbid a child to attend school for some six months after recovery is apparently complete, and all adults who are engaged in work involving mental strain should have a corresponding holiday of three months when at all possible. Children who 'show any signs of weakness of mind after recovery ought to be kept very quiet and free from strain until long after all signs of intellectual weakness dis- appear. Epidemiology. — Sporadic cases of epidemic cerebro-spinal meningitis are frequently met with in many parts of the British Islands and America, but of recent years epidemics of considerable gravity have occurred in Glasgow, Edinburgh, Belfast, the United States, and various parts of Germany. An epidemic tends to decline during the warmer months of the year and to show exacerbation during the winter and spring. Method of Infection. — While it is beyond doubt that the infecting organism in epidemic cerebro-spinal meningitis is the diplococcus intracellularis of Weichselbaum, it is by no Epidemic Cerebro -Spinal Meningitis. 136 means so certain how this organism gains entry into the human body, and how infection is conveyed from an infected person to another. It is probable that the organism enters by the nasal passages and tonsils, but study of the throats of patients suffering from epidemic cerebro-spinal meningitis has not revealed the presence of the organism, and it is quite possible that the disease is carried from person to person by people who are not yet themselves the victims of the disease and may never become so, whose nasal and buccal discharges may contain the organism in abundance, but who are them- selves apparently healthy. In studying the period of incubation of cerebro-spinal meningitis one is struck by the fact that while two members of a household may fall ill within twenty-four hours, other members of the household may escape entirely, indicating rather that the two who were attacked by the disease had been infected from a common source, than that one took the disease from the other. The disease is not easily transmitted from the sick person to those surrounding him, as is shown by the fact that it is nursed with safety in the wards of general hospitals, but it seems likely that in the dirt and dust of houses, in unclean streets and back courts, the infecting organism may flourish and spread the disease, in some instances very widely. Period of Infectivity. — A patient who has suffered from epidemic cerebro-spinal meningitis is probably not infectious beyond the establishment of convalescence, and it is safe to allow him to mix with his fellows as soon as his strength per- mits him to be up and doing. Death- Rate. — The death-rate has varied very much in different epidemics. In certain extremely limited outbreaks it has been recorded as between 4 per cent, and 27 per cent., but in larger epidemics it has varied between 41 per cent, and 75 per cent. During the Glasgow epidemic between May, 1906, and May, 1908, the death-rate was 74.8 per cent., one oi the highest recorded. Home Prophylaxis. — Beyond the general precautions taken in the isolation and care of patients suffering from any one of the infectious fevers as indicated in the introductory 136 diaper VIII. chapter, little ueed be done. It is the practice of many physicians to recommend the daily irrigation of the nasal passages with a solution of sodium salicylate in water, grs. x to the ounce, and the washing of the throat with the same solution night and morning during such times as the disease may be prevalent, and there is much to be said in favour of this practice among dwellers in towns, where a little chronic inflammation of nose and throat is so common, and the defen- sive power of the tonsils and nasal mucous membrane thereby impaired. The general health of all children during an epidemic should be very strictly attended to. Public Health Administration. — All cases occurring in insanitary districts should be reriioved' to hospital, and the houses in which cases have occurred must be thoroughly dis- infected either on the removal of the cases to hospital or on their convalescence if nursed at home. All bedding, clothing and furniture which has been in contact with the patient should be dealt with either by steam or by formalin solution, the walls of the house, the floors, lobbies and back yards con- nected with the house should be washed with formalin, and all ashpits and ashbuckets should be cleaned with chloride of lime solution. In view of the possibility of the disease being spread by expectoration, notices intimating this fact ought to be posted in districts where the disease is occurring, and the streets and pavements, public stairs and entries should be washed at least once a day with water charged with perman- ganate of potash or some other suitable disinfectant. Faulty drainage systems must be corrected and the necessity for public and personal cleanliness insisted on. ( 137 ) Chapter IX. ANTHRAX. Synonyms. — Splenic Fever ; Malignant Pustule ; Woolsorters' Disease. Fr.: Cliarbon; Mai de Eate. Ger. : Milzbrand. Definition. — An acute infectious fever, characterised usually by an external lesion of skin or mucous membrane^ and possibly a subsequent generalised blood infection with en- largement of the spleen, but sometimes primarily septicsemic without visible external lesion. It is caused by a micro- organism, the Bacillus Anthracis, first described as conveying the specific infection of the disease by Davaine, in 1863. The name Bacillus Anthracis was given to it by Cohn, and the fact that it contained spores was first demonstrated by Koch. Rash. — IN"o rash has been described as typical of the disease. Incubation Period. — -This is, as a rule, only possible of estimation when the disease begins with a local affection of skin or mucous membrane, and even then may be difficult to determine with any degree of accuracy. It is usual to say that the incubation-period may vary from a few hours to some ten days. Clinical Types. — The three forms in which the disease is met with commonly in man are malignant pustule, gastro-in- testinal anthrax, and pulmonary anthrax. Malignant Pustule, the charbon of French writers, ap- pears as a vesicle set in a browny and inflamed base, usually produced by the inoculation of some scratch or slight wound of the skin or mucous membrane, and is situated on the face. 138 Cha'pter IX. angle of the mouth, lip, buccal mucous membrane, the neck, liand or forearm or any exposed part. A slight pricking and burning sensation is first felt by the patient in the infected part and a papule soon appears on which forms a clear vesicle, sometimes of considerable size. The vesicle ruptures and dries up, forming a dark almost black scab. Round this cen- tral scab a ring of closely-set vesicles frequently forms. The base of the vesicles becomes dark and indurated, and a deep red or purple areola forms round it, while a brawny oedema quickly spreads in the adjoining tissues. Sometimes there is marked inflammation of the lymph channels, and the neigh- bouring lymphatic glands may become enlarged and tender. The time elapsing between the appearance of the vesicle and the formation of the typical pustule with its dark centre, hard base, deep red areola and surrounding cedema is usually about two days, and during this time the general health of the patient may not be affected, save by a feeling of slight malaise. At the end of that time, however, the temperature rises, and the patient suffers from headache and varying degrees of prostration, pain in the limbs and sweating. Delirium may be present and death from an acute septicaemia with collapse may occur about the fifth to eighth day of ill- ness. In other cases a spread of the infection to the lungs, intestine or brain takes place, and the patient may die with the signs of a rapid pneumonia, violent abdominal pain, diarr- hoea, and vomiting, or the symptoms of serious cerebral trouble — headache, delirium, restlessness and ultimately coma. As the symptoms become general the spleen usually enlarges so that it is palpable below the costal margins. In rare instances the pustule proceeds to spontaneous cure — the central part sloughs out, the surrounding indura- iion disappears, and the ulcer which remains heals somewhat slowly. But in the great majority of cases where the pus- tule is allowed to develop without surgical interference, symp- toms of general septicsemia supervene and the patient dies. Intestinal anthrax is a rare condition, even when it fol- lows on a malignant pustule, and is practically invariably fatal. It is not likely to be diagnosed during life, as its symptoans are simply those of a profound gastro-enteritis with Anthrax. 139 marked general symptoms of toxaemia. Vomiting and diarr- hcea set in after a short time of malaise, headache, anorexia, and pain in the back and limbs. The evacuations frequently contain blood. Dyspnoea and cyanosis make their appear- ance early and the jDatient may be eitlier mildly delirious (jr stuporose. Convulsions may occur, of an epileptiform type, and tliere may be some tetanoid spasm of the arms. Fever may not be high, and death is ushered in by extreme collapse. The duration of this type of the disease is from a few hours to about a week. Pulmonary Anthrax, like the intestinal form of the dis- ease, may occur either as a primary condition or as the sequel of a malignant pustule. It is not quite so fatal as the intestinal form. The symptoms of onset are prostration and a sense of great oppression in the chest. Respiration is not com- monly rapid, but is laboured and difficult. Cough is present, and may or may not be accompanied by expectoration, which is usually profuse and blood-stained. Physical examination of the lungs reveals little but generalised rhonchi, and some moist crepitation at the bases. The face is cyanosed, and the extremities are usually cold and blue. The temperature is elevated in the rectum, although in the axilla or groin it may be subnormal. The pulse is rapid, of low pressure, and mar be markedly irregular. Death may be preceded by delirium or coma, or the patient may be quite conscious to the end, which comes suddenly with rapid cardiac failure. Such cases are usually fatal within five days, sometimes within the first twenty-four hours, and if a patient survives for a week, it is said that he has a cliance of recovery. Other forms are those where the symptoms are entirely cerebro-spinal, and the patient may suffer from what appears to be acute meningitis, with vomiting, headache, irregular respiration and pulse-rate, delirium and headache, or coma, sometimes a little retraction of the head and even episthotonos. In another class of case the patient may present no symptoms referable to any organ, and merely show signs of a profound toxtemia with fever and delirium or coma. In this last class of case the spleen may be enlarged. Such irregular forms of the disease are always fatal. 140 Cha'pter IX. Diagnosis. — There is little difficulty in the diagnosis of a typical malignant pustule where a central scab and ring of vesicles are present set in a hard reddened base with sur- rounding brawny oedema, but even when this is present it is well to try to establish the diagnosis by a search for the bacillus of anthrax. As a rule it is easily recovered from the ring of vesicles or the base of the pustule by incision, and the making of a smear-preparation of the exuding fluid, but if the pustule has sloughed considerably it is often impossible to obtain recognisable forms of the organism. The appearance of the organism is very typical — long thick bacilli with rather squared ends showing in many instances evidence of spore- formation in the shape of clear oval spaces interrupting the stained protoplasm of the organism. In cases where much sloughing of the pustule has taken place the bacilli may be unrecognisable from degeneration and the only indication of the infecting organism may be the presence of ill-stained oval bodies suggestive of spores. Under these circumstances it is necessary to make a culture from the remains of the vesicles and from the reddened area after incision, and if the organism or its spores are present a growth should be obtainable on agar after twenty-four hours' incubation at 37° C. The bacillus stains well with ordinary basic anilin dyes, and gen- tian violet is a convenient and rapid stain. In cases of primary cerebral, septicsemic, intestinal and pulmonary an- thrax the recovery of the bacillus is the only means of arriving at a correct diagnosis. In the majority of such cases the bac- illus may be recovered from the peripheral blood-stream, either by the direct examination of smear-preparations, by incubation of 5 or 10 cubic centimetres of blood in peptone bouillon at 37° C, or by injecting a few cubic centimetres of blood into some susceptible animal such as a rabbit or guinea-pig. The bacillus can usually be recovered from the spleen by puncture in cases where the symptoms are general and severe, but as the anthrax spleen is soft, this is not a practice to be recommended. Puncture of the spleen by a Pasteur's pipette is a method useful for the recovery of the bacillus M^hen a patient has died with symptoms resembling a general infec- tion with anthrax, and under circumstances where there was a possibility of such infection occurring. Anthrax. 141 In arriving at a presumptive diagnosis of anthrax, the occupation of the patient must always be considered, remem- bering that butchers, cattlemen, shepherds, wool-sorters and workers in horse-hair are those most likely to be exposed to infection by the B. Anthracis. Treatment. — Where there is any visible external lesion it should be freely excised, and the resulting wound swabbed with pure carbolic acid or a strong solution of caustic potash, or the actual cauterj^ may be applied freely to the raw sur- faces. In some countries the malignant pustule is destroyed by the actual cautery or caustic potash without incision. The practice of filling the wound with powdered ipecacuanha after excision of the pustule has been attended with good results. The success of surgical treatment depends largely on the stage at which the disease is encountered. If the pustule is in an early stage, before there are any constitutional symptoms, ex- cision offers considerable hope for the patient's recovery, especially if the pustule be -situated on the hand, arm or leg. When it is situated on the neck, there is more chance of the early involvement of lymphatic glands than if it were situated at more distant parts, and excision offers less hope of cure, while there is always danger of the oedema of the surrounding tissues causing suffocation either from pressure on the trachea, or from actual spread to the epiglottis or larynx. If it be situated on the face, angle of the mouth, lip, or buccal mucous membrane, the chance of preventing a general infection by excision of the local focus is much more remote, indeed, in certain situations, e.g., the buccal mucous membrane or the eyelid, excision is extremely difficult. When the infection is general, whether primarily so or secondary to a malignant pustule, the patient generally dies, although certain cases of the pulmonary variety who have survived the first week of illness have been known to recover. Beyond surgical inter- ference, where serum is not used, treatment must be purely palliative and consists in relieving pain and subduing rest- lessness by the use of morphine hypodermically or some pre- paration of opium by the mouth, and in stimulating the patient when there is any indication of collapse or cardiac failure by the use of alcohol and hot applications on the heart. Where siffus of cardiac failure have declared 142 Chapter IX. themselves tlie 'coiulitioii is so liojDeless tli'at treatment .*s carried out rather from a sense of diity than from any hope of good result. Within recent j^ears,, however, Sclavo of Siena has pre- pared- an anti-anthrax serum obtained by immunising asses. This serum is not as accurately standardised as antidiph- theritic serum, but its immunising powers are tested on rabbits before it is put into circulation. Sclavo uses the serum alone in his treatment of anthrax cases, and this is the more general practice in Italy, but in England it has been used in combination with local treatment of the pustule. The dosage should be large, 50 cubic centimetres as a first dose, and 40 cubic centimetres on each succeeding day for two or three days, until the symptoms have abated. Sometimes a single dose is sufficient, and the number of doses necessary will de- pend on the severity of the case. It is of the utmost import- ance that this treatment should be begun as early in the course of the disease as possible. The results of serum therapy are very encouraging. Legge's views are to be found in the report of the Milroy lecture, 1905, in the British Medical Journal for March 18th of tht^t year. He analyses 67 cases, of which 56 were treated with serum alone, and out of these 67 cases only two died. In 1903 Sclavo reported his results in 167 cases when he had a case-mortality of only 6.09 per cent., at a time when the mortality in the rest of Italy was 24.1 per cent. The serum seems to be quite innocuous even in large doses, and is well borne when injected into a vein. From the cases reported it would seem that no case of moderate severity need die if serum is used in the early stages, while many cases which looked hopeless were cured by the use of the serum, even when the situation of the pustule made excision impos- sible. One of the advantages of the early use of serum is that it prevents loss of tissue from sloughing of the pustule in a marked degree. In the intestinal, pulmonary and cerebral types of the disease, or in any case where the bacilli are found in the blood stream or which seems of considerable gravity, the serum should be giA^en intravenously, and, indeed, intra- venous administration of serum is the only form of treatment which oifers the slightest hope of the cure of such cases. Anthrax. 143 When patients suifering from malignant pustule Lave been treated with the serum, their convalescence is usually strikingly rapid and complete. Epidemiology. — Anthrax is primarily a disease of liorses, sheep, cattle, deer and goats, and is met with practically in every part of the world. In the United States and Australia it is rare, and while it is comparatively common in Great Britain, it does not occur in this country with anything like the same frequency as it occurs among the susceptible animals in France, Germany, Russia, Italy, Turkey, Asia, South America and in some of the Northern parts of Africa. Pastures be- come infected so that new flocks or herds arriving there con- tract the disease, and may in their turn infect other pastures by their discharges. The infection of fields has been known to result from the scattering over them of infective refuse from factories or the carrying of infective material from workshops to them by floods. Anthrax may be carried from animal to animal by blood-sucking flies. Method of Infection in Man. — Anthrax is always trans- mitted to man by contact, direct or indirect, with infected animals. Shepherds, cattlemen, butchers and men employed in slaughter-houses become infected through some abrasion o£ their skin. I recollect one case in a man who, suspecting tuberculosis in a cow which had died mysteriously, made an opening into the thorax through which he introduced his arm to examine the pleura for nodules. He was conscious at the time that he grazed his forearm on a rib, and a few days afterAvards noticed that the scratch was inflamed and itchy. A typical malignant pustule developed which was removed, and the man recovered. Tanners and woolsorters are frequently infected by hides and wool imported from infected districts. Those who work with horsehair in the making of mattresses, furniture and saddles are also liable to become infected from imported hair. Siberian horse-hair is particularly dangerous in this respect, and its importation is discouraged in Great Britain. There is nothing which shows the extraordinary powers of re- sistance of the anthrax spores more than the fact that girls sometimes contract anthrax who are employed in the stuffing^ 144 Chapter IX. of mattresses and furniture with black horse-hair which has been previously curled by heat and dyed by chemical pro- cesses. Tanners, butchers, shepherds and cattlemen com- monly contract the external form of the disease; woolsorters are more liable to the internal forms, from the inhalation or swallowing of infective dust, while workers in horse-hair con- tract both, the internal form rather predominating. There is no doubt that sometimes the infection is conveyed t-o man by the bites of insects, while the source of infection in a few cases seems to have been infected meat which had been eaten. Period of Infectivity. — It is safe to assume that when convalescence is established there is no longer any danger of the patient being infectious. It is probable that the bodies of men and animals who have died of the disease remain infective for a long time, and the careless disposal of these may help to spread the infection. Death- Rate. — This varies greatly with the types of the disease. In the external forms, which have been treated by excision or cautery, or both, the death-rate, when the pustule is situated on the extremities, is probably between five and ten per cent. ; when it is situated on the face or neck, about 25 per 'Cent. Of the internal forms, the cerebral and intestinal types are practically always fatal, and the death rate in the pul- monary type is probably between 70 and 80 per cent. Home Prophylaxis. — For workers among wool and hair, butchers, shepherds and tanners it is of the greatest import- ance that the hands should be thoroughly cleaned after work, and the slightest abrasion of the skin on the exposed parts of the body should be treated antiseptically and sealed. Those in attendance upon anthrax cases ought to observe carefully the same precautions, and must remember that the sputum in the pulmonary type and the motions in the intestinal type are probably highly infective, should be handled with the greatest care, and must be disposed of by burning or by mixing with tin equal quantity of a 1 in 500 solution of perchloride of mer- cury or a strong formalin solution, and allowed to stand for some hours before being allowed to pass into the drains. All 'dressings should be burnt as soon as they are taken off, and Anthrax. 145 bedclothes should be frequently changed and immersed in a 1 in 500 solution of perchloride of mercury or strong solution of formalin before being boiled previous to washing. If the patient is nursed at home he should be isolated as strictly as possible. Public Health Administration. — When a case of anthrax has occurred in man the Plonie Office must be formally notified by the usual certificate, and the local authority warned of its occurrence. The source of infection must be investigated, and if it be found that the infection has been introduced by wool, hair or hides, the suspected consignment ought to be destroyed, the place from which they come notified, and the condition of sheep, cattle, and horses in that district investi- gated. In the case of repeated infected consignments coming from the same district abroad, it may be necessary for a time to prohibit the importation of wool, hair or hides from that district. Similarly if the infection is due to diseased cattle or sheep in the case of butchers, workers in the slaughter- house, and shepherds, the strictest investigation must be made in the districts from which the cattle or sheep come and the source of the infection removed, whether it be infected pas- ture or buildings or unrecognised cases of anthrax among the flocks and herds. If the infected cattle or sheep have come from abroad, it may be necessary to exercise for some time a careful supervision of all consignments from the country which has supplied the diseased animals, and, if necessary, even to prohibit altogether further consignments from that country until evidence can be produced that there is little or no danger of diseased animals being again imported. Disinfection of the houses, bedding, clothing and furni- ture which have been used by a patient seized with anthrax should be thoroughly carried out with strong formalin solu- tions, and the walls, floors, stairs and lobbies of the house where the case has occurred must be dealt with in the same way. It is to be remembered that although the bacillus itself is easily killed, its spores are extraordinarily resistant. It is best that the bodies of all cattle and human beings who have died of anthrax should be disposed of by cremation. ( 146 ) Chapter X. GLANDERS. Synonyms. — Farcy, Equinia, Malleus. Fr. : La Morve, Le Farcin. Ger. : Eotzkranklieit, Wurmkrankheit, Driise. Definition. — An acute infective disease characterised by granulomata affecting the mouth and nares (glanders), and the subcutaneous and muscular tissues (farcy), caused by a specific micro-organism, Bacillus IfaZ/ez, discovered by Schiitz and Loeffler in 1882. Rash.- — In some cases there is a more or less generalised erythema, and a papulo-pustular eruption is among the typical manifestations of the disease. Incubation Period. — This is difiicult to determine accur- ately, and is probably very variable. It is usual to say that the incubation period is from five to fifteen days, but it is possible that this period may be exceeded. Clinical Types. — Glanders in man, as in the horse, may follow an acute or chronic course, and some writers speak of acute and chronic glanders, meaning glanders primarily at- tacking the nose and the mucous membrane of the respiratory tract, and of acute and chronic farcy — glanders manifesting itself as nodules in the subcutaneous tissues which break down, and which are often associated with enlargement of the lymph-glands and, possibly, phlegmonous inflammations. There seems little use to confuse by the use of the term ''farcy." In nasal cases the lesions are the same as the subcutaneous, rapidly forming granulomata that tend to break down, forming small abscesses and ulcers. Glanders. 147 Acute Glanders. — The symptoma of invasion are those common to any acute febrile condition, and the patient com- plains of headache, general malaise, pains in the back and limbs, anorexia and nausea. Shortly after these premonitory symptoms, the temperature is raised, but it is not until some days later that the typical lesions make their appearance, and if these appear first in the nose, it may be some time before a diagnosis is arrived at. The mucous membrane of the nose becomes congested and invaded by nodules and the whole nose swells. The nodules break down rapidly and a purulent discharge comes from the nostrils. At the same time it is common to have an eruption of papules round the nose and mouth and over the face generally which quickly become pus- tular, after which they burst, leaving little superficial ulcers, or dry up to form scabs. Small patches of a purplish erythema are also seen, and on palpation they are found to overlie a small firm nodule, like an erythema nodosum, which is tender. The nodule enlarges, softens and breaks down, while the skin often shows bullae which burst as the nodule softens, and with the breaking down of the nodule a ragged ulcer is formed. Similar nodules form deep in the muscles and also soften and break down while the skin over them inflames, gives way, and an ulcer forms. Haemorrhages may occur into or "around the nodules. A subacute pneumonia is frequently met with, and in some cases, after a short period of malaise, the initial illness may closely resemble an attack of acute lobar pneu- monia, and it is not until the development of cutaneous lesions, either nodules or papules, some days later, that the true nature of the infection may be apparent. In certain cases the formation of nodules may be associ- ated with all the signs and symptoms in neighbouring large joints of a more or less acute arthritis — pain, tenderness and swelling round the joint and fluid effusion into the joint- cavity. The fluid is at first clear and serous, but after some days it becomes purulent. In one case mentioned by Goodall, suppuration did not take place for thirteen or fourteen davs. Occasionally a subperiosteal abscess may form, either alone or in connection with a suppurating joint. Sometimes the first obvious lesion appears at what was probably the 148 Chapter X. site of inoculation in the skin. In such cases a phlegmonous inflammation arises at the probable site of inoculation and little swellings appear along the course of the lymphatics. These suppurate and there is also enlargement and possibly suppuration of the lymphatic glands. Pain and swelling of neighbouring joints occur but superficial lesions of the skin are not common. The symptoms, beyond the symptoms of invasion, depend absolutely on the situation in which the first nodules appear. If in the nose, the disease will at first resemble an extra- ordinarily acute nasal catarrh; if in the muscles, the associ- ated pain may resemble acute rheumatism; if in the lung, an attack of acute lobar pneumonia. Chronic Glanders. — The chronic type of glanders pre- sents symptoms and lesions similar to those met with in the acute type, but the course of the disease is slow and its mani- festations less active. The period of invasion is prolonged, and a patient may suffer for weeks from malaise, headache, loss of appetite, slight fever, nasal catarrh, and pains in joints and muscles before the appearance of subcutaneous or intra- muscular nodules. On examination, the nasal catarrh may be found to be associated with some ulceration of the mucous- membrane, and an indolent ulceration may be present in the mouth. The subcutaneous and intramuscular nodules slowly soften and the more superficial form ragged, sluggish ulcers, while the deeper discharge through unhealthy sinuses. The ulcers and sinuses tend to heal and break down again, and this tendency is a notable feature in the disease. Cellulitis may result from infection of the chronic glanders sores by pyo- genic organisms. It is to be remembered that, although the disease may be running a chronic course, an acute exacerba- tion raaj occur at any moment. In some cases the disease may appear onlj^ as a chronic in- flammation and ulceration of the larynx, trachea and bronchi, the patient suffering from hoarseness and cough, and a diag- nosis of glanders may not be made unless an acute exacerbation of the disease occurs with the formation of the typical nodules in the skin and subcutaneous or muscular tissues. Glanders. 149 Diagnosis. — Before the development of the typical lesions, glanders lias been mistaken for smalljjoa, when the papular and pustular eruption on the face and body has been unusually profuse ; for enteric fever when a prolonged pyrexia and mild pulmonary affection have been the chief features in the early part of the attack; for acute lobar 'pneumonia where consolidation and abscess formation in the lung with an her- petiform eruption about the nose and mouth have been the obvious lesions; and for acute rheuw.atisw, in those cases where pain in muscles and pain, swelling and effusion in a joint have preceded the appearance of deeply seated nodules in a limb. Where, as sometimes happens, the fever is markedly remittent or intermittent, the diagnosis of some obscure septica^inia or pyoe-Tnia has been made, and in cases where there is, at the beginning of an attack, a prolonged pyrexia without any obvious lesions, the case is frequently mistaken for enteric fever or influenza. In those acute cases which present marked signs of nasal ulceration the diagnosis is not usually difficult, as there is no other disease which pro- duces such marked and rapid swelling of the whole nose and is associated with a papular eruption which rapidly becomes pustular, but it is to be remembered that marked nasal impli- cation is not very common. Similarly when the primary lesion is in the mouth, its characters and its association with a papulo-pustular eruption on the face, make it unlikely to be mistaken for anything else. But both the papular stage and the pustular stage of the eruption may closely simulate small- pox, although the course of the disease and the eruption are very different in the two infections. In glanders, the erup- tion appears only after many days of premionitory symptoms, and is never vesicular, w^hile in smallpox the papules appear on the third day of illness, and run through a definite course as vesicles before becoming pustules. In the type of glanders which may give rise to a diagnosis of acute rheumatism it is uncommon to find more than one joint affected, quite unlike the implication of one joint after another which is the rule in acute rheumatism, and if effusion into a joint does occur, it is almost certain to become purulent. The typical lesions in glanders, nodules which break down and form abscesses in the 150 Chapter X. subcutaneous tissue and in the muscles, serve to differentiate the disease from other conditions, even from enteric fever, where it is very unusual to have abscess formation until well on in the third week of illness, and in which abscess-forma- tion is rather inter- than intra-muscular. Widal's test and the making of cultures from the blood will also help to differentiate the disease. The occupation of the patient is a valuable aid to a pre- sumptive diagnosis of glanders. It always occurs among tliose who are associated with horses, and it is well to suspect this disease in any one whose occupation or tastes bring him into close contact with the horse and who has developed an acute suppurative condition or an obscure febrile disorder whether associated or not with eruptive nasal catarrh, or the formation of cutaneous or intra-muscular nodules. The ultimate diagnosis must be inade on the recovery of the Bacillus Mallei from the lesions. The bacillus is short, straight or slightly curved, having rounded ends. It is best stained by carbolthionin-blue. It grows rapidly in any or- dinary medium and is a facultative anserobe. In chronic cases of the nasal type, the bacillus may not grow on culture- media inoculated from the secretions of the nose, and it may be necessary to make an emulsion of the secretion in sterile salt-solution and inject it into the peritoneal cavity of a male guinea-pig, when, if the bacillus is present, an inflammation of the testicles and skin of the scrotum occurs, and death results in two or three weeks, with widespread glanders in the viscera. Malleiu, a fluid containing the active toxins of the bacillus, may be used as a test in obscure chronic cases, in the same way as tuberculin. If the patient suffers from glanders both a local and general reaction follow on the injection, if he is not suffering from glanders, no reaction follows. Complications. — The rarer manifestations of the disease, such as subperiosteal abscess, pericarditis, and meningitis, may perhaps be best described as complications. The other complications are of the pysemic and septicaemic kind which may arise from a secondary infection of the lesions by Glanderx. 151 pyogenic organisms — cellulitis, lymphangitis, suppuration of lymphatic glands, pyogenic bronclio-pneumonia, &c. Sequelae. — In the few cases who recover no notable sequelae as a rule occur except a prolonged physical and psy- chical enfeeblement due to the long and severe febrile illness. Treatment. — The treatment of acute glanders in the human subject is very hopeless, since the signs which make the diagnosis possible do not appear until the disease has been active for many days. If a wound has been infected, it should be treated with the actual cautery as early as possible. Lugol's solution should be injected into the pustules and nodules, and some 40-50 cubic centimetres of bullock's serum may be injected subcutaneously or intravenously, on the ground that cattle, being immune to glanders, may have in their serum a substance naturally antagonistic to the bacillus mallei and its products. The general strength of the patient should be maintained by rest, careful feeding and stimulation, but the outlook is bad, and very few cases re- cover from this form of the disease. In chronic glanders the skin lesions should be scraped, washed with Lugol's solution and packed with iodoform gauze. The nose should be washed out with a solution of boric acid, borax or permanganate of potash, and every visible ulcer ought to be touched with lactic acid or chloride of zinc. Repeated " malleinisation" may be practised as recommended by Babes, aVtb — t\^^'^ ^^ ^ cubic centimetre being in- jected every two or three days for some months if necessary. The patient must be put under the best possible surroundings as regards hygiene, rest and food. Diet. — In acute glanders the patient must be given a fluid and semi-solid diet of as high a nutritive value as pos- sible, and stimulants may be given freely. In chronic glanders the diet should be liberal and sus- taining, including eggs, fish, lightly cooked steak or chop, and roasted or boiled beef and mutton. Stout is a useful form of stimulant in such cases. Epidemiology. — Glanders is primarily a disease of the horse, and is met with wherever horses are used, but especi- ally in the larger towns. In the British Islands it appears 162 Chapter X. among the horses of London and Glasgow more than in any other districts. It is, however, a rare disease in man, and very few deaths are reported annually in the United Kingdom from this canse. It has been acquired in the laboratory, and may be communicated by one human being to another. It affects almost exclusively those who work among horses. The cases which appear are always isolated, and the disease never becomes epidemic in man. Method of Infection. — It is probable that in many cases glanders is acquired through some small abrasion of the skin or mucous membrane, but it may also be acquired by the ingestion of infective material. It may be conveyed directly from tli€ horse to man and from man to man, and also through the medium of stable litter. Period of Infectivity. — In acute glanders the few cases which recover are probably not infectious after convalescence is thoroughly established, but in clironic glanders it is diffi- cult to give a definite limit for the period of infectivity. It is, however, reasonable to suppose that after the complete healing of every accessible lesion the patient is no longer a danger to the community. Death-Rate. — Upwards of 90 per cent, of all persons attacked with acute glanders die, and even in the chronic form of the disease the mortality is probably well over 50 per cent. It is usual to give a more favourable prognosis where the disease is limited in distribution, as when only the skin or one extremity happens to be affected. "When the external lesions tend to heal the outlook is also more favourable. Home Prophylaxis. — Cases of glanders whether acute or chronic should be strictly isolated and the usual precautions taken with body-clothing, bed-clothes and discharges. The local authority must be advised of the occurrence of any case. Those in attendance on the patient ought to be extremely careful to seal any abrasions on the skin which happen to be present, and ought to wash the hands and clean the nails most scrupulously after touching the patient. All those who work in stables ought to watch horses carefully for any signs sus- picious of glanders and on the occurrence of such signs have I Glanders. 153 the animal tested with inallein by a competent veterinary sur- geon. Public Health Administration. — All cases ol acute glan- ders should be removed at once to hospital, unless their homes are such as admit of the most complete isolation with good hygienic surroundings. C'lnonic cases niay remain at home unless their houses are very small and dirty, in which case they also should be removed. The source of infection must be traced and all horses among which the patient was working examined and, if necessary, tested with mallein to establish a diagnosis of glanders when the horse is the subject of a chronic or latent type of the disease. The diseased horse, if worth the trouble, may be treated by repeated malleinisation ; if not, it must be killed and the carcass destroyed. The stable must be cleaned, washed down with strong formalin solution, and kept under supervision by the veterinary authority for some months. ( 154 ) Chapter XT. INFLUENZA. Synonyms. — Epidemic Influenza; "the Russian In- fluenza." Ft. : La Grippe. Ger. : Grippe. Definition. — An acute specific fever, characterised by pyrexia, pain in the back and limbs, headache, and disturb- ances of the gastro-intestinal tract, the heart, the respiratory tract and brain, due, probably, to the action of the Bacillus Infiuenzce discovered by Pfeiffer in 1892, Incubation Period. — The incubation period of influenza is very short, varying from one to three days. Rash. — No rash has been observed as typical of the disease. Clinical Types. — It is usual to describe attacks of in- fluenza as conforming to one or other of five types, the simple febrile, the catarrhal, the hroncliitic, the gastro-intestinal and the cerebral, but it is unusual, save in the last, to have in- fluenza occurring without some degree of catarrh in the res- piratory passages — the classification is made only to indicate what the outstanding features are in certain groups of cases. The siTnple febrile type, has generally a sudden and severe onset. Without a moment's warning the patient may be seized, while at work or while walking in the street, with a severe rigor, accompanied by a feeling of general malaise and great enfeeblement, so that he can hardly drag one foot after the other. Almost immediately he may suffer from nausea, vomiting, giddiness and very severe headache either referred to the frontal region or behind the eyeballs, and he is seized Influenza, 155 with acute pain in the back, particularly in the lumbar region, and aching in the limbs, referred rather to the muscles and bones than to the joints. He is conscious of a dry burning sensation in the nose, throat and eyes, and may suft'er from the commencement from a " substernal rawness." The tem- perature rises at once, sometimes as high as 105° or 10G° F., and a temperature of 104° F. is very commonly observed. Pulse and respiration are greatly increased in rate, and the patient has a troublesome frequent cough not usually ac- companied by expectoration. An herpetic eruption frequently appears about the lips, and blotchy erythemata have been oc- casionally observed on the skin of the trunk and limbs. After some three days of pyrexia, headache, malaise, prostration, anorexia, pain in the back and limbs, and dryness in throat, eyes and nose, the temperature subsides and the symptoms abate, some slight coryza and faucial secretion appearing as the temperature falls. Convalescence is uncomfortable and tedious, and it may be many months before a patient re- covers his full mental and physical vigour, although his attack has been of the simple uncomplicated febrile type. In the catarrhal type, after the usual symptoms of inva- sion, the patient is seized with acute catarrh of the eyes and nose, lachrymation may be extreme, and a profuse watery acrid discharge comes from the nostrils. The nasal discharge becomes purulent, and the conjunctivae become deeply in- jected. The fauces and tonsils are usually acutely inflamed, and cough is troublesome, and may be attended with a feeling of "tearing" behind the f'ternum and slight mucous expec- toration. Sleep is disturbed on account of the obstruction in the nose. Beyond a few snoring rhonchi heard in the upper part of the chest, no physical signs are apparent on examina- tion of the lungs. The catarrh lasts for about a week and then clears up, sometimes with a little purulent expectoration ejected after slight coughing, and derived presumably from the fauces and trachea. It is not uncommon, however, for such catarrhal cases to assume the bronchitic type, where the inflammation spreads from the fauces and trachea to the bronchi and lungs, and which constitutes one of the most dangerous types of the disease. 166 Chapter XI. Shortly after the catarrhal symptoms appear the patient is seized with a sense of constriction in the chest, breathing is rapid and difficult, and cough is almost incessant and very distressing. Expectoration is scanty and viscid, sometimes purely mucous, sometimes tinged with blood, and sometimes mixed with small greenish mucopurulent masses, but always difficult of ejection. Auscultation of the chest reveals the presence of sibilant rhonchi and a few sticky rales. In a cer- tain proportion of cases the temperature subsides in about a week. Before it reaches normal the expectoration becomes mucopurulent and fairly profuse and numerous rhonchi with mucous and sub-mucous rales are audible on auscultation of the chest. Even after the temperature has reached normal, the cough, expectoration and physical signs remain for several days at least and only disappear slowly as convalescence progresses. In other cases, however, the tem- perature remains high at the end of the first week, and the general condition of the patient and the phj^sical signs make it plain that the catarrh has spread to the bronchioles and alveoli, and a lobular pneumonia is in progress. The tem- perature may be very high, even hyperpyretic, the patient tends to become cyanosed and may die, with gradually in- creasing dyspnoea and slow cardiac failure. In some epi- demics, shortly after the occurrence of the initial catarrhal symptoms a lobar pneumonia develops in a considerable pro- portion of cases, which slowly involves one lung and, after the lapse of a week or ten days, at a time when crisis might reasonably be expected to occur, the other lung may become involved, and the consolidation spreads in it as in the lung first attacked. Such cases are extremely dangerous, and very often fatal. In those where crisis does occur the patients tend to collapse more frequently than in an ordinary lobar pneumonia, and if they rally from the crisis their convales- cence is difficult and protracted. Delirium is very common in the bronchitic type, especially on the occurrence of pneu- monia, whether lobar or lobular. The gastro-intestinal type is that in which there is added to the symptoms of the ordinary febrile type the symptoms of an acute gastro-enteritis, — vomiting, diarrhtiea and acute Influenza. 157 abdominal pain. In some cases the ^astro-intestinal symptoms are very urgent and the patient may die of asthenia or col- lapse. Cases are occasionally met with in whicli the gastro- intestinal symptoms are the first which present themselves, and in these the diarrhoea is apt to he very profuse and watery, attacking the patient with great suddenness, and fol- lowed by profound collapse, almost choleraic in its intensity. Such cases very frequently prove fatal. The cerebral or nervous type is not common in Great Britain, but in the course of some epidemics has been met with frequently on the continent of Europe. The onset of the cerebral symptoms occurs frequently without previous warning, but in some cases it is preceded by a few days' malaise with aching in the back and limbs and catarrh of the upper rcvspiratory passages. The patient may become restless and violently delirious and may suffer from acute headache, and stiffness of the neck and of the muscles of the jaw may follow later. Tlie delirium lessens in a few days and the patient may die comatose or slowly recover. In other cases severe headache or pain in the distribution of the fifth ner\e or a sudden convulsion may be the first indication of illness, and these may be quickly followed by the occurrence of aphasia, a monoplegia, or hemiplegia, and stupor or coma may supervene. In certain cases the patient may suddenlv become hemiplegic, aphasic and comatose without having been previously ill, as in a case of sudden cerebral haemorrhage or embolism. It is a striking fact that in the cerebral type of influenza there may be practically no fever, and the pulse rate may not be raised. The great majority of attacks of the cerebral type prove fatal after a few days' illness, but occa- sionally recovery takes place. Afild cases of influenza are very frequently met with, in fact they are the predominant type where no serious epidemic is raging. As a rule they are modifications of the simple feb- rile or catarrhal types, and have an insidious onset without rigor, so that one class of cases may present the characters of an ordinary nasal catarrh with perhaps more prostration during convalescence than is normal to a common cold, while 158 Chapter XI. oiliers suiter from headache, pain in the back and limbs, mental depression or giddiness with little or no fever. Even in such modified cases convalescence is slow, and patients suffer from mental depression, loss of the power of concentra- tion and from muscular weakness out of all proportion to the severity of their illness. It is usual to describe the primarily bronchitic as the most dangerous of all the types of influenza, but many practitioners will agree that the most dan- gerous of all is that which begins as a mild form of the disease with little fever and few symptoms of catan'h, so that the patient does not immediately lie up, but struggles on for days until he falls a victim to one or other of the graver manifes- tations of the disease. An attack of influenza with an acute and severe onset protects by its very severity, and even if it develops as the bronchitic type of the disease, the patient, having been under observation from the onset, is more likely to survive a severe bronchitis or a pneumonia than one who has been weakened by over-exertion and exposure while suf- fering from a mild type of the disease with insidious onset, before the development of pulmonary trouble. Diagnosis. — A typical attack of the simple febrile or the catarrhal type is usually easy of diagnosis, the only disease likely to be confused with a simple febrile attack being acute rheumatism, and there the definite location of pain in the joints and the less sudden onset will help to make the dis- tinction plain. In the pulmonary type, if there is much con- solidation of lung, the clinical differentiation of an influenzal from an ordinary acute pneumonia is very difficult, and, in those cases where the influenzal pneumonia is frankly lobar, impossible, without bacteriological examination Similarly, accurate diagnosis in the mild catarrhal types is also impos- sible without the recovery of the bacillus. In the cerebral type, lumbar puncture should be performed when the symp- toms simulate those of a meningitis, to exclude the possibility of the case being one of epidemic cerebro-spinal or tuber- culous meningitis. Certain cases of influenza are mild and prolonged, with a tendency to relapse, and the use of Widal's test will help to differentiate such cases from enteric fever, and the use of Influenza. 159 Calmette's ophthalmic reaction or of Von Pirquet's cutaneous reaction will help to exclude certain forms of tuberculosis which they may closely resemble. It is generally supposed that the bacillus influenzoe of Pfeiffer is the causal agent in epidemic influenza, and this organism may be recovered from the upper air-passages and the sputum. The bacillus is small and slender, with a tendency to stain at the poles and not at the centre. Gram-negative and growing only on media which contain haemoglobin. It is very rarely found in the blood- stream, and does not give rise to true purulent meningitis. Cohen has described in the Anmales de V Institut Pasteur (1909, xxiii, 273), a bacillus which he recovered from the blood stream and from the subarachnoid space in certain cases of purulent meningitis, and which resembles the B. influenzae of Pfeiffer both morphologically and in cultural characteristics, but has a different pathogenicity towards animals. This organism may bear the same relation to the B. influenzae as does the B. paratyphosus to the B. typhosus. AVithout the recovery of the B. influenzae it may be quite impossible to differentiate a mild catarrhal type of the disease from the infectious coryza due to the micrococcus catarrhalis, in which a certain amount of shivering and pain in the limbs is very frequently met with. Complications. — Cardiac degeneration with dilatation and failure are two of the most serious complications of influenza, and while they occur more frequently in cases of a severe bronchitic or pneumonic type they do occur in cases where the other symptoms have been deceptively mild. The symp- toms are breathlessness, even on slight exertion, a rapid and irregular pulse, and some degree of cyanosis. The heart may be markedly enlarged to either side on percussion, and systolic murmurs may be audible at both the mitral and tri- cuspid areas. The symptoms of dilatation and failure of the heart not infrequently follow some exertion on the part of the patient or after he has been permitted to sit up or walk too soon. Death may occur with great suddenness, while in some cases the symptoms may persist for many weeks or even months before death supervenes, and in others a slow and tedious recovery is made. Pericarditis and endocarditis are 160 Chapter XL occasionally met with, and a few cases of acute infective endocarditis as part of an influenzal septicaemia have been recorded. Various swpinirative affections are met with as compli- cations in influenza, the more common of which are acute purulent otitis media, abscess in the antrum of Highmore and empyema of the frontal sinuses. From these conditions, as from the acute suppurative "parotitis which occasionally occurs, the B. influenzae has been recovered. Pleurisy, both dry and with effusion, and eTnpyeina are occasionally met with, and laryngitis, both acute and subacute, sometimes occurs. In rare instances haeanorrhages occur from the nose, lungs or intestine, and an optic neuritis which does not usually proceed to atrophy has been described as an unusual complication. Sequelae. — During convalescence the patient is pecu- liarly susceptible to chill, and bronchitis and pneumo7iia of a very dangerous kind may follow on any undue exposure during convalescence. It is said that phthisis is apt to follow ■on an attack of influenza, and also that an attack of influenza wall cause an exacerbation of his disease in a phthisical patient, but it would be well if these statements were founded ■on careful bacteriological examination, as it is a matter of common observation that the onset of phthisis pulmonalis may in certain cases very closely resemble the onset of influenza, and curious attacks of fever with prostration are met with in the course of phthisis, although in neither class of case has the B. influenzae been isolated from the sputum or nasal secretion. The most troublesome and constant sequelae are those affecting the Tnuscular and nervous systems, where lassitude, muscular weakness, a rapid pulse, mental depression and loss of the power of concentration may persist for many months after the attack has passed off. A tendency to vertigo may also persist for a long time. Peripheral neuritis has been ob- served, but rarely. It is no uncommon thing for a man whose work is mental and taxing to find that he is unable to study for many months after his attack of influenza, and he is con- scious during that time that his "head is easily tired" and that he is incapable of prolonged concentration, while his memory. Influenza. 161 although previously good, has become very treacherous. This loss of mental power tends to increase the depression which is so usual during convalescence, and a true melancholia may supervene, in the course of which a suicidal tendency may develop. In an epidemic of influenza in Scotland in 1890, an athletic highly educated young man who was one of the school inspectors appointed under the Scottish Education Department contracted tlie disease, and, altliough, his attack was only a moderately severe one of the simple febrile type, his mental depression was such that during con- valescence he went to the railway and laid his head down before an advancing express train. The form of mental de- rangement which follows influenza is usually melancholia, but various forms of mania have also been described. All kinds of neurasthenic and psychasthenic manifestations are apt to occur. The sense of taste and smell may be impaired for long after convalescence is established. Treatment. — An essential in the treatment of influenza is that the patient should be kept in bed from the beginning of his attack until the evening temperature has been normal for at least three days, and until all catarrhal symptoms have dis- appeared. Thereafter he should remain indoors for some days, and should, if possible, take a holiday of some weeks' dura- tion before resuming w^ork, more especially if his work in- volves worry or mental strain. In this way many fatalities, and much of the distress caused by prolonged physical and mental weakness during convalescence would be avoided. During the acute stage headache and fever may be re- lieved by sponging with cold or tepid water or by the appli- cation of cold compresses, as in enteric fever. A mustard plaster very often relieves the pain in the back. A combina- tion of sodium salicylate (grs, iii), and the Liquor of the Acetate of Ammonia (Tl|^xx) repeated every two hours is efficacious in promoting a reasonable moisture of the skin, and in relieving pain in the limbs; it tends, moreover, to lessen the intense feeling of congestion in the nose and frontal sinuses, which is often so distressing. Quinine in the form of the ammoniated tincture is also of service in cases where there is much fever, and should be given in doses of 3i repeated M 162 Chapter XI. every three or four liours. When there is any bronchitis or laryngeal inflammation, Ammonium carbonate (grs. iii.) may be given in combination with spirit of Chloroform (TI^ sv.), and Camphor water (^i), the mixture to be repeated every two hours, and hot inhalations containing oil of Eucalyptus or Thymol will often relieve. I have found that a dry inhala- tion composed of Tr. lodi Aetherialis, 01. Creosoti, 01. Eucalypti, et Spt. Chloroformi, in equal parts, is very ser- vicable when there is any bronchial, tracheal, or laryngeal catarrh, giving ten drops on the sponge of a Squire's oro-nasal inhaler to be used for fifteen minutes frequently during the twenty-four hours. The application of heat to the front of the chest will often relieve the painful feeling of constriction even in adults. In bronchitic and pneumonic cases the state of the pulse and restlessness of the patient may demand the use of whisky or brandy, and this is best given in two or three doses in the twenty- four hours of §i each rather than distributing the same amount over the day in small doses every three or four hours. When there is much restlessness and delirium ^ without any pulmonary or bronchial catarrh, the hypodermic injection of ^th gr. of morphine may be used with advantage, and repeated every three hours until quiet is produced. In cases where coma had supervened. Sir William Broad- bent recommended intramuscular injection of several grains of the hydrobromate of quinine, repeated if necessary three or four times in the day. In cases which have shown acute cardiac failure it is best to use the hypodermic injection of strychnine, gr.^Vj with some twenty minims of ether, and to push digitalis after the patient has once rallied. In all cases where the pulse con- tinues to be rapid, say over 110 for several days, digitalis should be used freely, combined, when there is much general irritability, with Ammonium bromide in doses of 10-20 grains. Suppurative complications must be dealt with surgically as they arise. The muscular and mental weakness which is so trouble- some during convalescence should be treated by rest, change of scene and cheerful surroundings, while the bi-hydrochloride Influenza. lO'j of Quinine in doses of half a grain, with 5 minima of dilute nitro-hydrochloric acid, 3-5 minims of the Liquor of Stry- chnine and some Compound Infusion of Gentian may be given with advantage thrice daily before food. It is of the utmost importance that any patient who shows the slightest tendency to melancholia should be very carefully watched on account of the liability which such people show to develop suicidal tendencies. Diet. — The diet during the acute stage of influenza should be bland and fluid, iced if the patient so desires it, and should consist rather of very thin gruels, milk diluted with soda-water or barley-water, and barley-water itself rather than soup, to which many patients profess a strong objection. As convalescence is established, a generous diet should be given as soon as the patient's appetite permits, and the greatest care should be taken that its nutritive value is high. To those who are accustomed to the use of alcohol in health it should be given during convalescence, as the sense of well- being which it induces is of value, but it should not be urged on those who are not accustomed to take it, as the very sense of well-being which it produces may cause the establishment of a habit of alcoholism in those who were previous!^' abstainers. Epidemiology. — Influenza swept across Europe from Russia in 1889, and since 1890 Great Britain has been liable each winter to epidemics of greatly varying severity. In some years the disease has shown itself mainly as an unusually severe kind of nasopharyngeal catarrh which has tended in certain cases to spread to the bronchi, and after which con- valescence was tedious, while in others the grave types have predominated, and patients have died in considerable numbers from influenza of the pulmonary and intestinal types. One attack confers little or no immunity. It is a common thing to find that patients have had two attacks of moderately severe influenza in the same winter, but many who seem to fall a victim to the disease almost every year say that the first at- tack they had was severe and typical, while the subsequent two or three attacks have been atypical and mild, but that after a few mild attacks, they have again suffered from a severe and M 2 164 Cluipter XL typical iuHiienza which is again followed by two or three mild attacks, and so the rotation goes on. It is, however, difficult to be certain about the accuracy of their statements, as any infectious coryza associated with aching in the limbs and back is too readily diagnosed as influenza at the present day. Method of Infection. — Influenza can be spread by direct contact with infected persons, and also by means of various fomites, such as clothing, furniture, letters, parcels, &c. Most severe epidemics are preceded by the occurrence of a few sporadic cases, which presumably spread the disease among those with whom they come in contact. The tendency for in- fluenza to spread through institutions and households is in itself proof of its great infectivity. Period of Infectivity. — Wliile it is true that the disease is most infectious in its early stages, patients are capable of conveying the infection to others directly for at least some days after the acute symptoms have subsided, and it is prob- able that infected fabrics are capable of retaining the infec- tion for a long time after they have been in contact with a patient suffering from influenza. It seems likely, judging from the frequent small outbreaks of the disease in country dis- tricts which occur shortly after the arrival of supposed con- valescents on holiday, that we are too careless in our isolation of cases of influenza and in the disinfection of clothing and other articles which have been exposed to the infection. Death-Rate. — The percentage mortality among cases at- tacked is small, but in any widespread epidemic so many of the community are attacked by the disease that the fatal cases cause a marked increase in the local death-rate during the period of the epidemic. Influenza is much more fatal in elderly people than among young adults, while children usually exhibit a mild type of the disease. Pre-existing car- diac disease, a tendency to bronchitis, any organic disease of the kidneys or liver, or a bad history with regard to alcoholic excess are all factors which militate against the recovery of a patient. The mortality is high among those who show severe cerebral or gastro-intestinal symptoms, who have much bron- chial catarrh, who develop pneumonia, either lobar or lobular, or show any marked tendency to cardiac failure. Influenza. 165 Home Prophylaxis. — A patient suffering fjoiu influenza ought to be isolated as fax as possible from the other members of the household; his room should be vacated at the end of the attack and its contents disinfected before it is re-occupied. All bed clothes and washable materials in the room should be steeped in a 1-20 solution of carbolic acid and afterwards washed. The carpets, hangings, furniture, and outer clothing ought to be sprayed with formalin solution and thoroughly aired before being used again, while the walls should be ex- posed for twenty-four hours to the vapour of formalin, and the room freely ventilated for at least a day. It would seem probable that the organism of influenza is capable of living for long periods in furniture, in the corners of rooms, and in clothing which has been exposed to infection. I know of one family, the members of which were for years the victims of attacks of influenza of a very typical kind occurring in early winter or spring until they thoroughly disinfected their house and furniture, besides the usual repapering and painting of the rooms, during one summer when they were on holiday. In the past two years no member of that household has suffered from influenza. Public Health Administration, — Although influenza is not a notifiable disease, it is well that the local authority should afford facilities for the disinfection of houses and clothing to those who may desire it, and who are unfavourably situated for the carrying out of efficient disinfection for them- selves. ( i^« ) Chapter XII. PULMONAEY TUBEECULOSIS. Synonyms : — Consumption; Phthisis Pulmonalis. French : La Phthisie. German : Schwindsucht. Definition. — An inflammatory process in the lungs charac- terised by catarrh, consolidation, caseation and fibroid changes, caused by the B. tuberculosis, discovered hj Koch in 1882. Incubation Period. — The incubation period of phthisis pulmonalis is quite indefinite. The only case which I have known in which it seemed likely that the time of infection could be fixed with any accuracy was where a young woman was undergoing a course of *' Weir-Mitchell " treatment in a nursing home. She was in the home for some eight weeks, and three months after she left, she developed symp- toms which made her physician suspect the existence of phthisis pulmonalis, and the sputum was found to contain large numbers of the B. tuberculosis. Enquiry was made at the nursing home with a view of discovering a possible source of infection, and it was found that the patient who had been the last occupant of the room in which the young woman received her " Weir-Mitchell '' treatment, had died of an advanced tuberculosis of the lungs, and the room had not been disinfected before the admission of another patient. It is probable that the incubation period may be anything between a week or two and some years, during which the bacillus lies latent and produces no apparent disturbance of the patient's health. But anything like accurate determina- tion is usually impossible, as it is only after repeated exposure Pulmonary Tiiherculons. 167 to infection, and even then most commonly as tlie result of an hereditary predisposition or a loss of resistance on the part of the patient due to tlie influence of some other disease, that pulmonary tuberculosis is acquired. Rash. —No rash has been observed as typical of the disease, but, as in all the acute infectious fevers, erythemata and morbilliform rashes have been observed as unusual occurrences in its course. Clinical Types. — In discussing the clinical types of pul- monary tuberculosis I do not propose to describe at any length the physical signs to be met with in the lungs, as they fall more naturally to be described in a treatise on general medi- cine, and I shall merely indicate briefly the signs met with in the several types v/hich are necessary for the diagnosis of the disease and its complications. The clinical types usually described are miliary tubercle of the lung, yneuTnonic 'phthisis, chronic phthisis with softening, and fibroid phthisis. Miliary tubercle of the lung is commonly a part of a general infection b}^ the B. tuberculosis of the whole body and the lungs are affected along with the other viscera. Its onset, unless ushered in by the occurrence of meningeal symptoms, resembles that of enteric fever. Physical signs in the lungs are frequently absent, and if present they resemble those of an acute catarrhal affection involving the smaller bronchi — diffuse sibilant rhonchi, mucous, submucous and subcrepitant rales. When the pleura are involved some fine crepitus will be aiidible. As a rule there is a widespread diminution in the volume of the respiratory murmur, and small areas of dull percussion may be detected, while it is not at all uncommon, especially in children, to find that the front of the chest yields a hyper- resonant note on percussion, due possibly to an acute emphy- sema. The temperature is raised, and may be high, 102° and 103° F. being quite usual readings. The fever is usually of the continued type. The pulse is rapid and soft. Breathing is difficult and rapid, and there is in the great majority of cases very marked cyanosis of the lips, face and extremities. 168 Chapter XII. even of the skin generally. Witli this type of pulmonary tuberculosis the spleen and liver may be enlarged, meningitis may develop, and tubercles may be visible in the choroid. There may be acute diarrhoea or constipation with considerable swelling of the abdomen. It may be said definitely that this form of the disease is always fatal, and may run its course in a week or two. Sometimes, however, it may be protracted for several weeks, or even months. Pneumonic phthisis : In this type of the disease the lesion may have the character of a lobar 'pneuTnonia or of a hroncho- ■pneumonia. The onset is usually sudden and severe, often with rigor, and the patient suffers much with cough and pulmonaiy distress. The physical signs may be those of lobar pneumonia, and nothing save the examination of the ispit may give any indication of the infecting organism. In certain lobar cases the disease may be fatal within the first fortnight^ but as a rule, its course is more prolonged than an ordinary acute lobar pneumonia, and death does not commonly occur until the patient has been ill for a couple of months. The temperature at the first behaves just like that of an acute lobar pneumonia, and physical examination shows that one lobe or more of a lung is in a stage of consolidation. Instead, how- ever, of having a crisis about the seventh or eleventh day, as in an ordinary acute lobar pneumonia, the condition tends to be aggravated, the temperature becomes markedly remittent and the pulse rate increases, the sputum becomes muco-purulent and often has a greenish colour. Signs of softening are to be made out in the lung and the examination of the sputum will reveal the presence of tubercle bacilli and elastic tissue. In the majority of cases death occurs at anything between the third week and the third or fourth month, but in some cases the acute symptoms pass off and the disease assumes a chronic type. In those cases where the lesion is hroncho-pnewtnonic , the onset is also sudden and acute, resembling closely the onset of an ordinary broncho-pneumonia. At the end of a week or two, however, the symptoms show no abatement, the temperature takes on a markedly remittent character, and the patient may die after an illness of a few months, or the disease may drift Pulmonary Tuberculosis. 1(50 into the chronic form. There is nothing in the character of the physical signs to indicate that the broncho-pneumonia ia tuberculous, as they differ in no way from those of a broncho- pneumonia of an ordinary type. In both kinds of pneumonic phthisis the patient is cojn- monly flushed at the onset, but becomes more or less cyanosed as the disease progresses. The lesions in the lung tend to be more frequently apical than in non-tuberculous pneumonia and broncho-pneumonia. Clironic "phthisis with softening. — This type may be chronic from the commencement of the disease, or may result from one or other of the pneumonic types. Where the onset has been acute and severe the chronic type develops from the pneumonic by a gradual modification of the symptoms. Fever becomes less marked, cough and wasting are not so urgent, the patient loses the flushed febrile look and begins to feel stronger and have more appetite. The physical signs in the chest tend to limit themselves to one or other upper lobe, collateral catarrh disappears, and the definite lesion com- pounded of catarrh, consolidation and softening becomes gradually more and more apparent. Excavation may proceed and a cavity form, or the disease may spread to other parts of the lung and the phenomena of moist crepitations, bronchial breathing or signs of cavity may be discovered in the lower parts of the lung, whereas the primary lesion was situated in the upper. Pleurisy may develop, with or without effusion. As the softening proceeds the sputum becomes muco-purulent and even frankly purulent, while as a cavity forms the typical ''nummular" expectoration may be met with. The temperature is, as a rule, markedly remittent, with a morning fall and an evening exacerbation. The daily variation may be large, and it is not uncommon during the course of one of the more rapidly advancing cases of the chronic type to have frequent febrile movements of considerable severity. In a certain proportion of cases the disease goes on to spontaneous cure, even after treatment of the most inadequate description. The moist sounds in the lung disappear, constitutional symp- toms abate, and cavities, even of considerable size, dry up and shrink, causing little embarrassment. In other cases, however. 170 Chapter XII. the disease does not tend to cure, but steadily advances with variable rapidity. Febrile exacerbations are common, and the patient suffers from a profound toxaemia begotten both of the B. tuberculosis and the pyogenic infections which are so com- mon in the softening lung. An acute pneumonia or broncho- pneumonia may be superadded to the tuberculous condition, and even after years of chronicity the patient may die of an acute form of phthisis following, apparently, on the occur- rence of some acute infection other than tubercle. Death may ensue from asthenia or one of the numerous complications which may occur. The great majority of cases of phthisis are, however, chronic from the beginning. Their onset is insidious and slow, and it may be long before a patient feels ill enough to consult a physician and further delay may result from diffi- culties in early diagnosis. A slight "cold" which does not get well properly and which is accompanied with cough, an unexplained ansemia, dyspepsia, loss of weight, and an in- creasing sense of lassitude and "unfitness," may be the first indications that anything is wrong, and even when the patient comes under observation it may be long before any physical signs are discovered in the chest. Soon, however, a little dullness at one or other apex or over the apex of the lower lobe of a lung becomes apparent, and auscultation reveals a degree of bronchial breathing which varies with the situation of the lesion, being sometimes loud and marked and sometimes distant and difficult of detection. At the same time it is usual to be able to detect at least a few rales with inspiration, although these may be masked by the development of a bron- chitis which is confined to the apical region of one or other lung. In some cases a fairly widespread bronchial catarrh may be the first lesion detected in the chest, and may give rise to no suspicion until it is found that, while it clears up in other parts of the lungs, it lingers at an apex. Sometimes the occurrence of hfemoptysis is the first sign of illness, and after this occurrence the signs of a lesion at one apex usually develop fairly quickly. The progress of a case after an early apical lesion is detected varies much in individuals according to their natural resistance and their social and climatic Puhnonary Tuhermdons. 171 enviroument. In cases where tlie patient lias command of money or influence or lias no people directly dependent on him, he may be placed under circumstances which will lead at least to an arrest of the tuberculous process, and be able to afford himself the leisure and the freedom from money-earn- ing which is a necessary part of the treatment. In a certain number of cases a naturally great resistance will enable him to keep the disease in check even under unfavourable circum- stances, but in the great majority of patients who are the subject of phthisis, unless able to undergo treatment under very favourable climatic and hygienic conditions, the disease develops and spreads until death follows on years of useless- ness and invalidism during which the patient has the misery of seeing his occupation slip from him and his immediate dependents living either on the resources of the parish or the goodwill of friends. Catarrh, consolidation, softening and excavation extend, and the patient dies from asthenia or from some complication as already described. The refractoriness of certain cases which show few and insignijficant physical signs in the chest leads one to suspect that a widespread but deeply- seated lesion may express itself most inadequately by appre- ciable physical signs. In estimating the severity and progress of a case of chronic phthisis the general condition of a patient is of far greater value than the physical signs in the chest; it is not the local but the constitutional effects of the toxins which are to be dreaded. Everybody is familiar with the man who lives on with half his lung tissue gone, and also with the unfortunate who dies with a local lesion curiously disproportionate to the severity of his general symptoms. The consideration of these natural variations of the disease are of the utmost importance when the question of treatment comes to be considered. Fibroid phthisis. — In this type of the disease the main lesion is a fibrosis of the lung which may follow on a tuber- culous pleurisy with thickening of the pleura, or on a chronic tuberculous broncho-pneumonia. In many cases it follows on the arrest and limitation of a chronic tuberculosis of the lung where a cavity has formed which becomes surrounded with a dense layer of fibrous tissue, when the pleura become thickened 172 Chaper XII. and the fibrosis spreads tLrougliout the lung. Fibroid phthisis is extremely chronic in its course. The physical signs are those of shrinking of the affected lung with some compensatory emphysema on the oj)posite side. Signs of cavity may be apparent, indicating either the presence of an old cavity, the result of previous softening, or the dilatation of a bronchus secondary to the shrinking of the lung. When the cavity is bronchiectatic expectoration is apt to be profuse and foetid. Cough is troublesome and may be paroxysmal in character. Oedema of the legs and feet may result from failure of the right heart, and amyloid degenera- tion of the kidney, spleen or liver may occur from the long- continued suppuration in a cavity or in dilated bronchi. Complications. — All the viscera may become infected by the bacillus of tubercle during the course of pulmonary phthisis. Tuberculous ulceration of the larynx, and of the mouth, tongue and gastro-intestinal tract generally may take place. A tuberculous meningitis may occur, and tuberculosis of the liver, spleen and kidneys are met with as the result of a generalised tuberculous infection secondary to a lesion in the lung and bronchial glands. Tuberculous pyosalpinx is not uncommon among women in advanced stages of pulmonary phthisis, and tuberculosis of the bladder and testicle may also occur. Degeneration of the cardiac muscle and thicken- ing of the pulmonary artery are frequently met with, and in the later stages of the disease a rapid feeble pulse with dysp- noea which is exaggerated on exertion is very common. In such cases apical and basal systolic murmurs are audible, usually without any valvular lesion being present. Loss of appetite and pain or discomfort after food are often extremely trouble- some and hinder treatment. Diarrhoea is frequently a serious complication even early in the disease but is more common in the later stage, due to ulceration of the ileum with concomitant catarrh, or, in some instances, to amyloid degeneration of the mucous membrane. Haemoptysis may occur late or early in the disease. When early, it is not in itself dangerous, although it may be severe and prolonged, but when it appears as a late occurrence, in connection with cavity-formation or a fibroid condition of the Pulmonary Tuberculosis. 173 lung it may be extremely Juiig-erous und is not infrequently fatal. Diagnosis. — The diagnosis of pulmonary consumption depends very largely in most cases on the discovery of jjhysical signs, and, as the patient usually presents himself in the early stages of the disease, these may be slight and limited. A little deficiency in expansion in one or other apex, with diminution in the volume of the respiratory mur- mur and a little impairment of the percussion note may be fill that there is to indicate the lesion, and in no department of clinical medicine do finesse and accuracy tell so much as in the detection of an early lesion in phthisis. The slightest variations from the normal in expansion of the chest and in the results of auscultation and percussion should be carefully noted, and the sputum should be examined in every suspicious case. In certain cases the detection of bronchial breathing, with or without moist crepitations or occasional clicking rales, together with slight but definite dullness on percussion make the diagnosis easy w^hen combined with the history of the case and study of the temperature. In other cases, however, although they have suffered from cough and certain constitu- tional disturbances, the most careful examination by a com- petent physician may fail to reveal the presence of any phy- sical signs, and the diagnosis may be arrived at only after careful study of the history and temperature and examination of the sputum. In many cases the occurrence of a pleurisy, with or without effusion, is tlie first incident in the patient's illness, and the detection of a pleurisy in a young person should always arouse in the mind of the physician the sus- picion that it may be of tuberculous origin. Haemoptysis, severe or slight, may be the first circumstance which draws the patient's attention to the state of his health, and is, in the absence of any obvious lesion in the heart, nasopharynx or pharynx, very suggestive of early phthisis. A catarrhal con- dition of the lung which becomes limited and unilateral and does not clear up in a few weeks should make the physician careful to exclude the possibility of its being the result of an infection by the B. tulDerculosis. Most patients give a history of general deterioration in health, a cough which, although 174 CJiapter XII. perhaps not severe, will not yield to ordinary treatment, some loss of appetite and dyspepsia with more or less pallor and, tbe most common part of the story, distinct loss of weight, sometimes very marked. There is frequently a history of sweating at night, and some pain in the upper part of the chest. All young subjects who suffer from chronic dyspepsia, persistent slight auEemia, and rapid and unexplained loss of weight, should be most carefully examined for signs of tuber- culosis, and no examination is complete without the careful and repeated examination of the sputum for the bacillus of tubercle and a systematic observation of the temperature, especially after exercise in the afternoon. Many patients wdth no physical signs suggestive of phthisis but who suffer from one or more of the symptoms just described will be found to have a distinct, if slight, rise in temperature each afternoon or evening, and may have the bacilli of tubercle in their sputum in considerable numbers. One negative examination of sputum is not sufficient to exclude the possibility of phthisis, indeed even repeated negative examinations are not enough for the physician of experience. It is far better to treat on suspicion than to wait for absolutely definite evidence, especially as many cases who have been ailing for long with indefinite symptoms, having no definite signs in the chest and no bacilli in the sputum, may suddenly present all the signs of a rapidly advancing phthisis, and in such cases the end often comes with startling rapidity. In children, the sputum is difficult to obtain, and when they cannot be made to expec- torate, coughing should be induced by putting the finger deeply into the mouth, and the mucus adhering to it should be examined for bacilli on withdrawal. It is of the utmost importance, for purposes both of diagnosis and prognosis, that the history of a case suspected of phthisis pulmonalis should be carefully ascertained, A predisposition to phthisis is un- doubtedly hereditary, and while all hereditary predisposi- tions can be modified, and many can be eradicated, by environ- ment, it is a matter of common experience that a bad family history is a serious handicap to a patient with consumption, and a valuable aid to the diagnosis of latent pulmonary tuberculosis. Pulmonary Tuberculosis. 175 In examining the cliest of a patient suspected ol phthisis, the physician ought to remember that next to the upper hjbe the apex of the lower lobe is the most usual place for the physical signs of the disease to make their first appearance. The X-rays are a powerful aid in the diagnosis of I)m1- monary tuberculosis. The production of a general reaction by the use of tuber- culin has been recommended for diagnostic purposes in doubtful cases, and while many believe that the practice i& scarcely justifiable, I have never seen bad results follow on the use of the old tuberculin if it is given in doses of ttttttt c.c. as an initial doee. Calmette's reaction is advocated by some, but as in some cases a serious inflammation of the eye has been the result of the procedure, it is not to be strongly recommended. Yon Pirquet's skin reaction is frequently of service. Treatment. —The medical treatment of no disease has under- gone so much modification in the past twenty years as that of phthisis. The realisation that many cases of pulmonary consumption proceed to spontaneous cure has led to the general adoption of the " open air " and '' climatic " forms of treat- ment, which have for their object the improvement of the patient's general condition by "fresh air and good food," thus increasing his resistance to the disease, and which have raised so many hopes in the minds of consumptives. What the outlook of a patient suffering from pulmonary tuberculosis was in early Victorian days can be realised from the descrip- tion given in "Nicholas Nickleby." "There is a dread 'disease," writes Charles Dickens, "that so prepares its ' victim, as it were, for death ; which so refines it of its ' grosser aspect, and throws around familiar looks unearthly 'indications of the coming change; a dread disease, in ' which the struggle between soul and body is so gradual,. ' quiet, and solemn, and the result so sure, that day by day, ' and grain by grain, the mortal part wastes and withers ' away, so that the spirit grows light and sanguine with its '' lightening load, and, feeling immortality at hand, deems it ' but a new term of mortal life ; a disease in which death and ITG Chapter XII. *' life are so strangely blended, that death takes on the glow ■" and hue of life, and life the gaunt and grisly form of death ; ■" a disease which medicine never cured, wealth never warded ■"off, or poverty could boast exemption from; which some- ■*' times moves in giant strides, and sometimes at a tardy "sluggish pace, but, slow or quick, is ever sure and certain." These are the words of a layman and a man prone somewhat to dramatic exaggeration, but the substance of the passage is true in the main, and the attitude towards phthisis up till the last quarter of the nineteenth century was one of hopelessness, and every quack with a new nostrum was always sure of a clientele. Since then, however, the treatment by fresh air and reasonable feeding has changed the attitude of the patient and the physician alike, and the results obtained in sanatoria, lioth at home and abroad, seem to warrant a hopeful attitude towards the disease. The early days of sanatorium treatment -vrere rendered ridiculous by the inclusion among the therapeutic measures of an over-feeding so gross that those of strong stomach who could tolerate an overloading which was nothing short of disgusting grew fat and unwieldy, and, while they put on that weight which was supposed to be the great indica- tion of betterment, showed in eyerj other way that they had acquired little added powers of resistance and broke down in lare-e numbers when sent back to face life once more at home. No more ridiculous statement has ever been made in medical literature than that if a patient grows fat the disease may be considered as a negligible quantity. It is greatly to the credit of Huggard of Davos that he stood out against over- feeding and looked upon an increase of weight above the patient's normal as no favourable sign. At the present day over-feeding has largely slipped out of the treatment of phthisis and much more stress is laid on other things. Gradu- ated exercise as introduced by physicians in continental sana- toria and health resorts has been developed lately by Paterson of Frimley to a great degree of perfection and his results are most encouraging, indeed surprising. Excessive feeding has no place in his programme, and his patients receive just as much food as is necessary for the work which they are doing. The general principles which underlie the modern treatment of Pulmonary Tuberculosis. 177 pulmonary tuberculosis are these — the putting of a patient under as good hygienic conditions as possible as regards fresh air, food and cleanliness, and helping him to acquire an immunity against the B. tuberculosis, so that his tissues may be able to bring about that cure of the disease with cicatrisa- tion of the infected foci which, as the study of lungs j)ost mortem has shown us, takes place so frequently even under most unfavourable circumstances. Paterson's work has made it clear that, although the local lesions may not entirely dis- appear, it is possible to raise the immunity of the patient so much by exercise of a suitable kind that he may be able to do work without discomfort and without constitutional dis- turbance in spite of the existence of the local lesion, indicating that although the bacilli may be present in the lung, they have sunk to the level of mere saprophytes, so far as the pro- duction of symptoms is concerned. To have the patient in as clean an atmosphere as possible is one of the important parts of the treatment, and much wind, damp, and dull depressing weather are adverse climatic influences. It was because the high Alpine climates fulfilled these conditions, because their atmosphere was still and exhilarating and their hours of sun- shine more numerous than in any part of Great Britain, and because they were far removed from the contamination of manufacturing towns, that their reputation as health-resorts for consumptives stood so high. But their altitude is to many a great disadvantage, while the cold snow-atmosphere is unfavourable to those who suffer from bronchitis or laryngeal tubercle, and within the last ten years sanatoria have sprung up in many parts of the British Islands which have given results, perhaps not so good as those to be obtained in better climates, but sufficiently good to show that the modern treat- ment is far in advance of the old. In the great majority of cases the life of the patient is prolonged and rendered more comfortable, while his training in the knowledge of the infec- tivity of the disease and in the best methods of prophylaxis, has greatly reduced the danger of his presence in the com- munity. But the disadvantages of the ordinary sanatorium treatment soon became apparent. While a certain drag was put on the disease, while physical signs disappeared and patients N 178 Chapter XII. were able to return to their native places in better state than when they left, the habits of invalidism were strong in them, and they had for the most part acquired a timidity in resuming work, a timidity which was greatly justified by the breakdown of so many who tried to take up work again as usual. Something was wanting. Although the disease was arrested, the slightest overstepping of rules resulted in most cases in at least a partial recurrence of symptoms, and it became evident that the patient dismissed from the sanatorium as " cured " was still among the ranks of the unfit. After a struggle for a time against ill-health the break-down came again, and the patient had to retire from active life and live once more for his health. When he was a man of means, who could provide for his family and still live abroad or in favourable climates at home, his case was not so hard, but when he had no private means and depended entirely on his daily work for a living and for the means to support his family, his condition w^as not only a tragedy to himself and his immediate dependents, but a burden to the community in which he lived. Parish relief was necessary in some form or other both for himself and his family, and his use as a wage-earner was gone. It was evident that the immunity acquired by rest, fresh air, and gentle, more or less regulated, exercise was not enough, in the majority of cases, to allow a man to do full work and preserve his health. The work of Wright brought new light to bear on the subject of acquired immunity and has made it possible to use inoculation and auto-inoculation as most useful aids to the "open-air" treatment of pulmonary phthisis. Tuberculin rightly used, and exercise properly supervised and regulated, have brought new hope to those who had been bitterly dis- appointed by the results of treatment merely by "fresh air and good food." All patients suffering from phthisis should be put to bed at once, and careful observations made of their temperature. It is usual to find, even in early cases of the more chronic type, that the temperature is somewhat raised, the fever being of a remittent or an intermittent type with a morning reading of nearly normal or normal, and a rise in the afternoon to a; Pulmonary Tuberculosis. 179 register that is subfebrile or febrile. The temperiituic sfiould always be taken at 4, G and 8 p.m., so as to be certain tli;it lite evening rise is not being missed, if there is fever, the patient must be treated, as in enteric fever, by absolute rest and not permitted to do anything for liimself. Absolute rest ought to be maintained until the evening temperature has been normal for a few days, and the patient begins to feel better and stronger. At the end of that time he may be allowed to get up, at first only in the afternoons, and in a few days, if no febrile disturbance follows this move, he should go for a slow walk of, say, half-a-mile on the level. If he is fairly vigorous and has no fever within an hour after his walk, the walk should be extended after three or four days to a mile, and again to a mile and a half and again after some days to two miles, while into the extended walk should be introduced a mild incline to make the patient do actual work against gravity. The pace should be steady, slow and deliberate, and no hurrying should be allowed. If a severe reaction occurs, afj shown by a feeling of malaise and chill, with fever which does not disappear within an hour after exercise has ceased, abso- lute rest must again be enforced and only after all fever has disappeared should the patient be allowed to walk again. If no severe reaction occurs the next move is to make the patient walk carrying a small quantity of earth in a basket from one place to another and then empty it, going back with the empty basket for more earth, always taking care to be deliberate and slow in all movements. The amount of weight carried should be carefully increased until the patient can carry and empty out baskets filled with several pounds of earth for six or seven hours in the day. His next work ought to be trimming wood with an axe, followed by using a lawn mower. Cross-cut sawing may then be attempted, after which he should begin to shovel light earth, the size of the shovel being care- fully graduated to his capacity, and the final kind of work should be the use of the pick, taking care that, at least at the commencement of the work, his movements should be regular and not over-active. Such is a rough outline of Paterson's method of treatment as carried out by him at Frimley, and his results would seem to fully justify his faith in it. If the N 2 180 Chapter XII. patient has a severe reaction at any stage of the treatment, he is at once put back to absolute rest. After all fever has dis- appeared, he is brought back, after a couple of days out of bed without exercise, to a day or two's mild walking, and is then put straight on to the work at which he broke down. It will be seen at once that the principle involved in this method of treatment is one of auto-inoculation, and the object is to produce by work a reaction that is within the patient's powers of endurance. If a severe reaction occurs it shows that the auto-inoculation has been too great, and a period of rest must follow. When, however, the reaction has subsided, it is not necessary to work up slowly again to the point at which the severe reaction has occurred, but work may be resumed at the point up to which tolerance has been educated. One of the great advantages of this method of treatment is that the patient is receiving inoculation b}^ the toxins of his own bacilli, which is known to be an important point in successful vaccine-therapy, but the results which Paterson obtains at Frimley may possibly be obtained for the many who are unable to be treated there by a system of graduated exercise, even when there is no opportunity for the use of the axe, saw, shovel and pick, combined with the use of tuberculin. The great disadvantage of the human tuberculin at present avail- able seems to me to be that it is a vaccine obtained after the passage of the B. tuberculosis through an animal and not made from bacilli cultivated directly from human beings. Twort has shown that the bacillus of tubercle can be easily cultivated directly from the sputum, on suitable media, and if a vaccine were able to be made from the particular organism infecting each patient directly from their sputum, it is probable that vaccine-therapy in pulmonary tuberculosis might give much better results than at present. We do not know what altera- tion takes place in the virulence of the B. tuberculosis dur- ing its passage through an animal, but that some alteration does take place is extremely likely. Even at the present, however, the careful use of tuberculin has given good results in the hands of many physicians. It is usually injected hypodermically, but Latham has obtained encouraging results after its administration by the mouth. Pulmonary Tuberculosis. 181 Methods of u.nn^ in a different place. An energetic campaign ought to be directed against the bed-bug — the houses should be fumigated with burning sulphur or liquid S0„, beds should be thoroughly washed with a boiling solution of 1-20 carbolic acid or 1-1000 perchloride of mercury, and all clothing and blankets should be destroyed. Habits of personal and domestic cleanliness should be inculcated amongst the natives as far as possible. Q ^ FEVERS OF UNCERTAIN BACTERIOLOaY. Chapter XV. SCARLET FEVER. Synonyms : Scarlatina. Fr. : Scarlatine. Ger. : Scharlacli. Definition. — An acute specific infectious fever, cliarac- terisecl by sudden onset, a characteristic eruption, and a well- marked lesion in the throat. Incubation Period. — The incubation period of scarlet fever is short, varying between one and seven days. The usual in- cubation is 2-4 days. Rash. — When typically developed the rash of scarlet fever is easily recognised, but in none of the eruptive fevers does the rash present so many variations and modifications, both in character and distribution, as in scarlatina. The rash is essentially a punctiform erythema, consisting of small closely- set bright red points on a ground of paler red. It appears about twenty-four hours after the onset of symptoms, becom- ing visible first on the sides of the neck and upper part of the chest and spreading gradually over the whole body, involving the legs and feet last of all. While it is, in typical cases, very general in its distribution, the palms of the hands and soles of the feet do not show punctation, although they may be deeply flushed. The back and upper part of the chest are often so deeply flushed that the punctae cannot be readily dis- tinguished, while on the abdomen the punctse can often be seen as bright points on a skin that is, perhaps, only rather yellower than normal, or onh^ faintly flushed. On the forearm and front of the legs, the rash is seldom so Scarlet Feoer. 217 iiinfoi'iiily (listril)ute(l us elsewhere (jii llie body, iiiid lends to assume a patchy and rather indeterminate character, while ill these reg-ions, also, it is frequently quite definitely papular. This papular character is particularly evident on the front of the legs about the shins, and may help g-reatly in the diag- nosis of a case of scarlet fever when the patient has come under observation after the rash has begun to fade. Many people describe the face in scarlet fever as being merely flushed and not invaded by the rash, but in most cases with a well-developed rash it will be seen that the punctiform erythema does invade the face in the lateral aspect, spreading up a little from the angle of the jaw, and the forehead is also frequently invaded, although the malar region shows no IDunctce but is merely flushed. Pressure of the fingers over an area of skin invaded by the eruption temporarily blanches the part, but the marks left by the fingers are distinctly reddish yelloAV and not white like similar marks left after pressure over a flushed area in health. The rash also invades the soft palate, and, indeed, this may be the first situation where it is visible. In addition to the usual faucial and tonsillar congestion the punctate char- acter of the rash is sometimes very striking on the soft palate and may aid considerably in the early diagnosis of a case of scarlatina. Red staining, which does not disappear on pressure, is often visible along the lines formed by the natural folds of the skin, particularly in the neck and in the flexures of the elbow and knee. A miliary eruption frequently appears as a result of the hyperaemia of the skin, and numberless tiny vesicles are visible, particularly on the neck and chest, apparently over the site of the punctxe. These dry up and rupture, leaving small pin- point openings which may be the starting point of desquamation. The scarlatinal rash begins to fade, as a rule, about the fourth day, and has mostly disappeared at the end of a week. The eruption is, however, not always so typical. It may appear otx\j on the neck and chest, leaving the rest of the body free; it may present, in certain grave cases with severe early 218 Chapter XV. toxaemia, a dusky blotchy appearance with no regularity of distribution and with none of the punctate character met with in the typical eruption ; in some malignant cases it is altogether absent; in many mild cases it is represented by a faint blush, limited to the neck, back and chest, or of fairly general distribution, which may fade in a few hours leaving no apparent trace behind. In the mild cases, however, while the rash has been faint and evanescent, papules may persist in the region of the shins which may afford a certain help in diag- nosis. In a few cases the blotchy character of the rash which is so common on the legs is apparent also on the thighs, arms and back, and the case may be extremely difficult to distin- guisli from a rather aberrant type of measles. In certain severe toxic cases petechise appear, either alone representing the rash, or in association with a badly-developed and dusky punctiform erythema of quite irregular distribution. As the rash fades, or just as it has faded, desquamation of the cuticle occurs. This begins as a powdery desquamation on the face and lobes of the ears somewhere about the fourth or fifth day after the appearance of the rash. Then small " pinholes " appear on the neck, upper part of the chest and upper arm, usually from the seventh to the tenth day. The process spreads downwards over the trunk and arms and the hands begin to show desquamation about a fortnight after the onset of illness and the feet about a week later. As a general rule desquamation is complete, save on the palms and soles, about four weeks after the onset of the disease, and the palms are usually free at the end of the fifth week. The tough skin of the soles of the feet, however, has seldom com- pletely separated until the end of the sixth or eighth week, and may not desquamate completely until the tenth or twelfth week of the disease. Occasionally the skin separates in large sheets on the back and, still more rarely, may be shed from the feet and hands in the shape of complete casts of the ex- tremities, like gloves. After desquamation is complete, a secondary desquamation may occur, either general in distribu- tion, or more commonly confined to the hands and feet. The dates of desquamation given above are only rough averages. In many cases desquamation may be complete. Scarlet Fever. 219 save on the hands and feet, within a fortniglit, while in other cases, usually mild, desquamation may not appear anywhere until about the fourth or fifth week of tlie disease. It is sometimes so slight as to be practically imperceptible, and in many mild cases all that can be seen is a little powdery desquaimation at the anterior borders of the axilla), at the root of the neck and in the groins, and a little roughness of the shins with some powdery desquamation between the fingers and between the toes. As is the case with all the manifesta- tions of scarlet fever, desquamation may be so profuse and typical as to be impossible to miss, or, on the other hand, so slight mid atypical as to afford no belp in t})e diagnosis of the case, save only in conjunction with other signs and symptoms. Clinical Types. — It is usual, in describing the various types of scarlatina, to mention the ordinan^ ^^jpe? or scarlatina simplex; the malignant type; the type in which pyogenic manifestations in the throat constitute the chief feature of the attack or scarlatina anginosa; and the mild type. It must be remembered, however, that although many cases can be accurately classified under one or other of these headings, one meets cases which are on the border line of two classes, and one may have difficulty in labelling them as simple or anginous, as anginous or malignant, as simple or mild, but so long as it is understood that such classifications are used merely for convenience, and are not accurate, it is well to adhere to the accepted grouping of the various types. Scarlatina Simplex. — The onset is sudden and acute. The attack may be ushered in by headache, vomiting, rigor and sore throat occurring almost simultaneously; or sore throat, with a feeling of heaviness and slight general malaise, may precede the headache, vomiting and sensation of chill by some hours. A convulsion may take the place of rigor in young children. The sore-throat increases rapidly in severity, the tonsils enlarge, the mucous membrane of the nose and naso- pharynx may decome dry and turgid, so that the patient com- plains of a " swollen " sensation at the back of the nose and probably breathes by the mouth. The tongue becomes rapidly coated with a white fur, and exudate appears on the tonsils. 220 Chapter XV. There is pain and tenderness over the cervical glands, which in most cases can be felt to be slightly enlarged. Pain in swallowing is a common feature of the disease at this stage. Appetite is absent, but the patient feels very thirsty. In about twenty-four hours the rash develops. The appearance of the face is very characteristic. It is flushed save for a circumoral ring of comparative pallor. The e^-es are com- monly blood-shot, and the punctiform rash is visible on the temples and at the angles of the jaw. Although the eyes are bloodshot, there is none of the lachrymation and photophobia which are so common in measles. The temperature rises quickly to high registers from the commencement of the ill- ness, and the pulse is rapid, full and bounding, the pulse-rate being unusually rapid in proportion to the rise in tempera- ture. The patient may be delirious almost from the onset of the illness and is usually restless and uncomfortable, sleeping only for short periods at a time and complaining of pain in the throat, headache and general uneasiness. In about three days the headache disappears, the throat symp- toms abate, the tendency to delirium lessens, the fever shows larger remissions, and towards the end of the first week the temperature falls by rapid lysis, with a corresponding drop in the pulse-rate to normal. As the temperature falls, the swelling and acute congestion of the throat disappear, but a certain amount of undue redness of fauces and tonsils may persist for weeks. The tongue which is at first coated with a thick creamy fur presents, about the second or third day of fever, the typical " strawberry " appearance, due to the projection of swollen papillae through the fur. As the temperature falls the tongue grows clean, and, after the fur disappears, has a raw rough appearance, with enlarged papillae projecting from the surface. As desquamation pro- ceeds the tongue verj^ often has a smooth glazed look. In un- complicated cases of scarlatina simplex the patient's troubles are now mainly over and he has only to look forward to a somewhat lengthy convalescence regulated by precautions for his own safety and against his infecting others. Scarlatina Maligna presents a very different picture. In its fulminant type a patient may be suddenly seized with Scar I ft Fener. 221 headache, rigor, vomiting and high fever, becoming wildly delirious, and shortly afterwards comatose,