HX64115917 *C1 06 .M78 Text-book of the eru RECAP Wtm HH ■ Bj£ Columbia Wlxubtt&ity in tfce dtp of Jleto gorfe College of $&paitf an* anb burgeon* 3Br. (alter P. SJame* Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookoferuptiOOmoor Fit?. J Fia. V INTESTINAL LESIONS Fiy.3 TYPHOID FEVER.. TEXT-BOOK ERUPTIVE AND CONTINUED FEVERS. BY JOHN WILLIAM MOORE, B.A., M.D., M.CH., UNIV. DUBL.; FELLOW AND REGISTRAR OF THE EOYAL COLLEGE OF PHYSICIANS OF IRELAND; PHYSICIAN TO THE MEATH HOSPITAL, DUBLIN ; JOINT PROFESSOR OF PRACTICE OF MEDICINE IN THE SCHOOLS OF SURGERY OF THE ROYAL COLLEGE OF SURGEONS IN IRELAND ; CONSULTING PHYSICIAN TO CORK-STREET FEVER HOSPITAL, DUBLIN, AND TO THE WHITWORTH HOSPITAL, DRUMCONDRA ; EX-SCHOLAR AND DIPLOMATE IN STATE MEDICINE OF TRINITY COLLEGE, DUBLIN. WILLIAM WOOt) & COMPANY MEDICAL PUBLISHERS, NEW YORK. 1892. &0 t\t nfurea HUmorg of MY FATHER, WILLIAM DANIEL MOORE, M.D. Dubl. et Cantab., M.R.I.A., {April 19, 1813— October 28, 1871), I DEDICATE THIS BOOK. PBEFACE. It may be desirable to state very briefly the circumstances under which this work has come to see the light. To write a Text-book on Fever while the splendid mono- graph of Charles Murchison is our possession to all time may well be deemed presumptuous. But, on the threshold, I would disclaim any intention of allowing the present work — " hoc parvum opusculum " — to enter the lists with that unrivalled masterpiece. However, even since Dr. William Cay ley, in 1884, edited, with excellent good taste and literary skill, the posthumous edition of Murchison's Treatise, the study of the Continued Fevers has received a great impetus, and the necessity of a sound knowledge of Fever by every practitioner of medicine has been more and more recognised. As regards the Eruptive Fevers, we possess no work at all analogous to, or comparable with, that of Murchison on the Continued Fevers. It is true that a very full and accurate description of these diseases is to be found in the third edition of Hilton Fagge's and Pye-Smith's " Text-book of the Prin- ciples and Practice of Medicine," published in 1891, The standard works on Practice of Medicine also contain a number of chapters devoted to this subject; and I am aware that a Text-book upon the Eruptive Fevers by Dr. Alexander Collie has been published within the last few years. Notwithstanding all this,, I make bold to say that full justice has not up to the present been done to so important and fascinating a theme. While I cannot pretend to have adequately supplied an admitted want in medical literature-r- Ylll PREFACE. namely, a reliable and comprehensive Text-book of the Eruptive Fevers, yet I have endeavoured to focus in its pages the most recent views on the aetiology, bacteriology, symptoms, pathology, and treatment of this group of maladies. Of late years the Spirit of Scientific Discovery has been abroad. In the realms of both Curative and Preventive Medicine its presence has been felt, but in no direction more than in the fertile field of Bacteriology. The microbic origin of enteric fever, erysipelas, pneumonia, cholera, and diphtheria, has been practically demonstrated, and kindred investigations are still engaging the earnest attention of the foremost thinkers in this country, on the Continent, and in America. We are not yet in a position fairly or accurately to gauge the gain to Humanity and to Science which will accrue from such researches as those of Burdon-Sanderson and E. Klein, of Robert Koch, of Louis Pasteur and Toussaint, and of other toilers in the vast field of original investiga- tion, but they bear glowing testimony to the advance, by leaps and bounds, of Medical Science. They teach the lesson — so full of encouragement to the God-fearing and man- loving physician — that, in the not distant future, success will surely crown his noble effort to combat disease, to save life, and to stem the rising tide of human misery and despair. The study of Fever has always had a peculiar attraction for me. Perhaps this arose in part from the fortunate cir- cumstance that as a medical student I enjoyed the advantage of the philosophic teaching of William Stokes and was a daily witness of the lynx-eyed observation of Alfred Hudson in the wards of the Meath Hospital. These are names to conjure with from the bead-roll of authors upon Fever. But above and beyond this personal consideration, it has always seemed to me that each individual case of Fever pre- sented to the attending physician or to the clinical student an epitome of the Principles and Practice of Medicine. PREFACE. ix " Fever," said Fordyce, nearly a century ago, "is a disease which affects the whole system ; it affects the head, trunk, and extremities ; it affects the circulation, absorption, and the nervous system ; it affects the body, and it affects the mind ; it is therefore a disease of the whole system, in the fullest sense of the term." This being so, we surely are in a position to study diseases of the three great cavities of the body, diseases of the circulation, of the lymphatic, digestive, and nervous systems in an individual case of fever. If our object is — as it should be — to accurately gauge the state of our fever patient, we cannot attain this end by a mere super- ficial examination. On the contrary, every known method of physical examination must be applied, and this too as regards every system of the body in rotation. It would be equally disastrous to our fever patients were we, on the one hand, to treat a case which showed cerebral symptoms as if inflammation of the brain or its membranes was really present, were we, on the other hand, to act upon the unwarranted assumption that the kidneys in a given patient were sound and efficient. In a word, there is no other disease which demands on the part of the physician a closer and more intelligent observa- tion, a more minute and searching physical examination, a more subtle and refined train of reasoning, a more careful weighing of evidence for or against, and a more conscientious and painstaking management from start to finish. The Royal College of Physicians of Ireland — to their credit be it spoken — many years ago recognised the paramount importance of a close study of fever by all candidates for the License to Practise Medicine granted by the College. The President and Fellows required, and still require, that every candidate for that License shall produce evidence of having for not less than three months studied Fever in a recognised Clinical Hospital containing fever-wards, and of having re- X PREFACE. corded, from daily personal observation, the notes of at least five cases of fever to the satisfaction of the attending clinical physician, as attested by his signature. The University of Dublin requires of all candidates for the degree of Bachelor in Medicine or for the Diploma in Medi- cine a certificate of personal attendance on Fever Cases, with the names and dates of the cases attended. The Royal University of Ireland requires evidence of per- sonal attendance on at least ten fever cases during three con- secutive months in a Fever Hospital of repute, or in the fever wards of a General Hospital. The Irish Medical Licensing Bodies have thus nothing to be ashamed of in so important a matter. At their Summer Session in 1890, the General Medical Council, on June 5, adopted the following resolution : — "Resolved, — That no qualification in Medicine ought to be granted without evidence of clinical instruction in Infectious Diseases." This resolution was adopted in consequence of the receipt of a communication from the Local Authority for Glasgow under the Public Health (Scotland) Act. To this body belongs, therefore, the credit of initiating this important public recognition of the Clinical Study of Fever. It is, therefore, plain that in future a personal study of fever will be an indispensable part of medical education. This was one of the considerations which led me to write a book which, I hoped, might serve as a reliable guide to the student of fever. In the spring of 1891, the Trustees of the Queen Victoria Jubilee Nursing Institute asked me to deliver a course of lectures on Fevers and Fever-Nursing to the nurses and probationers who were working under the auspices of the Institute among the sick-poor of Dublin and its suburbs in their own homes. The notes which I compiled for that PUEFACE. XI course of lectures first suggested the idea of publishing a book on the Nature and Treatment of Fever. As to any special qualifications for my self-imposed task, I can lay claim to none, beyond the fact that for a period of thirteen years I was one of the Visiting Physicians to Cork- street Fever Hospital, Dublin. It may, perhaps, be objected that in writing this book I have leaned too much on the clinical experience and on the literary labours of others. No doubt the following pages bristle with the names of authorities ; but I have always endeavoured to test their statements by the touchstone of my own experience, nor have 1 hesitated to freely criticise any observations or opinions apparently unwarranted by certain facts, which appeared to me to be, perhaps, capable of a different interpretation. It may be necessary to observe that all the Temperature Charts in the nine Plates which illustrate this book are, with three exceptions — the two charts of the temperature ranges in relapsing fever and the chart which shows a crisis in enteric fever, and which I owe to the kindness of Dr. H. T. Bewley — reproduced from among many hundreds taken in my own cases at Cork-street Fever Hospital and at the Meath Hospital. The pleasant task remains of expressing my grateful acknowledgments to several friends who kindly helped me in my work. My cordial thanks are especially due to Dr. H. T. Bewley, Assistant Physician to the Adelaide Hospital, and Dr. Edward E. Lennon, Senior Clinical Assistant to the Meath Hospital, who undertook the labour of reading over the proof sheets as they issued from the press. To them, and also to Dr. James Little, Dr. T. W. Grimshaw, Regis- trar-General for Ireland, Dr. Walter G. Smith, and Dr. C. J. Nixon, I am deeply indebted for valuable suggestions and useful references. XU PREFACE. Nor should I omit to mention the trouble taken in search- ing out books and original papers by Mr. S. W. Wilson, the Librarian of the Royal College of Physicians of Ireland on the Foundation of Sir Patrick Dun. I desire also to acknowledge the courtesy of Dr. William Cayley, the editor of the third edition of Murchison's work on the " Continued Fevers," and of the eminent firm of publishers, Messrs. Longmans, Green, & Co., in permitting me to reproduce a series of very instructive Diagrams from that work. In conclusion, I can but express the hope that the following pages will prove useful to some of that devoted band who have already entered, or are about to enter, upon the practice of the noblest of all Professions — the Church not even ex- cepted. JOHN WILLIAM MOOEE. 40 FlTZWILLIAM-SQUABE, WEST, DUBLIN, Decemhr 21st, 1891. CONTENTS. PART I. -INTRODUCTION. CHAPTER I. The Intimate Nature of Fever. Page Meaning of the terms "Fever" and "Pyrexia." — Pyrexia, or "Feverish- ness," is either primary (idiopathic, specific, or essential Fever) or secondary (symptomatic, non-specific, or non-essential Fever). — Definitions of Fever. — Theory of Animal Heat. — The "Thermal Apparatus" (Maclagan). — The " Thermal Nervous System " (Donald Macalister). — The Neurotic and Metabolic Theories of Fever. — Cantani's views as to the nature and use of the Fever Process. — "Das Heil-Fieber." — The Pathology of the Infective or Specific Fevers. — The Essential Phenoraeua of Fever. — Why does the Fever Patient waste ? — Why is he thirsty ? — How may water be supplied to the Fever Patient 1 — The therapeutical uses of water 1 CHAPTER II. The Intimate Nature of Contagion. Communicable and Non-communicable Diseases. — The " Germ Theory of Disease." — Meanings of the term "Contagion." — Zymotic Diseases. — A typical example of Fermentation. — Nageli's Classification of the decomposition-pro- ducing Fungi : Moulds, Yeasts, Fission-fungi (including Bacteria).— Characters and sub-divisions of the Fission-fungi, or Schizomycetes. — Non-pathogenic l\Jicro-organisms or Microbes (Saprophytes). — Pathogenic Micro-organisms or Microbes (Parasites). — Division of the latter into — (1.) Non-infectious, but toxic, organisms ; (2.) Truly infectious organisms. — Toxins, or Ptomains. — Crookshank's Classification of Bacteria. — Aerobic and Non-aerobic Micro- organisms (Pasteur): their food and drink. — ISporulation : "Resting Spores." — Explanation of supposed spontaneous, or de novo, origin of Infectious Fevers. — Specific, infective microbe, virus, or contagium. — Seat of the Development of the several Contagia. — Inoculation. — "Contagious" and "Infectious" Diseases 12 XIV CONTENTS. CHAPTER III. Micro-parasitic Diseases. Page Substitution of this term for "Zymotic Diseases." — "Infective Diseases." — Liebermeister's Classification: 1, Miasmatic; 2, Miasmatic-Contagious; 3, Parasitic-Contagious (Infectious or Contagious). — Endemic, Epidemic, Sporadic, and Pandemic : definition of these terms. — Theories of Immunity. — Natural and Acquired Immunity. — Metschnikoff's theory of Phagocytosis. — Phago- cytes (Germ. " Fresszellen "). — " Micro-Strife " (A. Wynter Blyth). — Acquired Immunity. — Classification of Micro-parasitic Febrile Diseases : 1, The Eruptive Fevers or Exanthemata ; 2, The Contin ued Fevers ; 3, The Intermittent Fevers. — Cyclical course of the Specific or Essential Fevers: 1, Incubation; 2, Invasion ; 3, Eruption ; 4, Defervescence ;" 5, Desquamation ; 6, Convales- cence. — Quarantine. — Isolation. — -Influence of the Micro -parasitic Diseases on e; ch other --......-18 CHAPTER IV. The General Principles op Treatment op the Eruptive and Continued Fevers. part i. — preventive treatment, or prophylaxis. Preventable Diseases. — Preventive Treatment, or Prophylaxis. — Disinfec- tion : — Antiseptics, Disinfectants, Germicides, and Deodorants.— Dr. Shelly's Classification of Disinfectants. — Dr. Emerson Reynolds' General Plan of Disinfection. — Official Regulations for Disinfection adopted in Berlin. — Disinfection within the Living Body. — Receptivity. — Exciting and Predis- posing Causes of Disease. — Acquired and Natural, or Hereditary, Predisposition to Disease. — The chief Predisposing Causes of Febrile Disorders - - 30 CHAPTER V. The General Principles of Treatment of the Eruptive and Continued Fevers. part ii. — curative treatment. Principles of Treatment of Fevers— 1. To neutralise the Fever Poison: sanitary surroundings, mineral acids, antiseptics. — 2. To promote elimination : fresh air, diluents, diuretics, diaphoretics, aperients or laxatives, beneficial effects of common salt (chloride of sodium). — 3. To reduce temperature : hygienic measures — bloodletting (general or local), saline cathartics, diaphoretics, antipyretics (Cantani's Views on Antipyresis) ; cold water treatment— tepid sponging, the wet-pack, the application of ice-cold compresses, the cold bath, the ice-cradle (Fenwick). — 4. To maintain nutrition: food to be both nutri- tious and digestible, peptonised food, times for feeding the fever patient, feeding through the nares or by the rectum ; administration of alcoholic stimulants— indications for their use, signs of their agreeing with the patient, avoidance of exhaustion. — 5. To relieve distressing symptoms : headache, sleeplessness, nervous excitement, delirium, stupor, convulsions, hyperesthesia, rheumatoid and neuralgic pains, thirst, persistent vomiting, tymp-inites or meteorism, hiccough, diarrhoea, intestinal haemorrhage. — 6. To obviate and COUNTERACT LOCAL COMPLICATIONS AND SEQUELS - - - - 48 CONTENTS. XV PART II.— THE EXANTHEMATA, OR ERUPTIVE FEVERS. CHAPTER VI. General Considerations. Page Cullen's classification of Diseases. — Four Orders of Pyrexiae. — Definition of the Exanthemata. — Meaning of the term ££d.v6wf*a.. — Enumeration of the common acute Micro-parasitic Diseases which are called "Eruptive Fevers." — Smallpox, the " paradigm " or type ...... gy CHAPTER VII. Variola, or Smallpox. Nomenclature. — Definition. — Etiology (historical sketch). — Exciting cause : contagion. — Predisposing causes : susceptibility, from non-protection, season, race. — Bacteriology of Smallpox. — Modes of dispersion of th^ morbid poison. — " Striking Distance " of the disease. — Chief Stages of Infectiveness. — Clinical History : Incubation, Invasion, Eruption (its five stages of development : Specks of Hypersemia, Papules or Pimples, Vesicles, Pustules, Scabs or Crusts), Desiccation, Desquamation. — Variolous Exanthem upon the Mucous Mem- branes, but not upon the Serous Membranes ----- 69 CHAPTER VIII. Smallpox (continued). CLASSIFICATION AND VARIETIES. Classification of Smallpox based upon the distribution and amount of the Rash : Variola discrbta, confluens, coh^erens, cortmbosa. — Symptoms of Confluent Smallpox : its mortality and sequelae. — Meaning of the terms " Semi- confluent "or "Coherent," and "Corymbose," Smallpox. — The latter said to be a very fatal variety - - - - - - - -82 CHAPTER IX. Smallpox (continued). TEMPERATURE. — VARIETIES. — COMPLICATIONS.— PATHOLOGY. — DIAGNOSIS. — PROGNOSIS Temperature : Two distinct Types of Fever in Smallpox— viz. 1. A brief continuous Fever ; 2. A relapsing Fever. — Prodromal or Initial Fever. — Secondary Fever, or Fever of Suppuration or of Maturation. — Hyperpyrexial Temperature in Fatal Cases. — Varieties of Smallpox : Discrete, Confluent, Benign or Varioloid — 1. Variola sine Exanthemate, 2. V. cornea (Hornpox), 3. V. verrucosa (Wartpox) ; Malignant (V. maligna) — 1. Purpuric, 2. Haemor- rhagic (Purpura variolosa), 3. V. hemorrhagica pustulosa of Curschmann, V. nigra? of Sydenham, V. cruentse.— Table of the varieties of Smallpox. Complications and Sequels, affecting the skin, eyes, ears, nose, tongue, larynx, respiratory organs, digestive organs, circulatory system, kidneys, nervous system, genitals, blood, joints. — Pathology : Morbid anatomy and histology. — Diagnosis, Prognosis, and Mortality - - - 87 XVI CONTENTS. CHAPTER X. The Preventive Treatment of Smallpox. Page Smallpox communicable ; but one attack confers immunity from a second. — Preventive Measures : 1. Isolation ; 2. Inoculation ; 3. Vaccination. — Inoculation illegal. — History of Inoculation. — Clavelisation. — History of Vaccination. — Value of Vaccination in controlling prevalence and mortality of Smallpox. — Marson's views as to the use of Multiple Vaccinal Cicatrices. — Periodical Revaccination. — Circumstances which conduce to success of Vaccination.— Jenner's "Golden Rule." — Bovine and Humanised Lymph. — Performance of Vaccination. — Bryce's Test. — Vaccina : its local and consti- tutional symptons.— Vaccino-stphilis. ..... 102 CHAPTER XI. The Cdrative Treatment of Smallpox. No specific for Smallpox — two great Principles of Treatment : (1) to guide the essential disorder, (2) to combat secondary affections. — "Hot Regi- men " treatment of olden times. — Thomas Sydenham's "Cooling Regimen." — Treatment of Discrete, Confluent, and Hsemorrhagic Smallpox. —Two dangers in Confluent Smallpox : general blood-poisoning, and exhaustion. — Antiseptic Treatment. — Prevention of "Pitting." — Dr. Stokes's views. — Three Indica- tions for Treatment : (1) to exclude air, (2) to keep the surface in a perma- nently moist state, (3) to lessen the local irritation. — Hebra's Treatment by the Warm Bath. — Dr. Stokes's account of this method. — Hebra's apparatus for the Continual Bath. — Treatment of Affections of the Skin in Smallpox, and of the various Local Affections. — Turpentine and Ergot in Haemorrhage. — Trans- fusion of Blood. --------- 113 CHAPTER XII. Varicella, or Chickenpox. Nomenclature. — Derivation of the term " Chickenpox." — Definition. — ^Etiology (historical sketch). — Clinical History : Incubation, Invasion, Erup- tion, Desiccation. — No secondary Fever. — Not a fatal Disease. — Complications and Sequela? : Varicella gangraenosa (Jonathan Hutchinson). — Dermatitis gaagraenosa — " Varicella-prurigo " (J. Hutchinson). — Diagnosis from Lichen, Herpes, Pemphigus, and Varioloid. — Prognosis and Treatment. - - 125 CHAPTER XIII. Morbilli, or Measles. Nomenclature. — Definition. — ^Etiology. — Bacteriology. — Chief Stages of Infectiveness. — Epidemics in Faroe Islands and in Fiji. — Seasonal Preva- lence : Measles a disease of Spring and Autumn. — Clinical History : Incubation, Invasion, Eruption, Desquamation. — Furfuraceous Desquama- tion. — Convalescence complete on the Eighteenth Day. - - 133 CONTENTS; xvii CHAPTER XIV. Measles (continued). CLASSIFICATION. — COMPLICATIONS. — TEMPERATURE. — PATHOLOGY. — DIAGNOSIS. — PROGNOSIS. I J age Classification of Measles: Niemeyer's.— Benign and Malignant. — Benign : Morbilli sine catarrho ; Morbilli sine morbillis. Malignant : Purpuric Measles ; Asthenic or Adynamic Measles ; Complicated Measles. — Causes of Complications (Hebra). —Complications of the staee of invasion : Convulsions, spasmodic catarrhal laryngitis (false-croup), suffocative catarrh, epistaxis, otitis, diarrhoea, colitis ; of the stage of eruption : morbillous diarrhoea, capillary bronchitis, pneumonia, diphtheria (true-croup) ; of the stage of desquamation : glandular enlargements, otitis, cancrum oris (noma), gangrene of the vulva, acute desquamative nephritis, acute miliary tuberculosis, herpes, eczema, etc., pleuritis, chronic ophthalmia, atrophic keratitis. — Temper \ture in measles. — Pathology. — Diagnosis : from epidemic rose-rash, scarlatina, smallpox (Grisolle sign), varicella, simple rose-rashes, typhus. — Prognosis - - 142 CHAPTER XV. The Treatment of Measles. Prophylaxis : quarantine, isolation, hygienic measures. — Curative Treat- ment : no specific for measles — treatment is symptomatic and hygienic. Treatment of Complications : Malignant Measles — cool baths (Dieulafoy). — Initial convulsions, false and true croup, epistaxis, otitis, diarrhoea, ophthalmia, glandular enlargements, noma, gangrene of the vulva, acute tuberculosis - 150 CHAPTER XVI. Scarlatina, or Scarl£t Fever. Nomenclature. —Definition. — ./Etiology (historical sketch). — Area of Diffu- sion. — Epidemic and sporadic outbreaks — Rate of Mortality most variable. — Predisposing Causes : Climatic influences ; season. — Exciting Cause : Spe- cific poison — "Contagium Vivum." — Professor Klein's Researches: Streptococcus scarlatinas. — Hendon Cow Diseasf. — Clinical History : Scarlatina simplex, anginosa, and maligna. — Varieties of Scarlatina simplex. — Stages of Incuba- tion, Invasion, Eruption, Desquamation. — Prominent Symptoms : Vomiting, sore-throat, tache scarlatinale, "strawberry-tongue," albuminuria - . 154 CHAPTER XVII. Scarlatina (continued). aberrant forms. — complications and sequels. — temperature. Irregular or aberrant forms of scarlatina : (1.) Rudimentary or abor- tive : (a.) simple scarlatinal angina (scarlatina faucium), (/3.) latent scarlatina (scarlatiue fruste) ; (2.) Scarlatina anginosa — diffuse cellulitis of neck (" tippet- b CONTENTS. neck"), diphtheria ; (3.) Scarlatina maligna : (a.) Angina maligna, (13.) ataxic scarlatina, (7.) hsemorrhagic scarlatina — "Scharlachtyphus." — Complications and Sequelae : Diphtheria, acute rheumatic arthritis and serous inflammations, acute desquamative nephritis, pleuritis, bubonic swellings, pyaemia, boils and abscesses, otitis, eye affections, eczema, chorea. — Temperature ranges in Scarlatina ......... \qq CHAPTER XVIIL Scarlatina (continued). Pathology, Diagnosis, and Prognosis. Pathology of Scarlatina : The blood — the cutaneous affection — the throat and sub-maxillary glands. — Cerebro-spinal system. — The abdomen — small intestine — psorenterie — kidneys . — G-lomerulo-tubal Nephritis (Klebs). — E. Klein's views. — Diphtheritic Pyelitis. — Changes in the urine. — Dropsy. — Inflammations of (a.) serous membranes, (/3.) of synovial membranes of the j lints. — The heart — acute parenchymatous myocarditis — cardiac failure. — Diagnosis : Erythema, Smallpox, Measles, Rotheln, Erysipelas, Diphtheria, Acute Rheumatism. — Prognosis and Mortality. — Causes of Death - - 173 CHAPTER XIX. The Treatment of Scarlatina. Prophylaxis not so difficult of attainment as in the case of Measles. — Sug- gested prophylaxis by drugs not reliable. — Effectual prophylaxis consists in Isolation. — Curative Treatment : no antidote yet discovered.— Biniodide of Mercury (Illingworth). — Treatment must be largely symptomatic. — Treatment of Scarlatina simplex : expectant. —Hebra's recommendations. — Guaiacum and Ozonic Ether Test for Blood-pigment in Urine. — Treatment of Scarla- tina anginosa : cold water treatment, quinine, ice, cold compresses to neck, drugs. — Treatment of Scarlatina maligna: combat ataxic symptoms ; in haemorrhage, use local and general astringents. — Treatment of Complications and Sequelae : Diphtheria, rheumatism, acute desquamative nephritis, ursemic convulsions, pleuritis, endocarditis, bubonic swellings, diffui-e cellulitis, pyaemia, acute furuncular diathesis, diseases of the ear, conjunctivitis, keratitis, acute eczema, chorea - - . - - - - - - - l!-2 CHAPTER XX. Rotheln, or Epidemic Rose Rash. Nomenclature. — Definition. — ^Etiology (historical sketch). — Clinical His- tory : Incubation, invasion, eruption, desquamation. — Temperature. — Com- plications and Sequelae. — Pathology. — Diagnosis. — Claims of Rotheln to be considered a distinct disease. — Prognosis : entirely favourable. — Treatment - 193 CONTENTS. XIX CHAPTER xxr. Erysipelas. Page r Nomenclature. — Definition. — iEtiology. — Erysipelas both a local and a specific disease. — Medical or Idiopathic and Surgical or Traumatic Erysi- pelas. — Predisposing Causes : traumatism, a previous attack, sex, age, climate, season. — Exciting Causes : contagion, inoculation. Doctrine of the Contagiousness of Erysipelas is now proved. — Bacteriology : Streptococcus Eryxipelatis (Fehleisen) -------- 202 CHAPTER XXII. Erysipelas {continued). clinical history — temperature — diagnosis — Prognosis and mortality. Clinical History. — Varieties of Erysipelas according to depth of surface affected : (1.) Simple or cutaneous ; (2.) Phlegmonous, or cellulo-cutaneous ; (?.) Diffuse cellulitis. — Stages of incubation, invasion, eruption, defervescence. Erysipelas faucium, pulmonurn. — Temperature. — Diagnosis. — Prognosis and Mortality ......... 21(1 CHAPTER XXIII. Treatment of Erysipelas. Expectant Treatment. — Constitutional (or General) and Topical Treat- ment. — Constitutional Treatment : tincture of the perohloride of iron, quinine, ammonia and bark in effervescence, salicylate of sodium (Hallopeau), cold baths, alcoholic stimulants, effervescing draughts in gastro-intestinal dis- turbance, opium or morphin in threatening delirium. — Topical, or Local Treatment : indications — (1.) to relieve pain and tension; (2.) to check the spread of inflammation ; (3.) to destroy the infectious matter in situ. — Leeches are contra-indicated. — "Ectrotic" method. — Topical use of nitrate of silver. — Rectified oil of turpentine. — Sulpho-carbolate of sodium. — Sprays. — Special treatment of oedema of the eyelids, sore tbroat, laryngitis, and cedema of the glottis, tension of the skin, gangrene ...... 221 PAET III.— THE CONTINUED FEVERS. CHAPTER XXIV. General Considerations. Classification into Exanthemata, Continued Fevers, and Intermittent Fevers is non-essential but convenient. — Claims of Typhus and Typhoid or Enteric Fevers to be classed as Exanthemata. Three reasons why they are not so-classed. — Cullen's definition of the Continued Fevers. — Murchison's classification of these Fevers. Objections advanced to certain of his statements 229 XX CONTENTS. CHAPTER XXV. Febricula, or Simple Fever. Page Nomenclature. — Definition. — ^Etiology and History. — Probably of specific origin, like the otherfevers — probably auto-infective — Clinical History : Four Forms — 1. Ephemera ; 2. Synocha, or Acute Inflammatory Fever ; 3. Ardent Continued Fever of the Tropics ; 4. Asthenic Simple Fever. — Diagnosis. — Prognosis. — Pathology. — Treatment. ------ 233 CHAPTER XXVI. Typhus Fever. Nomenclature — Literature — Definition — Geographical Distribution — ^Etiology — Exciting and Predisposing Causes — Facts known relative to the Specific Poison of Tophus: 1. Modes of infection; 2. Its striking distance not great ; 3. Poison readily absorbed by " fomites ; " 4. Period of infec- tiousness : Convalescence ; 5. ftlon-inoculable ; 6. One attack confers immunity ; 7. Of light specific gravity ; 8. De>troyed by dry heat ; 9. Typhus not an epizootic — Murchison's doctrine of the spontaneous generation of typhus — Proofs of its infectiousness — Arguments for and against its spontaneous origin — Predisposing Causes : Sex, Age, Season, Temperature and Moisture in the Atmosphere, Occupation, Idiosyncracy, Intemperance, Bodily Fatigue, Mental Fatigue and Depressing Emotions, Previous Illness, Recent Residence in an infected district, Overcrowding and Defective Ventilation, Destitution and Deficient Alimentation — Conclusions ... - - 239 CHAPTER XXVII. Clinical Description of Typhus Fever. Stages of Typhus: (1.) Incubation — about twelve days, or less. (2.) Inva- sion— earliest symptoms referable to the Nervous System. (3.) Nervous Excite- ment (Earlier Eruptive Stage). Objective Symptoms: typhus rash, maculae, subcuticular mottling, "Mulberry Rash" (Jenner). Delirium: ferox, tremens, typhomania (Galen). (4.) Nervous Prostration (Later Eruptive Stage) — characterised by ataxia and adynamia. Petechia? — the " Typhoid State " — its symptoms. (5.) Defervescence or Crisis. Modes of Crisis : sleep, slight diarrhoea, diuresis, perspiration. (6.) Convalescence. — Duration of Typhun. — Blasting Typhus, or T. siderans. — Typhus levissimus. — Relapses. — Temperature in Typhus. — Hyperpyrexia ------- 2.15 CHAPTER XXVIIL Analysis of the Chief Symptoms of Typhus. The Surface : Fades typhosa. — Skin : maculae or petechia?, sudamina, herpes, poisonous odour, which is most infectious ; branny desquamation, atrophy of nails, laches bleudtres, purpura spots, vibices, profuse sweating — an ominous form of crisis. — Circulatory System : Pulse, vital condition of the Heart — Dr. Stokes's views — Question of stimulants.— Respiratory System: Rate of breathing — varieties of respiration — Hypostatic congestion — Breathing CONTENTS. Page offensive.— Djgkstive System: Anorexia, boulimia in convalescence — Condi- tion of the tongue — " Parrot Tongue " — Sordes. —Diarrhoea. — Urinary System : Characters of the urine. — Nervous System : Headache, delirium, mental state, wakefulness, " coma-vigil " (Chomel), " coma-vigil " (Jenner), loss of muscular strength, decubitus, muscular paralysis, agitation, rigidity, general convulsions. — Lesions of Organs op Special Sense : The eye, ear, nose, taste, sensibility of the skin. ------- 271 CHAPTER XXIX. Complications and Sequels of Typhds. Causes of Complications in Typhus. Complications affecting (1) the Res- piratory Organs : Bronchitis, pneumonia, gangrene of the lung, pleurisy, tuberculosis, haemoptysis, laryngitis. (2) The Blood and Circulation : Acute haemophilia, pysemia, venous thrombosis, phlegmasia dolens, arterial thrombosis and embolism, heart diseases. (3). The Nervous System : Meningitis, mental disease, paralysis, neuralgic and rheumatoid pains. (4). The Organs of Digestion : Erysipelas of the pharynx, haetnatemesis, diarrhoea, dysentery, intestinal haemorrhage, jaundice, peritonitis. (5). The Urinary Organs : Nephritis, vesical catarrh, haematuria. (6). Diseases of the Integuments and Bones : GSdema, bed sores, gangrene, noma or cancrum oris, " hospital gan- grene," buboes. (7). Other Specific Diseases : variola, scarlet fever, diph- theria, erysipelas, typhoid fever ------- 284 CHAPTER XXX. Typhus — {continued). Varieties of Typhus : Inflammatory, nervous or ataxic, adynamic, ataxo- adynamic or congestive, Typhus siderans, Typhus levissimus, abortive, catarrhal. Diagnosis: from relapsing fever, enteric fever, "jungle fever," purpura, measles, meningitis, delirium tremens, asthenic or "typhoid" pneumonia, uraemia — Prognosis and Mortality : Bad signs in typhus ; death-rate influ- enced by age, sex, condition of life and habits, season, pregnancy, fatigue, priva- tion, late treatment — Pathological Lesions: (1) General; (2) Special, affecting the integumentary, respiratory, circulatory, nervous and digestive systems of the body — Pathology of the " Typhoid State " . . . 293 CHAPTER XXXI. The Treatment of Typhus. Prophylactic and Curative Treatment (or " Management ''). Preven- tive Measures : Personal cleanliness, good food and air-space, ventilation. Management : hygienic measures adopted at Cork-street Fever Hospital, Dublin. Nursing. Medicinal treatment must be purely symptomatic. Water Treatment. Quinine. Alcoholic Stimulants. Food. — Treatment of Compli- cations and Sequels : Pulmonary congestion, bronchitis, paresis, incontinence of urine, convulsions, bedsores, phlegmasia and thrombosis, cedema. Con- valescence : costive bowels. Tonics. Change of Air ... 305 XX11 CONTENTS. CHAPTER XXXII. Relapsing, Famine, or Spirillum Fever. Page Nomenclature— Definition — iEtiology (historical sketch) — Mode of Preva- lence—Predisposing Causes — Geographical Distribution — Exciting Cause — Bacteriology — Spirillum Obermeieri — Inoculation Experiments — One Attack of Relapsing Fever confers no immunity against a second - - .313 CHAPTER XXXIII. Clinical Description of Relapsing Fever. Sudden onset. — High Temperature Abrupt crisis. Intermission. — Re- lapse. — Low mortality. — " Bilious Typhoid " (Griesinger). — " Yellow Fever of the British Islands" (Graves').— Heart murmurs. — Stages and duration. — Temperature. — Complications and Sequelae - 321 CHAPTER XXXIV. The Diagnosis, Prognosis, Pathology and Treatment op Relapsing Fever. Diagnosis from : Typhus, enteric fever, simple continued fever, remittent fever (''jungle fever "), yellow fever. ^Presence of the spiroehsete in the blood is pathognomonic. — Prognosis and Mortality : Unfavourable symptoms. Pathological Anatomy. — Treatment : no specific for Relapsing Fever. Hygienic and Expectant Treatment. — Nitre. — Treatment of symptoms and complications. — " Bilious Typhoid " (Griesinger.) — Convalescence - - 328 CHAPTER XXXV. Enteric, or Typhoid, Fever. General Considerations. — Essential difference between typhus and enteric fevers not recognised in the past — reasons for this. — Evils of not differentiating between typhus and enteric fevers. — Fundamental distinctions. — Liebermeister's views - ... . . . . . . . 335 CHAPTER XXXVI. Enteric Fever (continued). Nomenclature. — Synonyms. — Definition. — Literature and History. — Geographical Distribution. — ^Etiology : Predisposing causes : sex, age, defec- tive sewerage and drainage, season, temperature and moisture, soil and under- ground water. — Immunity. — Exciting cause. — Bacteriology : Bacillus typho- sus (Eberth). — Supposed spontaneous origin of enteric fever. — This doctrine is now untenable. — Resting spores. — Paths of Infection : currents of air, (Irinking water, milk, meat. —Mode of invasion .... 339 CONTENTS. XXIII CHAPTER XXXVI L Clinical Description of Enteric Fever. Pago Stage of Incubation or Latent Period— Stage of Invasion — Stage of Glandular Enlargement — Ulceration and Sloughing — Amphibolic Stage — Stage of Lysis — Convalescence— Duration of the Fever - - 363 CHAPTER XXXVIII. Analysis of the Symptoms of Enteric Fever. The Physiognomy of Enteric Fever. — The Surface : lenticular rose-spots, taches bleudtres, purpura spots, vibices, sudamina, accidental or adventitious rashes. — Desquamation. — The Circulation. — The Respiratory System. — The Digestive System : nausea, vomiting, meteorism or tympanites, gargouillement, constipation, diarrhoea, intestinal haemorrhage. — Spleen. — The Urinary System. — The Nervous System : Liebermeister's four grades of nervous dis- turbance. — Angel Money's observations on muscular irritability. — Organs of Special Sense : the eye, ear, nose, cutaneous sensibility. — Emaciation - 369 CHAPTER XXXIX. Relapse in Enteric Fever. Relapse is a rare occurrence — Definition of True Relapse — Relapses not to be confounded wich Recrudescences — Clinical Kecord of a case of Relapse — Statistics of Occurrence of Relapse — Relapse not so dangerous as the first attack — ^Etiology of Relapse — Probable influence of : (1.) Constipation ; (2.) Enlargement of the Spleen ..--.-- 384 CHAPTER XL. Enteric Fever (continued'). temperature— complications and sequels. Temperature important in diagnosis and prognosis. — Initial or Prodromal Stage : remittent type. — Fastigium : continuous type. — Amphibolic Stage. — Defervescence: remittent type with "spiking." — Test of complete recovery. — Remittent type of pyrexia in young children. — Moderate pyrexia in old patients. — Apyrexial or Afebrile Enteric Fever. Complications and Sequelae : of respiratory tract, the circulation, the nervous system, organs of special sense, digestive tract, the urinary organs, female organs of generation, tissues, integu- ments, and bones ; marasmus, sudden death. — Coexistence of other specific diseases „•-- ....... 392 CHAPTER XLI. Varieties of Enteric Fever. " Typho-malarial Fever." — Varieties of Enteric Fever : Abortive form (fievre muqaeuse), latent form (Typhus ambulator ius), "gastric," or "bilious fever," spleno-typhoid, acute or inflammatory form, infantile remittent fever (" worm fever," or "gastric fever"), senile enteric fever, afebrile or apyrexial form - - --• -■-.- - - - 405 XXIV CONTENTS. CHAPTER XLIT. , Enteric Fever (continued). Diagnosis— Prognosis and Mortality — Pathology. Page No single symptom pathognomonic of Enteric Fever.— Diagnosis depends on aetiology, course of the disease, and particularly the temperature. — Ehrlich's Test. Diseases apt to be confounded with Enteric Fever : Typhus, relapsing fever, remittent fever, scarlatina, smallpox, pyaemia and puerperal fever, gastro-intestinal form of influenza, tuberculosis, trichuriasis, ulcerative endocarditis, acute rheumatism, &c. Prognosis and Mortality : Influence of age, sex, season, station in life, recent residence in an infected locality, intensity of the poison, family constitution, personal constitution and habits, previous diseases.— Modes of Death: Coma, syncope, asthenia or anaemia, hyperpyrexia (rarely) — Fatal Complications. — Pathological Anatomy : Specific Lesions. — Non-Specific Lesions : affecting muscles, heart, liver, kidneys, nerve-cells, salivary glands, pancreas, larynx ... 408 CHAPTER XLIII. Intestinal and Splenic Lesions of Enteric Fever. Specific Lesions of the small intestine, mesenteric glands, spleen. — The stomach, duodenum, and jejunum usually healthy or seat of non-specific lesions. — Neighbourhood of Ileo-caecal valve, the chief seat of disease in both ileum and ceecum. — "Enterica sine enterilide."—" Infective Granuloma" (Hilton Fagge). — The Intestinal Lesion : its four stages — (1.) enlargement and infiltration ; (2.) softening and ulceration; (3.) "typhoid ulcer;" (4.) cicatrisation. — Plaques dures et molles (Louis). — Plaques reticulees et gaufries (Chomel). — Characters of the "Typhoid ulcer." — "Atonic ulcers." — "Shaven-beard" appearance (I'etat pointille). — Perforation of the peritoneum. — Lesions of the Mesenteric Glands. — Lesions of the Spleen : Putrilage, abscess - 419 CHAPTER XLIV. The Prophylaxis of Enteric Fever. Measures to be adopted for Checking the Development of the Fever Poison : Efficient drainage system. —Improved water-closets. — Drinking water to be taken direct from the main. — Use of chemical disinfectants. — Measures for Preventing the Propagation of the Fever Poison : Disinfection of excreta. — Treatment of bedding and body linen. — Ventilation of sick room. — Trace origin of first case of fever in each outbreak .... 430 CHAPTER XLV. Curative Treatment of Enteric Fever. No Specific for Enteric Fever. — Principles of Treatment apply equally to this fever and to typhus. Curative Treatment or Management : Hygiene, Diet, Stimulants, Antiseptic Drugs: — Iodide of Potassium, calomel, arsenic, antimony, /3-naphthol, salicylate of bismuth, salicylate of magnesium, carbolic acid, the sulphites, turpentine, free chlorine, quinine, oil of eucalyptus, camphor, creasote, thymol, napbthalin, salol - - - - - - 435 CONTENTS. XXV CHAPTER XLVI. Curative Treatment of Enteric Fever (continued). Pago Antipyretic Treatment : (1). The Water-treatment (hydrotherapy, or balneotherapy), cold, cool, and warm baths; immersion treatment (Dr. James Barr) — Description of Apparatus. — (2). Reduction of Temperature by means of the Ambient Air (de Souza). — (3). Antipyretic Drugs : Quinine, salicin, .salicylic acid, the salicylates, salol, phenazone, acetanilid, kairin, thallin, digi talis, veratria, resorcin or thymic acid with acetanilid. — Hilton Fagge's Placebo -.---.-.„. 450 CHAPTER XLVII. Curative Treatment of Enterio Fever (continued). treatment of certain complications and sequels. Strong Decoction of Coffee and Caffe'in in Ataxia and Adynamia. — Inhalation of Oxygen in Broncho-pneumonia. — Prevention of Bedsores. — Treatment of Epistaxis. — Treatment of Intestinal Symptoms, Complica- tions and Sequelae : Constipation, diarrhoea, tympanites or meteorism, vomiting, abdominal pain, haemorrhage from the bowels, peritonitis, perforation, medical and surgical measures - - - - - - -461 CHAPTER XLVIII. The Curative Treatment of Enteric Fever (concluded). management in convalescence. Unwonted exertion, exposure to cold, indiscretion in diet are all to be avoided. — Treatment of ; Constipation, atonic diarrhoea. — Reduce stimulants day by day. — Solid Food : anecdote narrated by Dr. Stokes. — Rules for gi vino- Solid Food : Fish, boiled or broiled — not fried. — Dietaries recommended by Hilton Fagge, Murchison, von Ziemssen, Niemeyer, F. Woodbury, Hutchinson, Lauder Brunton. — Medicines in Convalescence. — Change of Air. — Pro- longed Rest ------... 475 CHAPTER XLIX. Infection and Immunity. Klemperer and Klemperer's researches on Infection and Immunity. — Case of acute fibrinous pneumonia. — Pneumotoxins and anti-pneumotoxins. — Dr. A. C. Abbott's conclusions ....... 432 PART I. INTRODUCTION ERRATA. Page 25 — Line 7 from bottom, for "fastidium " read "fastigium." Page 42 — Line 4 from top, for "minute " read "second." Page 202 — Line 7 from top, for " not" read "now." Pages 320 and 324 — For " Moschutkovsky " read " Motschutkovsky. Page 326— Line 4 from top, for "Plate VI." read "Plate VII." TEXT-BOOK EEUPTIVE AND CONTINUED FEVERS. PART I.— INTRODUCTION. CHAPTER I. The Intimate Nature of Fever. Meaning of the terras "Fever" and "Pyrexia." — Pyrexia, or " Feverish - ness," is either primary (idiopathic, specific, or essential Fever) or secondary (symptomatic, non-specific, or non-essential Fever). — Definitions of Fever. — Theory of Animal Heat. — The "Thermal Apparatus" (Maclagan). — The " Thermal Nervous System " (Donald Macalister). — The Neurotic and Metabolic Theories of Fever. — Cantani's views as to the nature and use of the Fever Process. — "Das Heil-Fieber." — The Pathology of the Infective or Specific Fevers. — The Essential Phenomena of Fever. — Why does the Fever Patient waste ? — Why is he thirsty ? — How may water be supplied to the Fever Patient ? — The therapeutical uses of water. The word Fever means literally " a burning." It is derived from the Latin Febris (Gk. TrvpeTOs), and in kindred forms appears in the chief modern European tongues. Thus, we have lajievre in French ; das Fieber, in German ; la febbre, in Italian ; la Jiebre, in Spanish ; Feber, in both Swedish and Norwegian or Danish. The Spanish Calentura expresses the same idea. 8. The appropriateness of the term is apparent when we reflect that the essential fact in fever is preternatural body heat. This is in no small degree due to increased oxidation (combustion) of nitro- a " Fieber (irvpir6s = fever), febris eigentlich ferbris von fervere heiss sein ; appellamus a f>rvore febrin (Varro)." — Real-Encyclopadie der Gesammten JJeilkunde. Siebenter Band. Wien und Leipzig : Urban und Schwarzenberg. 1886. S. 171. B 2, THE INTIMATE NATURE OF FEVER. genous and carbonaceous substances furnished to the blood by the tissues, but mainly by the food. a To the feverish state, the term Pyrexia, or Feverishness, is applied. Pyrexia is not a classical Greek word, but is connected with, and derived from, the future indicative tense of the verb 7rvpi(T(T(i) (fut. 7rvpei;(o), to be in a state of 7rvp6To V OJ o 3 weel mplete ilescen _2 .5 o c CM © 4J a. 00 c! > O s O B £ t» 0) c a DO ao oo 09 00 •w 00 X 00 k> Pi &►> >> S>-» C*> >-. >> s 03 03 oi 03 03 et 03 e8 2 ■T3 T3 13 T3 13 "3 ■a TJ a) oo OO co -* CO CM "5 ° ■* "»• ^ 1-1 1-1 1-1 1-1 i-l .-I < ** rt cm : a .2 U ►» >> >- ° >. >> >-» _ * t>"> C g >-> s ^ B a b g<~ s r^ C a ,M fl s a fi°J 95 03 pq 03 o3 5 e3 a£ £ £* 03 03 03 u 03 03 u PQ Q a pq ^ , o t-, 'J3-. «> a Uj Q CM oo OS CO .03 CO — ■ CM CO 1 ^< CO 2 ^~ O co 5D P> £2- r*« «-> © oo no # ao 00 oo CO QQ .2 ° t- e O « J *58 "3 "oo "S "8 *m "5 » u tk "S "fcn >i "5 t» ^J "u ■52 J o h^ O J l-J T3 >> t*> T3 'p ,q i> 08 03 u Js 03 rH CO T3 T3 CO CO (N a) H3 c e3 (4 o ■(J c o o — > ^3 o A, T3 a c3 w h CM 72 ^t?" >» a 03 - o3 ^1' fl H 3 CO B o CM rjj O ->* © 00 CM -o ■> 00 00 03 03 P-, (*j 13 T3 S3 .2 o3 13 •<* o3 Ift T3 O ■* OS >> CM CM O -** t- ■-1 Oi *~? 00 01 ^ 00 *-• S °3 n i— l pH O r-l O CM 1 — 1 ^ ^ C O I— t fl O CM >> 03 -a r-l rl ce -a X OS bo 3 .S3 * 5* ^co 03 o J3> "el a CO c a. o 00 <0 OS 03 0) 03 _g c3 o 00 C a) "0 _£!. ^ *00 :0 t. 12 '0 a, >5 00 -B Oi 5 a CO Ph w E" Eh X ■eiyeiiiamcrexjj saaAa^ JO 'SJ9A3^ 8AI!}dlUg 8 RX panui^uoQ aqx 30 CHAPTER IV. The General Principles of Treatment of the Eruptive and Continued Fevers. Preventable Diseases. — Preventive Treatment, or Prophylaxis. — Disinfec- tion: — Antiseptics, Disinfectants, Germicides, and Deodorants. — Dr. Shelly 's Classification of Disinfectants. — Dr. Emerson Reynolds' General Plan of Disinfection. — Official Regulations for Disinfection adopted in Berlin. — Disinfection within the Living Body. — Receptivity. — Exciting and Predis- posing Causes of Disease. — Acquired and Natural, or Hereditary, Predisposition to Disease. — The chief Predisposing Causes of Febrile Disorders. Part I. — Preventive Treatment, or Prophylaxis. Having regard to tlie view that — (1) the diseases we are con- sidering result from the introduction into the system of a specific micro-organism, which either acts as a poison itself or produces in the body a toxic agent of a chemical nature, while (2) the " suscep- tibility" or " receptivity " of the infected individual varies without limit, according to his healthy or unhealthy surroundings, his state of health at the time, and a natural or acquired immunity — we are justified in speaking of specific infectious (infective) diseases as preventable. As this is so, it follows that the subject of treatment arranges itself under two headings — preventive and curative. Both these terms must be used with a certain amount of reservation — in a general rather than in a precise, an abstract, or an absolute sense. From this point of view we may adopt the terms " Preventive Medicine" and " Prophylaxis " a with all reverence and with the utmost propriety. The prophylaxis of the acute specific fevers consists in — (1) the destruction of the virus or contagium before it can enter the system ; (2) the adoption of measures which will have the effect of lessening the receptivity of the individual, or — in other words — a Gk. TTpo, fut. Trpoi slower the smallpox come out, the milder they prove and the better they ripen. Those appearing on the first day of the illness are esteemed the worst kind, those on the second, milder, those on the third still more gentle, and on the fourth, the most favourable." Trousseau and nearly all modern authorities concur in this view, but Curschmann thinks it is not warranted for all epidemics. It may, however, be accepted as a sound working proposition, although there is one striking exception to it. In consequence of great organic lesions— as Sydenham writes, ob atrocius aliquod symptoma — the eruption may be retarded till the sixth or seventh day both in distinct and confluent cases — " malo semper omine." Trousseau b , in illustration, mentions the case of a woman, aged 30, in whom the rash did not appear until the fifth day. At the beginning of her attack of smallpox she had all the symptoms of sporadic cholera — vomiting, purging, cramps, general coldness, blanching of the mucous membranes, dry, cold tongue, injection of the conjunctiva, and a dull appearance of the cornea. The choleraic symptoms ceased on the fourth day, and on the fifth the eruption of smallpox appeared. Again, a long experience in the wards of Cork-street Fever Hospital, Dublin, has led me to the conclusion that a purpuric or hemorrhagic tendency early in smallpox post- pones — it may be indefinitely — the appearance of the true variolous exanthem. To this subject it will be necessary to return. III. Stage of Eruption. — The true exanthem, or rash, of smallpox appears first on the head, neck and face, and about the wrists, next on the trunk, lastly on the lower extremities. In severe cases, as has been already mentioned, it shows itself on the second or even on the first day ; in mild cases its coming may be postponed until the fourth day. The usual day for its appearance is the third, inclusive, from the earliest symptoms. When the " pocks " a Boerhaave. Prax. med. "Vol. V., page 302. [Quoted by Sydenham, loc. cit.l b Glinique Midicale de l'H6tel Dieu de Paris. Paris : J. B. Bailliere et Fils. 1865. Deuxieme Edition. Tome premier, page 6. 8MALLP0X. 79 fulfil their whole life-history, they are seen to pass through the following stages of development : — 1. Specks of Hypersemia, like the fine pricks made with a needle, and sometimes like recent fleabites (first day of rash). 2. Papules, or Pimples, such as are met with in persons affected with lichen or prurigo (Trousseau), at first slightly raised, then conical, already hard or " shotty " to the touch, feeling like grains of shot underneath the skin (second and third days of the rash). 3. Vesicles filled with a clear, transparent fluid at first, but which quickly becomes lactescent or milk-like. " By the fourth or fifth day of the eruption (seventh or eighth of the disease)," continues Dr. Hilton Fagge, " the vesicle is generally as large as a split pea, hemispherical in form, and opaline in appearance." 4. Pustules formed by a further change in the contents of the vesicles in which young cells increase and multiply, causing them to assume a more and more opaque and yellow appearance, and to increase quickly in size (sixth and seventh days of the rash). About this time a central depression is found in these pustules. This is the so-called umbilicus, at the bottom of which the opening of a hair follicle or sweat gland is frequently observed (Curschmann). This carries us on to the 10th day of the disease, when the rash has reached its fullest development. The pustule, when at its height, is often quite hemispherical, the umbilicus having disap- peared in consequence of the rupture of the retinaculum which formed it. These pustules are really small abscesses. They become extremely painful, and the pain is accompanied by great swelling of the affected parts— greatest where the tissues are loosest or most relaxed, as in the eyelids and lips, and about the prepuce. In the confluent variety, about to be described, the face swells to a shapeless mass, rendering the patient absolutely unre- cognisable. Each pustule is now surrounded with an inflammatory zone or areola, called the halo of the pustule. This period of fullest development of the rash is called the period of maturation, or ripening, It lasts about three days and is fol- lowed by — . ;80 SMALLPOX. 5. The last stage in the life history of the eruption, that of desiccation — the drying-up of the pustules — and the formation of crusts or scabs. IV, Stage of Desiccation. — Even before the eleventh day an exudation of a sticky fluid takes place, and a yellowish matter like thick honey oozes from the surface of the pustules. This, together with their other contents, speedily dries up, first in the centre, and brownish scabs are formed, which are at first adherent, but after- wards fall off in from 3 to 6 days, leaving elevations or projections of a violet red hue, like a cold skin. On the trunk and extremities, where desiccation begins later than on the face, the pustules frequently burst and their purulent contents, soaking into the bed and body linen, under godecomposi- tion upon the skin and in the clothing, causing an overwhelming stench about the 11th or 12th day of the disease. This occurs in the confluent, not in the discrete, form. With the drying-up of the pustules, the redness, swelling, and tenderness of the skin sub- side, the eyes reopen, the nostrils are cleared, and the features of the patient become once more recognisable. V. Stage of Desquamation. — After this, successive scales of epidermis form and peel off — a process which is called desquama- tion — ultimately leaving a small white puckered scar (cicatrix) should the variolous inflammation of the skin (dermatitis) have dipped deep and involved the papillary portion, or cutis vera. When every scab has fallen off and desquamation has ceased, the patient may be considered free from infection. About the same time that the rash of smallpox shows on the skin, a true variolous exanthem develops upon the mucous mem- branes in general. Of this we have ocular proof in the case of those parts of the mucous membranes which are visible and are most exposed to the air. Thus, the conjunctivae, the mucous membranes of the nose, mouth, pharynx and adjacent parts, are nearly always affected. Thence the rash extends through the whole system of mucous membranes, invading the larynx, trachea, and bronchi in one direction, the oesophagus, stomach, and intestines in another. It is true that Curschmann states that it is very doubtful if SMALLPOX. 81 real pustules are ever formed in the stomach ami intestines, although they have been described by the older authors (Robert, in his account of an epidemic in Marseilles). He adds that they are seen only in the lowest part of the rectum, close to the anus. Nevertheless, for many years I have had an opportunity of illustrating my lectures on Small- pox by exhibiting a series of beautiful original drawings, by the late Mr. J. Conolly, of the pathology of this disease. These drawings show the entire respiratory and digestive tracts thickly beset with a variolous eruption, presenting itself as whitish or pearly-gray elevations upon a reddened base, with abrasions or large irregular excoriations of the mucous membrane. During life the presence of such an eruption is evidenced by such symptoms as deafness, due to blocking of the Eustachian tubes (Wendt) ; hoarseness or aphonia ; cough and dyspnoea ; dysphagia, or difficulty of degluti- tion ; diarrhoea. According to Curschmann. true pocks upon the serous mem- branes are fables belonging to antiquity. 82 CHAPTER VIII. Smallpox {continued). Classification and Varieties. Classification of Smallpox based upon the distribution and amount of the Rash : Variola discbeta, oonfluens, coh^rens, corymbosa. — Symptoms of Confluent Smallpox : its mortality and sequelae. — Meaning of the terms " Semi- confluent" or "Coherent," and "Corymbose," Smallpox. — The latter said to be a very fatal variety. Before describing the behaviour of the temperature during the eruptive and subsequent stages of Smallpox, we may refer to a classification of the varieties of the disease based upon the distribution and amount of the rash, which has been handed down from the time of Sydenham, and has received universal acceptance. Under all circumstances, whether modified or unmodified, Small- pox appears under two principal forms — Discrete or Distinct, and Confluent. The first of these is generally free from danger ; the latter is one of the most terrible and fatal of diseases. Of confluent smallpox two modified varieties are described — namely, (1) Semi- confluent, or Coherent Smallpox ; and (2) Corymbose Smallpox. Variola discreta, vel distincta, is the name given to those cases in which the rash is sparse or scanty, the several papules or pustules being more or less widely separated from each other. Hence the term Discrete (from Lat. discerno, 1 separate). In this form the initial symptoms are, as a rule, less acute and less persistent, and the rash not infrequently stops short of the pustular stage {Variola crystallina). Variola confluens is the term applied to those cases in which the rash overruns the entire, or nearly the entire, surface of the body, and invades the mucous membranes also with great severity. The symptoms of the invasion stage are all intensified, and the rash appears as early as the second day. As additional and very characteristic symptoms, Trousseau mentions, (1) persistent diarrhoea, both in adults and in children ; (2) profuse salivation in adults, SMALLPOX. 83 resulting either from parotitis, or, as a reflex symptom, from inflammation of the mucous memhranes of the mouth — stomatitis (Curschmann) ; (3) great tumefaction of the face and eyelids, so that the latter sometimes burst or slough ; and (4) most painful swelling of the hands and feet. Salivation, or ptyalism, sets in early, and is extraordinarily pro- fuse. According to Trousseau, from one to two litres (that is, from 35 to 70 fluid ounces) of clear, but ropy or viscid, saliva may flow from the patient's mouth within twenty-four hours, and this ptyalism is accompanied by a burning, unquenchable thirst. To omit special mention of the delirium of confluent smallpox would be misleading. In the epidemics of 1871 and 1878, in Cork- street Fever Hospital, Dublin, the occurrence of delirium was one of the commonest and most striking features of the disease. It was often violent and noisy (delirium ferox) ; or busy, with extreme muscular agitation (delirium tremens) ; but in the later stages it assumed more of the low muttering type (typhomania of Galen). Both at the Meath Hospital and at Cork- street Hospital, attempts at suicide were made by delirious smallpox patients, and homicide has happened before now as a result of the same delirium ferox. Huxham, in his classical " Essay on Fevers," a graphically describes the rash in these cases as consisting of pocks which are "pale, crude, pitted, and sessile." The face is covered with pustules, which run together so that the epidermis is raised by a milky sero-purulent secretion, and the face seems as if it were dipped in tallow or covered with a mask of parchment — u Pergameno3 speciem visu horrendam (cutis faciei) exhibet? as Morton said in his " Pyretologia." b It is right to mention that, in confluent smallpox, while the face and hands may be absolutely covered with pocks, in other parts of the body the eruption may be more or less discrete, the amount and intensity of the pustulation seemingly being in direct proportion to the vascularity and inflam- matory state of the surface. This was pointed out several years ago in an admirable paper on the " Treatment of Smallpox " by the a London : J. Hinton. 1764. Page 127. b London. 1692. 84 SMALLPOX. late Dr. William Stokes, a Regius Professor of Physic in the Uni- versity of Dublin. Of this fact we have two proofs — in the first place, portions of skin which have been subjected to mechanical or chemical irritation, either before infection or during the stage of incubation, invariably throw out a veiy abundant pustular, and frequently a confluent, eruption even in discrete cases of smallpox. Conversely, and secondly, where the vascularity of a part has been reduced by pressure, local depletion, or removal of irritation by poulticing, bathing, or other means, the eruption of smallpox is distinct even in confluent cases. b The mucous membranes, like the skin, are the seat of a closely set rash in confluent smallpox, and very dangerous forms of second- ary inflammation are apt to place the patient's life in imminent peril. Glossitis variolosa, or inflammation of the tongue ; diphtheria, acute oedema of the glottis, intense and wide-spread bronchitis and pneumonia; violent, uncontrollable vomiting, retching, and diar- rhoea, are among the evidences we have of the serious engagement of the mucous membranes. Towards the close, should the patient survive, multiple pyaemic abscesses, erysipelas, and even gangrene may occur in those parts of the integument where the confluence is most pronounced. The mortality is, of course, very great in this form of the disease, at any stage of which the patient may succumb. In some epidemics, according to Trousseau, half the patients die ; in others, four-fifths, and in others, less fatal, one-third of those attacked perish. It is, therefore, the most deadly of all pestilences, yellow fever and cholera not excepted. The terrible feature of smallpox is that it kills not only in the acute stage, by dissolution of the blood or by the intensity of the fever, but also in the later stages and in convalescence. The most fatal epoch is about the eleventh or twelfth day, but even far on in the stage of desiccation death not infrequently results from exhaustion, or pyaemia, or some other complication. I will return to the subject of mortality later on. a See the Dublin Journal of Medical Science, Vol. LIIL, p. 9. Dublin : Fannin & Co. 1872. b Cf. Stokes, hoc. cit. SMALLPOX. 85 Should confluent smallpox end in recovery, convalescence is very tedious, and is frequently interrupted by serious sequelae, of which an " acute furuncular diathesis," as Trousseau calls it, is one of the commonest and most troublesome. It shows itself in the formation of successive crops of most painful boils, and of more or less deep- seated abscesses. In the stage of desiccation large, ecthymatoid crusts form upon the ulcerated surface of the skin. These become detached, leaving the dermis scooped out. Successive layers of thinner and thinner crusts form, and are shed during two, three, or four weeks, the idcerations finally cicatrising, leaving the rugged scars which seam the faces of those who have passed through confluent smallpox. To this disfigurement the term " pitting" has been applied. It is especially unsightly about the nose, the borders of the alae nasi appearing indented, and the bridge and tip of the nose split and torn. With the separation of the scabs, or sometimes later, the hair commonly falls off, in some cases in handfuls. If the variolous inflammation of the scalp has dipped deeply and involved the hair follicles to any great extent, the resulting alopecia, or baldness, may be permanent. More usually, the hair grows again, in a few cases more luxuriantly, if less smoothly, than before. It is not usual for the nails to fall off after smallpox, although the atrophic furrows across them, described and figured by A. Vogel, and mentioned by Murchison 8 as occurring in typhus fever, are not infrequently observed. I have stated above that two modifications of confluent smallpox are recognised as regards the distribution of the rash. These are the semi-confluent and the corymbose varieties. The term Variola semi-confluens, or Coherent Smallpox, is applied to those cases — (1) in which the pustules touch each other without coalescing, or (2) in which the eruption is confluent on and about the face, and more or less discrete elsewhere. & A Treatise on the Continued Fevers of Great Britain. Third Edition. 1884. Page 136. 86 SMALLPOX. Variola corymbosa is a term applied to those cases where the pustules are confluent in patches, or clutters (/copu/A/3o?, « cluster of fruit), these being separated by intervals of unaffected skin. Vascular parts, like the axilla?, groins, and popliteal spaces, are often the seat of such an eruption. Hilton Fagge says that he never saw a case of corymbose smallpox, but there is a beautiful drawing of it in the collection of J. Conolly's illustrations of smallpox observed in the Hardwicke Fever Hospital, Dublin, to which I have already alluded. According to Marson, formerly of the London Smallpox Hospital, this is a very fatal variety of smallpox, the mortality reaching 41 per cent. Strangely enough, in the London Smallpox Hospital it was scarcely less destructive to vaccinated persons than to those who were unprotected (Hilton Fagge). 87 CHAPTER IX. Smallpox (continued). Temperature — Varieties — Complications — Pathology — Diagnosis — Prognosis. Temperature : Two distinct Types of Fever in Smallpox — viz. 1. A brief continuous Fever ; 2. A relapsing Fever. — Prodromal or Initial Fever. — Secondary Fever, or Fever of Suppuration or of Maturation. — Hyperpyrexial Temperature in Fatal Cases. — Varieties op Smallpox : Discrete, Confluent, Benign or Varioloid — 1. Variola sine Exanthemate, 2. V. cornea (Hornpox), 3. V. verrucosa (Wartpox) ; Malignant (V. maligna) — 1. Purpuric, 2. Hsemor- rhagic (Purpura variolosa), 3. V. haemonhagica pustulosa of Curschmann, V. nigree of Sydenham, V. cruentse.— Table op the varieties op Smallpox. Complications and Sequels, affecting the skin, eyes, ears, nose, tongue, larynx, respiratory organs, digestive organs, circulatory system, kidneys, nervous system, genitals, blood, joints. — Pathology : Morbid anatomy and histology. — Diagnosis, Prognosis, and Mortality. Temperature. — As pointed out by Wunderlich, a the fever in variola exhibits two distinct types, which closely correspond, however, at their commencement. I. One of these types is a brief continuous fever, belonging in particular to the milder forms of variola discreta and to most cases of varioloid or modified smallpox, occurring chiefly although not exclusively in vaccinated or inoculated persons. This is the so- called Prodromal or Initial Fever of the stage of invasion. In the forms of the disease just mentioned, this continuous fever both begins and usually completes the febrile movement. The maximal temperature of the initial or prodromal fever is rarely less than 104° F. (40° C.) ; it generally exceeds this, reaching even 106° F. (41'1° C.). This great height is quickly attained, generally on the second day. Soon after the true rash of smallpox appears, the temperature falls more or less rapidly — usually from the fourth to the 8ixth day. The defervescence is either rapid and continuous, a A Manual of Medical Thermometry. New Sydenham Society. 1871. P. 337. 88 SMALLPOX. or slower and interrupted by a moderate evening exacerbation. In cases of uncomplicated varioloid and of mild discrete smallpox this defervescence is complete and final. The fall of temperature which occurs with the coming out of the rash of smallpox is pathognomonic of this disease, and is therefore of the first importance in diagnosis. It is exactly the converse of the behaviour of the temperature in measles, in which the fever is moderate up to the appearance of the rash, and then becomes more and more intense until the rash is most fully developed. It should be borne in mind that the initial or prodromal fever is often very severe even in the mildest cases. II. The other type of fever in smallpox is a relapsing type, which is characteristic of true smallpox in its severer and confluent forms. The falling temperature after the prodromal stage in this case either never reaches the normal line, remaining at subfebrile (99-5° to 100-4° F.), or even at febrile (points 100.4° to 102-2° R in the morning, rising to 103° F. in the evening) ; or the normal temperature is reached, if at all, tediously, and defervescence is by lysis. Then, with the beginning of the pustulation, or ripening {matura- tion) of the exanthem the temperature again begins to rise, ushering in a Secondary Fever — the Fever of Suppuration or of Maturation (" Eiterungsfieber " of the Germans) as it is called — which is of indefinite duration and varies in intensity according to the severity of the disease. In a sharp attack of discrete or semi-confluent smallpox, the temperature in this secondary fever rarely exceeds 103° or 104° F. There are morning remissions, and the duration is only a few days. In bad confluent smallpox, on the other hand, the fever runs very high, presenting sometimes a remittent course with marked exacerbations, sometimes a continuous range with occasional isolated elevations or spikings of temperature. Eepeated elevations of temperature above 104° F. (40° C.) during this fever of suppuration, or maturation, are a sign of great danger. In cases which tend towards recovery, defervescence takes place by an irregular lysis. In fatal cases, hyperpyrexial temperatures (107*6° F.=42° C.) are wont to occur before, at the moment of, Plate J. CHARTS OF TEMPERATURE RANGES IN SMALLPOX. Bajr Variola Discrete. iSJ't •* * •' * 7 * * '" ill jFy. 2. - VDiscrefa. Ikmst ■> -f ■' '■ ■ a -'J!' " '- '•» Z ~i — ~~~" " ---- X- ' jdti. J ±- " ±|. ■ ItrnirEiEEEiE i - i jtj- :: --- - ^\ Vlr r it^^rf ^ ' lM 'T-=P^ffi^ Z 3:pE|^ ,. H — — - - r - - ff- -i - -t p - ■ ■ i r ■ i 7 ^* <2 yCbk&rens jV, fc,«*ff ft«r .•HiutklSecviid.m Fcv Fiq. -irVfortfliwris iSwt 4 5 6 7 H 9 10 11 HI 11,1-1 iJ "1 1' H 'I I'H n & -« ' --l-i u -^- Afarfr-sd Sewnrfaryjfever Pig. 5-VMaUgna: Confluent et Purpurica ':■.:.'.„ 3 4 S (7 7 3 9 ID OS ' Et = E— : f|| L .- --- ====?:5±===z W HbtenseSecemdaj-yFeVi Ses-ereSecondrjwy Fever SMALLPOX. 89 or even after death. Th. Simon, of Hamburg, has published a two cases in which the temperature after death was 11075 and 112-1° F. respectively. In Plate IV., illustrating his work on " Medical Thermometry," Wunderlich includes a chart of the temperature in a case of smallpox fatal in the suppurating stage, in which the thermometer marked 109-2° F. shortly before death. The accompanying Temperature Charts are from cases observed by me in the wards of Cork-street Fever Hospital, Dublin, and the Meath Hospital and County Dublin Infirmary. [See Plate I.] Apart from the classical and recognised forms of Discrete and Confluent Smallpox, we meet also with the following varieties of the disease : — 1. Variola benigna (Varioloid — Fr. Variole modif.ee). This is a mild and abortive form of smallpox in which the pocks either fail to appear at all (Variola sine exanthemate, or V. sine variolis), or else fail to pass through the later stages of their development, stopping short at the papular stage (Variola cornea or Hornpox), or, if reaching the vesicular, drying up and shrivelling on the 5th or 6th day of the eruption (Variola verrucosa, or Wartpox). In other cases the exanthem passes rapidly and imperfectly through all phases of its development, producing more or less dwarfed forms of the pustules. Some readers may be sceptical as to the existence of a Variola sine variolis, but the evidence is overwhelming that there is such a form of smallpox. After a well-marked initial stage, the disease aborts and the patient is well in three, four, or six days at the latest. Dr. Hilton Fagge refers to one instance of this kind, which was attended by a characteristic roseola. Another example of it is thus recorded by Marson. A lady walked with a person already affected with smallpox. Twelve days afterwards she was taken ill : she was for a few hours delirious, but her illness passed off without eruption ; twelve days later still, her sister, who had not been out of the house for three months, was attacked with the same disease, which ultimately assumed a covflueni form. Curschmann mentions the case of a woman who was seized with shivering, a ChariU Anualen, XIII. Band V. 90 SMALLrOX. fever, headache, and pain in the back, so that — as variola was epidemic at the time — she seemed without doubt to be passing through the initial stage. On the fourth day defervescence occurred, no rash could be detected, and by the tenth day she felt perfectly well. However, she gave birth to an infant, which was covered with an early eruption of smallpox. This afterwards suppurated and proved fatal. 8. In the case of the so-called wartpox, also, the solid part of the pock remains for a long time, presenting the appearance of a wart — hence the name, "wart-pox" (Latin — verruca, a wart). As Curschmann points out, Varioloid is nothing more than a form of true smallpox with a milder course and a shorter duration. Many individuals are attacked only by this form because of a naturally slight susceptibility to the contagium of the disease. Again, when the immunity gained by a previous attack of small- pox, or from a previous inoculation, or from vaccination, has become impaired through lapse of time, then exposure to the poison may induce an attack of modified smallpox or varioloid. There can be no question that this mild form of so dreadful a disease as smallpox has become relatively much more frequent since vaccination was introduced about a century ago. As stated above, Hebra, Trousseau, and Curschmann, all con- sider that, as a rule, the development of the pocks is less the more extensive is the initial erythematous eruption. Viewed in this light the purely erythematous rashes of the invasion stage come to be of decided value in prognosis. I have already said that these rashes are to be carefully distinguished from the petechia which form in the earliest stage of some cases of the terrible purpuric or hsemorrhagic smallpox which I will now describe. 2. Variola maligna — Variola purpurica vel hemorrhagica. — Observations of some three thousand cases of smallpox in two hospitals and two epidemics has led me to the conclusion that, apart from confluent smallpox in which the patient's life is en- dangered by the amount of suppuration and the intensity of the a The Principles and Practice of Medicine. By the late Charles Hilton Fagge, M.D., F.R.C.P. London : J. & A. Churchill. 1886. Vol. L, page 225. SMALLPOX. 91 secondary or suppurative fever, Malignant Smallpox is to be recognised under two forms — (1) purpuric, and (2) hsemorrhagic. These forms differ merely in degree — in both the blood is pro- foundly altered, and devitalised to such an extent that it is incapable of throwing out or developing the characteristic eruption of small- pox. In the purpuric variety the dissolution of the blood leads to the formation of petechias, vibices or purple streaks or blotches, and ecchymoses — appearances connected with the skin which are sufficiently well known and do not require further definition. In haemorrhagic smallpox the dissolution of the blood is carried still further, so that a condition of acute haemophilia is produced — the ill-fated patient bleeds from every pore and orifice of the body. There is chemosis — he may even weep tears of blood. There is epistaxis — he bleeds from the lips and gums. He spits or coughs up blood, he vomits blood. The motions from the bowels are tarry. Blood pours from the kidneys, and in the female from the genital organs. The tongue looks as if it was parboiled, and there is an unquenchable thirst. Under these circumstances, unless the haemorrhage is staunched by turpentine and ergot, or ferric chloride, or pyrogallic, gallic, and tannic acids, or other means, death speedily ensues — too often indeed in spite of all that human skill and care can do. One of the most extraordinary as well as the most painful fea- tures of this deadly malady is the clearness of mind which often remains with the unhappy patient almost up to the time when he draws his latest breath. There is in some instances no delirium, no stupor, no dulling of the intellect whatever — the victim literally looks death in the face in full possession of his senses. It has happened to me to be asked by a patient at 11 a.m. how long he had to live, and that patient lay dead four hours afterwards. The cessation of the bleeding may bring back haemorrhagic smallpox to the purpuric form, and in the case of the latter variety of malignant smallpox the restoration of the blood, evidenced by the brightening of the purpuric spots, may be followed by the tardy development of a copious eruption of either aborted pustules (papules) — in which case the patient happily recovers speedily, and 92 SMALLPOX. without suffering from a fever of maturation — or true and fully- formed pustules, when the patient has still to run the gauntlet of a severe attack of confluent smallpox, with its secondary fever, com- plications, and sequele. This is the idea of malignant smallpox and its varieties which I have formed from a lengthened expe- rience. Strong muscular men and pregnant or recently delivered women are said to be particularly liable to fatal hemorrhagic smallpox, and this was certainly the case in the Dublin epidemics of 1871 and 1878. Curschmann, however, states that he has often seen this variety of the disease in delicate persons and in drunkards also. According to Marson the blood in this form of smallpox is "poisoned from the very first and is rendered very fluid and watery." In the fact that the true eruption does not develop, the two extremes of smallpox as regards gravity meet — the most benignant form, described by Sydenham, Peter Frank, and others, as Febris variolosa sine exanthemate — what de Haen called Variolar sine variolis — and the so-called Purpura variolosa, the most malignant form, leading, as we have seen, to almost certain death. Under this latter title Curschmann includes those cases in which the process designated " hemorrhagic diathesis " (which I prefer to call "acute hemophilia") imprints its frightful stamp upon the disease even in its initial stage, or during the eruptive stage, or at the close of the latter. We have just stated that hemorrhagic or purpuric symptoms may occur not only in the stage of invasion (when they constitute ordinary Purpuric or Hemorrhagic Smallpox — Purpura variolosa) — but also at almost any time in the stage of eruption. In order to distinguish these latter cases, as a matter of convenience, Cursch- mann employs the term Variola hemorrhagica pustulosa. In this form of purpuric smallpox, the true exanthem may become the seat of hemorrhage in the papular, the vesicular, or the pustular stage — most commonly, the pocks are about the size of a lentil when the bleeding into them begins, and the characteristic appearance is seen first on the lower extremities. SMALLPOX. 93 This variety of smallpox corresponds exactly to the " anomalous" or "irregular" smallpox of 1G70, so described by Sydenham, who also speaks of the malady as "this dangerous black smallpox" (Variolse nigrse), in which the eruptions " were more inflamed, and in the declension after their suppuration, frequently looked black." a Another name for this variety isVariolae craentae (Bloody smallpox.) From the foregoing description we may compile a Table of the varieties of Smallpox, which will prove useful for reference. It will be observed that Variola discreta finds a place in both portions of the Table :— I. Variola vera — Natural Smallpox. 1. Variola discreta, vel distincta. 2. Variola confluens — (1.) V. conjluens vera. (2.) V. semi-covjluens (Syn. : " Coherent Smallpox") (3.) V. corymbosa. 3. Variola maligna — (1.) V. purpurica. (2.) V. hemorrhagica. (3.) V. hemorrhagica piistulosa(Curschvaeinn). (Syn. : Variola nigra, vel cruente.) II. Variola modificata vel mitigata — Varioloid (Variole modifiee) — Modified Smallpox. 1. Variola benigna — (1.) V. sine variolis (Syn.: " Variolous Fever"). (2.) V. cornea, vel verrucosa (Sy?i.: " Hornpox," or "Wart- pox"). (3.) V. discreta, vel distincta. In drawing attention to this Table, I wish emphatically to enforce the view that all these various forms are merely modifications of one and the same disease — namely, Smallpox. We classify these varieties simply as a matter of convenience, and with Curschmann a The Entire Works of Dr. Thomas Sydenham. By John Swan, M.D. London : F. Newbery. 1769. Pages 179, et seq. [■ Variola? nigrce. 94 SMALLPOX. we should hold that "none of these forms are sharply defined amidst the great group of variolous affections ; but there is rather a gradual transition from one into the other, so that general out- lines are to be associated with the most customary designations rather than sharply circumscribed features."* Complications and Sequelae. 1. The Skin may be the seat of — (1.) Multiple Abscesses. (2.) Phlegmonoid Erysipelas. (3.) Boils— the "Furuncular Diathesis" of Trousseau. (4.) Bedsores. (5.) Gangrene — very rarely and only in the scrotum. (6.) Brownish Discolorations (pigment spots) and Acne pvstulosa on the face. 2. The Eyes may be affected in various ways — (1.) Conjunctivitis, from pustulation or from irritation by retained secretions owing to oedema of the eyelids. (2.) Abscesses and Sloughing of the Eyelids, caused, it may be, by the presence of even two or three pustules. (3.) Keratitis, or Inflammation of the Cornea from pustu- lation or from atrophy leading to ulceration — " Atrophic Keratitis." ._ . r ■ (4.) Iritis, and Suppuration of the Globe (Panophthal- mitis), causing loss of sight. (5.) Haemorrhages into the Retina in hemorrhagic small- pox, leading to Blindness. Hebra's experience on this point must be unique, for he asserts positively that, of more than 5,000 cases of smallpox, pustulation occurred on the conjunctiva in only one per cent. He holds that eye-sight is lost in smallpox only as a result of metastatic abscesses occurring as a sequela. b a Von Ziemssen's Cyclopedia of the Practice of Medicine. Art. " Smallpox." Vol. II., page 366. 6 Diseases of the Skin. New Sydenham Society. 1866. Vol. I., page 254. SMALLPOX. 95 3. The Hearing often suffers. Thus we may have — (1.) Chronic Suppurative Otitis. (2.) Caries of the Bones of the Ear, with partial or com- plete deafness. (3.) Suppurative Thrombosis of Cerebral Sinuses. 4. The Nose is sometimes the seat of ulceration. 5. The Tongue may be enormously swollen (glossitis), leading to dysphagia. 6. (Edema of the Glottis, ushered in by aphonia, often causes death about the eighth day. 7. Secondary affections of the Respiratory Organs such as — (1.) Laryngitis (Perichondritis laryngea), diphtheritic or catarrhal — aphonia is an ominous symptom in this complication. (2.) Tracheitis. (3.) Bronchitis, nearly always present in greater or less degree. (4.) Pneumonia, usually lobular or catarrhal. (5.) Pleuritis, with purulent effusion from the outset. 8. Secondary affections of the Digestive Organs are uncom- mon in Smallpox. They are — (1.) Diarrhoea, which may cause death, particularly in young children. (2.) Haematemesis or Melaena. 9. Secondary affections of the Circulatory Organs — (1.) Pericarditis — very rare in smallpox. (2.) Haemorrhages — (a.) cutaneous; (/3.) from mucous membranes ; (7.) from serous Membranes. 10. Secondary affections of the Renal Organs — (1.) Albuminuria. (2.) Hagmaturia. (3.) Acute Nephritis. 11. Secondary affections of the Nervous System — (1.) Delirium, with or without Meningitis. (2.) Acute Mania (Trousseau). (3.) Various Paralyses. 96 SMALLPOX. 12. Phimosis, from oedema of the prepuce. 13. Pyaemia, or Septicemia. 14. Joint Disease, with painful swellings, effusions of serum or pus, inflammation of cartilages and of bones, may occur. Pathology. — The morbid anatomy of the skin and mucous membranes must first be considered. " Unlike the papule of measles and of most other exanthemata," writes Dr. Hilton Fagge, " the papule of smallpox depends upon a definite change in the superficial and middle cells of the rete mucosum, which from the very commencement of the morbid process are swollen and opaque, and in their midst exudation quickly takes place, so that by the end of two days the horny layer of the epidermis is raised to form a minute conical vesicle." Subsequently, the pustule forms as a result of cell proliferation, and a central depression — the so-called umbilicus — develops, at the bottom of which the opening of a hair follicle or sweat gland is, according to Curschmann, frequently found. This fact suggests an explanation of the formation of the umbilicus, so characteristic of the smallpox pustule. Either of these structures — the hair follicle or the sweat gland — may form a retinaculum, tying down the roof of the vesicle in the middle. This explanation, however, is not always applicable, " since," says Dr. Hilton Fagge, " the pock does not necessarily bear a definite relation to any of the canals which traverse the cuticle. In all probability a similar function is then discharged by one of many other bands which cross the upper part of every vesicle in a direction more or less vertical, dividing it into a number of separate chambers" (or loculi). "This loculated character of the pock attracted notice long before its nature was understood ; it affords the reason why only a small part of the fluid is eva- cuated when a needle is introduced into the roof at a single spot. . . . Auspitz and Basch showed several years ago that all the septa in question are in reality formed out of the original cells of the rete mucosum, small bundles of which adhere together, and become stretched out into filaments and bands, as the exuda- SMALLPOX. 97 tion accumulates around them. In this fluid leucocytes are present in small numbers from the very first ; they go on increasing, and it gradually passes from transparent serum into opaque pus ; the change is complete in about six or seven days from the first appearance of the papule — that is, in the earliest part of the erup- tion, by the ninth or tenth day of the disease." The morbid processes in the skin are by no means confined solely to the epidermis. The papillary layer of the derma is also the seat of a variolous inflammation which may have very impor- tant and serious consequences. According to von Barensprung, a hvperaemia extends down through the whole thickness of the skin. The exudation which fills the vesicle and afterwards the pustule is derived from these vascular (hyperaemic) tissues. Some of the papillae are, according to Curschmann, flattened by pressure, becoming in consequence permanently atrophied. Others, however, are infiltrated by leucocytes to such an extent as to obliterate their nutrient blood-vessels and so to destroy their structure, converting them into a white or ash-gray substance — the diphtheritic pock of the German histologists. To prove this, Rindfleisch gives a draw- ing from an injected preparation, in which the affected area had failed to receive any of the colouring matter (Hilton Fagge). The liver, kidneys, and spleen undergo important morbid changes. The spleen is much swollen, its pulp soft and of a light red colour, in those who die early in the disease. It subsequently resumes its normal appearance except in purpuric smallpox, when it may be found small, hard, of a dirty dark red colour, sometimes with white or yellowish follicles (Ponfick). 8, The liver and kidneys are the seat sometimes of cloudy swelling (granular degeneration), sometimes of acute fatty degeneration resembling that produced by poisoning with phosphorus. Fatty degeneration is the more advanced condition in which granular swelling may terminate. These organs may be found normal when death occurs either too soon to permit of degenerative changes, or so late that they have a Ueber die anat. Verand. der innern. Organ, bei hamorrh. und pust. Variol. Berl. klin. Wochenschrift. 1872. No. 42. H 98 SMALLPOX. returned to their normal condition. The bile is generally pale and thin in confluent smallpox. The heart-muscle may undergo degenerative changes like those observed in the liver and kidneys. In Haemorrhagic Smallpox, large or small haemorrhages may be found in nearly all the viscera, ecchymoses in the serous membranes, and extravasations of blood in almost all the mucous membranes. Diagnosis of Smallpox. — The pain in the back may simulate lumbago, which is, however, apyrexial. The prodromal fever may be mistaken for simple continued fever, which has no rash. The initial rash and vomiting may be mistaken for scarlatina, but the marked sore throat of this disease is wanting. The initial macular rash, and the papular stage of the true rash, may be taken for measles, the marked coryzal symptoms of which are absent ; in measles too the fever increases as the rash comes out, while in smallpox it decreases. At the onset of a papular eruption it is often difficult to decide whether the case is one of measles or smallpox. The following method, called the "Grisolle sign," is a certain means of diagnosis. If upon stretching an affected portion of the skin the papule becomes impalpable to the touch, the eruption is caused by measles ; if, on the contrary, the papule is still felt when the skin is drawn out, the eruption is the result of smallpox. 8. The pain in the back is wanting in measles, which usually attacks young children, whereas smallpox commonly occurs amongst adults. The onset of smallpox and that of typhus often closely resemble each other, but the fever continues after the rash of typhus appears and the rash is macular rather than papular. Strange as it may appear, pustular syphilides have been con- founded with smallpox and vice versa ; but the clinical history should solve the question without much trouble. The differential diagnosis of smallpox and chickenpox (varicella) "■Sacramento Medical limes. February, 1889. See Sajous' Annual of the Univ. Med. Sciences. 1889. Vol. I. H.-77. SMALLPOX. 99 had best be postponed until the latter disease has been described (see Chapter XII., page 12o). The vast and unsightly swelling of the face in confluent smallpox is very like erysipelas, but a careful physical examination would set the question of diagnosis at rest. Dr. Robert Liveing a says that, of all diseases, perhaps glanders in an early stage is the one most likely to be mistaken for smallpox. The febrile symptoms are like those of smallpox, and the rash consists of hard infiltrations in the skin and mucous membrane, which quickly suppurate and form deep and inflamed ulcers. When these infiltrations are small and scattered, and before ulceration has begun, the difficulty of a diagnosis is by no means slight. Glanders is a rare disease and usually occurs in grooms and stablemen. The rash comes out in successive crops and ulcerates rapidly. Lastly, in both recent epidemics of smallpox in Dublin, male patients were sent into Cork-street Fever Hospital as suffering from smallpox, but on examination it turned out that the suspicious rashes, the presence of which caused them to be sent to hospital, were due to the fact that they were taking cubebs or copaiba — the rashes were medicinal rashes. In all cases, account should be taken of any prevailing epidemic ; we should also inquire whether the patient has been exposed to any infection and whether he has already suffered from any of the eruptive or continued fevers, which might be mistaken for small- pox, or, conversely, smallpox for them. Prognosis. — The mortality from smallpox depends on — (1) the patient's state as regards previous protection by an attack of natural smallpox, by inoculation, or by vaccination ; (2) the virulence of the disease itself — the hsemorrhagic form being the most deadly, next the purpuric form, then the confluent form ; (3) the general hygienic condition, or otherwise, of the patient's surroundings ; (4) the presence, or otherwise, of complications. Smallpox is most fatal to unvaccinated children under 5 years of age and to unvaccinated adults over 30 years. It is estimated a Diseases of the Skin. Fifth Edition. London : Longmans, Green & Co. 1887. Page 51. 100 SMALLPOX. that 50 per cent, of the confluent cases, and 100 per cent, of the malignant cases, perish. The influence of vaccination for good is unquestionable — the mortality being 50 per cent, among the un- vaccinated in general, 26 per cent, among the badly vaccinated, and only 2*3 per cent, among the efficiently vaccinated. In Sheffield, in the outbreak of 1887-88, of 4,703 cases, 474 proved fatal, or 10 per cent.; of 4,151 vaccinated patients, 200 died, or 4 - 8 per cent. ; of 552 unvaccinated patients, 274 died, or 49 6 per cent. a Hemorrhagic, or malignant^ smallpox may kill in four, five, or six days from the earliest symptoms. In confluent smallpox, on the contrary, the patient seldom dies before the eleventh day, and, in general, according to Trousseau, the most fatal epochs are the twelfth, thirteenth, and fourteenth days. In the case of a disease like smallpox, in which the blood is poisoned and destroyed from the outset, it goes without saying that defective sanitary surroundings — such as overcrowding, want of ventilation, bad house drainage, and so on — must enormously increase the patient's risk. Again, the complications and sequelae of the disease often slay the unfortunate individual who had escaped from the perils which beset the earlier part of his passage through smallpox. (Edema of the glottis, perichondritis laryngea (inflammation of the cartilages of the larynx), bronchitis (especially in winter), and diarrhoea may kill straight off; while pyaemia, septicaemia, and the furuncular diathesis, may exhaust the patient's strength after weeks or even months of suffering. In his " Medical Report " of Cork-street Fever Hospital, Dublin, for the year ending March 31, 1880, Dr. Reuben J. Harvey included a Table showing how protracted was the stay in hospital of many of the no n -vaccinated patients who ultimately recovered from smallpox. The high death-rate among the unvaccinated cases, fearful as it is, is not the only calamity the victims of a smallpox epidemic have to encounter. In the year named, 50 out a Report of an Epidemic of Smallpox at Sheffield, 1887-88. By Dr. Barry, Inspector of the Local Government Board for England. London. 1889.. SMALLPOX. 101 of 74 unvaccinated patients died in the hospital. Of the 24 who recovered, one-half were detained in hospital for a period of from one to three months ; and boils, abscesses, and eye-affections occurred in these cases with a frequency and severity altogether out of proportion either to their numbers or even the apparent severity of the primary attack. In the " Medical Report " of the hospital for the following year (ending March 31, 1881), I gave a similar Table, which illustrated the tediousness of the recovery of several non-vaccinated patients, who indeed escaped with their lives, but were fated to pass through weeks or months of suffering before they were fully convalescent. In one case 68 days, in another 77 days, and in a third 106 days were spent in hospital by these victims of non-vaccination small- pox. Even this was surpassed in the case of a man who was dis- charged after a sojourn of nine months and nine days. This unfor- tunate sufferer had as many as 42 large abscesses on his body as a sequel to the smallpox, but at length he happily recovered under antiseptic treatment. 102 CHAPTER X. The Preventive Treatment of Smallpox. Smallpox communicable ; but one attack confers immunity from a second — Preventive Measures : 1. Isolation ; 2. Inoculation ; 3. Vaccination. — Inoculation illegal. — History of Inoculation. — Clavelisation. — History of Vaccination. — Value of Vaccination in controlling prevalence and mortality of Smallpox. Marson's views as to the use of Multiple Vaccinal Cicatrices. — Periodical Revaccination. — Circumstances which conduce to success of Vaccination. — Jenner's " Golden Rule." — Bovine and Humanised Lymph. — Performance of Vaccination. — Bryce's Test. — Vaccina : its local and con- stitutional symptoms. — Vaccino-stphilis. This subject of the Treatment of Smallpox naturally falls under the two headings — Preventive Treatment, or Prophylaxis, and Curative Treatment. Preventive Treatment — The principles of the Prophylaxis of Smallpox are based upon two facts in the natural history of the disease — namely (1). Smallpox is eminently communicable. (2). One attack usually protects an individual from a second attack — confers immunity upon him. The preventive measures which call for remark are — (1). Isola- tion of the Sick ; (2). Inoculation ; (3). Vaccination. 1. Of these topics, the first has already been discussed in the chapter on the Preventive Treatment of the Acute Specific Fevers (see pages 30 et seq.). It will be sufficient, therefore, to repeat that isolation consists in the removal of sick to suitable epidemic hospitals, the providing of refuges for the inhabitants of infected tenement houses or other dwellings, efficient disinfection, and the establishment of convalescent homes. 2. As regards inoculation, the intention was to engraft a mild form of smallpox on a healthy individual, whose receptivity or susceptibility might be supposed to be slight or low in consequence of his existing good health. The disadvantages of this procedure was that it gave smallpox to many who would otherwise have, perhaps, escaped the disease altogether, while it was impossible to guarantee that the resulting attack of smallpox would be mild. SMALLPOX. 103 In 1840 an Act of Parliament was passed rendering smallpox inoculation unlawful in England (3 and 4 Vict., cap. 29). Inoculation was declared to be illegal in Ireland by the fourth section of the "Vaccination Amendment (Ireland) Act" of 1868 (31 & 32 Vict., cap. 87). The operation had been practised from time immemorial in China and Persia. The Chinese plan of giving smallpox to per- sons in health consisted in inserting into the nostrils tents of charpie covered with the dried crusts of the variolous eruption. They called the procedure "sowing the smallpox." From China and Persia inoculation or " engrafting " was introduced into Georgia, Circassia, Turkey, and Greece. In 1717, a very clever English- woman, by name Lady Mary Wortley Montague, wife of the British Ambassador at the Ottoman Court, wrote home glowing accounts of the marvellous results of inoculation as practised at Adria- nople, amongst other persons, upon her own son, a boy of six years of age. Her influence led to the open adoption of the procedure in England in April, 1721, and two years later, in 1723, Dr. Bryan Robinson, sometime President of the King and Queen's College of Physicians, first performed the operation in Ireland. Many years elapsed before it obtained a footing in France, where at first it had been rigorously prohibited by law ; but in 1756 the children of the Duke of Orleans were inoculated, and in 1758 the practice was introduced into most of the large towns. A favourite analogous procedure, practised since the last cen- tury by Continental veterinary surgeons and farmers, was called clavelisation — a term derived from clavelee, the French name for smallpox of sheep ( Variolas ovivce), a disease popularly known in England as " tag-sore," or " sheep-rot ;" in Italy as " vaccuolo." The object of clavelisation was by repeated inoculations to attenuate the virus of sheep-pox. And exactly in the same way it was sought, by employing virus from a discrete case of smallpox which had been modified by antecedent inoculation, to communi- cate a very mild variola. The operation consisted in raising the epidermis by means of a lancet charged with such an attenuated virus or lymph. A mere ] 04 SMALLPOX. prick was sufficient. The resulting symptoms were, first local, then constitutional. Thus, on the second day after inoculation, a small red pimple appeared at the site of puncture ; by the fifth day this had become a conical vesicle (sometimes umbilicated) ; on the seventh day, the vesicle had developed into a pustule, surrounded by a slightly red inflammatory areola, which gradually increased np to the ninth or tenth day, when a ring of secondary small pustules, true satellites of the first, formed upon the inflammatory areola. This pustule of inoculation resembled a kind of large pock which is sometimes found in natural smallpox, and to which Van Swieten, of Vienna, gave the name of Meisterpocken, master- pock, or what Trousseau called le maitre bouton. On the ninth or tenth day after inoculation, the constitutional symptoms used to make their appearance. They were, in a word, all the primary or prodromal symptoms of smallpox. Finally, about the eleventh, twelfth, or thirteenth day, the specific eruption was seen — in general but slightly confluent, following the course of ordinary or sometimes that of modified smallpox. I have given Trousseau's account of the phenomena attending inoculation at this length, because they are exactly analogous to the features presented after successful vaccination. 3. Vaccination (Germ. Kuhpockenimpfung). — About the middle of the eighteenth century the opinion gained ground in England that inoculation with cowpox lymph protected from smallpox. As Dr. E. Crookshank, in his elaborate " History and Pathology of Vaccination," says : — " In some parts of the country a belief existed among those who had the care of cattle that a disease of cows, which they called ' cowpox,' when communicated to the milkers, afforded them protection from smallpox." It is necessary to explain that various domestic animals are liable to a disease which is practi- cally smallpox. Thus, a variety of the grease (Ft. eaux aux jambes) of horses — in which an eruption appears usually on the foot-joints — is properly called " Variola? equina." The " tag-sore " (Fr. clavele'e) of sheep is " Variola? ovince ; " and the well-known '' cowpox," in which the eruption is almost exclusively observed upon the udder and teats of the cow is technically called " Variolat vaccina?" SMALLPOX. 105 Fr. picote), or, shortly, "Vaccina" (the form " Vaccinia" being etymologically incorrect). At a time when the majority of the people were deeply pitted with smallpox, the immunity enjoyed by the comely milkmaids of Gloucestershire and Devonshire from the unsightly scars left by the disease could not fail to attract attention. It was noticed that the dairymaids and farm -labourers were subject to an attack of sores on their hands, which seemed to arise from contact with pustules on the udders of milch cows. Those who suffered from this apparently local malady of sore-hands were observed to escape smallpox. At length, in 1774, Benjamin Jesty, a Gloucestershire farmer, who, however, had been born at Yetminster, in Dorsetshire, became so convinced of the protective efficacy of cowpox against smallpox that he inoculated his wife and two sons with cowpox — thus performing vaccination for the first time, and anticipating Edward Jenner by no fewer than twenty-two years. a On May 14, 1796, Jenner vaccinated a peasant lad, whom he failed to inoculate with smallpox two months afterwards. The crucial test was in this way applied to the efficacy of vaccination as a preventive measure. It would be foreign to my present purpose to linger over the history of vaccination ; nor is it necessary at this time of day to take much trouble to refute the views of the fanatical "anti- vaccination" party. Before the introduction of vaccination, the annual mortality from smallpox in England and Wales alone was at the rate of 3,000 deaths in every million of the population — this, according to the Census of 1891, would correspond to a loss of some 87,000 lives per annum — the population of England and Wales being 29,081,047 in April of this year. What are the actual facts ? In 1890, smallpox caused only 15 deaths in England ; and the average annual number of deaths from this disease in the ten years 1881-90 inclusive, was 1,227*8 — that is, one-seventieth part only of the death-rate of pre-vaccination times. But vaccination has not only diminished the number of cases of and deaths from smallpox — it is also found to influence the death- rate among those attacked to a very remarkable extent. In Sheffield, a See The Lancet, September 13, 18C2. Page 291. 106 SMALLPOX. in the outbreak of 1887-88 already referred to, of 4,151 vaccinated patients, 200 died, or 4-8 per cent. ; of 552 unvaccinated patients, 274 died, or 49*6 per cent. The following Tables are taken from a Report on the Epidemic of 1871-72, as observed in Cork-street Fever Hospital, Dublin, by Dr. T. W. Grimshaw, now Registrar-General for Ireland and Con- sulting Physician to the Hospital* : — Hospitals Cork-street Haidwicke Cork London Smallpox Hampstead (London) Homerton Table II. Mortality per Cent. Vaccinated Unvaccinated General 10-8 71-8 21-6 11-2 78-57 20-0 5-5 58-0 22-5 14-9 66-2 18-8 11-4 51-2 19-36 5-9 37-7 16-3 Table III. — Discrete Confluent Malignant Total Total Died s s Total Died fa Total Died Si Total Died ^ >■ Vaccinated - Unvaccinated 443 17 1 6 0-2 35-1 143 94 46 67 32-3 712 25 24 18 24 71-8 100-0 611 135 65 97 10-8 71-8 Total - 460 7 1-6 237 113 47-6 49 42 85-7 746 162 21-6 Percent, vac- cinated in each class ( 96-3 60-4 51-9 81-8 Of the vaccinated cases in the discrete variety, the mortality a See Manual of Public Health for Ireland. Dublin : Fannin & Co. 1875. Pages 172 & 173. Also Special Report on the Smallpox Epidemic, 1871-73, as observed in Cork-street Fever Hospital, Dublin. By T. W. Grimshaw, M.D. Being an Appendix to the Medical Report of that Hospital for the year ending March 31, 1873. Dublin : John Falconer. 1875. SMALLPOX. 107 was practically nothing (0-2 per cent.), only one patient having died. In that case the patient had inflammation of the lungs, probably quite independent of the smallpox. Of the unvaccinated patients, however, in this class, 35'1 per cent. died. In the con fluent cases the mortality among the vaccinated patients was 323 per cent., while among the unvaccinated it was as high as 7 i*2 per cent. In the malignant or purpuric variety, the mortality among the vaccinated patients was 71*8 per cent., or about the same as among the unvaccinated confluent cases, while in this variety not one unvaccinated case recovered. It may be merely a coincidence of percentage mortality ; but it is a remarkable fact that in the cases under consideration vaccination reduced the mor- tality of confluent cases to that of discrete unvaccinated cases, and that of malignant to that of confluent unvaccinated cases. The proportion of vaccinated to unvaccinated cases in each variety is considerably greater, except in the malignant form, where the proportions are nearly equal. The difference is most remarkable in the discrete variety, where the number of unvaccinated cases is very small — in other words, vaccination prevented a large number of these cases from being confluent. In my " Medical Report of the Fever Hospital and House of Recovery, Cork-street, Dublin," for the year ending March 31, 1879, I give an account of the still more terrible epidemic of 1876-1879, proceeding on very much the same lines as Dr. Grim- shaw's Report. The number of cases with which the Report deals is so large — namely, 1,804 from April 1, 1876, to March 31, 1879 — that the results may be fairly considered conclusive as to the modifying influence of vaccination over (1) the type of the disease, and (2) its fatality. Of 1,003 patients who suffered from discrete smallpox, 943 were vaccinated, and only 60 were unvac- cinated — the percentage of those vaccinated being 94'0. There were 10 deaths — the mortality being one per cent. Among these 10 deaths was that of an infant of 9 months, who was not vacci- na' ed. Seven patients succumbed to the complications of discrete smallpox, dying in or after, not of this disease. Of 604 patients suffering from confluent smallpox, 377 were 108 SMALLPOX. vaccinated and 227 were uuvaccinated — that is, 62*4 only of every 100 patients were vaccinated. There were 243 deaths, the rate of mortality being 40'2 per cent. But of the vaccinated only 22 per cent, died, compared with 70*5 per cent, of the unvaccinated. Of 197 malignant cases, 110 were vaccinated, or 55*8 per cent., and 77 were unvaccinated. The deaths numbered 151, the mor- tality being 76*6 per cent. Of the vaccinated 67 - 2 per cent, died, but of the unvaccinated 88 - 5 died. Of the 1,804 patients in all, who were admitted, 1,430, or 79-2 per cent., were vaccinated, and 374 were not vaccinated. There were 404 deaths, or a mortality of 22-3 per cent. Among the vaccinated 166 deaths occurred, the mortality falling to 11*6 per cent. Among the unvaccinated 238 deaths occurred, the mortality rising to 63 - 6 per cent. In very few instances, indeed, had the patients been revacci- nated, probably not in more than 5 of the whole 1,804 cases. Many years ago Mr. Marson, of the Smallpox Hospital, London, showed as a result of his examination of 5,000 cases, between 1836 and 1855, that the number of vaccinal cicatrices seem to influence the mortality from smallpox. The death-rate among patients having only one cicatrix was 7*73 per cent. ; that among those who had two cicatrices was 4*7 ; that in the presence of three cicatrices was 1*95, and that with four or more cicatrices was only 0*55 per cent. There can be no doubt that the protective efficacy of vaccination wears out gradually with the lapse of time. Periodical revacci- nation every seven or ten years is, therefore, necessary if small- pox is to be completely prevented, any case where revaccination at stated intervals has failed being always of a most peculiar nature. That vaccination has in rare instances done harm cannot be dis- puted. Unsuitable subjects have been vaccinated, or the lymph has been taken .from improper sources ; a but such mishaps afford no valid argument against the practice of vaccination, however much they may lead us to call in question the skill and care of the operator in each untoward case. a Grimshaw. Loc. cit. SMALLPOX. 109 The circumstances which conduce to the success of the operation are briefly the following : — 1. The subject to be vaccinated should be healthy. Special provision is made in the Vaccination Act for postponing the operation if the individual is not quite well. The presence of skin diseases and the propinquity of scarlet fever or erysipelas forbid the operation. The periods of teething and of weaning should be avoided for the performance of vaccination. 2. The vaccinifer should also be healthy, vaccinated for the first time, and, above all, free from any syphilitic taint. The best age is from 5 months to over a year old ; but vaccination may be, and — in epidemic times — should be, performed much earlier. In 1878, smallpox raging at the time, I vaccinated one of my own children at the age of three weeks successfully and without any untoward result. 3. The lymph should be taken between the fifth and eighth days. As a French medical poet, Casimir Delavigne by name, quoted by Trousseau, sings :— " Puisez le germe heureux dans sa fralcheur premiere Quand le soleil cinq fois a fourni sa carriere." " Draw forth the auspicious germ in its first freshness, When the sun has five times completed his course." The eighth day, inclusive, is generally selected in the United Kingdom as that of inspection. 4. The incisions, or scarifications, should not penetrate to the subcutaneous areolar tissue. They should be made with a scrupulously clean instrument. 5. Bleeding should be avoided as much as possible, lest the lymph should be washed away from the site of inoculation. Blood should not be drawn when piercing the vesicle to obtain the lymph. 6. Jenner's "golden rule" should always be observed, and that is — not to use lymph from a vesicle which has already showed the " areola," or inflammatory ring which forms around the vaccine vesicle at the beginning of the second week. 110 SMALLPOX. 7. A thin, serous, readily-flowing lymph should not be used. Good lymph is perfectly limpid and viscid or sticky. Whenever practicable, the lymph, which may be bovine or humanised, a should be carried directly from arm to arm. This, however, is often impossible, and so the lymph must be preserved for future use. The old-fashioned method was to allow the lymph to dry in a thin film on flat ivory or bone points. A much better plan is to preserve the lymph in hermetically sealed capillary glass tubes. Miiller, of Berlin, usually mixes the lymph carefully with two parts of glycerine and two parts of distilled water (by means of a small brush) in a watch glass, and preserves this diluted vaccine lymph in air-tight capillary tubes. The activity of the lymph is not impaired by this procedure, and the precious virus is economised. Vaccination is generally done upon the outside of the left arm — in girls, at the place where the scars will be as far as possible hidden by the future evening dress. At least two sets of minute punctures or scarifications are made with a vaccinating needle or lancet, moistened or "armed" with the lymph, at each side of the deltoid muscle as it passes down to its insertion on the outer aspect of the humerus. A little of the lymph should afterwards be rubbed into the punctures. Various instruments for vaccination have been designed, one of the neatest and best being Rose's " vaccinator." This ingenious little instrument consists of a lancet-blade at one end, and a series of prodding or "tattooing" needles, arranged like the five of dice, at the other. A rotatory movement projects the needles from the case, causing them to puncture the skin, and the lymph can then be rubbed in from the surface of the lancet. According to Hebra, the most satisfactory instrument is a lancet having one surface convex, the other hollowed and pre- senting a groove to which a drop of the lymph adheres. Another instrument, called by the Germans Impffeder, or Vaccine-pen, resembles a drawing pen, and consists of two parallel limbs with cutting extremities, between which the lymph is taken a That is, derived from the heifer or from a human being already vaccinated. SMALLPOX. Ill up by capillary attraction. In employing this instrument the vaccine matter is introduced beneath the cuticle by a horizontal or vertical incision (Hebra). Sir Thomas Watson a says that a very ingenious test, free from all ambiguity, by which we determine whether the cowpox is runniug its proper course or not, was devised by Mr. Bryce — hence called "Bryce's test." His plan was this. He vaccinated the other arm, or some other part of the body four or five days after the first vaccination. If the system had been properly affected by the first operation, the inflammation of the second vesicle would proceed so much more rapidly than usual that it would be at its height and would decline and disappear as early as that of the first : only the vesicle and its areola would be smaller. One of the earliest disciples of Dr. Jenner, Mr. Hicks, used in a doubtful case to repeat vaccination in a few days after the first operation, and he remarked that the second vesicle made " immense strides to overtake the first." Vaccina. — The symptoms of this affection are first local and then constitutional — the latter in most cases being very slightly marked. On the third day (inclusive) a patch of redness at the site of vacci- nation appears and rapidly develops into a papule or pimple, which in its turn, about the fifth day, becomes surmounted with a pearly vesicle, multi-locular, oval or circular in outline, with raised margin and depressed centre. This vesicle enlarges, while its contents also increase — remaining, however, clear as crystal — until the eighth day, when it attains its perfect growth. An inflammatory red zone, called the " areola," now develops, beginning round the base of the vesicle and thence spreading out, perhaps to a dis- tance of two or three inches. After the tenth day the areola fades, and the vesicle begins to shrink and dry up in the centre. The contained lymph^ becomes opaque and thickens. By the four- teenth or fifteenth day a hard, dry, brown scab forms, which finally separates and falls off about the twenty-first day. A circular, slightly depressed, foveate (or pitted) cicatrix remains, which — except in rare instances — is permanent through after-life. a Loc, cit., page 792. 112 SMALLPOX. During the earlier stages, the vaccine vesicles should be relieved from any pressure or friction, which might increase inflammatory action. In all cases, the vaccinated person should be seen on the eighth day — the day week — from the operation, when a certificate of successful vaccination may be given if the vesicle is well-formed and running a natural course. The constitutional symptoms are — slight pyrexia from the fourth day, becoming more marked from the eighth to the tenth days ; often derangement of the stomach and bowels during the stage of areola, with restlessness. The axillary glands may also swell, and rashes may show upon the skin — either a blush ( Vaccinal Roseola), or a crop of papules ( Vaccinal Lichen), or a vesicular rash ( Vaccinal Herpes). In normal cases all these symptoms subside in a few days, or they may fail to appear at all. Vaccino-Syphilis. — The inoculation of the syphilitic virus along with vaccine at the time of vaccination is, in the words of Dr. C. E. Shelly, the writer on the subject in Fowler's Dictionary of Practical Medicine, " the most lamentable accident by which care- lessness or misfortune can prejudice the performance of vaccina- tion." Since the incubation period of syphilis — namely, from three to five weeks — is much longer than that of vaccina, the latter affection usually runs its course before the local inflammation which constitutes a specific chancre begins. This is attended by the usual glandular enlargement {axillary bubo) and is followed in due course by the recognised secondary symptoms of constitutional syphilitic infection. If the precautions in the performance of vaccination described in the foregoing pages are strictly carried out, it is simply impossible that the disgraceful accident of simultaneously inoculat- ing syphilis can occur. 113 CHAPTER XL The Curative Treatment of Smallpox. No specific for Smallpox — two great Principles of Treatment : (1) to guide the essential disorder, (2) to combat secondary affections. — "Hot Regi- men " treatment of olden times. — Thomas Sydenham's "Cooling Regimen." — Treatment of Discrete, Confluent, and Hsemorrhagic Smallpox. —Two dangers in Confluent Smallpox : general blood-poisoning, and exhaustion. — Antiseptic Treatment. — Prevention of "Pitting." — Dr. Stokes's views. — Three Indica- tions for Treatment : (1) to exclude air, (2) to keep the surface in a perma- nently moist state. (3) to lessen the local irritation. — Hebra's Treatment by the Warm Bath. — Dr. Stokes's account of this method. — Hebra's apparatus for the Continual Bath. — Treatment of Affections of the Skin in Smallpox, and of the various Local Affections. — Turpentine and Ergot in Haemorrhage. — Trans- fusion of Blood. The superscription of this Chapter is in one sense somewhat mis- leading. No physician has ever yet cured a case of smallpox. No specific for the disease or for its many complications and sequela? has as yet been discovei*ed. Accordingly we must be content to set before us two great principles of treatment — first, to guide the essential disorder to a favourable termination ; and, in the next place, to combat secondary affections as they arise. There can be no doubt that the mortality from smallpox was enormously increased during the Middle Ages by mistaken and ignorant treatment. The old physicians did all they could to pro- tect the patient from cold and to promote a copious eruption, adopting the vulgar maxim that i' it was better out than in." In the fourteenth century flourished John of Gaddesden, author of a curious book entitled Rosa Anglica, court physician of the day, but " a very sad knave," as Sir Thomas Watson calls him. This repre- sentative physician of the Age not only put the unhappy smallpox patient on a "hot regimen," administering wine and cordials, piling on bed-clothes, and jealously excluding every breath of fresh air from the sick-room, but surrounded the half -suffocated victim with red curtains, red walls, and red furniture of all kinds — for in this colour there was, he pretended, a peculiar virtue. I 1 14 SMALLPOX. To the celebrated Thomas Sydenham, who lived in the seven- teenth century, belongs the credit of substituting for this barbarous and disastrous system of treatment the opposite or "cooling regimen" in smallpox, and this practice is pursued to the present day with the happiest results. Premising that the reader has mastered the general principles of treatment of the specific fevers laid down in Chapters IV. and V., I will proceed to consider what further measures should be adopted in the case of Smallpox under its three chief forms — Discrete, Con- fluent, and Malignant or Hemorrhagic. Discrete. — The patient, having been placed in bed in a large, airy and well- ventilated, but warm room, should be carefully and skilfully nursed : his hair should be cut close, his hands and face should be washed daily, or twice a day, with warm carbolised water, from 1 to 2 per cent, in strength, or with a weak solution of corrosive sublimate (1-2000). Warm baths are very useful and refreshing. The water may, with advantage, be tinged with per- manganate of potassium solution, bearing in mind, however, that this is decolourised at once and rendered inert by soap. Confluent Smallpox. — The pain in the back may be relieved by dry cupping, or by the application of an India-rubber bag filled with hot water, or by a hypodermic injection of ergotin. An ice- bag applied to the head will often control headache. In all the severer forms of the disease, the patient should not be allowed to assume the upright position for fear of syncope, which is especially likely to come on after a free evacuation of the bowels. In confluent smallpox the patient is beset by two dangers in par- ticular — general blood-poisoning from the intense and widespread suppuration, and exhaustion from pain, sleeplessness, delirium and long-continued fever. To check the development of a copious eruption antiseptics have been recommended and tried, but with no striking or even satis- factory results. One of the best and fullest accounts of the anti- septic treatment of smallpox will be found in a paper by my colleague, Dr. Arthur Wynne Foot, Physician to the Meath Hospital, in Vol. LIII. of The Dublin Journal of Medical Science, pages 242, SMALLPOX. 115 ct seq. The way in which he endeavoured to carry out this treatment in the wards of the Meatli Hospital during the epidemic of 1871-72 was by giving carbolic acid internally in the shape of the sulpho- carbolate of sodium (in doses of from 7 grains occasionally to 60 grains in water every third hour), or — when more suitable — the sulpho-carbolate of iron ; by giving the sulphurous acid of the British Pharmacopoeia, diluted with water — one drachm in a wineglassful or two of iced water — as the usual drink ; by spraying the larynx with it, and washing the nares and upper surface of the palate with solutions of sulphurous or of carbolic acid ; by keeping carbolised oil to the face; by washing the body with solutions of sulphurous acid or of vinegar and water ; by throwing pure sulphurous acid about the bed and bed-clothes of the patient; and by burning sulphur in the sick-room. My own experience is that in quinine and in perchloride of iron we possess the two most valuable antiseptics for internal use so far as smallpox is concerned. Quinine may be given in 5-grain doses thrice daily or oftener. This dose 7nay be administered in water with just enough dilute hydrochloric acid to dissolve it, or with dilute hydrobromic acid and water, or mixed with fresh milk when three grains of powdered camphor may with advantage be added to each dose. Either the tincture or the solution of ferric chloride may be given in 20 to 30 minim doses, with glycerine (3 ss.) and water (3 vii.), and perhaps a few minims of liquor strychninas hydrochloratis. If we possessed any certain means of checking the development of a confluent rash in smallpox, much distress and even danger to life in the first instance, and later on permanent disfigurement would be avoided. In a characteristic paper entitled " Some Notes on the Treatment of Smallpox," to which allusion has already been made, a Dr. William Stokes pointed out that the virulence of the pustulation and the tendency to pitting are directly as the cutaneous vascularity and heat of surface. In proof of this Stokes instanced the case of a strong and healthy young woman, who was admitted to hospital with symptoms of fever, including intense headache. ° See Chapter VIII., page 84. 1 1 6* SMALLPOX. For the relief of tins symptom she was leeched freely on the temples. The attack proved to be one of confluent smallpox, but on the face not more than two or three small aborting pustules made their appearance. " Who can doubt," asks Stokes, " that in this instance the depletion of the face influenced the local progress of the disease." Again, he quotes a case commented on by Dr. Graves — that of a man who contracted smallpox while under treat- ment in one of the surgical wards for a chronic affection of the knee-joint. The affected joint was strapped with mercurial plaister, which exerted such pressure on the neighbouring cutaneous capil- laries as absolutely to prevent the development of the eruption over the part. In a third case of severe confluent smallpox there was great tumefaction, accompanied with extraordinary heat of the face, and, in the hope of saving the eyes, poultices were applied over them. The patient recovered, but with deep and permanent pitting. There was, however, no pitting on the eyelids or in their immediate neighbourhood. From the date of this last case (1849) Stokes adopted as a routine practice the application of light poul- tices over the entire face, or of a mask of lint steeped in glycerine and water and covered with a corresponding mask of oiled silk. He found that, with but one exception, pitting was effectually prevented. In that case the patient was delirious, and could not be kept from tearing the poultices off his face. As the outcome of his observations, Stokes came to the conclu- sion that, if from an early period we protect the surface from the air and keep it in a permanently moist condition, marking will seldom occur. There are then three important indications of treat- ment : — 1. The exclusion of air. 2. The keeping of the parts in a permanently moist state, so as to prevent the hardening of the scabs. 3. The lessening of the local irritation. All the authorities are agreed that these indications should be as far as possible fulfilled. Dr. Charles West recommends strapping with mercurial plaister or sponging with a solution of corrosive sublimate, apparently attributing a specific action to the mercury in SMALLPOX. 117 each case. But for this there seems to be no warrant. Dr. Alfred Hudson used to smear the face with glycerine. Sir John Banks, K.C.B., many years ago suggested the application of an ointment composed of lapis calami nar is (native impure carbonate of zinc) and glycerine. Dr. Foot applied to the face carbolised oil — varying in strength from 1 in 4 to 1 in 8 parts ; he also recommended the application of flexible collodion to the papules as early as possible, for its late application only does mischief, forcing the pus to burrow backwards into the cutis, so increasing the der- matitis and insuring pitting. Mr. Marson, of the London Small- pox Hospital, waited until the pustules had burst and the discharge had begun to dry. He then applied the best olive oil, or a mixture of glycerine and rose water in the proportion of 1 in 3. He also recommended " cold cream," or oxide of zinc ointment, or olive oil and lime water (linimentum calcis, or " Carron oil ") or calamine mixed with olive oil. Curschmann speaks highly of the value of cold — even iced — compresses frequently renewed for the relief of pain, swelling and redness of the skin. The American practice to prevent pitting is exclusion from the room of the solar light and the application of a solution of boric acid (1 drachm to 1 pint of water) by means of compresses, frequently changed, or covered with oiled silk. In Germany a paste — composed of carbolic acid, 4 to 10 parts; olive oil, 40 parts; and prepared chalk, 60 parts — is spread on linen and applied to the parts where the eruption is apt to be worst. This application should be changed every twelve hours. 3 Dr. Lewentauer b suggests the application to the face by means of a mask, and also to the other parts on which the eruption is marked, of an ointment consisting of salicylic acid, 3 parts ; starch, 30 parts ; and glycerine, 70 parts. Bertrand c recommends the application, with a brush, as soon as a Outlines of Medical Treatment. By Samuel Fenwick and W. Soltau Fenwick. Third Edition. London : J. & A. ChurchilL 1891. Page 449. b Bulletin Oen. de Thcrapeutique. No. 32. 1889. Gazette des Hdpitaux. Paris. July 15 and 17, 1890, and Sajous' Annual of the Universal Medical Sciences. 1891. Vol. I. H.— ?2. 118 SMALLPOX. the eruption appears either on the face or in the pharynx of a mixture of 4 grammes (1 drachm) of boric acid to 50 grammes (1^ ounces) of glycerine. The eyes, meanwhile, should be bathed with a tepid saturated solution of boric acid. Talamon 3, applies ethereal solutions of various antiseptics by means of a spray apparatus. Salol does well only when the rash is slight and scanty ; in all cases corrosive sublimate is to be pre- ferred. He sprays the part for a minute 3 or 4 times a day — until desiccation takes place — with a solution consisting of corrosive sub- limate and citric acid, of each one gramme (15*432 grains), alcohol (90 per cent.) 5 cubic centimetres (80 minims), and ether, suffi- cient to make 50 cubic centimetres (1^ ounces). The eyes should be guarded during the application. Skoda prefers compresses moistened with solution of corrosive sublimate (gr. 2-4 to water §vj.). Hebra applies only cold water compresses. My own plan is to apply over the face a light mask of lint thoroughly soaked in a mixture of iced water and glycerine (a teaspoonful in an ounce of water) and covered with oiled silk. Closely akin to these various measures for lessening the irritation of the surface, keeping the eruption moist, and excluding air, is the treatment of smallpox by the warm or tepid bath. In his classical "Essay on Fevers," b Dr. John Huxham advises bathing not only the legs and feet but the arms and hands — " nay, and even the trunk of the body also," in certain cases of smallpox. His object, it is true, was to bring out the eruption well. He adds : " This is not altogether a new method : for Rhazes c advises the patient to be kept in a kind of Balneum Vaporis, to facilitate the eruption." Hebra appears to have had his attention drawn to the treatment of smallpox by the warm bath through observing its efficacy in the management of burns. In his practice in the Vienna General a La Medecine Mcderne. Paris. April 17. 1890. And Sajous' Annual of the Universal Medical Sciences, 1891. "Vol. 1. H. — 71. b London : -T. Hinton. 1764. Pages 137-138. c Vide Rhazes de Variolis et Morbillis. Cap. vi. Ex editione Mead. SMALLPOX. 119 Hospital patients suffering from extensive burns have been kept in the warm bath continuously for one hundred days with good effect. "It is clear," says Dr. Stokes, "that in the case of the continued warm bath we have the conditions just mentioned completely ful- filled, and that, too, as regards the entire person of the patient." In the paper from which I have so largely quoted, Dr. Stokes details a case in illustration of the use of the warm-bath treatment of bad smallpox. So graphic and striking as a word-picture is this clinical record that I know I shall be excused for transcribing it at length : — " Not many years since," wrote Dr. Stokes (in 1872), " one of our students, a very large and robust man, was attacked with smallpox, which soon showed itself in its worst characters. The fever at first was very hijjh, and the head-swelling and vascu- larity of the face intense. The eruption was universal, while the pustules on the face became confluent at an early period. " Delirium set in, and the patient tore off the dressings from his face so often that we desisted from their further application. After the tenth day the condition of the patient was most appalling. The delirium continued, the circulation became every day weaker and more rapid, notwithstanding the free use of stimulants ; the crusts were not only black, but on the legs where here and there there was less confluence, the blackness of the worst purpura appeared — a condition held by Hebra to be always fatal. The body was one universal ulcerous sore, and the agonies of the patient from the adhesion of the surface to the bed-clothes were not to be described. In addition to the usual foetor of smallpox in the stage of decrustation, which was present in the highest degree, there was an odour of a still more intensely pungent and offensive character, which seemed to pass through the bystander like a sword. I never before or since experienced anything similar. Stimulants alone, freely and constantly employed, seemed to preserve the patient alive ; the pulse was rapid, weak, and intermittent, and for several days we despaired of his life. "At this juncture I happened to describe the case to my col- league, Mr. Smyly, who suggested the trial of the warm bath, with the view of relieving the terrible suffering. A bath in which he 120 SMALLPOX. could recline was speedily procured, and, pillows being adjusted in it, we lifted the sufferer in and placed him in the recumbent position. The effect was instantaneous and marvellous. The delirium ceased as if by magic ; it was the delirium of pain, and the patient ex- claimed, ' Thank God ! thank God ! I am in Heaven ! I am in Heaven ! why didn't you do this before ?' The fcetor immediately and completely disappeared, so that on entering the ward no one could suppose that there was a case of smallpox in it. He was kept at least seven hours in the bath, during which time brandy was freely administered, and omitted only when he showed sym- ptoms of its disagreeing with the brain. He was then removed to bed. The surface was clean, and in many places the sores looked healthy and white. The bath was repeated next day, after which he fell, for the first time, into a tranquil slumber. From this time his recovery was progressive, delayed only by the formation of abscesses and the great soreness of the feet. " That this gentleman's life would have been sacrificed but for the timely use of the bath, few who have had any experience in prognosis can reasonably doubt. He was in the condition of a patient every portion of whose skin had been burned and ulcerated. The pustulation was almost universally confluent ; the purulent matter highly putrescent ; the hemorrhagic state developed, and the nervous system suffering — in fact, he had every symptom of the worst putrid absorption. " This case," adds Stokes, " and its singular result, in addition to the experience of Hebra, justifies the recommendation of the use of the bath." In a discussion on the treatment of smallpox at the Medical Society of the College of Physicians of Ireland, on March 20, 1872, Dr. Hawtrey Benson, Physician to the City of Dublin Hospital, detailed a very similar case to the foregoing. a The patient was kept in a slipper-bath, at a temperature of 98° F. for five hours and a half. He was then put to bed perfectly free from delirium, and, with the help of 15 grains of chloral (of which 60 grains had previously had no effect), he slept uninterruptedly for a Dublin Journal of Med. Science. Vol. MIL, page 325. 1872. SMALLPOX. 121 eight hours. The case progressed from that time forward without the slightest check. Professor Hebra's apparatus for the continual bath was exhi- bited in the London International Exhibition of 1862. It was also fully described, with an illustrative plate, in the Wiener allgemerne med. Zeitung, No. 43, 1861, as well as in the inventor's work on " Diseases of the Skin," translated for the New Sydenham Society in 1866 by the late Dr. Hilton Fagge (Vol. I., page 320). The apparatus consists of a bath, six feet long by three feet broad, made of wood and lined with copper or zinc. Exactly fitting its interior is an iron frame to which are fastened transverse bands of webbing, as in an ordinary bed. About two feet from one end of this frame is attached a head-support, which moves on a hinge and can be fixed at any angle by a simple piece of rack-work. The frame is covered with a blanket and is also provided with a horse- hair pillow ; it does not rest on fixed supports, but is suspended in the bath by cords attached to it at each end. These cords pass over two small rollers, placed one at the head, one at the foot of the apparatus and provided with handles, so that the whole bed can easily be raised or lowered within the bath. At the head of the bath, but at a higher level, is a vessel made of copper, which can be heated so that the water may be supplied at any required temperature. The supply pipe enters the bottom of the bath, the escape-pipe opening into it at the water-level. When the apparatus is in use water is kept flowing constantly through it, so that all impurities are rapidly washed away. To enable the face to be kept continually wet, or to be specially irrigated, additional small tubes, each provided with a rose, are connected with the copper vessel or reservoir. Before the patient is placed in the bath, it is filled with warm water, at a temperature of 90° to 100° Fahr., according to his inclination. A wooden cover, upon which a blanket is spread, is put over the lower part of the apparatus while the patient is in the bath. If it is desired that the head also should be covered, this is easily managed by roofing in the head of the bath by means of hoops upon which blankets are placed. 122 SMALLPOX. Four of these baths were put up in the General Hospital of Vienna under Prof. Hebra's supervision. The treatment of such affections of the skin in smallpox as bed-sores, abscesses, boils, erysipelas, and gangrene, consists largely in scrupulous cleanliness and efficient nursing. The body linen should be frequently changed. The patient should lie on a water- bed, or a woven-wire mattress, since the introduction of which into our hospital wards bed-sores have become much less common than before. The intense pain which attends the formation of pustules upon the soles of the feet and the palms of the hands is due to the thickness of the epidermis, which is with difficulty raised by the exudation and thus causes a counter-pressure on the cutis. Our object then should be to keep these parts moist and therefore soft, and this is effected by wrapping the feet and hands in wet cloths covered with oiled silk or gutta percha tissue as recommended by Hebra. a If this is done, no disagreeable sensa- tions are felt. Writing in 1764, Huxham said: "I would recom- mend also bathing the feet and legs in warm water, or milk and water, for a few minutes, two or three times a day before and at the eruption, and would likewise have cataplasms of milk and bread, b'tiled turnips, or the like, applied to the feet." b He did this '' to make a very powerful revulsion from the head and breast." The eyelids should be poulticed to reduce oedema, or kept covered with cold compresses. For atrophic keratitis cod-liver oil, iron, wine, and good food are indicated. Affections of the mouth, tongue, and pharynx are best treated with ice, antiseptic sprays of sulphurous acid, chlorinated soda solution, corrosive sublimate solution, or Condy's fluid well diluted, antiseptic gargles of quinine, chlorate of potassium, boric or lactic acid, carbolic acid, and so on ; linctuses of glycerine of tannin or of carbolic acid, boric acid, &c. In cases of laryngitis the internal use of ice is invaluable. Hot poultices should be slung round the neck and kept smeared with glycerine of carbolic acid or a 2^ per cent, carbolised oil. a Diseases of the Skin. New Syd. Soc. 1866. Vol. I., page 266. b Essay on Fevers. Page 136. SMALLPOX. 1 23 In the early stage leeches may be applied to the angle of the jaw. In like cases in scarlatina Graves recommended the application of relays of sponges wrung out of hot water to the front of the neck for 15 or 20 minutes at a time. Above all, the steam kettle should be kept going and the patient should be placed in a croup-tent and well supported by food and stimulants. In acute oedema of the glottis, Curschmann advises that an emetic should be given, if the patient is strong enough, or local scarifications or trache- otomy may be employed. The same measures as those advised for laryngitis may be adopted in bronchitis or other affections of the respiratory tract, in addition to dry-cupping (if the rash is not thick-set) and poul- ticing. Diarrhoea is often controlled by a starchy diet and brandy or port wine, and by poulticing the abdomen. If not, solution of pernitrate of iron may be prescribed, or pills of acetate of lead and opium, or — in the case of children — aromatic chalk powders. In cases of sleeplesssness and delirium, the hair should be cut close or the head shaved, ice may be applied as recommended by Stokes, unless there is much depression, and stimulants often agree. The drugs mentioned in Chapter V. may be prescribed according to circumstances. Attendants upon smallpox patients should always be on their guard against homicidal or suicidal attempts. Curschmann recommends that chloral hydrate should be admi- nistered by the rectum, in an enema containing from one and a half to two drachms, with eight ounces each of water and of mucilage. He says that variolous affections of the pharynx and larynx may be dangerously intensified by this drug. Lastly, while only too often it happens that all our efforts to combat hemorrhagic smallpox are in vain, we yet may save life by the administration of the solution or tincture of ferric chloride in full doses — 30 minims every third hour, or of gallic or tannic acid in 5 to 10 grain doses, or of pyrogallic acid, in one grain doses, or of ergot (ounce-doses of the infusion or 3 grains of ergotin dissolved in glycerine and water, the latter dose being given hypo- dermically if need be), or— best of all— of turpentine and ergot. 124 SMALLPOX. The formula for the last combination which we used at Cork-street Hospital was as follows : — 1^. Extract. Ergotse Liquidi, 3i>i ; Olei Terebinthinaa, 3iii 5 S[)t. vEtheris Nitrosi, 3ii 5 Spt. Rectificati, §i ; Ovi Vitellum ; Aquae Menth. Piperita?, ad gviii. Signa : One eighth part every 3rd, 4th, or 6th hour, as required. At Cork-street Hospital, also, in menorrhagia and metrorrhagia, cold to the vulva was of use, also slapping the buttocks with cloths dipped in ice-cold water. In several cases, hot water injected into the vagina, as recommended by Dr. Emmett of New York — the temperature of the water being from 98° to 110° F. — and cordially approved by Dr. Lombe Atthill, seemed to do good. In these awful cases, stimulants are imperatively called for — brandy, whisky, or wine according to circumstances, and especially " egg-flip " mixture and " turpentine punch." Curschmann recom- mends a further trial of transfusion of blood, which, he admits, has so far disappointed expectation. 125 CHAPTER XII. Varicella, or Chickenpox. Nomenclature. — Derivation of the term " Chickenpox." — Definition. — ^Etiology (historical sketch). — Clinical History : Incubation, Invasion, Erup- tion, Desiccation. — -No secondary Fever. — Not a fatal Disease. — Complications and Sequelae : Varicella gangrenosa (Jonathan Hutchinson). — Dermatitis gangrenosa — " Varicella-prurigo " (J. Hutchinson). — Diagnosis from Lichen, Herpes, Pemphigus, and Varioloid. — Prognosis and Treatment. Nomenclature. — Chickenpox. — Synon. : — Varicella, Crystalli. Germ, die Wasserpocken, Windblattern, or die fliegende Blatter ; Fr. Petite verole volante, La Verolette (Hatte), or Varicelle ; ltd. Ravaglione ; Eng. Waterpock or Glasspock. The term Chicken- pox is supposed by Dr. Hilton Fagge to be a corruption of Chick- pease, the French Pois chiches, dwarf-peas, or briefly Chiche from the Latin Cicer, the chick-pea. Definition. — An acute specific and highly infectious febrile disease, especially of infancy and early childhood, not dangerous to life, characterised by the appearance on the skin of successive crops of clear, colourless, watery vesicles. It is a separate and distinct disease from smallpox — a disease sui generis. The accompanying fever is moderate as a rule and of a remittent type, increasing and abating with the coming and going of the vesicular rash. ^Etiology. — Varicella is essentially a disease of childhood, and usually occurs before the first dentition is completed. Even suck- lings may be attacked, but among children over ten years of age the disease is infrequent. Thomas, a of Leipzig, never saw an adult suffering from varicella. Baader, b of Bale, carefully noted 581 cases — 382 occurred in children aged from 1 to 5 years ; 191, from 6 to 10 ; 7, from 11 to 15 ; 2, from 16 to 20 ; and 2 (?), from 20 to 40. Two years ago, a friend of mine, aged 25 years, himself a member of the medical profession, had in Dublin a well-marked attack of varicella. a Von Ziemssen's Cyclopaedia of the Practice of Medicine. Vol. II. Acute Infectious Diseases. Art. "Varicella." 6 Jahrbuch fur Kindirheilkunde. XVII., page 104. 126 CHICKENPOX. Varicella shows itself sporadically (in isolated cases) or in moderate and often-repeated local epidemics quite independently of smallpox. In Germany, Thomas says it appears yearly or even twice a year with great regularity shortly after the opening of the " Kinder-garten," or Infant-schools. Its appearance is not deter- mined by season, but it often follows in the wake of other specific fevers — scarlatina especially. It is supposed that the virus is generally inhaled. Its tenacity of life does not seem to be great : hence, perhaps, the limited spread of its epidemics. The contents of well-marked varicella vesicles have been inoculated with negative results by Heim, Vetter, Czakert, Fleischmann, and Thomas, in Germany; Boyce, in Edinburgh ; and J. Lewis Smith in America. Hesse, of Leipzig, occasionally succeeded in inoculating varicella, and Steiner was also successful in 8 out of 10 cases reported in the Wiener med. Wochen- schrift, No. 16, for 1875. In marked contrast with its practical non-inoculability stands the facility of its dissemination among little children by contagion. As a rule chickenpox does not recur, but Trousseau says that second attacks are not uncommon, and Gerhardt is said to have seen it recur for the third time. The nature of the specific virus of varicella is as yet unknown. Dr. A. Tschamer a claims to have isolated a hitherto unknown micrococcus, which he considers stands in a causal relation to the disease. But no definite conclusions have so far been arrived at. The earliest authentic descriptions of varicella date from the middle of the sixteenth century. About the year 1550 two medical writers, Vidus Vidius and Ingrassias of Naples de- scribed the disease under the name " Crystalli," in reference, no doubt, to the clear, crystal-like contents of the chickenpox vesicles. The Italian synonym was Ravaglione. The malady was first fully described and differentiated in England by Heberden in 1766 under the name of " Variolse pusillse." His paper was published in the first volume of the "Medical Transactions of the Royal College of Physicians," 1767. In it he pointed out the chief reason which made the recognition of chickenpox a matter of importance — a Archiv. f. Kinderheilkunde. Band II. Heft 3. CHICKENPOX. 127 namely, that those who had it might otherwise be deceived into a false security " which mipht prevent them either from keeping out of the way of the smallpox or from being inoculated" (Hilton Fagge). Two years previously, in 1764, Vogel is said to have introduced the name of "Varicella," which, like " Variola," is a diminutive of the Latin varus, a pimple. Clinical History. I. Stage of Incubation. — The stage of latency is believed to be on an average about as long as that of smallpox — namely, 12 days. Makuna a states that it varies from 8 to 17 days. Bristowe says b that in some cases it lasts exactly a week, but perhaps more com- monly a fortnight. According to Thomas it varies from 13 to 17 days, while Trousseau extends its duration to from 15 to 27 days. On the other hand, Gregory limited it to from 4 to 7 days. The discrepancy, in Dr. Hilton Fagge's opinion, arises from the fact that the length of the incubation has in general been calculated upon the veiy precarious basis of the interval between the dates at which different children of the same family have been successively attacked. Towards the close of this stage there is, according to Thomas, in some cases a slight rise of temperature. II. Stage of Invasion. — This stage, also called that of the "Prodromal Fever," is badly marked in varicella. It often happens that the child feels perfectly well until the rash appears. In other cases, however, malaise, loss of appetite, a feeling of sick- ness, headache, chilliness, and muscular pains precede the eruption by a few hours, or one to even three days. The "Prodromal Fever" is usually very slight, but occasionally a sudden rise of temperature to 101°, or — in severe cases — even to 104° takes place just before the rash appears. Once Thomas observed a transitory general erythema with a temperature above 106° F., but such an occurrence is quite exceptional. III. Stage of Eruption. — This may be ushered in by a roseolar scarlatiniform rash, but the true eruption consists of papules or measles, like the rose spots of typhoid (Trousseau), and deleble on a Lancet, Vol. II., page 350. 1375. h Theory and Practice of Medicine. Seventh Edition. 1890. P. 186. 128 CHICKENPOX. pressure (Gee), which rapidly change into vesicles. These do not, under ordinary circumstances, become pustular and are unaccom- panied by an inflammatory areola. The vesicles appear first on the trunk, especially the chest, then on the face and scalp, finally on the limbs. They increase in size up to the third or fourth day, when they are about as large as split peas. They become acum- inated or conoidal, and finally burst, shrivel, and dry up. They are not markedly umbilicated and are said to be not divided into compartments (loculi) like the pustules of smallpox. According to their shape, they were described by Willan and Bateman, in their work on Skin Diseases, published in 1806, as lenticular, conoidal, or globate. They contain a clear, watery, but afterwards straw- coloured lymph. Dr. Hilton Fagge describes the vesicles as sometimes having a red base, but sometimes being seated upon a perfectly colourless surface, so that the patient looks exactly as if he had been sprinkled with drops of clear water. When air exists under the roof of the vesicle, it has always entered through some aperture from without (Varicella ventosa, emphysematosa; Windpox). The visible mucous membranes, as well as the skin, are the seat of an eruption. Thus, vesicles are not uncommonly seen on the buccal mucous membrane, the hard and soft palates, the throat, lips and tongue, the conjunctiva? and gums (Henoch), and the genital mucous membrane in girls (Thomas). The febrile movement is not acute — indeed in some very mild cases there is a complete absence of fever. Usually, however, the fever is remittent, increasing at night (Trousseau), and in propor- tion to the amount of the rash, which may continue to come out in successive crops for even 10 or 12 days. In Willan and Bate- man's Delineations of Cutaneous Diseases there are two very good Plates illustrative of these appearances. Defervescence, when it occurs, is usually rapid (Hilton Fagge). IV. Stage of Desiccation. — This stage, or process, varies in duration owing to the development of the eruption in successive crops of vesicles. In the case of individual vesicles, desiccation takes place rapidly, the vesicular contents being partly absorbed CHICKENPOX. 129 and partly extravasated through bursting of the vesicle. A pit, or scar, may be left when the vesicle has become a pustule. A good example of this is represented in Plate XXXII. of the New Sydenham Society's Atlas of Skin Diseases. Unless in very rare instances, there is no secondary fever, and the disease — if uncomplicated — seldom or never destroys life. According to Trousseau and Canstatt, relapses in varicella are frequent, but Thomas never saw a true relapse — that is, the renewed appearance of the disease in its totality, and he rightly looks upon cases of so-called relapse as being really examples of recurrent crops of the rash. Complications and Sequelae. — These may almost be said not to exist, but in a communication to the Royal Medical and Chirurgi- cal Society on Tuesday, October 25, 1881, Mr. Jonathan Hutchinson, F.R.S., drew attention to a formidable and very dangerous, though happily rare, variety of the disease, to which he gave the name of "Varicella gangrgenosa." This malady, according to him, was well-known in Ireland in past times under the names of the " White Blisters," the " Eating Hive," and the "Burnt Holes." In proof of this, reference was made to a paper written by Dr. Whitley Stokes, of Dublin, in 1807, in which he proposed for the disease the name of "Pemphigus gangrsenosus." a " This dangerous form of the disease," writes Dr. Eustace Smith, 15 " is not confined to weakly, ill-nourished children, but is most common in them. It is, no doubt, connected with the curious ten- dency to spontaneous gangrene sometimes met with in children." According to several observers, this condition often attends acute miliary tuberculosis. " In gangrenous varicella," proceeds Dr. Eustace Smith, " the vesicles, instead of drying up in the ordinary way, become black and get larger, so that a number of rounded black scabs, with a diameter of half an inch to an inch, are scattered over the sui'face of the body. If a scab be removed, it is seen to cover a deep a The Lublin Medical and Physical Essays. Dublin : Gilbert & Hodges. Vol. I. 1808. Pp. 146, et seq. b Disease in Children. New York. 1884. Page 49. K ] 30 CHICKENPOX. ulcer. Around it the skin is of a dusky red colour. All the vesicles do not take on the gangrenous action, so that we find many varicellous scabs of ordinary appearance mixed up with the blackened crusts. The gangrenous process often penetrates deeply through the skin to the muscles, but under some of the scabs the ulceration is more shallow. These cases are very fatal. Mr. "Warrington Howard has reported the case of a weakly baby twelve months old, who weighed only six pounds and a half. The child was attacked with gangrenous varicella and died in a few days of pyaemia with secondary abscesses in the lungs." Dr. Radcliffe Crocker points out {Lancet, May 30, 1885) that this gangrenous eruption may occur in parts not the seat of the varicellous rash, and it is — in fact — well known and described as Dermatitis gangrenosa by various writers. I have myself seen a most remarkable case of the affection in a young lady, who for years suffered from urgent gastric symptoms, apparently of neurotic origin. Hutchinson, in his paper, states that loss of sight may occur from purulent irido-choroiditis in the course of gangrenous varicella. According to Hilton Fagge, it is a question whether the early stage of vesicular strophulus is to be regarded as distinct from chickenpox. If not, the favourable prognosis which is allowed by all writers must to some extent be modified, for whereas they speak of varicella as always ending in recovery, one of Hutchinson's cases of " Varicella-prurigo " terminated fatally. This is a remark- able skin affection which Mr. Hutchinson thinks arises out of varicella, but which Hilton Fagge believes to be an exaggerated form of Strophulus, or Red Gum. Diagnosis. — Chickenpox may be confounded with lichen, herpes, pemphigus, and varioloid. The vesicles may be somewhat clustered together, as in herpes. Trousseau speaks of an epidemic in the Jsecker Hospital, Paris, in which, during from 15 to 40 days, blebs or bullce like those of pemphigus kept appearing on different parts of the patients' bodies, leaving ulcerations which lasted for six weeks or two months. From the three first-named skin affections chickenpox is sufficiently distinguished by the age of the patients, their previous history, and the course of the disease. It is of the CHICK ENPOX. 13 L first importance to correctly diagnosticate varicella from small- pox. In cases of doubt, it will be better for the physician to act as if the disease were really varioloid, in order to protect the community. At this time of day, it seems hardly necessary to insist that varicella is a disease of its own kind {mi generis), absolutely distinct from smallpox in all respects. But the glamour which attaches to the name of the great dermatologist of Vienna — Hebra, and to that of his son-in-law, Kaposi — both of whom refuse to recognise the separate identity of chickenpox, render imperative a statement of the grounds upon which a differential diagnosis is based. Of these the principal are here given after Trousseau's account, con- tained in his masterly Clinique Medicate de V Hotel Dieu:— 1. Chickenpox has often prevailed epidemically without small- pox. Mohl, for example, states that from 1809 to 1823 chickenpox was annually observed at Copenhagen, from which smallpox was absent. On the other hand, varioloid has never been prevalent without coincident smallpox. 2. As to age, very young children are attacked by chickenpox, whereas smallpox in a population protected by vaccination usually shows itself in adults. 3. Chickenpox had been described and known long before the introduction of vaccination, previously to which date vario- loid was rarely met with. 4. Vaccinated children readily take chickenpox, not so smallpox, even in the form of varioloid. 5. Children who have had chickenpox may contract smallpox even soon afterwards. In the Lancet for 1877 a case is recorded of an nnvaccinated child, who was admitted into St. Thomas's Hospital for chickenpox, but who was placed on the floor containing the smallpox wards because the diagnosis was at first uncertain. Two days afterwards vacci- nation was performed, which succeeded. Eight days later still the child fell ill with modified smallpox (Hilton Fagge). 6. The two diseases may co-exist. In 1845, Dr. Delpech pub- lished a case of this kind. 132 CHICKENPOX. 7. The virus of chickenpox never gives rise to smallpox, and the converse of this proposition is believed to be equally true. 8. Chickenpox is generally held to be non-inoculable, whereas smallpox is notoriously inoculable. 9. Second attacks of chickenpox are not uncommon, while small- pox rarely occurs twice in the same person. 10. The eruption of chickenpox may set in after 24 hours, that of varioloid is postponed to the fourth or fifth day. 11. The febrile movement in chickenpox continues after the spots appear, that in varioloid subsides. 12. In chickenpox the spots come out in successive crops and the fever is slight and remittent. 13. The characters of the spots are essentially different in the two diseases. 14. Chickenpox is not a deadly disease, whereas even the mildest form of smallpox may prove fatal. The interested reader will find an excellent statement by Dr. Samuel Jones Gee of the arguments in favour of the non-identity of varicella and variola in Vol. I. of Reynolds's System of Medicine. Prognosis and Treatment. — The simplest measures suffice in the management of a disease which is generally so harmless that Thomas thinks that any prophylactic isolation of the patient is quite needless. In passing, I may state that I, for one, do not concur in this view. Dr. Douglas Powell a considers that eczematous eruptions after varicella, with concurrent swollen glands, may lead to the development of phthisis. All that is necessary in a case of ordinary chickenpox, however, is to keep the child indoors, pre- scribe a milk and broth diet, avoiding strong animal foods, and regulate the bowels by gentle aperients. Sir William Aitken recommends stewed prunes or baked apples to fulfil this indication. We should further give mild diaphoretics, if the skin is dry and itchy and the fever acute. Lastly, it is most desirable to protect the vesicles as far as possible from injury by rubbing or scratching, lest a secondary and more severe dermatitis, resulting in scarring, should be set up. a On Diseases of the Lungs and Pleurce, including Consumption. London : H. K. Lewis. Third Edition. 1886. Page 413. 133 CHAPTER XIII. Morbilli, or Measles. Nomenclature. — Definition. — ^Etiology. — Bacteriology. — Chief Stages of Infectiveness. — Epidemics in Faroe Islands and in Figi. — Seasonal Preva- lence : Measles a disease of Spring and Autumn. — Clinical History : Incubation, Invasion, Eruption, Desquamation. — Furfuraceous Desquama- tion. — Convalescence complete on the Eighteenth Day. Nomenclature. — Measles (originally Mesles or Maseles), a cor- responding to the German Maal, marks or moles — and Masern, spots (the Sanscrit Masura, spots), ltal. Morbilli ("The little plagues," being diminutive of II Morbo, the plague) ; Lot. Rubeola (so called by De Sauvages, 1760); Fr. Rougeole; Dutch, Mazelen ; Danish and Norwegian, Mreslinger ; Swed. Massling ; Span. Sarampion ; ltal. Rosolia, or Roselia ; Arabic, Hhasbah (Rhazes and Avicenna). Definition. — A highly infectious, acute, febrile disorder, usually setting in with, and throughout accompanied by, catarrh of the mucous membranes, especially those of the eyes, nose, and respira- tory passages ; characterised by the appearance on the fourth day of a deep rose-red, or crimson inclining to purple, eruption of soft papules or pimples, which spreads over the whole body in the course of thirty-six hours, and is preceded and accompanied by sharp fever. This terminates by crisis between the sixth and eighth days, coincidently with the fading of the rash. Conva- lescence is apt to be complicated with affections of the glandular system and respiratory organs. iEtiology. — The question of the native seat of measles baffles all research (Hirsch). The disease was probably widely diffused over Europe and Asia in the middle ages, and at the pi'esent day the area of its distribution is practically conterminous with the entire habitable globe. Its separate identity was first shadowed forth by Forestus (1563), but it is to Sydenham (1676) that we owe the full differential diagnosis between measles and smallpox. a Joh. Anglicus. Praxis Med. Aug. Vindel. 1595. Page 1,041. 134 MEASLES. Age does not affect the occurrence of measles as much as is generally supposed. It is a disease of all ages, although Thomas rightly declares that children under six months old enjoy a con- siderable immunity, or rather are less susceptible to the disease. In communities unprotected by a previous outbreak, measles attacks individuals of all ages. The bacteriology of measles is scanty — the authorities on the subject up to the present being Salisbury {American Journal of the Medical Sciences, 1362 a ), Keating {Phil. Med. Times, 1882), and Cornil and Babes (Les Bacte'ries, 1885). According to Edgar M. Crookshank, b round cocci and diplococci have been observed in the catarrhal exudations, in the papules and in the capillary vessels of the skin, as well as in the blood of patients attacked by the disease. The materies morbi, therefore, may be considered to exist in the expectoration and in the cutaneous debris. There is no doubt that measles is " taking," or infectious, from the first sneeze or cough — that is, from the very beginning of the initial or prodromal stage (in- vasion). Hence, the chief difficulty in checking its spread amongst the members of an attacked household. It is most infectious, however, in the eruptive stage, and probably not very infectious in the stage of desquamation. Its " striking distance " is believed to be considerable, but the contagium is less persistent than that of scarlatina (Hilton Fagge). One attack usually, but not necessarily, protects from a second — acquired immunity is not so constant after measles as it is after smallpox. Measles is a highly infectious and a very deadly disease when it attacks an unprotected community — that is, a community not leavened with the virus and in conse- quence not immune. Two notable illustrations of this have become a Dr. Salisbury, of Newark, Ohio, United States, many years ago demon- strated his ability to produce a disease indistinguishable from measles by means of musty straw. Dr. Henry Kennedy, of Dublin, reported in the Dubl. Journ. of Med. Science (Vol. XXXV., 1863, p. 60), a case in which a disease like measles arose in connection with musty linseed meal. Thomas, of Leipzig, disposes of Salisbury's statement that the rashes produced by decaying straw afford protection against measles, by saying that it " is not to be believed for a moment." 6 Manual of Bacteriology. Second Edition. London : Lewis. 1887. Page 214. MEASLES. 135 matters of medical history within recent times. They are as follow : — In the spring of 1846, measles was accidentally imported from Copenhagen into the Faroe Islands, which had enjoyed an immunity from the malady for sixty-five years (from 1781). On March 20 of that year a workman left Copenhagen, being then unwittingly in the incubation stage of measles. He landed in the islands on March 28, and developed symptoms of measles on April 1. His two most intimate friends were in due time attacked, and the malady spread until at last 6,000 out of a total population of 7,782 contracted the disease. Age afforded no protection — old men and women fell victims as readily as young children. This outbreak is of special interest, as it enabled Dr. Panum, of Copenhagen, who was its historian, to make a series of most valuable investigations into the length of the incubation period in measles. In 1875 the Fiji Islands, in the Pacific Ocean, were annexed to the British Crown. From the Medical Times and Gazette of June 12 in that year, we learn that "the first advantage (?) derived by annexation" — so the Fiji papers of March 20, 1875, describe it — ^ is the introduction of measles, and for this the islanders are indebted to H.M.S. 'Dido,' which came down and discharged her diseased passengers, utterly regardless of any consequences that might ensue." The disease made great ravages throughout the whole of the islands. Tui Levuka and other chiefs succumbed to it, and even the hardy mountaineers in the interior had consider- able havoc made in their ranks. The germs of the disorder were taken into the mountains by the chiefs who had been brought over to Levuka — the capital — and entertained on board the Dido. The disease, which was almost always followed by dysentery (morbillous colitis), assumed the form of a plague. Seasonal Prevalence. — Although like smallpox, apparently independent of climate — for it is met with alike amidst Arctic snows, in temperate latitudes, and under the tropical sun — measles prevails especially in the spring and autumnal quarters of the year. An analysis of the weekly returns of deaths from measles in the Dublin Registration District, published by the Registrar- 1 36 MEASLES. General for Ireland, long since led me to the conclusion that a mean temperature above 58*6° was not favourable to the spread of this disease, and that a mean temperature below 42*0° was equally inimical to its prevalence. 3. These results are in strict accord with those arrived at by Dr. Edward Ballard, who says b that the only condition concerned in the arrest of the spread of measles in summer is the rise of the temperature of the air above a mean of 60° F., while towards winter a fall below 42° F. also distinctly tends to check the disease. The accompanying Diagram (2), copied from the Annual Summary of Births, Deaths, and Causes of Death in London and other great towns for 1890, by the Registrar-General for England, is based upon the weekly returns of deaths from measles in London for the fifty years, 1841-1890, inclusive. In it, the mean line represents an average weekly number of 34 deaths from the disease under discussion, and the weekly curve shows a double maximum and a double minimum, the larger maximum falling in November, December, and January, with an extreme excess of 50 per cent, in the fourth week of December, and the smaller in May and June, with an extreme excess of 25 per cent, in the first week of June. The larger minimum falls in August, September, and October — extreme deficit being 45 per cent, below average in the last week of September, and the smaller minimum in February and March — extreme deficit, 30 per cent, below average in the third week of February. Clinical History. — A typical case of measles may be considered to run through four stages, which we will now study in detail — they are, in chronological order, the stages of incubation, invasion, eruption, and desquamation. 1. Stage of Incubation. — Ten days, as a rule, elapse between the reception of the poison into the system and the manifestation of the earliest febrile and catarrhal symptoms, or fourteen days between infection and the appearance of the rash. These are a Manual of Public Health for Ireland. 1875. Pages 300, 301. b Eleventh Report of the Medical Officer of the Privy Council. 1868. No. 3. Pages 54-62. ^ •Ji hi _j '.* ~| < MEASLES. 137 Panum's estimates, based on his observations in a newly-infected community, the inhabitants of the Faroe Islands in 1846. Under other circumstances, the determination of the length of the incuba- tive period of measles must be attended with the greatest difficulty- owing to the multiplicity of infecting centres. As commonly happens when a specific virus is introduced into the system by what may be called " a short cut," the stage of incubation is shortened after inoculation. Hebra, who successfully inoculated with the nasal mucous, found that in such cases the symptoms showed them- selves in 8 days, the difference in time representing the effect of the resistance offered to the invading virus by the skin and mucous membrane. In 1876 I had an opportunity of observing a case of measles even from the stage of incubation, and the following facts will be of interest : — On March 26 in that year, a married lady, aged twenty-one, fell ill of measles. Her parlourmaid had sickened with the same disease ten days (inclusive) previously, that is, on March 17. At 3 p.m. of the 26th, Mrs. A. B. felt thirsty, chilly, and fatigued. Her appetite failed. The rash appeared on the face on the after- noon of the 3 Oth (5th day), the fastigium (103'4° F.) was reached at 1 p.m. of April 1 (7th day), when the eyes were suffused and the rash fully out. Defervescence was complete on April 3. The clinical chart will be found in Plate II., Fig. 1. (See page 146.) In this case the duration of the latent period was almost certainly 10 days. In the spring of 1877 both measles and scarlatina were prevalent in Dublin, and it was difficult effectually to isolate the incoming cases in the Epidemic Wards of the general hospitals. In two instances at the Meath Hospital scarlatina patients unfortunately contracted measles while convalescing. In both cases the symptoms of measles were detected on the eleventh day after exposure to the contagium of that disease — that is, on the eleventh day after admission to hospital. The clinical charts are given in Plate II., Figs. 2 and 3. (See page 146). Few or no symptoms attend this preliminary stage. Towards its close, fatigue, lassitude, and nausea may be felt, and the pulse beats faster than in health. At this time, also, an ephemeral 138 MEASLES. fever, followed by defervescence, has been noticed by Thomas, of Leipzig. 2. Stage of Invasion. — The initial stage is longer in measles than in any other of the exanthemata. It lasts 4 or 5 days. The disease begins suddenly with the usual nervous symptoms of an acute fever, and, in addition, a remarkable group of symptoms con- nected with the mucous membranes. The patient, " sickening for measles," is seized with shivering ; or, if a child, perhaps has a fit of convulsions. He complains of lassitude, headache, and pains in the joints. The skin becomes hot and dry, the pulse beats quickly, and there is a rapid rise of temperature to 102-5° or even 104° F. by the evening of the first day. This " initial fever," as Wunderlich calls it, is usually followed by an equally sudden fall of temperature, so that by the morning of the 3rd day the thermometer readings are normal (98-4°) or only slightly febrile (99° or 100°). As the eruptive stage approaches, a fresh rise of temperature begins. The physician should be on his guard against mistaking the initial or prodromal fever of measles for a mere febricula or ephemeral fever of non-specific origin. But it is the catarrhal symptoms which are so eminently characteristic as to be pathognomonic of measles. From the outset the patient sneezes, the eyelids itch and swell, and become very red on the inside ; the eyes water (lacrymatiori), look bloodshot and shun the light {photophobia.) A flow of acrid tenacious mucus takes place from the nostrils, the nose seems stopped up and then often bleeds (epistaxis), and, in a word, the individual seems to be suffering from a " bad cold in the head " (coryzd). At the same time, the throat feels raw and sore, the voice becomes husky, and a hoarse, brassy cough sets in, occurring in paroxysms or " kinks." Simul- taneously there is a catarrhal diarrhoea in many cases, the motions being green and unhealthy-looking. On the second day an efflorescence may spread over the skin, leading to a wrong diagnosis of scarlatina. This accidental rash may also simulate urticaria because of the itchiness which accompanies it. It is, doubtless, erythematous in character. About this time, further, according to Dr. Hilton Fagge, an eruption of scattered points and spots may be MEASLES. 139 seen over the mucous membrane of the soft palate. Thomas, of Leipzig, also says that indications of the cutaneous rash may some- times be seen on the face during this stage, in the form of minute; puncta, around which the characteristic papules afterwards develop. 3. Stage of Eruption. — Towards the close of the fourth day — rarely earlier, very rarely later — the appearance of the true rash of measles is heralded by a renewed rise of temperature and an exacer- bation of all the symptoms connected with the mucous membranes. In many cases there is a profuse serous diarrhoea ; and sometimes the eruptions from the bowels become glairy and bloody, indicating the presence of morbillous colitis. The eruption appears on the face first, next on the back of the wrists, afterwards on the trunk, lastly on the limbs. It consists of small red specks, slightly elevated and velvety to the touch, on the forehead and face, closely resem- bling flea-bites (Sydenham and Hilton Fagge). It is to be remem- bered, however, that the face generally escapes the infliction of flea- bites. These specks become grouped in crescentic patches, leaving interstices of skin of normal colour. The rash, therefore, is in general discrete rather than confluent, although in some cases it is really confluent. It is of a deep rose or crimson colour, inclining to purple (Hilton Fagge). There is some swelling of the face during this stage. On the trunk and limbs the papules are less prominent than on the face. Sometimes the true eruption is inter- spersed with a crop of miliary vesicles with an inflamed red base. Occasionally — to use Sydenham's words — " the eruptions turn livid, and then black ; but this happens only in grown persons, who are irrecoverably lost upon the first appearance of the blackness, unless they be immediately relieved by bleeding and a cooler regimen." These varieties of the rash give rise to the terms Morbilli Iceves, Morbilli papulosi (the French Rougeole boutonneuse), Morbilli miliares, Morbilli confluentes, Morbilli hcemon-hagici (Mayr and Hebra). During the eruptive stage the perspiration has a peculiar heavy odour, which Niemeyer compared to the smell of a freshly plucked goose. The eruption reaches its fullest development in thirty-six hours from the time of its first appearance — that is, on the sixth day. It is then dusky, and the skin begins to look rough and 140 MEASLES. dirty. As the rash comes out, the coryzal symptoms increase, and the temperature rises to its fastigium or acme of 104° to 105° F. on the evening of the 5th day, or on the 6th day — the fever being most intense when the eruption is at its height. In this behaviour of the temperature in the Eruptive Fever of measles we have a diagnostic of the first importance between smallpox and this disease. There is an old tradition that a sudden fading of the rash in measles is an ominous sign ; but its truth is disputed by Thomas of Leipzig. At the same time there can be no doubt that the rash develops badly or not at all in the presence of a complication. This occurrence is to be distinguished from those rare instances in which we have measles without a rash (Morbilli sine morbillis). With the fading of the rash, defervescence begins, and is almost completed within 48 hours, being so rapid and sudden as to be diagnostic of measles. Here we have another marked contrast between the behaviour of the temperature in smallpox and in measles respectively — apyrexia in measles taking the place of the secondary fever in smallpox. The rash fades after the sixth day slowly and in the order of its appearance, leaving yellowish red stains, which may persist for several days. In the early stage of its subsidence the eruption of measles exactly resembles a profuse maculo-petechial rash in typhus fever, which, indeed, is often called the " measly rash of typhus." The morbillous catarrh — both respiratory and intestinal — frequently persists at this stage, and a nummular expectoration indicates that the bronchioles share in the affection. Now and then it happens that the catarrhal symptoms of measles are wanting, or nearly so. To this aberrant but mild form of the disease Dr. Willan gave the name of Morbilli sine catarrho. 4. Stage of Desquamation. — This commonly begins about the eighth day and ends about the eighteenth day, counting from the first symptoms. The skin peels off in small bran-like scales, hence the term furfuraceous desquamation (Lat. furfur, scurf or bran). Trousseau says that these tiny branny flakes are seldom seen, because they adhere to the dress if the patient perspires, and in this opinion MEASLES. 141 Hebra concurs. But a careful search will hardly fail to reveal this branny desquamation taking place across the bridge and along the sides of the nose, as well as about the mouth and on the neck. In uncomplicated measles, convalescence may be said to be complete on the eighteenth day from the earliest symptoms. In rare cases a relapse of the eruption. has been known to occur, associated with a return of the fever movement also. In these cases, according to Thomas, the spots appear on parts of the skin previously uninvaded by the exanthem. These relapses are of short duration. Lewin a mentions an anomalous course of measles in two boys. The rash disappeared suddenly, without causing any percep- tible injury to the patients, but only to return after two weeks. In one case, the renewed attack ran a normal course ; in the other, this occurred only after a second equally harmless interruption of several days. " Such a course," says Thomas, " is perhaps a parallel one to many of those relapses appearing after the first eruption, also to Trojanowsky's recurrent form of measles." b a Jahrbuck filr Kinderheilhunde. Vol. 42, page 95. b See Dorp. med. Zeitung. 1873. 142 CHAPTER XIV. Measles (continued). Classification — Complications — Temperature — Pathology — Diagnosis — Prognosis. Classification of Measles : Niemeyer's. — Benign and Malignant. — Benign : Morbilli sine catarrho ; Morbilli sine morbillis. Malignant ; Purpuric Measles ; Asthenic or Adynamic Measles ; Complicated Measles. — Causes OF Complications (Hebra).— Complications of the stage of invasion : Convulsions, spasmodic catarrhal laryngitis (false-croup), suffocative catarrh, epistaxis, otitis, diarrhoea, colitis ; of the stage of eruption : morbillous diarrhoea, capillary bronchitis, pneumonia, diphtheria (true-croup); of the stage of desquamation : glandular enlargements, otitis, cancrum oris (noma), gangrene of the vulva, acute desquamative nephritis, acute miliary tuberculosis, herpes, eczema, etc., pleuritis, chronic ophthalmia, atrophic keratitis. — Temperature in measles. — Pathology. — Diagnosis : from epidemic rose-rash, scarlatina, smallpox, Grisolle sign, varicella, simple rose-rashes, typhus. — Prognosis. Classification of Measles. — Niemeyer describes three varieties of the disease under the headings— 1. Morbilli vulgar es, simplices, vel erethici ; a 2. Inflammatory or synochal Measles ; 3. Asthenic, typhous, or septic Measles. Another convenient arrangement of the cases is into the two groups of benign and malignant. In the former are included two species — 1. Morbilli sine catarrho ; and 2. Morbilli sine morbillis. In the latter we have three species — 1. Purpuric Measles ; 2. Asthenic or Adynamic Measles ; and 3. Complicated Measles. According to Thomas the form of benign measles in which there is rash, but no catarrh (Morbilli sine catarrho) is especially apt to occur in very young infants, and is attended with little or no fever. Probably many cases of Rotheln were formerly classified as non- catarrhal measles. The occurrence of measles without the rash (Morbilli sine morbillis) is probably a rare clinical experience. Malignant Measles. — 1. Of this form of the disease the purpuric variety is very infrequent. Trousseau in his vast expei'ience met with but two cases. It is observed chiefly in young and sickly children " Gk. ipe6KTriK6s, irritative, or provocative, from epedlfa, to rouse to anger, to excite. Hence, rubefacient (or causing redness). MEASLKS. 143 (Hilton Fagge). The rash is profuse and dark, the skin is dotted over with petechias and vibices, while blood oozes from the mucous membranes in all parts of the body. Death generally takes place in a few days. In Willan and Bateman's Atlas of Skin Diseases B will be found an illustration of the appearances presented by the skin in a form of the disease which Dr. Willan called Rubeola nigra. This, however, must be quite different from Purpuric Measles, for he says the dark purple or black colour of the rash continued from the eighth day for ten days or longer " without materially disturbing the functions of the patient." Such a description could never applv to the " Black Measles " of the older writers — the Morbilli nigri, vel petechiales — which has been just described. The ostensible fre- quence of this form long ago is, according to Thomas, to be explained in part " by the preposterous treatment of old times," partly by the fact that measles and scarlatina were confounded together and malignant forms of scarlet fever were described as measles. I agree with Hilton Fagge also that no doubt cases of hasmorrhagic smallpox were sometimes classed as " Black Measles." 2. In asthenic or adynamic measles, the symptoms are severe and persistent — the fever is intense so that the patient is soon ex- hausted, the pulse becomes rapid and feeble, delirium gives place to somnolence, and at last the " typhoid " or " ataxic " state ensues and terminates too often in early death. The term " ataxic state " is applied to a group of symptoms which indicate extreme nervous prostration, namely, sleeplessness, delirium, small rapid pulse, quick shallow breathing, agitation and restlessness, tremors, plucking at Ihe bedclothes, dilatation of the pupils, and finally deepening coma and insensibility. I will return to this subject later on. 3. According to Hebra, the cause of complications must be sought for — (a) in individual peculiarities of the patient, (/3) in the conditions under which he lives, and (7) in the special charac- ters of the prevailing epidemic — to use Sydenham's classical phrase, the " epidemic constitution " of the time or place. "■Delineations of Cutaneous Diseases. London: Longmans, Hurst, Eees, Orme, and Brown. 1817. 144 SlEASLES. It will be convenient to consider the complications of measles as they present themselves in the stages of onset or invasion, of the rash, and of convalescence respectively. Stage of Invasion. — Measles is not uncommonly ushered in by an attack of convulsions in young or nervous children. Such an attack or " fit " is simply an exaggerated rigor with cerebral pheno- mena. It is not of very serious import unless it persists for over two days. Trousseau mentions a very remarkable case in which the tonic stage of the convulsive fit lasted for two minutes and a half and death occurred. The mucous membrane of the larynx is often the seat of ulcerations and erosions, which occasion severe laryngeal symptoms, constituting the condition known as " false-croup," or spasmodic catarrhal laryngitis. The cough is dry and harsh, frequent and spasmodic. The voice is hoarse, every movement of the larynx is painful, and and inspiration is laboured, accompanied with wheezing, whistling sounds like those of asthma. At times, especially after a fit of coughing or when drinking, suffocative spasms and a painful sense of oppression across the chest occur (Mertens a ). Suffocative catarrh may occur during any of the stages of measles. Its symptoms are : high fever, oppression of the chest, dyspnoea, and moist cough. Children, as a rule, do not spit out, but swallow the expectoration — hence it cannot conveniently be examined ; but in adolescents and adults the sputa consist at first of thin, limpid mucus ; afterwards they become copious and muco-purulent in character, occasionally rusty or prune-juice, if the so-called croupous pneumonia supervenes. Three stages or degrees of bronchitis — the most common and the most perilous of the com- plications of measles — are recognised : ordinary tracheo-bronchial catarrh, capillary bronchitis or bronchiolitis, and broncho-pneu- monia — also called catarrhal pneumonia, or lobular pneumonia. In young children this affection is dangerous from purely mechanical causes — suffocation being brought about by oedema of the bronchial mucous membrane and accumulation of secretion. Of the three forms of bronchial affection just described, tracheo-bronchial a Canstalt's J ahresberkht. 1852. IV. Page 210. MEASLKS. 14-; catarrh is most common in the stage of invasion ; the other and severer forms in that of eruption. Epistaxis, or nose-bleeding, may be so severe as to endanger life or permanently injure health. Otitis is hard to diagnosticate in an infant, but cries and delirium from pain should suggest the presence of ear-trouble, and sup- puration leading to otorrhoea usually solves the difficulty in 3G or 48 hours. Diarrhoea is dangerous if continuous to the time when the rash is due to appear, if the rash does not " come out " well, and if the eyes look sunken with dark rings around their lids. The intestinal morbillous catarrh often attacks the colon, causing Colitis with glairy, bloody stools, and tenesmus. This accident usually occurs in the eruptive stage. Stage of Eruption. — In this stage, in addition to morbillous diarrhoea, capillary bronchitis and pneumonia are frequent and most dangerous complications of measles. Their approach is indicated by, perhaps, an attack of convulsions — a most fatal occurrence in this stage of the disease— by persistently high tem- perature after the sixth day, and by early and rapid fading of the rash. Bronchitis is a very obstinate complication, running on, it may be, to twenty or thirty days should the patient survive so long. Diphtheria of the pharynx and of the larynx, membranous laryngitis, or true croup, is another dangerous, though rare com- plication of the eruptive stage. The diagnosis is based on the detection of false membranes and the presence of signs of laryngeal stenosis, or narrowing, due to mechanical obstruction. Stage of Desquamation. — During this stage we meet with, as sequela? and in addition to broncho-pneumonia, glandular enlarge- ments in the neck and in the thorax (bronchial glands). These may go on to suppuration and cicatrisation, or the glands may become the seat of tubercular deposits or infiltrations. Otitis in this stage may involve the middle ear, and affect the brain and dura mater through the mastoid cells ; or it may give rise to purulent infection by inducing septic phlebitis and throm- bosis of the cerebral sinuses. Trousseau, in his Clinical Medicine, L 146 MEASLES. reports a remarkable case in point, which was seen in consultation and diagnosticated by Dr. Peter. 8, Cancrum oris or noma, and gangrene of the vulva, may occur in delicate, badly-fed and badly-clothed children, sometimes speedily destroying life, but in non-fatal cases leaving disfiguring losses of tissue. Acute desquamative nephritis is much less common in measles than it is in scarlatina. Acute miliary tuberculosis often supervenes upon an attack of measles, the tubercles invading specially the lungs and the membranes of the brain. Herpes and eczema often follow measles, attacking the upper lip, nasal fossae, posterior nares, and Eustachian tube. Pleuritis was observed as a sequela of measles by the late Pro- fessor Fleetwood Churchill, of Dublin, and by Professor Seidl. Chronic ophthalmia (" Exanthematous ophthalmia" of War- drop), with " granular lids " and distressing photophobia, and atrophic or secondary keratitis, must be included among the many eye affections which follow measles. In considering the subject of the complications and sequelae of this disease, it should never be forgotten that an attack of measles often sows the seed of even a fatal constitutional delicacy. Temperature. — According to Wunderlich, the characteristic features in the temperature movement in measles are — 1. In the stage of incubation, a short preliminary fever course in the form of an ephemera, in which the thermometer may mark 102*8° to 103*6°. This is followed by a pause or interval of several days quite free from fever. 2. An initial or prodromal fever occurring in the stage of in- vasion, the temperature rising from the time of the first symptoms to 102'4°, and even 104°, on the evening of the first day. Next day a decided fall, so that on the third day the temperature is either normal or sub febrile. This a Lectures on Clinical Medicine delivered at the HStel Dieu, Paris. New Syd. Soc. Translation. 1869. Vol. II., page 231. PlaUE. CHARTS OF TEMPERATURE RANGES IN MEASLES. Mg. I- Simple, Wcwks. Jig. 2. -Measles. , ■''after, Scar/.ztiJiccJ Da, «r ., !>■*.■ ... - jjjj Dayof 4- 5 6 7 a 9 10 11 >h.: ■ ■■, ra 13 14 15 is 17 is :.' ::•- ::i '■:' ■■< v ?5 ."} :v = :EE=E E = z:i:=;=zi : Fz: : f ;z: = z:;: W0-+- tt3. Iff _±±__ M = =*: = 'n^^Plfl^^H «-ii\ Ei±E -■hitEE - : -— Scar&x&'rca. ^eojte iv'f/ 3-Meosles, /after Scarlatina..] Fig J— Si. |jg£ 7 3 9 10 11 IZ n wJE — Ei;:"" =:::z^=:^::: *==HH=!!ee= MEASLES. 147 pyrexial movement may easily be confounded with an ephemeral fever. 3. The true eruptive fever, setting in shortly before the rash is due, and consisting of (a) a moderately febrile stage which lasts from 36 to 48 hours, and (/3) the stage of fastigium which corresponds in point of time with the fullest develop- ment and extension of the exanthem, and lasts from one and a-half to two and a-half days. 4. Decided defervescence in uncomplicated cases begins according to rule in the night, and generally runs a rapid course, being completed — after one or two evening exacerbations — by the eighth or ninth day of the attack. The appended charts will illustrate the behaviour of the tempera- ture in measles. (See Plate II.) Pathology. — Among the pathological changes produced by measles, Mayr and Hebra mention, in the first place, a catarrhal inflammation of the mucous membrane of the respiratory tract ; but assuredly the intestinal mucous membrane is also the seat of a specific catarrh. It is true that Thomas, of Leipzig, while stating that, as a rule, the mucous membranes of the nose, the throat, the upper air- passages, and the conjunctivae are attacked, and often much sooner than the outer skin, cannot admit any similarity of this affection of the mucous membranes with that of the skin, and so does not recognise the perfect justness of the term " exanthem of the mucous membranes." But the appearances described by Thomas himself, by Hilton Fagge, and by others in connection with the visible mucous mem- branes, as well as the catarrhal symptoms, justify us in concluding that the mucous membranes are really the seat of an exanthem, or, more correctly, an enanthem — a view which the analogy of smallpox altogether supports. The nasal mucus, according to Mayr and Hebra, is at first trans- parent, afterwards opaque; its reaction is always alkaline, never acid. The same authorities assert that the efflorescence consists essentially in the pouring out of exudation around the mouths 148 MEASLES. of the hair-sacs. This view is disputed by Thomas, who says that, if the hair-follicles specially participated in the inflammatory process in morbillous dermatitis, the scalp would necessarily be the proper focus of the exanthem, and the palms of the hands and the soles of the feet would remain free — neither of which is the case. G. Simon also, in 1848, found no change in the hair-sacs, sebaceous glands, or cutaneous papillae, but described the epidermis as being still in immediate contact with the corium, although slightly swollen at those points where papules exist. Diagnosis. — The recognition of measles depends, first on the exanthem ; secondly, upon the mucous membrane symptoms and the characters of the fever (the behaviour of the temperature) ; thirdly, upon a consideration of the existing epidemic and the exposure of the patient to the virus of measles. Measles must be distinguished from — Rotheln, or Epidemic Rose Rash (Roseola) ; Scarlet Fever, Variola, Varicella, simple Roseolar Rashes, and Typhus Fever. In epidemic rose rash, the stage of invasion is only 1 to 3 days, the pyrexia is much less than in measles, the catarrhal symptoms are slight, and the rash is less typical. The lymph-glands also are more swollen than in measles. In scarlet fever there is a short invasion, only 24 hours ; vomit- ing is constantly observed ; catarrhal symptoms are absent, while there is early and severe sore throat with marked swelling of the lymph-glands. The tongue presents the appearance known as " strawberry-tongue." The fever runs a continuously severe course and drops gradually by lysis, with morning remissions and evening exacerbations. The rash is commonly confluent, consisting of bright red or scarlet points with a diffuse hyperasmic blush. The kidney affection of scarlatina is wanting in measles. The most common error of diagnosis is between measles and smallpox, but the development of the pustular rash of smallpox sets the question at rest. At the beginning, too, confluent small- pox presents an eruption on the second day compared with the fourth or fifth day in measles. The papules of smallpox are hard and shotty ; those of measles are soft and velvety. The application of the test called the "Grisolle sign " is also to be remembered (see p. 98). MEASLES. 149 Absence of catarrhal symptoms, a short invasion-stage, its slight pyrexia, and the life-history of the vesicles, serve to distinguish varicella from measles. Simple rose rashes are distinguished by absence of fever and of catarrh, and by their inconstant and evanescent nature. Typhus in children may be mistaken for measles, although my experience is that young children have typhus as a rule lightly, with only a scanty rash or without any rash at all. The catarrh of measles is wanting, its rash is brighter than that of typhus, and does not pass through the macular and petechial stages of the typhus eruption. The diagnosis may be assisted, as Murchison says, by examining other members of the same family who may be affected at the same time. Measles usually attacks children ; typhus rarely attacks children before the adult members of a family. Prognosis. — This in primary and uncomplicated measles is thoroughly favourable, death from the severity of the infection alone being extremely rare (Thomas.) The mortality of measles varies greatly from time to time according, as Sydenham would say, to the " Epidemic Constitution " of the time and place. Sometimes only 2 or 3 per cent, of the patients die ; occasionally, the death- rate reaches the alarming figure of 50 per cent. In 1845 and 1846 Trousseau says he lost 22 out of 24 children with broncho-pneu- monia in the Necker Hospital, Paris. a Measles is a mild disease in sucklings under six months old ; it becomes severe at the first dentition, and is sometimes very severe in adults. In pregnancy it is a dangerous malady. It is most fatal among persons who are ill-nourished, rachitic, or tuberculous (scrofulous.) It kills from 6,000 to 14,000 children yearly iu England, 90'5 per cent, of the victims being under five years of age. Unfavourable symptoms in a case are: great weakness and excitement from the outset ; a hot, dry skin ; a hard and rapid pulse ; quick, laboured respiration with a short cough ; early fading of the rash, or a change of colour in it ; or a persistent (petechial) rash. By far the most fatal complication of measles is bronchitis in its severer forms. a Clinique medicale de I'H&tel Bieu de Paris. 1865. Tome L, page 145. 150 CHAPTER XV. The Treatment of Measles. Prophylaxis : quarantine, isolation, hygienic measures. — Curative Treat- ment : no specific for measles — treatment is symptomatic and hygienic. Treatment of Complications : Malignant Measles — cool baths (Dieulafoy). — Initial convulsions, false and true croup, epistaxis. otitis, diarrhoea, ophthalmia, glandular enlargements, noma, gangrene of the vulva, acute tuberculosis. I. Prophylaxis. — Owing to the fact that measles is infectious from the outset, and that the first case in a household may readily be mistaken for an ordinary cold, the attempt to stay its spread by adopting preventive measures, and especially isolation, is practically futile, Hence the extreme difficulty of arresting an outbreak of this disease in a family or a community. Should an individual have been exposed to the infection of measles, at least sixteen days' quarantine will be necessary before he can be pronounced safe. A patient, again, who has passed through an attack of measles, should not be declared free from infection until at least three, and preferably four, weeks have elapsed from the first symptoms. It will be remembered that the stage of desquamation generally lasts until the eighteenth day. With the view of lessening the susceptibility to measles, the greatest attention should be paid to the sanitary surroundings of a community. II. Curative Treatment. — Dr. Hilton Fagge aptly points out that " the general plan of treatment in measles and in scarlatina is the same, for in neither of these maladies have we any specific method of dealing with the malady itself." Bearing in mind the tendency to catarrh of the respiratory mucous membranes which exists in measles, a mild, equable atmosphere is essential (60° to 65° F.). In winter and spring a steam kettle should play in the sick room, at all events at night. Ventilation must be effected with caution, all draughts or undue lowering of temperature MEASLES. 151 being carefully avoided. Children should be closely watched at night lest in their feverish restlessness the bed-clothes should be thrown off, and they in consequence should be exposed to cold. The hands and face should be washed daily. The patients should be allowed to drink water freely, or bland mucilaginous drinks like linseed tea, barley water, and toast-water. The diet should consist of milk and animal broths, the latter to be thickened with rice, arrowroot, or gelatine in cases of diarrhoea. On the other hand, in constipation (which, in measles, is rare), oranges, stewed prunes, baked apples, and so on, may be given. During the stage of desquamation, the patient should be kept as far as possible in bed. Warm baths are specially useful, as they relieve troublesome itch- ing, remove the debris from sweat and desquamation, and generally soothe the patient. The surface of the skin may afterwards be oiled with advantage — liniment of camphor, a weak carbolised oil or soft paraffin, or " hazeline cream," being used for the purpose. All exposure to cold should be avoided until the catarrhal symptoms have entirely disappeared. In convalescence, fresh air, driving in the open country, and change of air to the seaside or some sheltered inland health-resort, are most desirable. Among drugs suitable for administration to convalescents from measles, mention may be made of quinine, saccharated carbonate of iron, cod-liver oil with saccharated solution of lime, and chloride of calcium. The skill of the physician is often taxed to the uttermost in the treatment of the complications of measles. In malignant measles, Dieulaf oy, of Paris, recommends a a bath at 26° C. (78-8° F.) for twelve minutes, with cold affusion on the head. These measures will reduce temperature (102'9°) and the respirations (70). A second bath at five o'clock in the afternoon ; a third at 9 p.m., a fourth at 2 a.m., a fifth at 5 a.m. These will probably be followed by marked improvement, reduction of tem- perature, and sleep. A sixth bath, at 6 p.m. The cold bath re-establishes the secretion of urine, the skin ft La Pratique Joumaliere des Hdpitaux de Paris. Par le Professeur Paul Lefort. Paris J. B. Bailliere et Fils. 1891. Page 312. 1 52 MEASLES. becomes soft, and temperature falls to 101*1° 'F. As regards the rash, it becomes pale but runs its course. In a case of initial convulsions Trousseau's advice is excellent — "Wait — avoid boisterous practice." Find out if the patient is subject to fits. If the attack persists, compression of the carotids may be practised in the way recommended by Trousseau — namely, by pressing with the thumb on the common carotid opposite to the affected side of the body, or alternately on each side of the neck, keeping up the pressure for some fifteen minutes, In false and true croup the patient should be placed in a croup- tent, and a simple plan recommended by Graves and heartily approved by Trousseau should be followed. This is an application during twenty or twenty-five minutes of relays of sponges soaked in hot water to the neck and throat. These same measures will prove useful in suffocative catarrh also, in which hot poultices and the application of a cuirass of cotton wool or French wadding to the chest wall are very effective. Trousseau recommends stinging the chest with nettles (urtication) as an effectual means of producing counter-irritation. In epistaxis, the application of ice to the forehead and that of a cold key to the nape of the neck are household remedies not to be despised. Either iced water or very hot water may also be injected into the nostrils. In extreme cases it becomes necessary to plug the posterior nares. In otitis, the external meatus should be gently syringed, or a chamomile flower soaked in warm almond or olive oil, or in vaseline, may be inserted every few hours, taking care to cleanse the passage each time. Sometimes the application of a single leech to the mastoid process allays pain and affords immediate relief. While diarrhoea is often checked by good nursing and suitable dieting, it may be necessary, as recommended by Trousseau, to give minute doses of opium in lime-water (one-thirtieth of a grain in 24 hours), or to administer albuminous enemata, if colitis occurs. Alterative doses of perchloride of mercury may also be of use. Dr. Charles West recommends decoction of logwood with white sugar and port-wine. This mixture stains linen or cotton fabrics. MEASLES 153 For ophthalmia, fomentations with strained decoction of poppies or infusion of chamomile, or both, or with cold tea — which contains tannin — often give relief. When a sequel of measles, ophthalmia requires constitutional treatment — iron and quinine, cod-liver oil, and wine or eggflip. Glandular enlargements are best combated by a generous, wholesome diet, with milk, cod liver oil, iron, iodide of iron, quinine, chloride of calcium, and arsenic. Change of air is especially desir- able in the management of this troublesome sequela. Fresh air and perfect cleanliness are the best preventives of noma, gangrene of the vulva, and such like complications. The patient's strength must be supported by nutritious food and wine. Caustics may be used in certain cases — namely, hydrochloric acid, nitrate of silver, sulphate of copper, or the actual cautery. The prevention of acute tuberculosis may be attempted by change of air, wholesome surroundings, a nutritious diet with goat's milk and koumiss (mares' milk fermented), syrup of the chloride of calcium in milk, cod liver oil, syrup of the iodide of iron, compound syrup of the hypophosphites or of the phosphates, and syrup of the lacto-phosphate of lime. A favourite combination with me is embodied in the following prescription : — IL Liquor. Calcii Chloridi, 3vj ; Acid. Hydrochloric, dil., 3j ; Liquor. Strychninas Hydrochlor., 3j ; Acid. Hydrocyanic, dil., 5ss ; Liquor. Arsenic. Hydrochlorici, 3 3 s ; Aquae Chloroformi, ad gviij. M. fiat. Mistura. The dose of this mixture for an adult is a tablespoonful by mea- sure in water twice or thrice daily after food. A child aged 10 or 12 years may take half this dose. 154 CHAPTER XVI. SCAELATINA, OR SCARLET FEVER. Nomenclature. —Definition. — etiology (historical sketch). — Area of Diffu- sion. — Epidemic and sporadic outbreaks — Rate of Mortality most variable. — Pkedisposing Causes : Climatic influences ; season. — Exciting Cause : Spe- cific poison — "Contagium Vivum." — Professor Klein's Researches: Streptococcus scarlatina. — Hendon Cow Disease. — Clinical History : Scarlatina simplex, anginosa, and maligna. — Varieties of Scarlatina simplex. — Stages of Incuba- tion, Invasion, Eruption, Desquamation. — Prominent Symptoms : Vomiting, sore-throat, tache scarlatinale, "strawberry-tongue," albuminuria. Nomenclature. — " Febris scarlatina " (Ital. Scarlatto, scarlet) was the name by which Sydenham (1675) and afterwards Withering (1778) designated this disease. Hence the synonyms "Scarlatina" (Boissier de Sauvages, Vogel, and Cullen) and " Scarlet Fever." It had been described as far back as 1556 by Ingrassias, of Palermo, under the name " Rosalia." The equivalents are : — Latin, Febris Rubra (Heberden). Germ. Scharlachfieber, or, shortly, Scharlach. Fr. Fievre rouge, Scarlatine. Ital. Scarlattina, Febbre rossa. Span. Escarlatina. Danish and Norwegian, Skarlagensfeber. Swedish, Skarlakansfeber. Dutch, Scharlakenkoorts. Morton, a contemporary of Sydenham, described the disease as Morbilli confluentes, confounding it with measles. Another name was Morbilli ignei, that is, " Fiery Measles." Definition. — An acute specific infectious fever, characterised by a sudden onset with vomiting, rigors, and prostration ; early and persistent sore throat, deep injection of the mucous membranes of the throat, which are swollen and inflamed; very rapid pulse-rate and high fever ; and especially by the appearance upon the skin after a few hours of a minutely punctiform scarlet rash, which is most intense on the third day, and afterwards fades gradually, to be succeeded by profuse desquamation of the cuticle in both small and large flakes. A specific nephritis is a not uncommon complica- tion or sequela. Three varieties of the disease are recognised — namely, simple, anginose, and malignant scarlatina. JEtiology. — The origin and native habitat of scarlet fever are SCARLATINA. 1").") quite unknown. By far its largest area of distribution is on Euro- pean soil (Hirsch). In Germany, France, the British Islands, Scan- dinavia, and Russia, it is one of the chief factors in the statistics of sickness and mortality. Up to the present it has a very scanty diffusion in Africa and Asia. It occurs but rarely in India, is said to be unknown in Japan, and assumes generally a mild type in Australia, Tasmania, and New Zealand, in which countries it first broke out in the beginning of 1848. The first appearance of scarlet fever on the soil of North America dates from 1735, when it broke out in Kingston, Massachusetts, thence spreading to Boston and other places near, and finally overrunning the whole of the New England States in the course of the next few years.* Nearly a century elapsed before scarlet fever began, about 1830, to be generally diffused over South America. The area of diffusion of scarlet fever is much smaller than that of smallpox or of measles. Its epidemics arise at long intervals — ten or twenty years or more often intervening between two succes- sive outbreaks at a given place. Its epidemics are, however, of protracted duration ; and sporadic outbreaks arise from time to time in the intervals. Scarlatina displays extreme variation in its intensity — the rate of mortality being almost nil, or only from 3 to 5 per cent, of those attacked, in some epidemics; but in others rising to 30 per cent, or upwards. No more striking proof of this can be adduced than the words in which Sydenham described scarlet fever — "Hoc morbi nomen, vix enim altivs assurgit." According to Graves b — the his- torian of the disease in Ireland— in the months of September, October, November, and December of the year 1801, scarlet fever "com- mitted great ravages in Dublin, and continued its destructive progress during the spring of 1802. It ceased in summer, but returned at intervals during the years 1803-4, when the disease changed its character, and although scarlatina epidemics recurred a The Practical History of a New Epidemical Eruptive Miliary Fever. By Dr. Douglas. Boston : 1736. Reprinted in The New England Journal of Medicine, January 1825. P. 1. b A System of Clinical Medicine. By R. J. Graves. Dublin : 1843. P. 493. Also Clinical Lectures on the Practice of Medicine. By the late R. J. Graves. Dublin : Fannin & Co. 1864. Pages 230, et seg. 156 SCARLATINA. very frequently during the next 'twenty-seven years, yet it was always in the simple or mild form." In 1834-35 another destruc- tive epidemic raged in Dublin, and so to the present day outbreaks alternately benign and malignant have been observed, according as the " Epidemic Constitution " varied, as Sydenham would say. Predisposing Causes. — Climatic Influences do not play a pro- minent part in determining the geographical distribution of the disease, for although the tropical and sub-tropical regions of Asia and Africa have so far almost entirely escaped scarlet fever, yet it has often prevailed epidemically in the tropical countries of South America; and, on the other hand, in certain cold or temperate climates scarlet fever is among the rarest of diseases. There is, however, evidence that season does influence its preva- lence. " Scarlatina" observes the Registrar-General of England, 4 " discovers a uniform, well-marked tendency to increase in the last six months, and attain its maximum in the December quarter, the earlier half of the following year witnessing a decrease." In Dublin, also, the disease is almost invariably most prevalent and fatal in the fourth quarter of the year. From an analysis of the weekly death-rate from scarlatina in Dublin it would seem that this fever shows a tendency to increase when the mean temperature rises much above 50°, while a fall of mean temperature below this point in autumn checks the further rise of the mortality. 15 In this city, scarlet fever is most fatal in the forty-sixth week of the year (middle of November) and least fatal in the twenty-fourth week (middle of June). Dr. Edward Ballard draws inferences which confirm these results. The " Annual Summary of Births, Deaths, and Causes of Deaths," of the Registrar-General of England, for 1890, is illustrated by the annexed Diagram (3.), showing the weekly mortality curve for scarlet fever in London on an average of 30 years (1861-1890). The curve consists of a single wave, which rises to its crest (60 per cent, above the mean line, which represents an average weekly number of 44 deaths) in October and November, while the trough a Twenty-eighth Annual Report of Births, Deaths, and Marriages. Page 38. b Manual of Public Health for Ireland. 1875. Pages 303 and 304. c Eleventh Report of Med. Officer of Privy Council. 1868. No. 3. Pp. 54-62. q: UJ > LU Ix. H LU I q: N < to o ^ tO ?3 l K ^ t*o k~ r— < <^n :> ■'-- < "~~ a: \77\lS 10 f W 102 • K>0' ss- -Hill Fig. 5.- S. Typhoides Figt 6. — S. McUzgtrvcis SCARLATINA. 10 L examination he was ascertained to have had measles three or four years previously in the County Carlow. The case, therefore, w;ib regarded as one of Rotheln. On January 14, a bad case of scarla- tina was placed in the next bed to that occupied by George G., and between him and the door of the ward. On January 20, he was seized with sore throat and vomiting, and next day the rash of scarlatina came out. The clinical chart of this case will be found in Plate III. (Fig- I.) The incubation period here coul I not have exceeded six or seven days. This stage of latency may be unattended by symptom 3 , or towards its close there may be slight headache, malaise, lassitude, and loss of appetite. II. Stage of Invasion. — Like the stage of incubation, this period may be of very short duration — most commonly only twenty-four hours. Sometimes it is still shorter, or very rarely it may extend to several days, as in a case reported by Trousseau, in which rebel- lions cerebral symptoms persisted for eight days and then suddenly subsided on the appearance of sore throat and the rash of scarlet fever. But such a case is altogether exceptional, and Dr. Hilton Fagge considered that a question might fairly be raised as to its original nature. This pre-eruptive, prodromal, or initial stage is shorter in scarlatina than in any other fever. The onset of the malady is abrupt. In children, the earliest symptoms are usually vomiting and diarrhoea, rigors, or a convul- sive seizure. According to Trousseau, the occurrence of convul- sions during the first or second day is always a sign of danger, whereas in other exanthemata it is not of evil omen (Hilton Fagge). In adults, sore throat is generally the first symptom : it is accom- panied by chilliness or rigors, headache, malaise, and prostration. Meanwhile both pulse and temperature rise quickly. Even on the evening of the first day, a child's pulse may range between 140 and 160, his temperature may rise to 103°, 104°, or even 105°. This rapidity of the pulse-beat is almost pathognomonic of scarlatina. The skin is hot and dry. Hilton Fagge says that from the time of Addison the pungent heat of the skin in scarlet fever has been spoken of at Guy's Hospital as comparable only with that which is 162 SCARLATINA. to be felt in acute pneumonia (calor mordax). The tonsils, soft palate, and uvula are deeply injected and often more or less swollen with pappy exudation, resembling ulcers, upon their surface. They are plum-coloured. The neighbouring lymphatic glands in the neck also are frequently swollen. The Schneiderian mucous membrane and the conjunctiva are seldom engaged — thus affording a diagnostic from measles. III. Stage of Eruption. — The rash generally shows itself within 12 or 24 to 30 hours from the first symptoms. It may be detected very early on the sides of the neck and over the chest, as well as in the neighbourhood of large joints. It afterwards spreads to parts of the face, to the abdomen, and over the limbs. Thomas insists that only the forehead and temples are invaded by the rash, the cheeks showing only the ordinary flush of fever. The centre of the chin and a zone round the mouth usually remain free from it. The rash consists of minute red dots, with a general or patchy suffusion of the skin, of a bright scarlet colour, which suggested to Sir Thomas Watson, Bart., a comparison to the colour of a boiled lobster. On the forearms and legs and on the backs of the hands and feet, the papules are larger and more prominent than else- where. The palms and soles show only a faint diffused blush. The eyelids, cheeks, hands, and feet usually swell slightly. Bouchut drew attention to a sign of some diagnostic value, which is called the Tache scarlatinale. This is a white stripe or streak which develops and lasts for a few moments when the finger is drawn across the reddened surface — the contractile power of the cutaneous arterioles being increased. Accidental pressure, by the bedclothes, &c, produces a precisely similar effect, which is well represented in Plate XXII. of Willan and Bateman's " Delineations of Cuta- neous Diseases." Probably nowhere is the eruption so marked as on the abdomen and along the inside of the thighs. Sometimes a "millet-seed" rash of tiny vesicles {miliaria) is observed. These become filled with a milky (lactescent) fluid after 36 to 48 hours. In other cases the eruption is blotchy, macular, or papular. According to Trousseau, the amount of the rash is in SCARLATINA. 162 general proportionate to the severity of the attack, but in compli- cated or malignant cases it may be badly developed. The rash reaches its limits by the second or third day, then fades gradually, leaving persistent blood-coloured (petechial) lines in the folds in front of the elbows, in the axillae, and popliteal spaces. These streaks may be of use for diagnosis. The appearances presented by the tongue in scarlet fever are characteristic. At first, it is covered with a thick, creamy, white fur, through which the enlarged and hyperasmic papilla? project as little scarlet protuberances. The fur is soon shed (early desquama- tion), leaving the tongue red and raw, so as to resemble a ripe strawberry — hence the expression " strawberry-tongue" and " cat's tongue." The fever runs very high in this stage, and the pulse beats very quickly (140-160). Defervescence is gradual, extending over from 3 to 8 days. The temperature " spikes" slightly in the evenings, but remits in the morning. To such a temperature chart Wunderlich assigns the name " easel-like." This term will be explained further on, under the heading " Temperature." IV. Stage of Desquamation. — The process of " peeling" sets in on the neck and chest between the sixth and ninth days ; then it affects the limbs, the hands, and lastly the soles of the feet. Branny scales come off from the face (furfuraceous desquamation), flakes of cuticle are shed from the trunk, and sometimes " gloves " of skin from the hands and feet — even the nails may be shed. Much more frequently, however, interference with the nutrition of the nails is shown by the formation of a transverse groove upon them. This was fully described by A. Vogel in the case of typhus fever, and is illustrated by drawings in Murchison's work on the " Continued Fevers of Great Britain." Dr. Samuel Wilks drew special attention to this atrophic furrow in the nails of scarlet fever patients. In this stage, albuminuria often makes its appearance, one reason being the shedding of the tubal epithelium in the kidneys, in con- sequence of which albumen escapes into the urine. 164 SCARLATINA. Hilton Fagge describes the process of desquamation as taking place in a manner which I have often observed. " The first step," he says, " towards the throwing off of the epidermis at a particular spot is often the formation of a little opaque raised vesicle, very- like thdse which are characteristic of eczema, but dry; this breaks at the summit, leaving a free edge in the shape of a ling, which gradually becomes larger and larger. 1 ' The duration of the stage of desquamation is really indefinite — in some cases lasting for a fortnight only, in others for several weeks — perhaps, even months. Relapse is a very infrequent phenomenon in scarlatina. The most recent contribution to the literature of the subject will be found in the number of the Edinburgh Medical Journal for October, 1891, in which Mr. George P. Boddie reports two cases of what he terms " a true relapse or recrudescence in scarlet fever," illustrated by the temperature charts. Of the nature of the second case Mr. Boddie speaks with some reserve, but he has no doubt as to the first case. A boy, aged fourteen, passed through an ordinary attack of scarlatina simplex, followed by slight albuminuria and desqua- mation, partly scurf-like, partly flaky. He was out and about when, on the 37th day, he was again seized with symptoms of scarlatina. Desquamation began on the 7th day, and was more extensive than in the first attack. At the end of five weeks — 72 days from the first illness — the boy was perfectly well. Mr. Boddie has appended to his clinical record a very full 'resume of the literature on the subject of "Relapse in Scarlatina." Trojanowsky a states that among 300 cases (260 children and 40 adults) he has seen 18 relapses (15 children and 3 adults), that is, 6 per cent. Thomas and Kbrner, both of Leipzig, distinguished between what they call a pseudo-relapse (em Pseudo-recidiv) and a true relapse (ein wahres Recidiv.) These authors have severally seen cases of the latter. Kbrner, in particular, supplements his paper by giving notes of 38 cases of true relapse as reported by various writers, whom he names. Henoch 13 gives notes of 8 cases. a Jahvbuch fur Kinderheilkunde. 1873. b Lectures on Children's Diseases. New Syd. Soc. Vol. If., p. 232, et seq. SCARLATINA. In* 5 Gumprecht, among 228 cases of scarlatina at the Friedrichshain Hospital, says he met with 13 " pure cases of relapse" — i.e., b'l per cent. French writers, such as Jaccoud, a and Rilliet and Barthez b express the opinion that scarlatina is capable of recrudescence or relapse like typhoid fever, and that we possess well authenticated cases of this phenomenon. English writers are more sceptical. Thus Hilton Fagge c asserts that " relapses are seldom or never seen." Drs. Ashby and Wright, in their Handbook on the Diseases of Children (page 213) say, " Reinfection or relapses are said to take place in some instances.'' In supposed cases of relapse which came under their own notice, " there was considerable doubt as to the correctness of the original diagnosis." Dr. E. 0. Hopwood, d of the London Fever Hospital, estimates, however, that " a relapse, or true second attack of scarlet fever, occurs in about one-half per cent, of cases at any time from the tenth day of the first attack, and is followed by a second descpia- mation. It may be of any grade of severity." Fiirbringer, the writer of the brilliant article on " Scharlach " in the Real-Encyclopddie der gesammten Heilkunde, states that it always appeared to him that the relapse was " a fever following the true initial scarlatina, independent of it, caused by no apparent compli- cation, of very variable type, and lasting for days or w T eeks." As for my own experience, I cannot recall a single instance in which a true relapse came under my cognisance, although I have often observed accidental febrile movements during convalescence from scarlatina. a Traiti de Pathologie Interne. 1883. III. 558. b Traite des Maladies des Infants. 1891. III. 153. c Principles and Pract. of Med. Vol. I., p. 216. 1886. A Did. Pract. Med. Edited by J. K. Fowler. 1890. Art. "Scarlet Fever." 166 CHAPTER XVII. Scarlatina (continued). Aberrant Forms — Complications and SEQUEiiE — Temperature. Irregular or aberrant forms of scarlatina : (1.) Rudimentary or abor- tive : (a.) simple scarlatinal angina (scarlatina faucium), (/3.) latent scarlatina (scarlatiue fraste) ; (2.) Scarlatina anginosa — diffuse cellulitis of neck ("tippet- neck"), diphtheria ; (3.) Scarlatina maligna : (a.) Angina maligna, (/3.) ataxic scarlatina, (y.) hemorrhagic scarlatina — "Scbarlacbtypbus." — Complications and SequeLjE : Diphtheria, acute rheumatic arthritis and serous inflammations, acute desquamative nephritis, pleuritis, bubonic swellings, pyaemia, boils and abscesses, otitis, eye affections, eczema, chorea. — Temperature ranges in Scarlatina. In the last Chapter a word-picture was attempted to be drawn of scarlet fever as the disease presents itself in a typical or normal case. But a striking feature in the malady is its polytypical cha- racter, the great variability of its symptoms and of its course. It will be necessary, therefore, shortly to describe some of its leading irregular or aberrant forms, as Hilton Fagge calls them. 1. Of the rudimentary or abortive, and therefore mild and favourable forms, the most frequent is (1.) Simple Scarlatinal Angina. This is observed usually in adults, whose predisposition to the disease is slight, during the prevalence of an epidemic. Its features are — fever of moderate intensity, slight sore throat with redness and some swelling of the mucous membrane, pain in the neck, and, it may be, enlargement of the cervical glands. This mild scarlatinal angina was described by Dr. Alex. Tweedie, in an excellent monograph on Scarlatina,* under the name Scarlatina Faucium. In Graves's " Clinical Lectures " b will be found a series of cases of it detailed by the late Dr. John Ridley, of Tullamore, a The Cyclopcedia of Practical Medicine. London : 1834. Vol. III. Art. "Scarlatina." b hoc. cit. Page 247. SCARLATINA. 167 King's County. Thomas* says : " Such attacks generally disappear in a few days, but they should receive the same attention which is paid to the unmistakable disease ; every throat affection during a scarlet fever epidemic is suspicious ! " This is all the more neces- sary as the most malignant forms of the disease may arise from scarlatina faucium. (2.) In other cases, the throat affection is absent or so trifling that it does not account for the existing fever. There may be a slight rash, and the cervical glands may be enlarged. In such attacks, joint affections of a rheumatic nature or kidney trouble may supervene. This is disguised or Latent Scarlet Fever — the form to which Trousseau gave the name of " defaced scarlatina " (Scarlatine fruste). As an inscription is defaced by being in part obliterated, so a disease may be defaced by the absence of some of its prominent and distinguishing features. 2. In marked contrast to the foregoing mild forms, we often meet with that severe variety to which the name Scarlatina anginosa is given. It is the second of the three classical forms. In this anginose variety the constitutional disturbance and fever are well marked, and, in addition, the patient as early as the second day com- plains of stiffness and pain about the neck and jaws, and under the ears, the throat feels rough, deglutition is difficult and painful, and there is some hoarseness. The tonsils are swollen, and of a deep purple or plum-like colour. On their surface small whitish specks of pappy or pultaceous exudation appear. These resemble ulcera- tions, but are really accumulations of secretion from the mucous crypts or follicles — which have taken on increased action — and of epithelium, which is already desquamating freely. The mucous membranes of the pharynx, mouth, and nose, all share in this affection, so that both respiration and deglutition may be seriously interfered with ; an offensive sanious discharge takes place from the nostrils, the breath is foetid, the voice becomes nasal, and drinks return by the nose. The scarlatinal affection of the nasal mucous membrane may also extend to the cavities adjacent to the nose especially the antrum of Highmore ; or not infrequently to the Eustachian tubes, in which latter case deafness of a temporary, a Von Ziemssen's Cyclopaedia of Medicine. Art. " Scarlatina." 16$ SCARLATINA. sometimes of a permanent, nature, is added to tbe patient's troubles. Nor does the mischief end here. In this form of the disease, the tonsils may suppurate, or, still worse, become gangrenous after an abscess has formed and burst — the destructive process extending to and eating away the arches of the palate, the uvula, and even the whole of the soft palate itself. Ulceration of the tonsils may also lead to erosion of the internal carotid artery, necessitating ligature of the common carotid of the same side. It is in scarlatina anginosa, also, that after the eighth day the cervical glands swell sometimes enormously, a low erysipelatous or phlegmonoid inflammation engaging the cellular tissue of the neck. The swelling which attends this " diffuse cellulitis " gives rise to the expression "tippet-neck" — a condition said to be fatal if it involves both sides of the neck. The brawny swelling is often white, smooth, glossy, and hard as a board; it pits on pressure, but conveys no sense of fluctuation. It is situated at the angle of the jaw, or involves the whole lower jaw, stretching upwards to the temples and downwards to the clavicles.* The diseased mucous membranes in scarlatina anginosa lastly afford a fertile soil for the growth of the micro-organisms of diphtheria — the Streptococcus described by Oertel, and the Bacillus of Loffler. As a matter of fact, diphtheria is a not uncommon complication of the disease. 3. Some of the severer forms of scarlatina anginosa just described might justly be included under the heading Scarlatina maligna. But apart from the malignant form of scarlatina anginosa, formerly called Angina Maligna (Fothergill, 1754), the term Scarlatina maligna is reserved specially for two terrible varieties of the malady — Ataxic Scarlatina and Hsemorrhagic Scarlatina. Nervous or Ataxic Scarlet Fever is ushered in with rigors, convulsions, and even tonic spasms with trismus, incessant vomiting a A good account of " Diffuse Cellulitis of the Neck," by Mr. Henry Gray Croly, President of the Royal College of Surgeons in Ireland, will be found in the Dublin Journ. of Med. Science for May, 1873, Vol. LV., page 407, Not. 17, Third Series. SCARLATINA. 169 find diarrhoea, wakefulness, agitation, and restlessness with deli- rium, and high fever (hyperpyrexia). A temperature of 115° F. was observed by the late Dr. Bathurst Woodman in some patients, 8 but this must be considered as altogether phenomenal. The maximum observed by Wunderlich was 110''6° F. (43*o° C) The foregoing symptoms are quickly followed by another group indicative of profound nervous prostration (ataxia) — namely, muscular tremors (subsultus tendinum), plucking at the bed-clothes {carphology or Jloccitatio), thecoma vigil described by Sir Win. Jenner, Bart., dilated pupils, coma, quick shallow breathing, and extreme rapidity and feebleness of the heart's action, and profuse cold or clammy sweating. Needless to say that such attacks prove rapidly fatal. The rash is badly, if at all, developed, and the diagnosis of scarlet fever depends largely on the occurrence of undoubted cases in the same house or the immediate neighbourhood. In the other variety of malignant scarlet fever, with early severe constitutional symptoms of a "typhoid," "ataxic," or "septic" character, the rash comes out late and imperfectly. Its colour is dark — " a livid violet," as Hilton Fagge calls it — and reddish brown points of hEemorrhage, with petechias and vibices, are found scattered over a large part of the surface in children — less exten- sively in adults, over the neck, chest, back, and skin near the large joints. When the rash presents this hemorrhagic form the tonsils and gums are generally of an abnormally dark colour (Mayr). Such a rash is figured in Plate XXII. of Willan and Bateman's " Deli- neations of Cutaneous Diseases." Haemorrhages take place from the mucous membranes, especially of the nose, colon, and urinary passages. In women, menorrhagia may occur. The internal organs may be the seat of haemorrhages in both sexes, and finally pleuritic or pericardial hemorrhagic extravasations may take place (Thomas). To these grave forms of the disease Hebra gave the name of Scharlachtyphus, or Scarlatinal Dissolution or Decomposition of a Medical Mirror, February, 1865. See note 2, page 204 of Dr. Woodman's Translation of "Wunderlich 's Medical Thermometry lor the New Sydenham Society. London. 1871. 170 SCARLATINA. the Blood, regarding them as instances of a scarlatina without localisation and affecting the blood alone (eine Scarlatina ohm Localisation, ein im, Blute verlaufender Scharlach). 8, Complications and Sequelae. — Among the complications of the acute stages of scarlet fever we may include the ataxic symptoms above described, the acute haemorrhagic diathesis (haemophilia) of the malignant variety, and the sore-throat of the anginose form, with its consequences. But, in addition to these, mention must be made of the following complications : — 1. Diphtheria, in which the mucous membranes of the mouth, pharynx, and nostrils become covered to a greater or less extent with a false membrane of an ashy gray colour and leathery con- sistence, closely adherent, and, if removed, quickly replaced on the ulcerated and bleeding, or simply ulcerated surface. This com- plication is almost invariably associated with albuminuria and is generally followed by various paralytic symptoms and dangerous heart failure, or attacks of angina pectoris vaso-motoria of Nothnagel. 2. Acute rheumatic arthritis and inflammations of the serous membranes occur tolerably often in the course of scarlet fever— all the phenomena of an attack of acute rheumatism may be present, and permanent endocardial mischief may result. 3. Acute desquamative nephritis generally sets in towards the close of the first, or in the second week, or at any time during con- valescence. It is a parenchymatous and interstitial (E. Klein) inflammation, and is ushered in with suppression of urine (anuria) or haematuria, oedema of the eyelids, pallor, thirst, and high temperature. When the urine is passed it is found to be scanty, highly albuminous, as the result — (1) of haemorrhage from intense hyperemia, (2) of an abnormal perviousness of the walls of the glomeruli in conse- quence of which transudation of albumen takes place into the urine (Strumpell). The urine also is of high specific density (1020-1030), smoky appearance, and acid reaction. Some of the densest urines are met with in acute scarlatinal nephritis, and Dr. Walter G. Smith b a Hebra. Diseases of the Skin. New Syd. Soc. 1866. Vol. I., page 201. 6 Saundby. Lectures on Briyht's Disease. Bristol : John Wright & Co 1889. Page 177. SCARLATINA. 171 has recorded a sp. grav. of 1065 in one instance. Under the micro- scope altered red blood corpuscles and granular, bloody, and epi- thelial tube-casts are visible. Barthez and Rilliet have observed anasarca in one-fifth of all their cases of scarlet fever. The affec- tion may terminate— (1) in recovery; (2) in death, with convul- sions ; or (3) very rarely in chronic general nephritis. 4. Pleuritis, with purulent effusion as in any septic fever. 5. Bubonic swellings, which occur chiefly in the neck towards the decline of the rash. During convalescence, the sequelae most likely to occur are — 1. Pyaemia. 2. Boils and abscesses. 3. Otitis, with perforation of the membrana tympani from pres- sure by pus pent up in the middle ear. Wendt contrasts the catarrhal inflammation of the Eustachian tube or of the middle ear which accompanies measles, with the suppurative otitis media of scarlatina. A still more serious condition is when mastoid disease occurs, with its consequences — inflammation of the dura mater, thrombosis of the cerebral sinuses, pulmonary embolism and puru- lent infiltration, cerebral abscess, panophthalmitis from embolism. 5. Eye affections, namely, diphtheritic conjunctivitis, atrophic keratitis, panophthalmitis, retinitis albuminurica. 6. Eczema. 7. Chorea, or St. Vitus's Dance {Dance de St. Guy), in two, three, or even six months after the attack. Temperature.— The behaviour of the temperature in scarlet fever is less typical than it is in smallpox or measles. Usually, however, one of the first symptoms is a rapid and continuous rise of temperature in a few hours to 103° or 104° F. With the coming out of the rash the thermometer may be seen to rise slowly, with only slight morning remissions, the height finally reached being almost always above 104°, very commonly over 104*9°, but seldom in cases which terminate favourably over 105*8° (Wunder- lich). As a rule, the intensity of the fever bears a tolerably close relation to that of the exanthem. 172 SCARLATINA. When the rash begins to fade, defervescence commences. It may; occur quickly and uninterruptedly by crisis; but in an overwhelming majority of cases it is protracted, requiring from three to eight days for its completion. "As a rule," says Wunderlich, " it occurs in tin's fashion, that from day to day the temperature gets gradually lower and lower, and slopes like an easel, or almost easel- wise (Staffel- weise), or goes down with trifling remissions, falling especially at night, remaiuing about the same from morning to evening, or perhaps sinking a little till it reaches the normal." It is only very seldom that a remitting defervescence produces a remote resem- blance to that which is peculiar to typhoid or enteric fever. Complications, of course, interfere with the usual temperature ranges. A subnormal tempei'ature — seldom, however, below 96'8°— • accompanied by other symptoms of collapse, is not of infrequent occurrence towards the close of the stage of defervescence. An anomalous course of temperature is not uncommon — thus, it may be persistently rather low— a condition which does not exclude danger, and by no means guarantees a favourable terminatiou. Again, in Scharlachtyphus (the so-called " typhoid-scarlatina "), the temperature may remain more or less high for a fortnight or longer after the rash has faded. It is sub-continuous or remittent in form, yet in general it takes a descending course. In fatal cases, the temperature is very erratic, but sometimes it reaches very high degrees indeed. Wunderlich met with a pre- agonistic reading of 43'5° C. (110-3° F.), and Woodman's still more extraordinary observations have been already noted. Plate III. contains a series of charts culled from my own Notes, which will fairly illustrate the behaviour of the temperature iu scarlatina. 173 CHAPTER XVIII. Scarlatina {continued). Pathology, Diagnosis, and Prognosis. Pathology op Scarlatina : The blond — the cutaneous affection— the throat and sub-maxillary glai'ds. — Cerebro-spinal system. — The abdomen— small intestine — psorenterie — kidneys . — G-lomerulo-tubal Nephritis (Klebs). — E. Klein's views. — Diphtheritic Pyelitis. — Changes in the urine. —Dropsy.— Inflammations of (a.) serous membranes, (/3.) of synovial membranes of the joints. — The heart — acute parenchymatous myocarditis— cardiac failure.— Diagnosis: Erythema, Smallpox, Measles, Rbtheln, Erysipelas, Diphtheria, Acute Rheumatism. —Prognosis and Mortality. —Causes of Death. Pathology. — The blood is darkened in colour, thin, and generally contains an excess of white blood corpuscles. The walls of the blood-vessels often imbibe the colouring matter of the blood, and thus appear inflamed (Thomas). The cutaneous affection of scarlatina is not merely a hyperemia, but is also characterised by an exudation into the rete Malpighii. Histologically, Loschner, of Vienna, found exudation cells in this structure, and Dr. Hilton Fagge thinks they were probably seen by Dr. Fenwick also, who further observed that the basement membrane of the sweat-glands was thickened, and their channels were obstructed by an overgrowth of epithelium or by extravasated blood. That the eruption bears no definite relation to these glands or to the hair follicles, seems to follow from a case reported by Landenberger and quoted by Thomas, a in which it did not fail to develop itself over an immense cicatrix from a burn which extended over the thigh, abdomen, and back, " the skin having been destroyed in its whole thickness." Slight desquamation followed, and the scar underwent diphtheritic necrosis throughout a portion as large as the hand. The process of desquamation may involve the nails of the fingers and toes, and the hair may fall out. Lentin and Bicker have seen warts drop off after scarlet fever. a Art. "Scarlatina," in von Ziemssen's Cyclopcedia of Practical Medicine. Page 212. 174 SCARLATINA. The changes in the organs of the throat are as essential features in the pathology of this disease as the exanthem itself. They have been sufficiently described under the heading Scarlatina anginosa. Barthez and Rilliet found the submaxillary glands enlarged, hypersemic and softened, and in a later stage, grayish, soft, and the seat of purulent infiltration. The affection of the cellular tissue is undoubtedly inflammatory, and probably results from septic poison- ing, or from haemorrhage — it is a diffuse cellulitis. Notwithstanding the occurrence of severe cerebral and spinal symptoms in bad cases, the cerebro-spinal pathology of scarlet fever may be regarded as a negative quantity. As regards the abdomen and its contents, the only specific changes are those met with in the small intestine and in the kidneys. From the duodenum to the caecum and colon the mucous membrane is more or less injected, and Brunner's and Lieberkiihn's glands, as well as the solitary follicles and Peyer's patches, are swelled and prominent, giving rise to the appearance known as psorenterie. a Deiters describes the patches as being sometimes ulcerated, when a most striking resemblance to the changes found in typhoid or enteric fever is presented. Next to the skin and throat, the kidneys are the organs most frequently affected by scarlatina. Early in the disease a catarrhal condition is found, the epithelium in the medullary substance being cloudy, desquamating in large masses, and being rapidly washed away. Later, a true parenchymatous nephritis sets in, when the cortical substance is particularly affected. In the severer cases, the capsules of the kidneys are easily detached and the organs are enormously enlarged (Biermer). Klebs has occasionally found the kidneys firm and hyperaemic but not enlarged, with nucleolar growths in the connective tissue between the capillary loops of the Malpighian corpuscles, com- pletely compressing the calibre of the vessels and so causing anuria. The morbid process begins in the Malpighian corpuscles, and then a Gk. ty&pa, scabies or itch, mange ; evrepov, the intestine. The French use the word Psore as a geDeric title for vesicular and pustular maladies of the skin, and the idea of roughness is also connected with the Greek tydpa. SCARLATINA. 175 follows the course of the convoluted tubes (Glomerulo-tubal Nephritis). Even when no renal symptoms are present, E. Wagner says that the kidneys are in a condition of congestive hyperemia either with or without a more or less marked degree of albuminous infil- tration. Very rarely the severer forms of parenchymatous nephritis are met with even in the beginning of scarlet fever; as a rule, however, not before the end of the second, or in the third week. So far as I know, the fullest account of the pathological changes in the kidney induced by scarlatina is contained in a communica- tion made to the Pathological Society of London by Dr. E. Klein, on April 17, 1877. a The early changes are met with in the vascular apparatus and certain of the glandular parts of the kidney. The vascular changes are limited, for the most part, to the cortical portion of the organ. They are — (1.) Increase of nuclei (probably, epithelial nuclei), covering the glomeruli of the Malpighian corpuscles. (2.) Hyaline degeneration of the afferent arterioles of the Malpighian corpuscles. (3.) Multiplication or germination of the nuclei of the muscular coat of the minute arteries, and a corresponding increase in thick- ness of the wall of these vessels. The changes referring to the glandular part of the kidney are indications of parenchymatous nephritis consisting in swelling up of the epithelial lining of some of the convoluted tubes and germination of the nuclei of epithelial cells, especially in portions of the ascending tubules lying close to an afferent arteriole of a Malpighian corpuscle. Granular matter, and even blood, may be found in the cavity of Bowman's capsules and in the convoluted tubes, and also cloudy swelling and granular disintegration of the epithelium in some parts of the convoluted tubes. In some cases there appears to be detachment of epithelium from the membrane of the larger ducts of the pyramids. Klein considers that the multiplication of the muscle-nuclei and a The Anatomical Changes of the Kidney, Liver, Spleen, and Lymphatic Gl'inds in Scarlatina of Man. Trans, of the Path. Soc. of London. 1877. Vol. XXVIII., p. 430. ] 76 SCARLATINA. the corresponding increase in thickness of the coat, accompanied by an increase of thickness and number of the muscle-fibres, does not mean a real hypertrophy. He suggests, also, that the anuria and uraemia of scarlatina are brought about, not, as is supposed by Klebs, by a compression of the vessels of the glomeruli by the nuclear germination, but by the glomeruli being shut out of the circulation owing to the changed state of the arterioles, which are abnormally contracted, probably under the influence of some stimulus (perhaps, some blood irritant). In early cases the parenchymatous changes found are slight. The second set of changes refer to cases which died later than the first week, beginning with about the ninth or tenth day. Here we find changes due to interstitial as well as parenchymatous nephritis — they are (1.) The appearance of round cells, lymphoid cells, or whatever they may be called, in the connective tissue of the kidney; (2.) Certain concomitant alterations of the urinary tubes. The infiltration with round cells is observable after the end of the first week in the connective tissue around the large vascular trunks, whence it spreads into the basis of the pyramids, and espe- cially into the cortex. Portions of the latter, and — very seldom — portions of the basis of the pyramids also, are converted into a pale, firm, round-cell tissue, in which the original urinary tubes of the cortex become gradually quashed and lost. This interstitial nephritis begins about the end of the first week, and is followed by a marked increase in the parenchymatous nephritis. This latter consists in crowding of the urinary lubes with lymphoid cells, granular and fatty degeneration of the epithelium of the uriniferous tubes, and the formation of cylinders of different kinds in the tubes. The intensity of the parenchymatous change is, in fact, dependent upon the degree of the interstitial nephritis. A very curious fact, pointed out by Klein, is the deposit of lime matter in the epithelium and lumen of the urinary tubes, first of the cortex, then also of the pyramids at an early stage of scarlatina, when the kidney otherwise shows only very slight change. Biermer, Coats, and Wagner regard the occurrence of interstitial nephritis in scarlatina as unusual. Each of these observers describes SCARLATINA. 177 one case as unique. According to Klein, on the contrary^ the general rule is that cases of scarlatina which die after about nine or ten days show more or less well-marked interstitial nephritis. In scarlatina hemorrhagica, Huguenin demonstrated a diphtheria of the mucous membrane of the pelvis of the ureter (diphtheritic pyelitis) which had given rise to copious hematuria. The changes in the urine which mark the rise, progress, and subsidence of acute parenchymatous nephritis are the following : — 1. An increasing turbidity, with grayish-white or dark-coloured sediments, consisting of an excess of epithelium — cloudy and degenerated or swollen — granular detritus, and red and white blood corpuscles. 2. When haemorrhage from the renal parenchyma supervenes, the urine becomes reddish-brown, or " smoky," and very turbid from urates, depositing them and an abundance of epithelium and casts — bloody, epithelial, and granular. The secretion is very concentrated — shown by a high specific gravity (1025-1030), much diminished in quantity, sometimes almost suppressed. Albumen is present in daily increasing quantities. The albu- minuria has been already explained above (see page 170). 3. Improvement is indicated by an increase in the amount of urine secreted. It becomes clearer and of lower specific gravity, loses its dark colour, no longer contains blood or throws down sediments, and contains albumen in daily diminishing quantity. The tube casts are now less numerous, and are partly epithelial or granular, and partly hyaline or waxy. The usual duration of the albuminuria is from two to three weeks, and casts are discharged for about a month. Dropsy is a common result of scarlatinal nephritis. It usually shows itself as anasarca, when desquamation apparently ceases ; less frequently as an effusion into the serous sacs (ascites, hydro- thorax, hydro-pericardium, hydrocephalus), or as oedema of the lungs and glottis, or as a general dropsy. It is right to mention that dropsy may also be present without albuminuria, and not due to any obvious cause, so far as the kidneys are concerned. It sometimes even occurs without marked anaemia. M 178 SCARLATINA. Inflammations of the serous membranes, with sero-plastic or purulent exudation, occur now and then. They are independent of the kidney affection, although often observed during its course. Pleuritis is the most common of these inflammations ; meningitis, peritonitis, and pericarditis, occur less frequently. Inflammations of the synovial membranes of the joints are usually met with just when desquamation is beginning, but may occur at any other period. They constitute what is known as scarlatinal rheumatism. The condition presents itself either as a more or less intense synovitis acuta with serous effusion, or as a suppurative arthritis, terminating in ostitis and periostitis, caries and necrosis, or pyaemia and death. Scarlatinal rheumatism may also be accompanied by peri- or endocarditis. The heart muscle suffers severely, especially from the hyper- pyrexia which accompanies the severer forms of scarlet fever. Its fibres are the seat of an acute molecular disintegration or of a more chronic fatty degeneration, the result of an acute parenchymatous myocarditis. At the close of the first volume of his " Lectures on Children's Diseases," translated for the New Sydenham Society in 1889, by Dr. John Thomson, Professor E. Henoch, of the Univer- sity of Berlin, speaks of " the fatty albuminous degeneration of the heart muscle which occurs pretty often after acute infectious disease, especially scarlet fever, diphtheria, and typhoid, and clini- cally gives rise to no symptoms, except, perhaps, those of cardiac debility." (Page 491.) In the second volume of the " Cyclopaedia of the Diseases of Children" a there is a short, but interesting, article on "Acute Parenchymatous Myocarditis," from the pen of Dr. J. Mitchell Bruce, Physician and Lecturer on Therapeutics at the Charing Cross Hospital, London. This article seems to me to throw much light on the aetiology of the anginal attacks of acute febrile dis- orders. Under the names of " acute parenchymatous degenera- tion," "albuminous degeneration," "febrile softening of the heart," "infectious myocarditis," Dr. Bruce says that from time to a Edited by Dr. JohnM. Keating, of Philadelphia, and published by Messrs. J. B. Lippincott and Company, of the same city. SCARLATINA. 179 time has been described a kind of acute change in the muscular tissue of the heart, which occurs in acute febrile and infective diseases. The opinions of pathologists as to the nature of this disease have long been, and are still, conflicting, some maintaining that it is truly inflammatory, others that it is degenerative only. "Parenchymatous myocarditis" is the result of acute febrile and infective processes, such as scarlatina, diphtheria, variola, typhus, typhoid, and relapsing fevers, septicaemia and pyaemia, more rarely measles. The condition may be set up during the later, as well as in the earlier, stages of these diseases, or even during convalescence. In it the heart is sometimes distinctly dilated ; the myocardium is of a dirty grayish red or grayish yellow colour, with occasional extravasations ; its consistence is soft ; its substance is lax, flabby, and friable. Thrombi may be found in the ventricles. Microscopi- cally, the muscular fibres are swollen, their striation is more or less lost and replaced by granular (albuminous) and fatty molecules ; occasionally they undergo waxy degeneration (Zenker). Along with these evidences of degeneration, there are found certain appear- ances which suggest regeneration. Lastly, the blood-vessels are dilated and the seat of thrombosis, with cbliterative endarteritis of the arterioles. Dr. Bruce points out that the pathological connection between this acute parenchymatous change and its cause is still unsettled. It may be the' result of the specific action of the several poisons, or of the pyrexia, or of both, on the. protoplasm. It is closely related to fatty degeneration of the heart — indeed, if the destruc- tive part of the process be in excess, it rapidly proceeds to fatty dege- neration, which then covers, or takes the place of, the other changes. As regards the symptoms, cardiac failure is the chief evidence of this condition of the myocardium. Diagnosis. —We have to distinguish Scarlatina from Erythema, Smallpox, Measles, Rotheln, Erysipelas, Tonsillitis, Diphtheria, and Acute Rheumatism. 1. Erythema is distinguished by the fact of its limited distribu- tion — being absent from the neck and extremities, and by its irregular mode of spreading. The fever is slight. There is no sore throat, or swelling of the cervical glands, or kidney affection, or desquamation. 180 SCARLATINA. 2. It is only at the beginning of an attack of Smallpox that an error of diagnosis could be committed. The adventitious prodromal rash of smallpox sometimes closely resembles scarlatina, and the throat also may be sore. In arriving at a diagnosis, bear in mind the prevailing epidemic, note the pulse-rate and temperature, examine the throat and cervical glands, and watch the case closely. 3. Scarlatina is distinguished from Measles by the early appear- ance of the rash, the absence of coughing and sneezing, and the character of the fever. In measles — the early angina, the strawberry tongue, and the glandular swellings of scarlet fever are wanting. 4. The diagnosis between Scarlatina and Rotheln is often most difficult. We must be guided by the prevailing epidemic, the short duration of the rash, which shows on the face also, and of the fever in Rotheln, the trifling angina, and the comparatively slow pulse of that disease, in which also the kidney affection and other complica- tions of scarlatina are wanting. 5. In Erysipelas, which, by the way, is often accompanied by sore throat, the rash is localised and not punctate, the surface is smooth, there is marked oedema of the connective tissue, and vesicles or bullae may form. In scarlatina, desquamation may occur in places where there has been no antecedent eruption ; in erysipelas this is never the case. 6. Acute Tonsillitis, Cynanche tonsillaris, or Quinsy, with its high temperature, swollen tonsils, cedeinatous uvula, and plum- coloured fauces is not infrequently confounded with scarlatina. The diagnosis depends on the history of exposure to infection or otherwise, and the absence of the vomiting, the rash, and the albumin- uria of scarlatina. Generally also one tonsil is more engaged than the other in tonsillitis, whereas the scarlatinal affection is bilateral. 7. In a case, which seems to be one of primary Diphtheria, a careful search should be made for the ill-developed rash of scarlet fever, and regard should be had to the occurrence of other cases of the latter disease in the immediate neighbourhood of the patient. 8. Acute Kheumatism, although often accompanied by sore throat and by accidental papular or miliary eruptions, is distin- guished by usually attacking adolescents and adults rather than SCARLATINA. 181 children, by its profuse acid and sour-smelling perspirations, by the absence of the strawberry tongue, glandular swellings, and renal complications of scarlatina, and by its whole course. Prognosis. — This is uncertain under all circumstances, for scarlet fever is one of the most treacherous of maladies, and therefore the opinion should always be guarded no matter how mild the attack may seem to be. Mayr wrote : " That scarlatina, even in the mildest form, is never a trifling complaint, is a maxim which has been only too fully verified by many sad cases." a Sydenham's opinion as to the benign character of the disease has already been quoted — u hoc morbi nomen ;" but Loschner some forty years ago used an equally epigrammatic and a truer phrase, when he said, " I have never seen a benign epidemic." The mortality very frequently reaches between 13 and 18 per cent.; but in not a few outbreaks it is as high as 25 per cent., or may reach even to 30 and 40 per cent. Age influences the death-rate to a great degree. It is, on the average, 20 per cent, among children under 5 years. So also does social status, but to a far less extent. Family idiosyn- crasy plays an important part in determining the mortality from scarlet fever. Even in a mild epidemic, a family may here and there be decimated, the disease seeming to act as a deadly poison in certain households. As to adult cases, the mortality is highest among pregnant and puerperal women and invalids. Unfavourable Signs in a case are : Hyperpyrexia, dyspnoea, extreme rapidity and feebleness of the pulse, early collapse, badly developed and dark-coloured rashes, persistent vomiting and diar- rhoea, delirium or coma, sloughing of the fauces (angina ganora?- nosa), diphtheria, purulent arthritis, and other severe complications especially nephritis with anuria, and diffuse cellulitis of the neck. Death occurs, according to Hebra, from — (1.) Dissolution of the Blood. (2.) Paralysis of the Nervous Centres (Ataxia). (3.) Suffocation, from (Edema of the Glottis. (4.) Pyaemia. (5.) Renal Disease. a Hebra. Diseases of the Skin. New SyA Soc. 1866. VoL I., page 213. 182 CHAPTER XIX. The Teeatment of Scarlatina. Prophylaxis not so difficult of attainment as in the case of Measles. — Sug- gested prophylaxis by drugs not reliable. —Effectual prophylaxis consists in Isolation. — Curative Treatment : no antidote yet discovered.— Biniodide of Mercury (Illingworth). — Treatment mnst be largely symptomatic. — Treatment of Scarlatina simplex : expectant. — Hebra's recommendations. — Gnaiacum and Ozonic Ether Test for Blood-pigment in Urine. — Treatment of Scarla- tina ANGINOSA : cold water treatment, quinine, ice, cold compresses to neck, drugs. ^Treatment of Scarlatina maligna : combat ataxic symptoms ; in haemorrhage, use local and general astringents. — Treatment of Complications and SequeLjE : Diphtheria, rheumatism, acute desquamative nephritis, ursemie convulsions, pleuritis, endocarditis, bubonic swellings, diffuse cellulitis, pyaemia, acute furuncular diathesis, diseases of the ear, conjunctivitis, keratitis, acute eczema, chorta. I. The Prophylaxis of Scarlet Fever is not attended with the vast difficulties which beset the attempt to control the spread of Measles. Although it would be going too far to deny that scarlatina is infectious in the stages of invasion and of early eruption, yet there can be little doubt that the poisonous virus is shed in greater quantity during the later stages of the disease, in the discharges from the nose and throat, in the motions from the bowels, most likely in the urine, but above all, in the desquamated cuticle. H A nce, breathing time is allowed the physician in which to plan and eive effect to precautionary measures. Again, the early appearance of the rash and the sore throat establish the diagnosis long before the period when measles declares itself — that is, on the- fourth or fifth day. Time, therefore, is not permitted to the malady in which to run riot through a family or household. In speaking of the Preventive Treatment of Scarlatina, I may state at the outset that all known drugs are without avail. Godelle vaunted hydrochloric acid as a prophylactic ; Giersing suggested the internal administration of carbolic acid ; Hufeland SCARLATINA. 183 and Hahnemann ascribed to belladonna a protective influence against scarlatina, and I have often known this drug to be given for such a purpose by orthodox physicians. But all in vain. Dr. W. G. Walford, of London, states that out of nearly 100 children exposed to infection and to whom full doses of liquor arsenicalis were given, in only two did the disease develop. Children bear arsenic well. Walford gives from 1 to 3 or 4 minims of Fowler's solution, according to the child's age, thrice daily. He combines with the dose 15 to 30 minims of sulphurous acid and a little syrup of red poppy (syrupus rhceados, B. P.) a Notwithstanding these statements I am of opinion, with Mayr and Hebra, that we must conclude that " the only effectual prophylaxis of scarlatina consists in isolating the patients from those who are unaffected as early and as completely as possible." This isolation should be kept up until desquamation has finally ceased. Reference may be made to Chapter IV. for the details which should be followed in carrying isolation, disinfection, and other preventive measures into effect. A scarlatina patient may go home or rejoin school, provided he and his clothes have been thoroughly disinfected, in not less than six weeks from the appearance of the rash, if desquamation has com- pletely ceased, and there is no complaint or sign of sore throat or of discharge from the nose or ears. II. So far, we have not succeeded in discovering an antidote for the virus of scarlatina — we have no specific remedy for it. The biniodide of mercury, if given early in frequent doses, is stated by Dr. C. R. Illingworth, b of Accrington, to shorten the disease and relieve the throat affection. He advises that a child aged between 2 and 6 years should be given every second hour 10 minims of solution of the perchloride of mercury with half a grain of iodide of potassium in a drachm of water. Dr. Eustace Smith recom- mends the addition to this mixture of small doses — say, half a grain — of chlorate of potassium. The term " Curative Treatment " must, however, be taken in a tt Lancet, 1882. And Brit. Med. Journ., 1884. b Brit. Med. Journ., 1886. 184 SCARLATINA. qualified and restricted sense to express the measures we adopt to help the patient safely through his illness. The treatment must, in a word, be largely symptomatic, and directed mainly against those complications and sequelae which disturb the regular progress of the disease. In mild scarlatina simplex we may adopt an expectant treat- ment more or less like that recommended by Hebra. 1. The patient should keep his bed throughout his illness in a fresh, airy room, with just as much covering over him as will pre- vent him feeling cold. Feather bed, coverlets, and movable screens, should all be avoided. 2. The patient should not be allowed to leave his bed until, for two or three days there has been complete absence of fever, thirst has disappeared, the skin has been soft and perspiring, and the pulse has been quiet. On getting up, a flannel or Jaeger suit should be worn. 3. About the end of the third week the patient may be ordered to take a tepid bath daily, or every second or third day, according to circumstances. 4. As soon as desquamation has ceased on the hands and feet, as well as on the face and body — that is, in the fourth week, the patient may be allowed to go out into the open air — weather per- mitting, and unless any fresh symptoms should arise to prevent this. 5. Cool, refreshing drinks, such as cold spring water, lemonade, acidulated water, are to be given freely, and at short intervals. 6. The diet should consist of weak meat-broth, chicken-broth, gruel, milk (peptonised, or mixed with aerated water or lime water in varying quantity), oranges, and cooked fruits. 7. The patient's hair may be combed every day ; his face and hands should be washed with soap and water. The bed and body linen may be changed as often as required. Tepid sponging of the whole body is useful and most refreshing. It may be practised once or twice a day. 8. The urine should be examined daily. With a view of antici- pating the danger of acute scarlatinal nephritis, it will be well daily to use the test for haemoglobin suggested by the Collective SCARLATINA. 185 Investigation Committee of the British Medical Association in their Report on Paroxysmal Hemoglobinuria* — that is, the guaiacum and ozonic ether test. With this the urine gives the blue tint characteristic of blood-colouring matter, when haemoglobin is pre- sent even without blood corpuscles. This test is best performed by adding to about a drachm of urine in a test-tube a few drops of fresh tincture of guaiacum and twenty or thirty drops of ozonic ether. The whole is to be well shaken and then allowed to settle, when the ozonic ether rises to the top, holding in solution the red colouring matter of the guaiacum tincture, of — if blood or its colouring matter be present — the blue pigment to which this has been transformed. In applying the test, instead of using ozonic ether, the same quantity of old turpentine will answer equally well. The best plan also is to make a fresh solution of a few grains of guaiacum resin in a little methylated spirit before each experiment. This test suffices, when a spectro- scopic examination cannot conveniently be made, to establish the diagnosis of hemoglobinuria, even before renal hemorrhage (hema- turia) has taken place. The hot air or vapour bath may be used if albuminuria is pre- sent, and during desquamation the tepid bath will be found both grateful and beneficial. It may be given daily and followed by dry rubbing and inunction with oil (Dahne, 1810), fat bacon, or suet (Schneemann, of Hanover, and Charles West, of London). In my own practice, I employ a weak carbolised oil (1 to 2 per cent.), or soft paraffin (vaseline), or camphorated oil (linimentum camphore, B.P.). Louis Starr 1 * recommends that the whole surface, including the scalp, should be anointed daily during desquamation with an ointment consisting of carbolic acid, 20 grains, thymol 10 grains, vaseline, or simple ointment, 1 ounce. The patient, after the anointing, should be put into a warm bath for five minutes, pro- tected from cold, and then removed to bed, the body being wiped dry beneath the bedclothes. 1 am aware that the practice of inunction has been objected to a See Brit. Med Journal, Jan. 2fi, 1884. P. 189. 6 Archives of Pediatrics. July, 1890. Philadelphia. 186 SCARLATINA. on the ground that it interferes with the free action of the, skin, but this objection is merely theoretical. I am satisfied that to keep the skin smooth, moist, and pliable in scarlatina is essential, and this indication is met by inunction or anointing. The other advantages of the practice are— as regards the patient, relief from itching and general discomfort, reduction of surface temperature, protection from cold, lessened risk of kidney congestion owing to the free action of the skin. From a prophylactic point of view, the fixing of the infectious scales of the epidermis by inunction is a consideration of the first importance. 9. Scarlatina is a great blood-destroyer, and in convalescence iron will be required, as well as change of air to the mountain slope or to the seaside. In Scarlatina anginosa additional treatment to the foregoing will be required. With the object of reducing the excessive fever (hyperpyrexia) which so frequently accompanies this variety of scarlet fever, the cold-water treatment described in Chapter V. (see pages 53, et seq.) should be carried out. Quinine also may be given freely with a twofold object — first, as an efficient antipyretic, secondly as an equally useful antiseptic. There is scarcely any form of " sore-throat" over which quinine does not exercise a more or less specific action. Again, the constant swallowing of fragments of ice is both grateful to the patient and effectual. Cold compresses of lint moistened with water and glycerine should be wrapped round the throat. The nostrils, mouth, and pharynx should be frequently washed or sprayed with chlorine water or warm water containing some common salt, or chlorate of potassium, or per- manganate of potassium (15 grains to the ounce), or sulphurous acid (I in 8) or carbolic acid and glycerine. In the case of the mouth and pharynx, these remedies may also be used in the form of a disinfecting, antiseptic, and deodorising gargle. The following formula for a guaiacum gargle is copied from the Pharmaceutical Record, January 5, 1891 : — $. Tinct. Guaiaci Ammoniati ; Tinct. Cinchonas Composite, aa 5SS ; Potassii Chloratis, gr. 60 ; SCARLATINA. 1S7 Mellis Purissimi, Jss ; Pulv. Gurami Acacia;, gr. GO ; Aquae, §iiss. M. ft. gargarisma. Signa : To be used as a gargle, and a tea- spoonful may be swallowed every second hour. Caustics of all kinds, in my opinion, had best be avoided in scarlatinal sore-throat. It is, however, right to mention that Trousseau recommends cauterisation with equal parts of strung hydrochloric acid and honey. He, no doubt, advises caution in the use of the remedy, which — if awkwardly applied — might cause spasm of the glottis. Among drugs other than quinine which are likely to be of use in this serious affection, the ferric chloride, sulpho-carbolates, hypo- sulphite of sodium, guaiacum, and salicylate of sodium may parti- cularly be noticed. The perchloride of iron may be given with advantage in comhination with chlorate of potassium and quinine. In America, a combination of boric acid and iron is, according to Fenwick, a favourite remedy. He gives this formula : — Boric acid, 30 grains; chlorate of potassium, 120 grains; tincture of ferric chloride, 2 drachms ; glycerine, one ounce ; syrup, one ounce ; water, 2 ounces. One teaspoonful every second hour for a child of five years. Lastly, a moderate — sometimes, a free — allowance of stimu- lants is necessary. The treatment of scarlatina maligna is too often of no avail — the patient dying poisoned in a few hours or days. It is our duty, however, to combat ataxic symptoms by the free administration of food and stimulants and by such remedies as carbonate of ammonia, quinine, bark, iron, camphor, and musk. "Derivation to the surface " — more particularly if the rash fails to appear or is badly developed — may prove of use. Wrapping the lower limbs and body in flannels or cloths wrung out of mustard and hot water is often effectual, and I have myself practised the method with success. Wunderlich recommends the warm, of hot, bath. Thomas speaks highly of the cold pack and cold affusion followed by warm wrappings. Max. Langenbeck has adopted with good results the use of the hot flat-iron, combined with a mustard bath and. subse- 188 SCARLATINA. quent warm wrappings. Blisters have been applied, but to my mind this is a doubtful procedure, regard being had to the usual tender age of the patients and to the kidney delicacy which so often accompanies the disease. Sloughing too would very likely follow the application of a blister. In the hemorrhagic variety of scarlatina maligna we must resort to general and local astringents, such as ferric chloride in full doses, gallic or tannic acid, ergot, hamamelis (or hazelinej, assisted by a nutritious diet and port wine. Owing to kidney delicacy, turpentine is usually contraindicated in scarlet fever. Ice, in every form of application or use, is an invaluable remedy. We have now to consider the treatment of the complications and sequelae mentioned in Chapter XVII. 1. Diphtheria. — The awful prostration which usually accom- panies this affection must be combated by food, wine, diffusible stimulants, bark, and quinine or iron. Young children, as a rule, take quinine very well if it is mixed with milk, and not dissolved in an acid medium, as it is too much the fashion to prescribe it. When there is a diphtheritic exudation, a spray should be used containing glycerine of carbolic acid (1 in 8), or lime water — the solvent power of which is very marked, or solution of mercuric chloride, or lactic acid (the strong acid, 1 drachm ; glycerine, 1 drachm ; water, 14 drachms), or papain (1 to 2 parts in 10 each of glycerine and water). Fenwick gives this formula : Carbolic acid, 1 drachm, or boric acid, 3 drachms ; " liquor potassae," 1 drachm ; chlorate of potassium, 2 drachms ; glycerine, 2 ounces ; lime water, 8 ounces — to be used as a spray, '" when the exudation is foul, jagged, and of a dirty brown appearance." At the London Hos- pital, a solution of sulphurous acid (one part to two or three of water) is frequently used as a spray. Powders, too, may be employed with an insufflator, such as salicylic acid, 2 drachms ; subnitrate of bismuth, 2 ounces (Fenwick). Oertel, the author of the monograph on " Diphtheria " in von Ziemssen's " Cyclopaedia of Practical Medicine," highly recommends the constant inhalation of steam at 113° to 122° F., passed into the mouth through a funnel. SCARLATINA. 189 2. The rheumatic affections of scarlatina are best treated like ordinary acute rheumatism ( u rheumatic fever "). The affected joints should be packed in wadding, or cotton wool, and bandaged ; while salicylic acid, salicin, salicylate of sodium, or salol should be given internally in large and frequently repeated doses. Should peri- or endo-carditis occur, much relief will be obtained by the application of a small blister over the epigastrium or precordial region, as recommended by Dr. Alex. Harkin, of Belfast. 3. Acute Desquamative Nephritis. — Dr. Austin Flint lays down the following indications for treatment in acute nephritis, including, of course, the condition met with in scarlet fever — (1.) Diminution of the intensity of the renal inflammation, promotion of resolution, and restoration of the excretory function of the kidneys ; (2.) Diminution or removal of dropsical effusion ; (3.) Elimination of urea through the skin and gastro-intestinal mucous membrane, if uraemia exists or is threatened. These indications will be met by adopting the line of treatment here sketched out. The patient should remain in bed, wrapped in a blanket, warm but not overwhelmed with bed-clothes ; clad in a long flannel night- dress from head to foot. He should be placed on a mild unstimulat- ing diet of milk, skimmed or in the form of buttermilk, farinaceous food, and light broths (veal, mutton, chicken, in moderation), all highly nitrogenous foods, such as eggs, butcher's meat, and strong beef tea being avoided. His thirst should be relieved by copious draughts of cold water or of one of the mineral effervescing waters which will safely increase pressure in the glomeruli, so that an aug- mented transudation may wash away coagula from the tubules of the kidney. Dry cupping, followed by poulticing over the kidneys, will almost certainly do good, and if the patient is robust and at the same time in much pain, local depletion by leeching or wet cupping over the loins may be practised with benefit. Even vene- section may be practised in a fairly strong subject (Thomas and Romberg). The bowels should be kept open by hydragogue cathartics, like jalap, bitartrate of potassium, 30 grains, with a drachm of honey 190 SCARLATINA. or treacle, scammony, elaterin (?), senna, and colocynth — more particularly if dropsical symptoms have superveued. All stimulating diuretics must, however, be shunned, for they only increase renal hyperemia. In this stage, much benefit will be derived from hot air, vapour, or even warm water baths. The hot air bath should not be prolonged beyond twenty minutes. It may easily be improvised, as suggested by Dr. Saundby, by setting a spirit lamp carefully under a stool or cradle in the bed, if one of the cheap tin lamps sold for the purpose is not available. The " wet-pack " already described may also be used with advantage to promote elimination through the skin. If uremic convulsions supervene, a full dose of sulphate of magnesium (Epsom salts) well diluted, or a bolus of calomel and jalap, may be admin- istered, although mercurials should, as a rule, be avoided in this affection — certain it is, that a patient in nephritis is very suscep- tible to the influence of mercury, and even one dose of calomel may cause salivation. For the relief of convulsions, also, the temples may be dry-cupped or leeched, and Trousseau's plan of compressing the common carotid artery in the neck on the side opposite to that affected by the convulsions may be tried. Com- pression may, indeed, be practised during fifteen minutes on each side of the neck alternately. Other means of relief are : a com- bination of chloral hydrate with one or other of the bromides, or inhalations of chloroform ; or the nitrites — trinitrin (nitro-glycerine), nitrite of sodium, nitrite of amyl ; or citrate of caffein or theobromo- sodio-salicylate (Diuretin) ; or an enema of black coffee (cafe noir). To prevent uraemia Frerichs recommends benzoic acid in doses of from three to fifteen grains, or more, according to age, either in pill or as a soluble benzoate. Four grains may be made up into a pill with a minim of glycerine or a grain of Canada balsam ; or ten grains of the benzoate of sodium, with ten minims of tincture of digitalis may be given in an ounce of infusion of gentian to an adult thrice a day (Saundby). Pilocarpin (^ gr. to ^o g r - every six hours, or ^ g 1 *- SUD_ cutaneously, for a child live years old) is mentioned by Dr. SCARLATTN'A. 191 Fenwick, as recommended in American practice. It has been used in this country also for many years, but requires great caution in its administration. In convalescence the patient should wear woollen clothing day and night, and in all seasons. The "Jaeger system" is both popular and efficient. In this stage of the complaint iron and quinine are the most useful drugs, and albuminous food should be given once all evidence of kidney inflammation has passed away. 4. For the relief of pleuritis and other serous inflammations, the thorough application of cold is recommended by Thomas, to prevent excessive exudation. Should effusion proceed rapidly in pleuritis, paracentesis thoracis (thoracentesis) must be practised. Endocarditis is best controlled by absolute rest, the continuous application of cold to the precordial region, and digitalis, conval- laria, or strophantus with nux vomica internally. 5. Bubonic swellings may be treated by diligent poulticing and painting with iodised glycerine. In the later stages, chloride of calcium, cod liver oil, iodide of iron, and saccharated solution of lime, are all well worth a trial. In the diffuse cellulitis of the neck, Mr. Croly, in the paper referred to already, strongly advo- cates early, deep, and free incisions, as recommended by the late Mr. W. H. Porter, Surgeon to the Meath Hospital. Only in young children is this practice open to question. 6. The treatment of pyaemia, and of the "acute furuncular diathesis," of which Trousseau speaks in the case of smallpox, has already been discussed when speaking of that disease. 7. The diseases of the ear in scarlatina require early and skilled attention, if their dangerous results are to be avoided. Wendt advises that both as a preventive and as a curative measure the secretions should be removed from the nostrils, posterior nares, pharynx, throat, and even from the proximal portion of the Eustachian tubes by douches and antiseptic or detergent gargles. The external auditory meatus should be kept clean and free by gentle syringing. Air should be forced into the middle ear from time to time, of course not by means of the catheter. If intense pain in the ear is complained of, leeching — even the application of 192 SCARLATINA. a single leech sometimes — gives great relief, followed by poulticing. The bathing treatment of severe scarlatina need not be interrupted, provided the auditory meatus is plugged with oiled cotton during the bath. 8. Conjunctivitis is relieved easily and effectually by water- dressings ; keratitis, by the application of cold and dilatationof the pupil by atropin. If the cornea threatens to slough, it should be punctured by a skilled hand. 9. An ointment of salicylic acid (10 grains to the ounce) often acts almost specifically in the acute eczema of children, such as follows scarlet fever. Or the paste recommended by Dr. Charles Szadek may be used, namely, salicylic acid, 30 grains ; vaseline, half an ounce; oxide of zinc and pure starch, of each 360 grains. 10. In chorea, tonics such as the scale preparations of iron, quinine, valerianate of zinc, and so on, together with change of air and scene, will prove beneficial. Note. — The most recent contribution to the literature of the Bacteriology of Scarlatina is a communication by Dr. H. Kurth, Konigl. preuss. Stabsarzt, entitled : — " Ueber die Unterscheidung der Streptokokken und iiber das Vorkommen derselben, insbesondere des Streptococcus conglomeratus, bei Scharlach." (" On the differ- ential diagnosis of the Streptococci, and on their occurrence, especially that of the Streptococcus conglomeratus, in Scarlatina "). Dr. Kurth's monograph was published in the seventh volume, second part, of the "Arbeiten aus dem Kaiserlichen Gesundheitsamte," Berlin, 1891. 193 CHAPTER XX. ROTHELN, OR EPIDEMIC ROSE RASH. Nomenclature. — Definition. — ^Etiology (historical sketch). — Clinical His- tory : Incubation, invasion, eruption, desquamation. — Temperature. — Com- plications and Sequelae. — Pathology. — Diagnosis. — Claims of Rotheln to be considered a distinct disease. — Prognosis : entirely favourable. — Treatment. Nomenclature. — Rotheln. Synon. — Rubeola (Orlow, 1758 ; a Hildenbrand, and even Thomas of Leipzig b ) ; Rubeola notha (other German writers) ; Rubeola sine catarrho ; Rubella (a diminutive of "Rubeola"); Roseola Epidemica. English, German Measles, Epidemic Rose Rash, Epidemic Roseola, Bastard Measles. Fr. Roseole (Trousseau) ; Exantheme fugace (synonym mentioned also by Trousseau). Germ. Rotheln (from roth, red). Borsieri described the disease under the name Essera Vogelii (Trousseau). Definition. — A specific and infectious eruptive fever, distinct and separate, of its own kind (mi generis) ; neither a hybrid of scarlet fever and measles, nor a modified form of one or other of those diseases — Rotheln breeds true. The disease begins suddenly after an incubation of about twelve days, with ordinary febrile symptoms of moderate intensity. The rash appears on the first or secoud day. There are slight catarrhal and anginal symptoms. Enlargement and induration of the lymphatic glands in the occi- pital and cervical regions is a constant epipheuomenon. The febrile movement is brief, and recovery is generally uninterrupted and complete. iEtiology. — The assumption of a specific roseola is based chiefly on the fact that at certain times epidemics appear in which individual cases bear a cansal relation to one another. Further, • a Be Rubeolas et Morbillorum Biscrim. Progr. Konigsb. 1758. h Von Ziemssen's Cyclopcedia of the Practice of Medicine. Art. Rubeola. Voh I., p. 199. 1875. O 194 ROTHELN. this disease affords no protection against either measles or scar- latina, whereas it does protect an individual from a second attack of itself. Lastly, it may attack those who have lately or previously passed through either measles or scarlatina. It is especially a disease of childhood, but may occur in adults up to the age of 40. Seitz reports a case in a woman aged 73. There is reason to believe that epidemics of Rotheln occur periodically like epidemics of measles. In his account of the disease, Thomas mentions two such epidemics as having prevailed at Leipzig in 1868 and 1874. In 1874, also, an epidemic was observed in New York by Dr. J. Lewis Smith. The first British writer on the disease was Dr. Robert Paterson, of Leith, and he adopted the German term Rotheln, which seems to be the most satisfactory name, for it precludes any possibility of confusion in nomenclature. Sir William Aitken draws a distinction between Roseola and Rubeola or Rotheln, for his description of the latter im- presses the reader with its severity compared with the trivial nature of the former. Trousseau, a however, makes no such distinction between Roseola and Rubeola, nor, indeed, does Wunderlich, who, in common with German writers generally, employs Rubeola, Rubeola notha, and Rotheln, as synonymous terms. It is curious to compare Sir William Aitkens' description of Rubeola with those given by the two authors named. He says : b " The prognosis requires to be as guarded as in scarlatina ; for, like scarlatina, rubeola is often an extremely and rapidly fatal disorder." Trousseau writes : " De toutes les fievres eruptives la ros^ole est la plus b^nigne : jamais elle nepresente de gravite, et ton jours elle se ter- mina spontanement sans que le m&lecin ait en aucune facon besoin d'intervenir." Wunderlich's translator, Dr. Bathurst Woodman, renders that author's opinion as follows : " Rubeola (Rubeola notha, Rotheln, or the so-called hybrid between measles and scarlatina, sometimes called Roseola also) does not necessarily entail any fever at all, and only a slight transient attack before and during the eruption. a Clinique Medicate de V Hotel Dieu de Paris. Deuxieme Edition. 1865. Tome I., page 151. b The Science and Practice of Medicine. Third Edition. Vol. I., page 351, ROTHELN. 195 The elevations of temperature are generally subfebrile, or at the worst moderately febrile." Dr. Hilton Fagge points out, in his " Principles and Practice of Medicine," that a precisely similar difference of opinion as to the severity of Rotheln is shown to exist when one compares the por- trait of the disease drawn by Paterson, Copland, and other writers of 40 or 50 years ago, and the account given of it by Thomas, of Leipz ; g, in von Ziemssen's " Cyclopaedia of the Practice of Medicine." The result of this difference of opinion was to shake Hilton Faggc's belief in the separate identity of Rotheln. Trousseau, however, puts the matter fairly and well when he asserts that Rotheln bears the same relation to measles and scarlatina that varicella, or chickenpox, does to smallpox. This is equivalent to saying that it is a totally distinct disease. In a Clinical Lecture on Rotheln, delivered at the Middlesex Hospital in 1874, Dr. Robert Liveing, no mean authority on the subject, condemns the synonyms " hybrid measles," or "hybrid scarlatina" assigned to this exanthematic fever as "most objectionable, inasmuch as they give colour to the erroneous notion that the disease is a combination of measles with scarlatina.'" a Clinical History : — I. Stage of Incubation — To the Irish Hospital Gazette for June 15, 1874, I communicated a series of three cases of Rotheln which had come under my notice within the previous year or so. Of these the first two occurred in a brother and sister, the latter of whom sickened 12 days after her brother. Dr. Murchison, speaking of a case, says : b '' About ten or fourteen days subsequently, a second child in the same family had a similar attack." In the New York outbreak of 1874, reported by Dr. J. Lewis Smith, the incubative period did not seem to be uniform. In some instances it appeared to be from seven to ten days, and in others from eighteen to twenty-two days. Thomas assigns to this sta°-e a duration of from 2^ to 3 weeks. a The Lancet. March 14, 1874. Page 360. b The Lancet. October 29, 1870. Page 595. 1 96 ROTHELN* II, Stage of Invasion. — The premonitory symptoms are some- times absent — or very badly marked. In a considerable number of the cases in New York in 1874, the patients were not known to be sick until the rash was observed covering the surface. Usually, however, the initial phenomena of a feverish attack are fairly pro- nounced — the patients are dull and languid, and complain of head- ache, chilliness, general discomfort, loss of appetite, thirst, pains in the limbs, vomiting and diarrhoea. The throat is injected, but the coryzal symptoms of measles are absent or are only slightly deve-, loped. In exceptional cases convulsions may occur. Dr., Lewis Smith met with clonic convulsions in a boy of 8 years. Nausea is a common symptom. III. Stage of Eruption. — In a few hours or on the second day the rash appears in different parts of the body, thence extending to the legs the next day. It may show itself first upon the face and neck, or down the back, or over the chest. Most frequently it resembles the rash of measles ; sometimes it is scarlatiniform in appearance, although Thomas denies this. The compound or hybrid eruption has been observed by Dr. Kuttner, of Dresden. 8, Lewis Smith says that the rash in the New York epidemic resembled more that of measles than of any other eruptive fever, but in one case, a. boy of three and a half years, it presented over the trunk very much the scarlatinous appearance. Dr. Liveing also describes the rash as consisting " of small rounded collections of minute red papules, which after a time coalesce and form larger irregular patches, just as in measles, but with apparently less tendency to become of a horse- shoe or crescentic shape. After a time the patches may all unite, and then the skin becomes to the naked eye of a uniform red colour, closely resembling that in scarlet fever." It will be observed that Liveing speaks of " papules," and the appearance in one of my cases quite bears out this description and Sir William Aitken's remark, that " the eruptive patches are felt to be distinctly elevated above the skin, some more than others, and always greatest in the centre of the patch." L. Smith says the rash " disappeared on pressure, caused a little roughness, as ascertained by carrying the 8 C'f. Dublin Hospital Gazette. Dec. 15th, 1858. KOTIIELNl 107 fingers over the surface, and faded without desquamation." The slightly raised rose-coloured spots or maculae of Rcitheln vary in size from a mere point to one-sixth of an inch in diameter. On the other hand Trousseau states that the patches of roseola do not project ahove the surface of the skin like those of measles — " Les taches rub^oliques ne sont plus en effet saillantes comme le sont les taches morbilleuses." 8. All writers are agreed that troublesome itching accompanies the rash, which fades gradually, sometimes (as in one of my cases) leaving dark and dirty, or yellowish stains like those in measles, which are visible for five, six, or more days. Simultaneously with the dermatitis, there is a mild inflammation of the mucous membranes covering the buccal, pharyngeal and nasal surfaces, and of the conjunctivae. This gives rise to a certain degree of sore-throat, sneezing, running from the nose, suffused, watery, or reddish eyes, with slight oedema of the lids, and often a muco-purulent secretion which, drying, glues them together, especially in the mornings. Lastly, allusion must be made to an almost pathognomonic sign of Rbtheln, and this is enlargement and induration of the lymph- glands, particularly those on the mastoid processes and behind the sterno-mastoid muscles, and those of the posterior chain below the occipital protuberance. Analogy would lead us to infer that the bronchial glands share in this pathological change — a point which has a material bearing, as I hope to show, on the prognosis. IV. Stage of Desquamation. — There is but little "peeling" in Rotheln. Lewis Smith says the rash " faded without desquama- tion." In one of my cases there was "slight desquamation on the bridge and at the sides of the nose ; " in another case, the skin was shed in large flakes as in scarlatina, and even the nails came off. Temperature. — The febrile movement is usually slight. Wun- derlich's opinion on this point has been quoted above. b Dr. Edward Ellis says : " The temperature in my own experience, has been remarkably low, rarely reaching and never exceeding 100° F. ; a Clinique Medicnle. Tome I. 1865. b A Practical Manual of the Diseases of Children. Second Edition. Page 73. 1 98 KOTHELN* sometimes ranging from 97° F. to 99° F." To the same effect, Dr. Lewis Smith observes : " The febl'ile movement was ordinarily mild, the pulse in ten uncomplicated cases ranging from 80 to 100, and the temperature from 98£° to 100°." In my own three cases the maximal temperatures noted were 102-4°, 98-2°, and 99 8° respectively. Complications and Sequelae may almost be said not to exist in Rotheln. In one instance, notwithstanding, I could not help regarding an attack of this disease as the starting point in a young barrister of chest delicacy, which nearly cost him his life, through profuse and repeated hamioptyses. Happily, after some years of invalid life he completely recovered. The occipital glands were much enlarged during this gentleman's attack of Rotheln, and in the light of his subsequent history the conviction was forced upon me that a similar enlargement of the bronchial glands had been followed by caseation and even tubercular disease. At all events, the possibility that Roiheln may be the starting point of phthisis pulmonalis can never in future be absent from my mind when culled upon to attend a case of this disease. Pathology. — This topic has been sufficiently discussed in the preceding remarks on the aetiology and clinical history of tlie affection. There is, in fact, little that is specific in the Morbid Anatomy of Rotheln. Diagnosis. — "Writing in 1874, Dr. Li veing a observes : — "German measles is not yet fully recognised by the profession in this country ; little or no account is given of it in our ordinary text-books on medicine, and its name does not find a place in the ' Nomenclature of Diseases,' drawn up by a Committee of the Royal College of Physicians. Under these circumstances, it is not surprising that errors of diagnosis should sometimes bring discredit on our profes- sion." In a Clinical Lecture on Rotheln, also delivered at the Middlesex Hospital, in April, 1870, the late Dr. Charles Murchison spoke in the same strain. b After describing two cases, he remarked : " The ailment from which these patients suffered is not generally a The Lancet, March 14, 1874, Page 360. b The Lancet, October 29, 1870. Page 595. ROTHELN. 199 recognised as a distinct disease ; and cases of it, when they occur, are apt to be puzzling, and sometimes to get the medical attendant into trouble from his inability to determine their real nature. Yet, on the whole, they are not very rare." The following cases will exemplify the difficulties which arise in connection with the diagnosis of Rbtheln. They are culled from the note-books of a physician of much skill and experience : — A lad, aged seven, showed the rash of measles on June 18, 1852. A second child, a girl, aged five and a-half, had the rash on June 29 ; a third, a girl, aged two, on June 30. The mother of these three children told the physician that the boy had a year before an attack of what was thought to be " spurious measles," the rash more vivid than on the present occasion, with sore throat and followed by desquamation of cuticle. He did not appear sick, was not confined to bed, and did not communicate the disease to any of the other children. On November 18, 1851, the same physician vaccinated a baby girl, aged three months. On the fifth day, the eyes watering, an eruption of ''roseola" came out and spread over the whole body. It was very evident on the scalp and trunk, was attended with a good deal of restlessness, and a disinclination to take the breast. It was at its height on the seventh day, and nearly gone on the eighth day after vaccination, in no way retarding the progress of the vesicle. On the 13th of the following month an eruption like measles came out on the baby's sister, aged nearly five years. She passed through her attack with very little constitutional disturbance and without much cough or catarrh. On July 20, 1854, the rash of genuine measles came out on the aforesaid baby, then aged four years. She had taken the disease from her elder brother, aged eight years and nine months, who, after three or four days of " off and on " feverishness, showed well-marked catarrhal symptoms and the rash of measles on July 8, 1854. On the 28th the measles eruption came out on the sister, who had been infected with Rbtheln in 1851, and who was now seven and a half years of age. 200 EOTHELN. In the three cases I detailed in the Irish Hospital Gazette, the chief points of diagnostic interest were — (1.) The trifling degree of pyrexia observed. (2.) The early appearance of the eruption — always within 48 hours. (3.) The presence of only slight hyperemia of the fauces without acute inflammation or ulceration. (4.) The evidence afforded by the second case of the series as to the infectious nature of this exanthem and as to the length of its period of incubation. (5.) The changeable character of the eruption. Notwithstanding the formidable account of this disease pre- sented to us by Sir William Aitken, the balance of opinion seems to be in favour of its comparatively trivial nature. Rotheln, indeed, may be said to derive its chief importance from so often and sometimes so closely resembling measles or scarlatina. The arguments which may be advanced in support of the claim of Rotheln to be considered a distinct disease are these : — 1. It occurs in persons who may already have had either measles or scarlatina, or both these fevers. 2. It does not protect from an attack of either of these diseases. 3. It does protect from itself, just as measles protects from measles, smallpox from smallpox, scarlatina from scarlatina, Trousseau, indeed, does not hold this view, for he says : " Une roseole ante^cedente ne preserve pas de nouvelles attaques." Borsieri went still further when he wrote : " Qui semel Us laboravit facile iterum pluriesque prehenditur." " He who has once suffered from it, is easily attacked by it again and again." 4 It can propagate itself — in the words of Dr. R. Liveing — " the seed, as a gardener would say, comes up true." 5. The subfebrile temperature of the early stage at once tends to preclude the possibility of scarlatina, and the probability of measles. 6. The early appearance of the rash distinguishes it from that of measles, while its usually " measly " character aids the diagnosis from scarlatina. . ; I.',: -: ROTHELN. 201 7. The anomalous combination of the coryzal symptoms of measles with the sore-throat of mild scarlatina, should excite suspicion as to the probable presence of Rbtheln. 8. The whole subsequent course of the disease and of its eruption affords grounds for a differential diagnosis. From ordinary Rose-rash or Roseola, and indeed from Erythema also, Rbtheln is distinguished by its pyrexia, enlarged glands, and throat symptoms. Prognosis. — From the close resemblance of the initial symptoms and eruptions, sometimes to those of measles, sometimes to those of scarlatina, the diagnosis of Rbtheln is often, as we have seen, a matter of considerable difficulty. Under such circumstances, the early prognosis should always be guarded. It is far better to have been mistaken in our diagnosis in assuming, for the time being, that we had to deal with either measles or scarlatina, than to have imperilled the lives of many children by neglecting to isolate the sick from the healthy in due time. Once the diagnosis is made, we may, ill most cases, pronounce an entirely favourable opinion. Let us bear in mind at the same time that even this " lightest of the acute exanthems " — as Thomas calls it — may occasion grave disturbances or even death in a delicate subject, and that the enlargement of the lymph glands which so constantly accompanies it may have far-reaching and untoward effects upon the patient's health and constitution. Treatment. — A case of Rotheln should be treated exactly as if it was one of simple measles. The child should be kept in bed while fever lasts, protected against cold, and suitably fed. Tepid or cool sponging will relieve itching. Watch should be kept upon the catarrh of the pharynx and of the air-passages. Warm baths are most useful in convalescence. In a word, good nursing and sound common sense alone are wanting to tide a patient over an attack. 202 CHAPTER XXI. Erysipelas. Nomenclature. — Defi»ition. — ^Etiology. — Erysipelas both a local and a specific disease. — Medical or Idiopathic and Surgical or Traumatic Erysi- pelas. — Predisposing Causes : traumatism, a previous attack, sex, age, climate, season. — Exciting Causes : contagion, inoculation. Doctrine of the Contagiousness of Erysipelas not proved. — Bacteriology : Streptococcus Ery~ sipelatis (Fehleisen). Nomenclature. — Erysipelas (Greek — ipvcri7re\a<;, Hippocrates, B.C. 430). Synon. — St. Anthony's Fire (Lot. Ignis Sacer). In Scotland it is called the "Rose." Germ. Rothlauf, Rose, Hautrose, Erysipelas. Fr. Erysipele, Feu Sacre, Feu de Saint Antoine, Mai de Saint Antoine. Ital. Risipola, Erisipela. Span. Erisipela. Dutch, Roos, St. Antonie's Vuur. Swedish and Norwegian or Danish, Rosen. The Etymology of the word " Erysipelas " is not settled. In the the Vet. Med. and Aphorisms of Hippocrates the word occurs in its Greek dress epvaiireka3 etiology. — Erysipelas is certainly to be regarded as a specific disease, because it depends upon the entrance into the system of a specific micro-organism — the Streptococcus erysipelatis of Fehleisen. In one sense, it is a local disease, inasmuch as the virus settles upon the spot which is afterwards to become the focus of the erysipelatous inflammation — the infection of the blood, and therefore of the whole system, being secondary. In this respect erysipelas is precisely analogous to diphtheria. A strong argument in favour of this view is afforded by the complete want of symmetry in the distribution of the skin affectiou which is so constantly observed. With equal propriety, however, erysipelas is classed with general diseases of specific origin, for like them it requires a certain incubative period for the development of its constitutional symp- toms. Dr. J. J. Pringle a well observes that the term erysipelas " is, unfortunately, applied loosely to many other diseases accompanied by an erythematous blush (simple lymphangeiitis, various erythe- mata), and also to certain conditions of phlegmonous «and diffuse cellular inflammation, which may complicate erysipelas but are due to a different virus — viz., the microbe of septicaemia." The old and classical division of erysipelas into Medical and Surgical, proposed by Borsieri and sanctioned and adopted by Sir Thomas Watson, Bart., is purely artificial, and being useless as well as unfounded in fact, should be abandoned. When the disease affected the head and face, apart from surgical injury, it was described as "Idiopathic" or "Medical Erysipelas." When it attacked the limbs, the body, or even the head after injuries, it was dubbed " Traumatic " or " Surgical Erysipelas." To Trousseau belongs the merit of pointing out the unreality of any such distinction. So long ago as 1856 Gubler b showed that facial, or the so-called " Medical " erysipelas, was only a propaga- tion of the disease from the pharynx, and not a metastasis, a theory which before that had been often advanced. Trousseau a A Dictionary of Practical Medicine. Edited by James K. Fowler, M.A., M.D. Art. "Erysipelas." London : J. & A. Churchill. 1891. b Memoiies de la Societe de Biologic. 1856. Page 40. 204 ERYSIPELAS. adopted Gubler's view, and as a result of most careful clinical observations maintained that the so-called idiopathic or medical erysipelas had almost always a starting point, which though it could not, strictly speaking, be called a wound, was at least a lesion — a very slight lesion it might be in some cases, such as a scratch, an eczema, an herpetic ulceration, an inflammation of the gum from a carious tooth, or a slight abrasion of the integuments at some point on the face, such as the corner of the eye, the nose, the lips, behind the ear, or on the hairy scalp. 8, Jn these views Volkmann, b B. Kbnig, Hirsch, d and Zuelzer* 5 all concur, and the question may be regarded as settled. Predisposing Causes. — (1.) It follows from the foregoing observations that we are to regard Traumatism as the most powerful predisposing cause of erysipelas in the abstract. So frequently has the disease arisen and spread in the wards of surgical hospitals, that the name "Erysipelas nosocomiale" has been applied to it. In a hospital the poison of erysipelas ofien' clings to particular wards, and even to particular beds, wiih extreme obstinacy (Hilton Fagge.) (2.) Although classed with the eruptive fevers, erysipelas presents some remarkable points of contrast to the other diseases included iu this category. The brief period of invasion, the frequency of relapse, the peculiarity of its constantly starting from some definite point, and finally the atypical course of the disease, protracted sometimes in wandering erysipelas for weeks and even months, are points of difference enumerated by Zuelzer, of Berlin, the author of the monograph on Erysipelas in von Ziemssen's " Cyclopaedia of the Practice of Medicine." To these should be added the striking fact that one attack of erysipelas so far from protecting an individual from, actually predisposes him to, another attack. 3. Sex does not seem to exercise any marked influence in pre- fl Clinique Medicate de VHdtelDieu de Paris. 1865. Tome I., page 165. b Art. " Erysipelas," in von Pitha and Billroth's Handbuch dtr allgemeine und specielle Chirurgie. Archiv. der Heilkunde. XL, 23. 6 Handbuch d. histor. und geoyrapk. Pathol. I., page 243. £ Von Ziemssen's Cy'dopcedia of the Practice oj Medicine. Art. " Erysipelas." ERYSIPELAS, 2()~> disposing to this disease. Of the fatal cases in England between 186: and 1868, 56 percent, occurred in males. 4. Erysipelas is a disease of the prime of life, the period from the 20th to the 45th year being specially concerned (Volkmann). 5. The influence of climate is not well marked, although ery- sipelas is mostly a disease of the temperate zone of both hemi- spheres. 6. As regards season, Hirsch believes that erysipelas is particu- larly prevalent in damp, changeable weather, with unstable tem- perature. Most writers are of opinion that the disease occurs more frequently in the colder than in the warmer months of the year. Exciting Causes. — These are briefly two — (1.) Contagion; (2.) Inoculation. The doctrine of the contagiousness of Erysipelas, first promul- gated by Wells a at the close of the last century, has been adopted in the United Kingdom since the time of Graves. In France it has received the influential support of Trousseau and other physi- cians of the foremost rank. In Germany Zuelzer and Hirsch accept it. Mr. C. de Morgan, in Holmes' " System of Surgery," cites, on the authority of Dr. Goodfellow, a most extraordinary instance in which erysipelas spread in regular order through award of thirteen beds to almost every patient in turn, going down one side of the ward and then up the other side. In the " Archiv. fur Heilkunde" for 1870 (Vol. XI., 23) Dr. B. Konig, of Rostock, records the facts relating to a small epidemic in the hospital of that town. The outbreak was clearly traced to infection from the pillows on the operating table, which had become deeply discoloured by dried blood from other patients. From the day when these pillows were removed no fresh cases of erysipelas occurred. The pillows were now soaked in water, and a brownish solution was obtained which was inoculated into two rabbits, with the result that one of them had an affection closely resembling erysipelas. From the point of ' a Transactions of the Society, for the Improvement of Medical and Chtrurgical Knowkdye. 1800. Vol. II., page 213. 206 ERYSIPELAS. inoculation, a diffuse dermatitis spread over the belly, produced (edema of the prepuce, bulla? and crusts in places, and disappeared after twelve days. Not to quote authors at unnecessary length on a point which may be regarded as settled, I will merely add my own experience on this subject. In November, 1874, I was placed by Dr. Stokes and Dr. Alfred Hudson in charge of a gentleman, aged thirty-seven, who was the subject of progressive locomotor ataxy, and who two days after exposure to cold on Friday, the 20th, displayed constitutional symptoms, which proved to be connected with an erysipelas of the scrotum. This first showed itself on Wednesday, the 25th, and by the 28th it had become gangrenous and involved the penis. On the 30th the right groin was implicated, and next day an erysipelatous patch appeared on the back of the right hand. Towards midnight of this day, December 1, a band of erysipelas spread across the nose and downwards into the month, finally invading the tongue, which became hugely cedematous. The urine was now considerably albuminous, spec. grav. 1018. It deposited amorphous urates and a few fragments of granular tube-casts. The patient, after violent delirium, began to sink rapidly, and expired at 4 a.m. of Thursday, December 3. A married sister, aged thirty-six, attended the patient with singular devotion for several hours before his death. On Tuesday, December 8, she complained of sore throat and weakness. Her pulse was extremely rapid, and she looked seriously ill. Next day the throat felt and appeared to be better ; but the mucous mem- brane of the nose looked unhealthy, and the orifice of the nostrils was swollen, puffy, and sore. On the following day the nasal mischief was more pronounced, but the throat continued to improve. On Friday, the upper lip became cedematous, and an attack of facial erysipelas was clearly in progress. On Saturday, the swelling spread upwards, and engaged the eyelids and forehead ; across the latter a well-marked line of demarcation ran. Temp, in axilla was now 102-3° ; pulse, 128. By 10 p.m. the inflammatory oedema had engaged the left ear, and reached the hairy scalp. ERYSIPELAS. 207 T. 103-5°. On Thursday, the 13th (6th day) the case was a typical one of facial erysipelas — P. 128; T. 103'8°. This lady's illness proved exceptionally severe, and for many days her life hung in the balance. The temperature rose to 105*4° on the evening of the tenth day, and violent delirium was followed by symptoms of profound nervous prostration and by paralysis of the bladder. Ultimately she recovered perfectly. On January 11, 1875, I took this note: "She is desquamating everywhere, as if after an attack of scarlatina." It should be mentioned that the valet of the unfortunate gentle- man whose illness cost him his own life and placed his sister's in such jeopardy, was admitted to the City of Dublin Hospital on December 11, 1874, a few days after his master's death, suffering from abscess in the right tonsil and an unhealthy-looking herpetic eruption, involving the right side of the neck and the adjoining ear. On February 21, 1884, Jane M. was admitted into Cork-street Fever Hospital, Dublin, on the fourteenth day of a severe attack of facial erysipelas. She died next day. On February 25th, Ward- maid Mary Lennon, who attended this patient, complained of not being well. On the 28th she was unable to leave her bed, com- plaining of severe shivering, headache, and pain in the back. It was ascertained she was suffering from facial erysipelas. Incuba- tion in this case was apparently four or five days. The most remarkable series of cases due to infection which have ever come under my notice, occurred in the year 1882. They illustrate especially the intimate relation which exists between erysipelas of the throat and ordinary cutaneous erysipelas. In the month of February in the year named, the Secretary of the Meath Hospital occupied as his sleeping apartment one of the Collis Wards ; in the other, separated by a central corridor, lay a surgical patient suffering from traumatic erysipelas. In a few days the Secretary complained of painful sore throat, which was accompanied by severe constitutional disturbance, high fever, and extreme prostration. After a short time the larynx became engaged, and symptoms of oedema of the glottis supervened. The treatment 208 ERYSIPELAS. adopted happily proved successful, and the patient gradually- recovered. He was devotedly attended and nursed by a sister who, in a few days, fell ill of a sharp attack of facial erysipelas, which ran a normal course. And now comes the interesting part of the story. During his sister's illness the Secretary sent bulletins as to her state to a married sister living in the County Sligo, at a distance of 130 miles. Letters written by himself were despatched on the 1 0th and 13th of March, and a post card followed on the 17th. The lady incautiously placed these letters and post card under her pillow at night, with the result that on the 21st of March she sicketied with severe sore-throat, accompanied by intense pain and much swelling. She was attended by a domestic servant, who in a few days developed an attack of facial erysipelas. Hirsch points out that epidemics complicated with throat- affection have been repeatedly described. Of one such outbreak at Montrose in 1822, Gibson a says : " The disease was not so much confined to the head or face as common erysipelas, but it frequently attacked other parts of the surface of the body. Sometimes the internal fauces were attacked, ■ and if it spread to the trachea it generally proved fatal." Trousseau b narrates a strikingly similar instance to those I have just detailed of the spread of erysipelas and of its alternating phases in different individuals. I give his very words : — " J'etais appele en consultation par mon honorable ami M. le docteur Paris, aupres d'un M. E. . . . chez lequel un de nos chirui'giens les plus habiles, °M. le Professor Nelaton, avait e'te oblige" de pratiquer le' debridement du meat urinaire afin de faciliter l'introduction d'instru- ments lithotripteurs. M. E. . . . succombait a un erysipele gangreneux du prepuce, qui avait eu pour point de depart cette petite incision. La veille de sa mort, sa femme, qui l'avait soigne avec une grande sollicitude, fut prise de frissons ; le lendemain elle avait une angine violente, et vingt-quatre heures apres un drysipele de la face d'une extreme gravite, qui l'emporta alors qu' elle semblait entrer en convalescence. La femme de chambre tomba malade en a Trans, of the Edinburgh Med. Chir. Soc, 1828. Vol. III., page 94. b CUnique Medicate de I'Mdtel Dieu de Paris. 1865. Vol. I. s page 171, ERYSIPELAS. 209 meme temps que sa maitresse, elle n'avait cegse" de donner des soins a M. E. . . . La maladie chez elle fut caracterisee surtout par une violente angine, et par un erysipele qui se limita aux paupieres." The question of the inoculability of erysipelas has been definitely settled by experiments on animals conducted by Orth, a Koch, b Tillmanns, and others, and most decisively of all by Fehleisen's inoculation experiments on man with micrococci of pure cultivation. 11 Bacteriology. — According to Lukomsky, e minute cocci occur in chains (Streptococci) in human erysipelatous skin, and in the fluid of erysipelatous bullae. They occupy the lymphatic channels of the skin, and spread along them as the disease progresses. These Streptococci erysipelatis, or Micrococci erysipelatosi, as Fehleisen called them, can be cultivated artificially in nutrient gelatine, or agar-agar, and according to Orth produce typical erysipelas when re-inoculated in man or animals. The characteristic erysipelatous blush is produced by inoculating these micro-organisms in the ear of a rabbit- In the human subject the disease was produced in fifteen to sixty hours after inoculation/ Fehleisen 8 made a number of inoculation experiments on human subjects with the therapeutical intention of dispelling tumours. All the experiments succeeded, and the erysipelas always ran a perfectly normal course. A beneficial result was obtained in cases of lupus, cancer, and sarcoma. Hence this induced disease has received the name "Erysipele salutaire." The pathogenic micro-organism of erysipelas spreads, as has been stated, by the lymphatics, which may be seen infiltrated with aggregated masses of spherules ; thence it penetrates into the tissues and forms chains or swarms of spherical cocci, 'Sfju in diameter. It excites a specific inflammation and leads to tissue necrosis. Cul- tivated on gelatine, it forms whitish colours but does not liquefy it. * Arch, fur experiment. Pathologic 1873. I., 81. b Untersuch. iiber die Aetiologie der Wundinfections-Krankheiten. 1878. c Billroth and Lucke's Deutsche Chirurgie. V., 75. * Deutsche Zeitschrift fur Chirurgie. 1882. XVI., 391. e Virchow's Archiv. 1874. LX, 418. f E. M. Crookshank. Manual of Bacteriology. Second Edition. 1889. P. 200. * Deutsche Zeitschrift fur Chirurgie, 1882, XVI., 391 ; and Sitzungsber. der Wiirzb. phys.-med. Qesellschaft, 1882. No. 8. P 210 CHAPTER XXIL Erysipelas {continued). Clinical History — Temperature — Diagnosis — Prognosis and Mortality. Clinical History. — Vabieties of Erysipelas according to depth of surface affected : (1.) Simple or cutaneous ; (2.) Phlegmonous, or cellulo-cutaneous ; (8.) Diffuse cellulitis. — Stages of incubation, invasion, eruption, defervescence. Erysipelas faucium, pulmonum. — Temperature. — Diagnosis. — Prognosis and Mortality. Clinical History. — Bearing in mind the poly typical nature of erysipelas, we are not surprised to find that its course is less cyclical than that of the other eruptive fevers. In fact no two cases correspond exactly in mode of origin, symptoms, and dura- tion. All stages of the exanthem may be observed simultaneously in the same individual — its beginning, acme, decline, and resulting desquamation. Notwithstanding this, it will be convenient to con- sider the disease in the same systematic way as the others of its class, premising that it is classified as regards the degree or depth of surface to which the inflammation penetrates as — 1. Simple, or cutaneous, Erysipelas. 2. Phlegmonous, or cellulo-cutaneous, Erysipelas. 3. Diffuse inflammation of the subcutaneous areolar or cellular tissue, or Diffuse Cellulitis. This is a commonly adopted but quite artificial classification. 1. Stage of Incubation. — This period is of rather indefinite duration. On an average it lasts about seven days, being sometimes shorter, sometimes longer — for example, Dr. Roberts assigns to it a duration of from 10 to 14 days. In the cases from my own practice, which I have detailed, the incubative period varied in length from 4 or 5 to 8 or perhaps 10 days, and these limits are probably the most common. ERYSIPELAS. 211 IT. Stage of Invasion, — Taking its origin in a herpetic ulcera- tion, or other more or less trivial lesion of the pharynx, mouth, lips, nose, ears, or eyes, facial erysipelas causes general discomfort, loss of appetite (anorexia), vomiting, and diarrhoea. It is usually ushered in hy chills, rigors, or even epileptoid convulsions, as pointed out by Dr. Hathurst Woodman. The temperature rises rapidly in a few hours, often to 104° F. (40° C), or even higher. Severe pain in the throat is commonly felt, especially in cases due to contagion. There is a vivid redness over the uvula, velum pa/ati, and tonsils, and the glands in the neck, and under the lower jaw, are nearly always swelled and tender on pressure. In an account of an outbreak observed in the Paris hospitals, Cornil describes a purple-red, shining, oedematous swelling of the whole pharyngeal mucous membrane, which appears as if varnished. The tonsils may remain free from these changes. Great pain is felt in swallowing (dysphagia), and there may be salivation. I would like to lay special stress on the painful nature of erysipelatous angina. It is a symptom the presence of which I have repeatedly verified by personal observation. To this variety of erysipelas the name Erysipelas Faucium is applied. III. Stage of Eruption. — After a few hours, or one, two, or three days, the erysipelatous inflammation spreads from the pharynx or its other point of origin on to the face, every part of which may be invaded except the chin, for an anatomical — or rather histo- logical — reason, which will be explained under the heading " Patho- logy." The dermatitis tends to advance in an ever-enlarging circle from the original focus, while a well-defined and raised margin marks the approach to a given spot of the accompanying swelling and redness. The natural lines of cleavage of the skin modify the rate and manner of extension of the inflammation. Where the skin is tightly stretched (as on the scalp) or firmly bound down (as on the chin), it progresses slowly and irregularly, or in a zigzag fashion, along the lines of least resistance. On the other hand, regions where the subcutaneous areolar tissue is lax (such as the eyelids and scrotum) become rapidly and enormously swollen (J. J. Pringle). The patient now complains of stiffness and a, burning, 212 ERYSIPELAS. tingling sensation in the affected area of the skin, the surface of which is swollen, red, hard, and tense from effusion of a serous fluid, rich in young cells, into the subcutaneous areolar tissue. The most striking woixUpicture of erysipelas with which I have ever met is Sir Thomas Watson's description. He says : — " The lips swell enormously, the cheeks enlarge, the eyes are sealed up by their (edematous and prominent lids, and all traces of the natural countenance are effaced. I know of no disease except, perhaps, the confluent smallpox, which so completely and speedily deforms and disguises the visage of the patient. A stranger seeing a young female in the height of the disorder, and revisiting her after her recovery, is astonished at the change. It seems as if, by some magic process, such as Ave read of in our nursery tales, a hideous monster has been metamorphosed into a comely damsel." a It has been already stated that the swelling and redness gene- rally stop at the edge of the hairy scalp. This was stated by Watson to be particularly the case if the dermatitis spread sym- metrically across the face from the nose; but the accuracy of the observation is with reason called in question by Trousseau. b Some- times — and in this respect it exactly resembles a scald — the inflamed surface becomes covered with irregular blebs or blisters (bullae), particularly on very vascular surfaces like the cheeks. Vesication, however, is often wanting, so there is nothing dia- gnostic in this phenomenon. The vesicles, or blebs, dry up into crusts, as a rule ; but where the dermatitis dips deeply, or the tension from oedema is extreme, as in the eyelids, suppuration is apt to take place, and the tissues may even slough. As regards a given portion of surface, when the redness has lasted three or four days, it fades, swelling quickly subsides, and desquamation sets in. Nothing is more curious than to see these changes taking place while the advancing disease is attacking other parts for the first time. During all this time the fever ebbs and flows according to the progress of the malady. * Lectures on the Principles and Practice of Physic. Third Edition. London : John W. Parker. 1848. Vol. II., page 827. 6 Clinique Medicale de VHdtel Dieu de Paris. 1865. Tome I., page 171. ERYSIPELAS. 213 IV. Stage of Defervescence. — When the swelling and redness cease to spread, the temperature falls rapidly in uncomplicated cases. In other instances defervescence is a very tedious process indeed, occurring by lysis rather than by crisis. Or the tempera- ture range may closely simulate that of pyaemia. This happens when the dermatitis wanders all over the body, or jumps (as it did in one of the cases detailed by me above) from one part of the body to another. This form of the disease receives the name of erratic or vagrant erysipelas (erysipelas migrans) — the " erysipele ambulant " of French writers. In such cases the illness may be protracted for one or two months, and not only every part of the surface of the body, but the whole tract of mucous membranes, and even the lungs, and, I believe, the pleurae, may in turn become affected. Dr. Peter, 11 of Paris, has drawn attention to the spread of the inflammation from the pharynx to the respiratory passages, causing bronchitis, bronchiolitis (capillary bronchitis), and pneumonia. In a case observed by me at Cork-street Fever Hospital many years ago, the reverse of this happened. A man was admitted suffering from Pneumonia migrans. After some days, a blush of erysipelas showed over one shoulder, and spread thence down the back, and simultaneously the pneumonic symptoms subsided. So great was the impression made upon me by this case that ever since I have recognised the propriety of considering erysipelas pulmonum as a distinct species of the great genus Pneumonia. Temperature. — But little remains to be added to the incidental remarks on the behaviour of the temperature which have been made in the foregoing account. " Facial Erysipelas," writes Wun- derlich, b " is pre-eminently a polytypical disease, and in many cases it is quite atypical." He adds : " At present it is not possible to associate special forms of erysipelas, or special causes of it, with particular forms of fever curves." The temperature commonly rises in a few hours to nearly 40° C. (104° F.) or even higher. So long as the cutaneous or anginal a Dictionnaire Encyclopedvque des Sciences Medicates. Tome IV , page 720. Art. " Angines." . , 1 devour. c Gk. ixaKj>6s, great, (puyiw, I devour. 218 ERYSIPELAS. structures affected with erysipelas. Metschnikoff says that they consume and destroy the debris of the dead and dying microphages. a According to Volkmann and Steudener, as the inflammation wanes, the leucocytes disappear in the subcutaneous tissue with extraordinary rapidity, breaking down in a few hours into a granular debris. In the superficial layers of the cutis they remain visible a little longer ; but within a day or two all signs of tissue changes may have vanished. Meanwhile, the vesicles or bullae have dried up into yellowish crusts. The cuticle is subsequently shed either in flakes or as a branny powder (Hilton Fagge), When the scalp is attacked, the hair usually falls off during con- valescence. Haight says that this happens because the external root-sheath is separated from the vitreous layer of the follicle as far as its junction with the papilla by the serous infiltration. The hairs quickly form again. Diagnosis. — The recognition of erysipelas is generally easy once the eruption has shown itself upon the skin. Frank has pointed out that when a patient has had febrile symptoms for some hours accompanied with pain, tenderness, and swelling of the lymphatic glands, erysipelas is doubtless coming on. Chomel held the same view, and Campbell de Morgan relates that " Busk is so convinced of the invariable occurrence of affection of the glands before erysipelas appears, as to consider it a pathognomonic symptom. " b In this view Trousseau also concurs, and he quotes the following passage from Borsieri, who noted swelling of the lymphatic glands as marking the onset of the malady : — " Illud etiam memoria, probe tenendum est, quod crebris ex observationibus constitit, si erysipelas artubus inferioribus incubiturum sit, inguinis et femoris glandulas conglobatas, vasis cruralibus additis, antequam se exserat, leviter dolere atque intumescere consuevisse, axillares vero ac cervicales, si brachiis aut superioribus locis immineat." The anginal form is often not easily recognised. The pain- a See the New Syd. Society's Lexicon of Medicine, sub vocibus " Macrophage" and "Macrophage." b Thomas Bryant. Manual for the Practice of Surgery. London : 1884. Fourth Edition. Vol. I., page 100. Clinique Medicale de I'Hdtel Dieu. 1865. Tome I., page 169. ERYSIPELAS. 219 fnlness, oedema, and implication of the cervical glands are impor- tant elements of diagnosis. Erysipelas has to he distinguished from — 1. Simple erythema (E. simplex), which is a transitory hyperaemia of the skin, running its course with little, if any, pyrexia, without pain, swelling, or desquamation. In it the glands also are not involved. 2. Urticaria, or nettle-rash, which is intensely itchy and con- sists of wheals distributed here and there over the body. 3. Simple lymphangeiitis, which shows a streaked or spotted, seldom a confluent, redness, extending centripetally, the inflamed lymphatics appearing like firm cords. It often terminates in sup- puration. 4. Diffuse phlegmonous inflammation, which shows a darker redness, nowhere sharply defined, and a board-like hardness. It generally ends in suppuration. 5. Pemphigus. — This is distinguished by its relative chronicity, its localisation, the absence of oedema, and the inconstant implica- tion of the lymphatic vessels and glands. 6. Eczema rubrum, in which the dermatitis is severe, painful, and oedematous. The pyrexia, however, and constitutional disturb- ances are ill-defined, and the disease is comparatively limited. A coloured drawing of acute eczema will be found in the New Syden- ham Society's " Atlas of Skin Diseases " (Plate X VI.). 7. Hilton Fagge has known blunders repeatedlv committed in the differential diagnosis of herpes zoster of the forehead and face, and erysipelas. Herpes does not cross the middle line ; there is no desquamation, and the vesicles in time dry up into characteristic dark brown eschars, embedded in the skin. I would add that the febrile move- ment in herpes zoster is not acute as a rule. Prognosis. — This, so far as facial erysipelas is concerned, is generally favourable. One of the Aphorisms of Hippocrates on Erysipelas is well worth quoting. It runs thus : " 'Epva-iireKas e^codev Kara^eofievov eicro) rpiireadai ov/c dyaOov, eacodev 220 ERYSIPELAS. Be e£a> ayadov* — " For superficial erysipelas to turn inwards is not a good sign ; for internal erysipelas to become superficial is a good sign." Billroth says the disease commonly lasts from 2 to 10 days: 14 days is an unusual duration. The longest case that he ever saw lasted 32 days and terminated fatally. Zuelzer assigns a much longer dura- tion than this, and one of my own cases ran to 66 days. The average duration is — 12 days (Velpeau) ; 13| days (Heyfelder) ; 10, 12, or 14 days (Zuelzer). Relapses and recrudescences are common. The mortality varies much according to circumstances — Wun- derlich had only 3 per cent, of deaths, Volkmann 5 per cent. ; in the American War (1862) the mortality among surgical cases was 11 per cent. Of 137 cases without complications which Billroth had under his care at Zurich, 10 died. Puerperal women, new-born children, old people, the subjects of debilitating chronic diseases, sufferers from any of the other erup- tive or continued fevers, the victims of intemperance, all run a bad chance if attacked by erysipelas. Erysipelas migrans is particularly dangerous, but ordinary ery- sipelas may kill, according to Trousseau, by coma, consequent on effusion within the head ; by asphyxia, owing to oedema of the glottis ; or by asthenia. This last cause of death operates espe- cially in the wandering or erratic variety. Although erysipelas most frequently ends in recovery, the pro- gnosis should be guarded in all cases. Bad signs are : evidences of blood-poisoning, severe head-symptoms, typhoid or ataxic symptoms, extension of the inflammation to the larynx or bronchial tubes, a dark coloured rash with livid vesicles or bullae, and— as pointed out by Dr. F. Roberts — a sudden disappearance of the external inflam- mation with a coincident development of internal symptoms. a Hippocratis Coi Aphorism. Lib. vi. Sec. 7. Aphor 25. Editio Foesii. Francofurti. 1624. 221 CHAPTER XXIIL Treatment of Erysipelas. Expectant Treatment. — Constitutional (or general) and Topical Treat- ment. — Constitutional Treatment : tincture of the perrhloride of iron, quinine, ammonia and bark in effervescence, salicylate of sodium (Hallopeau), cold baths, alcoholic stimulants, effervescing draughts in gastro-intestinal dis- turbance, opium or morphin in threatening delirium. — Topical, or Local Treatment: indications— (1.) to relieve pain and tension; (2.) to check the spread of inflammation ; (3.) to destroy the infectious matter in situ. — Leeches are contra-indicated. — "Ectrotic" method.— Topical use of nitrate of silver. — Rectified oil of turpentine. — Sulpho-carbolate of sodium. — Sprays. — Special treatment of oedema of the eyelids, sore throat, laryngitis, and cedema of the glottis, tension of the skin, gangrene. Many patients suffering from uncomplicated facial erysipelas quickly recover, with very simple management indeed. The expec- tant treatment is the rational treatment in such cases. Trousseau having alluded to the active measures adopted in some hospitals against the disease, somewhat satirically says : " Vous avez vu, malgre cela, la maladie guerir," and adds : " I'erysipele est done une de ces affections qui guerissent d'elles-memes, je parle de I'erysipele qui surprend l'individu en bonne sante, et non plus de celui qui survient dans le cours d'autres maladies." a This is all quite true, but we are often called upon and bound to adopt other means than those which the great French physician embraces under the term " expectant treatment," namely, to keep the patient in bed protected from draughts, to prescribe slightly acidulated diet drinks, to give laxatives as required, to relieve vomiting by purgatives, and to give nourishment freely — his very words are dramatic: "J'alimente, j'alimente alors meme qu'il y a de la fievre, alors meme qu'il y a du delire . . . au lieu de les tenir a une diete rigoureuse, je reste spectateur de la lutte de laquelle, je le sais, la nature sortira victorieuse, si je ne la trouble pas dans ses operations ; je me tiens les bras crois^s : et, je le a Clinique Medicate de I'tidtel Dieu de Paris. Tome I., page 174. Paris : 1865, 222 ERYSIPELAS. repete, parmi le grand nombre d'erysipeles que j'ai vus, trois tout au plus ont eu une terminaison fatale ; dans tous les autres cas la maladie s'est dteinte d'elle-meme." The treatment of erysipelas naturally falls under two headings — constitutional— or general — and topical, and yet it is hard to dissever one from the other, for to destroy the infectious matter is one of the objects alike of constitutional and of topical treatment. Constitutional Treatment. — Apart from the management of the surroundings, dieting, and nursing of an erysipelatous patient, the following remedies have enjoyed a well-merited reputation while not attaining to the rank of a specific against the disease : — 1. Tincture of the perchloride of iron, recommended by Hamil- ton Bell in 1851, has since then been given, especially in facial erysipelas, in full doses (20 to 30 minims) often repeated — that is, every second, third, or fourth hour. It may with advantage be prescribed with equal quantities of glycerine, and in peppermint or chloroform water. Mr. de Morgan, of the Middlesex Hospital, says that this treatment is most efficacious in shortening the duration of the attack and securing a rapid and satisfactory convalescence. He has given as much as an ounce to an ounce and a half of the official tincture in twenty-four hours, in the more severe forms of the disease. The ethereal tincture of the German Pharmacopoeia, which contains one per cent, of ferric chloride in a mixture of one part of ei her and three parts of alcohol, is a favourite preparation in Germany under the name of " Bestuscheff's tincture." In that country, however, quinine now enjoys a higher reputation, in consequence of the researches of Binz a and the recommendation of Liebermeister. When given in doses up to four and a half grains every two hours, quinine reduces the fever aud shortens the attack. A long experience leads me to recommend that quinine in such closes should be administered, not in an acid solution, but mixed with milk or plain water. There is really nothing new in the quinine treatment of erysipelas, for long ago a mixture of ammonia and bark in effervescence was regarded as a sovereign remedy. n The Elements of Therapeutics. Translated by Edward I. Sparks, M.A., M.B,Oxon. London : J. & A. Churchill. 1877. Pages 206, et scq. ERYSIPELAS. 223 Ninety grains of carbonate of ammonium in six ounces of decoc- tion of bai*k, to be taken in ounce doses, effervescing, with half an ounce of fresh lemon juice every four or six hours, was a standard prescription. M. Hallopeau a has employed and recommends the following method in the treatment of erysipelas with salicylate of sodium : — 1. Application to the part of compresses wet with a solution of salicylate of sodium (1 in 20) covered with oiled silk and frequently renewed. 2. Internal administration daily of four grammes (3j) of the salicylate, in three doses, in weak grog. M. Bochefontaine's experiments have shown that, if to a joint compresses wet in a solution of salicylate of sodium (1 in 20) be applied and covered with oiled silk, the drug will soon appear in the urine. Hallo- peau begins the internal treatment witli a calomel purge, and then gives sulphate of quinine and salicylate of sodium alternately, at a day's interval the one from the other. The results of this treatment, observed in twelve cases, were as follows: — 1. The temperature was undoubtedly lowered in those cases which presented marked febrile disturbance. 2. In most cases the duration of the disease was much abridged, judging from the statement of Velpeau that twelve days is the usual course. In several cases the disease seemed quite promptly controlled. 3. Up to the time at which he wrote the author had not observed the accidents which have occurred within his knowledge in typhoid- fever patients taking the same doses of the remedy. In one case there was a slight temporary delirium, which may not, however, have been due to the medicine. The author recommends suspension of salicylic acid treatment in this and other diseases as soon as cerebral disturbance or dyspnoea makes its appearance. I have myself followed this line of treatment in cases of erysi- pelas and with the happiest results, nor have I ever seen any untoward effects from the use of this almost specific remedy. To reduce the temperature Volkmann recommends cold baths — repeated, if necessary, three or four times a day. They are grateful a VUnion Medical, May 1, 1881, and New York Medical Journal and Obste- tricul Review, September, 1881. 224 ERYSIPELAS. to the patient and relieve head symptoms, but do not control the erysipelatous inflammation. The bath should be given at 80° F. and for 15 or 20 minutes. In ordinary erysipelas, alcoholic stimulants are contra-indicated, but in the severer forms of the disease their free administration is called for, subject to the conditions laid down in Chapter V., page 58. In gastro-intestinal disturbance, effervescing draughts are useful, or small doses of bicarbonate of sodium with rhubarb and calumba. Sehacht's "Liquor Bismuthi" also is an excellent adjuvant. A single dose of calomel (5 grains) is often advantageous in this con- dition. In threatening delirium, opium in full, but guarded doses, or hypodermic injections of morphin are most valuable remedies. Topical or Local Treatment has three ends in view — First, to relieve pain and tension ; secondly, to check the spread of the inflammation; thirdly, to destroy the infectious matter in situ. The first indication is met by covering the affected part with cotton wool so as to exclude the air ; by dusting it over with flour, or powdered starch, or a mixture of oxide of zinc and salicylated starch, or— best of all (for when wet, it does not cake on drying) — with a mixture of oxide of zinc and lycopodium powder, of each half an ounce, intimately shaken up with 15 to 30 minims of liquefied pure carbolic acid. If these means fail, the part should be fomented with flannels wrung out of a hot decoction of poppies (Sir Thomas Watson), or covered with spongiopiline, soaked in hot water and sprinkled with laudanum. The old-fashioned prejudice against " wetting the rose" has long since been given up, in medical circles at all events. Marc See, of Paris, 8, employs subnitrate of bismuth as a dressing. It is a preventive as well as a curative agent. It should be dusted as a powder topically over the solution of continuity, which is the point of departure of the malady. Leeches are contra-indicated in erysipelas, because each leech- * Paul Lefort : "La Pratique Joumaliere des Hdpitavm de Paris." 1891. Page 153. ERYSIPELAS. 225 bite would be a trauma or wound from which the specific dermatitis would take a new departure. Cold evaporating lotions, lead lotion, and poultices are supposed to predispose to gangrene in erysipelas. With the view of checking the spread of the dermatitis, various ointments for smearing over the erysipelatous surface have been proposed. Such are mercurial ointment (Ricord), and an unguent consisting of dried sulphate of iron, 60 grains ; glycerine, 20 minims ; lard, an ounce and a half (Alfred Hudson). The erysipelatous patch may be painted over with collodion, mixed with glycerine (1 part to 15 parts) or cod liver oil (Zuelzer and Fenwick.) Griscom employed glycerine, because it dehydrates the tissues and so exerts an antiphlogistic effects upon the inflamed parts. Under the name of the " ectrotic a method," Higginbottom in- troduced the topical use of nitrate of silver. A broad band of skin thoroughly washed and freed from fat, outside the advancing line of inflammation, was cauterised with nitrate of silver in substance or in strong solution (one in eight parts). Nunneley and Hasse recommended painting a cordon half an inch wide in the same way with tincture of iodine. To destroy the virus in situ, Copland applied rectified oil of turpentine — a practice which has gained the approbation of Liicke, Borgien, Bonfigli, and Zuelzer. With the same object in view, Nystrom and Westerland, two Swedish physicians, introduced the use of " aseptin," a powder, and " aseptin-ainykos," a liquid, com- posed of boric acid and oil of cloves. Still more recently carbolic acid (phenol) has been used, and especially by Hiiter in 1874 in the form of hypodermic injections of the strength of 2 per cent., which besides checking the spread of the erysipelas exert a local anaesthetic action, which is very grateful and beneficial. Wilde got good results from injecting hypodermically into the inflamed skin from 15 to 30 minims of a ten per cent, solution of sulpho-carbolate of sodium. The local application of compresses a " Ectrotic " (from the Greek tirrpamK-ds, belonging to abortion) is applied to medicines or modes of treatment which tend to produce the abortion or sudden cutting short of a disease. 226 ERYSIPELAS. wet with a 5 per cent, solution of salicylate of sodium, recommended by Hallopeau, has already been mentioned. Talamon, of Paris, with Richardson's spray-producer sprays for a minute over the external erysipelatous zone, both within and on the outside of the swelling, with the following solution : — ~fy. Hydrargyr. perchloridi, gr. 15^; Acid, citrici, vel tartarici, gr. 15^ ; Spt. rectificati, min. lxxx. ; iEtheris sulphurici, ad §iv. As this solution is caustic, the spray should not be directed on the eyes or the neighbourhood of the nostrils. The spray should be repeated twice or thrice daily. This is the best treatment for erysipelas in Talamon's opinion. If it is employed from the outset, the cutaneous inflammation yields from the first day and the attack ceases on the fourth day. In oedema of the eyelids, bathing with warm water coloured with Condy's permanganate of potassium fluid, collyria of sulphate of zinc (|- 1 grain to an ounce of rose water and a few drops of glycerine), and a blister to the nape of the neck as a derivative are measures, all of which have been recommended by high authorities. Trousseau objected to blistering as establishing a trauma or wound, but Graves and Hudson practised it with good results. In most cases, the hair should be cut close ; in some, the head should be shaved. In the latter event, great care should be taken to avoid hurting the skin, because of the influence of traumatism. For this same reason the vesicles or blebs of erysipelas should not be punctured, unless gangrene threatens. Sore-throat, laryngitis, and oedema of the glottis, are to be prevented or combated as suggested under the heading of scarlatina. Great tension of the skin is relieved by superficial punctures or incisions and by warm poulticing. In this way, also, the occurrence of gangrene may be avoided. Should this serious accident happen, or abscesses form, free incisions should be made, and the parts should be antiseptically dressed and poulticed. Prof. A. Wolfler, of Vienna, recommends the application of strips of adhesive plaster as a mechanical means of checking the spread of erysipelas. PART III. THE CONTINUED FEVERS, PART III.— THE CONTINUED FEVERS. CHAPTER XXIV. General Considerations. Classification into Exanthemata, Continued Fevers, and Intermittent Fevers is non-essential but convenient. — Claims of Typhus and Typhoid or Enteric Fevers to be classed as Exanthemata. Three reasons why they are not so-classed. — Cullen's definition of the Continued Fevers.— Murchison's classification of these Fevers. Objections advanced to certain of his statements. By no hard and fast lines are the fevers we are about to study- separated from the group which has up to this engaged our atten- tion. The accepted classification into Eruptive, Continued, and Intermittent Fevers is one rather of convenience than of absolute necessity. It is, in fact, to a large extent artificial and arbitrary. I have already shown that some authors have, without hesitation, included typhus among the exanthemata — indeed, "Typhus exan- thematicus " is one of the names by which this fever is known in Germany 8, as well as in England 13 — it is " Das exanthematische Nervenfieber" of German writers. In 1831, too, Dr. Roupell, of London, wrote of this fever as " Typho-rubeoloid," in allusion, no doubt, to the resemblance of the rash to that of measles. He and Peebles both maintained the right of typhus to rank with the exanthemata. a For example, Hildenbrand, Ueber den ansteckenden Typhus, Wien, 1810; and Schulz, Typhus exanthemat.icus beobachtet in den Winter monaten des Jahrei, 1847-48. Prag. Vierteljahrsschr. 1849. b For example, C. West : Account of Typhus exanthematicus in St. Bar- tholomew's Hospital in 1837-38. Edinb. Med. and Surg. Journ., Vol. L., 1838. But see also the Edinb. Med. and Surg. Journ., April, 1840, where Dr. West dis- cusses the very question whether typhus should be classed among the exanthe- matous Fevers, and decides it in the negative, while employing the term " Ex- anthematic Typhus." Edinb. Med. and Surg. Journ. Vol. XLIV., 1835. 230 GENERAL CONSIDERATIONS. Even typhoid or enteric fever has been considered an exanthe- matic fever. In 1699 F. Hoffmann, of Halle, described a fever under the name of Febris petechizans vel spuria, in contradistinction to Febris petechialis vera (or true typhus.) This fever was charac- terised by an insidious commencement, vomiting and purging, and by the appearance about the seventh day of an eruption on the trunk, consisting of elevated papules, which disappeared completely upon pressure. Is not this an accurate picture of enteric fever? Why, then, do we separate some fevers from the exanthemata and group them together as " Continued Fevers ? " Briefly, for three reasons. First, because two of these fevers — simple continued and relaps- ing fever — throw out no rash at all. Therefore, in no way could they be classed with the exanthemata. Secondly, because the occurrence of a rash, or eruption, is much less constant in both typhus and typhoid than it is in the case of eruptive fevers, properly so-called. It is true that Murchison says the eruption of typhus is very rarely absent. During twenty-three years it was noted in 93*2 per cent, of the 18,268 cases admitted into the London Fever Hospital. Murchison thinks this estimate too low, and says that in 1864 it was noted in all but 55 out of 2,493 cases, or in 97'77 per cent. But we should not lose sight of an important point bearing on this matter, which is that the cases ad- mitted to hospital are, generally speaking, those in which a positive diagnosis of typhus had been made before admission, and most pro- bably because of the presence of the characteristic rash, which Murchison himself says is pathognomonic. The slight and non- maculated cases are left behind in their homes, and so do not share in the elaboration of statistical results. Many years experience at Cork-street Fever Hospital has convinced me that the typhus rash is often absent, at all events in children. Murchison himself admits that, " in children it is oftener absent than in adults." As for enteric fever, the eruption is by no means invariably present. In the London Fever Hospital, in twenty-three years, it was detected in only 76*92 per cent, of the cases, Murchison remark- ing as to this, that •' the fact of the spots not being observed was, GENERAL CONSIDERATIONS. 231 perhaps, due to their not having been looked for with sufficient care." According to Edmund Parkes, a spots are absent in 2<> per cent, of the cases of enteric fever — a result which very fairly agrees with the statistics at the London Fever Hospital. Thirdly — Whereas the rashes of smallpox, measles, scarlatina, and erysipelas are shown, both clinically and histologically, to be true inflammations of the skin (dermatitides), the same cannot be alleged of either the rose-spots of typhoid or the maculae and petechia- of typhus. Both rose-spots and macula do not as a rule pass the stage of hyperaemia, and the petechias are, in Murchison's own words, u due to an infiltration of dissolved haematin into the tissue of the cutis." Cullen's definition of the continued fevers runs as follows : — "Febres, sine intermissione, nee miasmate paludum ortse, sed cum remissionibus et exacerbationibus, parum licet notabilibus, perstantes: paroxysmis quovis die binis" ("Fevers which ran their course without intermission, and do not arise from a paludal miasm, but continue with remissions and exacerbations, which are not, however, very marked : two paroxysms being observed in the course of any given day of twenty-four hours.") Murchison's Classification of the Continued Fevers of Great Britain and Ireland is the following : — A. Non-Specific. I. Simple Fever, caused by exposure to the sun, fatigue, surfeit, &c. II. Endemic (Enteric, Typhoid, or Pythogenic), the poison being contained in drinking water, emanations from sewers, &c. I Typhus, caused by contagion or by the concentrated exhalations from B. Specific IIL & IV. _ . ., . < squaua numan beings. Epidemic ) „ Relapsing Fever, arising from con- tagion or famine. In this Table, two points may fairly be criticised as being too dogmatic and certainly open to question. These are — the unqua- fl Association Medical Journal, 1856, p. 993. 232 GENERAL CONSIDERATIONS. lifted use of the term " Non-specific " in connection with the intimate nature of Simple Fever, and the doctrine that typhus may arise de novo, that is, may be spontaneously generated by the concentrated exhalations from squalid human beings. If simple fever is absolutely non-specific in its origin, it should find no place among a group of acute infective and essential fevers, which from the very nature of the case are to be considered as specific. Again, the doctrine of the spontaneous origin of a febrile disease like typhus lands us in the midst of greater difficulties than those which such a doctrine is intended to solve. It is opposed to all analogy and, in fact, it is quite unnecessary if we bear in mind the marvellous vitality of " resting spores " and the influence which a powerful combination of predisposing causes may have in calling into action the proper exciting cause of a catching or infectious (contagious) disease like typhus. These questions will come up for further consideration in our study of each of the Continued Fevers in the succeeding chapters. The order in which I propose to describe the different fevers is — (1) Simple Fever, (2) Typhus, (3) Eelapsing Fever, (4) Typhoid or Enteric Fever. 233 CHAPTER XXV. Febricula, or Simple Fever. Nomenclature. — Definition. — ^Etiology and History. — Probably of specific origin, like the other fevers — probably auto-infective —Clinical History : Four Forms — 1. Ephemera ; 2. Synocha, or Acute Inflammatory Fever ; 3. Ardent Continued Fever of the Tropics ; 4. Asthenic Simple Fever. — Diagnosis. — Prognosis. — Pathology. — Treatment. Nomenclature. — Simple Continued Fever {Lot. Febris Continua Simplex, Lieutaud, 1776). Syn. — Acute Continual Fever (Laugrish, 1735); Simple Inflammatory Fever (Huxham, 1739; Fordyce, 1791). Germ. Entziindungsfieber. Fr. La Fievre Inliammatoire. Ital. Febbre Inflammatoria. Gk. Kavao<; (Hippocrates). Spanish, La Calentura (Piquer, 1751). Ardent Fever [of the Tropics] (Burnett, 1812; Sir Ranald Martin, 1841; Copland, 1844); Synocha (Cullen); Fievre Synoque (Davasse, 1847). From its duration, this fever received many names, of which the chief are: — Synocha septimo die soluta (Hoffmann, 1700); Febris ephemera (Riverius, 1623 ; Sennertus, 1641; de Sauvages, 1760); Ephemera simplex (Boerhaave, 1738); Diary Fever (Strother, 1728). Germ. Das eintagige Fieber. Fr. Fievre Eph^mere. Ital. Effimero. Span. Efemera. From its causes, it was described by Boissier de Sauvages (1760) as " Ephemera a Frigore " and " Ephemera a Calore ; " and by Scriven, in 1857, as '' Sun Fever." The term "Febricula" is, of course, the diminutive of " Febris," and has reference to its comparatively trivial nature and short duration. It is also sometimes called " Herpetic Fever," from the frequency with which crops of herpes break out during its course, especially about the nostrils and mouth, and on the lips. Definition. — An acute Fever, said to be non-contagious, occur- ring sporadically in general, but occasionally assuming an epidemic 234 SIMPLE FEVER. form, arising from exposure to the sun, over-fatigue, a surfeit, inebriety, running a course of from one to seven, or rarely ten days, without eruption, but with marked febrile symptoms, tongue furred but moist; terminating critically with profuse sweating; often accompanied by herpetic eruptions ; rarely fatal unless in the Tropics ; no specific lesion in fatal cases. JEtiology and History. — This form of fever has been identified since the time of Hippocrates. In the paroxysm of any fever there are three stages — (1.) The cold stage, ushered in by rigors (also called the pyrogenetic stage) ; (2.) the hot stage, or stage of reaction (the fastigium, or acme) ; and (3.) the sweating stage, or crisis (de- fervescence). In simple fever these may all occur and be com- pleted within twenty-four hours. Hence such names for the disease as "ephemeral* fever," " diary fever," "das eintagige Fieber," and so on. In 1728, Strother described a " diary fever," distinct on the one hand from " spotted fever" (typhus), and on the other from "slow fever " (typhoid). The diary fever, he said, resulted " from hard drinking, or too great heat of the sun, or from a little cold ; " it needed " little help from physic," and it did " not last above three or four days." There can be no doubt that the term " Simple Fever " has become a refuge of many cases of mild typhus (T. levissimus, of Hilden- brand) and ill-defined typhoid fever or relapsing fever without the relapse, and so the sepai'ate identity of febricula has been called in question. But, as we have seen, from the earliest times the exist- ence of this disease has been recognised. Its ordinary causes are exposure to great heat or cold, surfeit or inebriety, gastric derange- ment, imperfect excretion, and mental or bodily fatigue. It is probable, but not yet proved, that simple continued fever may result from some specific contagion as yet not isolated. Analogy, in the first place, points in this direction. Next, although this fever is a sporadic disease, as it is commonly observed in temperate climates, yet epidemics of it have been described from time to time — for example, by Ingrassias, of Palermo, as occurring tt Gk. tin, upon ; Vi/xepa, a day. SIMPLE FEVER. 235 in Sicily in 1557; by Hoyer at Mulhausen towards the end of summer in 1700. In India, the "Ardent Fever," which according to Murchison is only the tropical variety of simple fever, often assumes an epidemic form during the hot dry season. Again, the whole cyclical course of the malady almost proves its specific origin, and lastly, one variety of it — the " feverish cold " or " acute catarrh " — is certainly infectious, or " taking," in a high degree. It may be that in most cases the virus of this form of fever is inbred in the body, rather than introduced into the system from without — that it is an auto-infective, or autochthonous 8 - disease. Children are most liable to suffer from febricula, adolescents are less so, and the infection becomes more and more infrequent as middle life is reached, and as old age approaches. Clinical History. — Apart from the Ardent Continued Fever of the Tropics, and another variety to which Murchison gives the name of Adynamic Simple Fever, simple continued fever shows itself under two principal forms — true Ephemera, and Synocha or Inflammatory Fever. 1. In the first or ephemeral form, the patient is suddenly seized with chills or rigors, followed by quick full pulse, flushed face, dry hot skin, loss of appetite, thirst, and headache. The limbs feel sore, as if bruised, the bowels are confined, and the tongue is coated but moist. The urine is scanty, high-coloured, dense (Spec. Grav. 1025-35), and towards the close of the fever deposits urates (lithates) in abundance. The symptoms pass off in twelve, twenty- four, or thirty-six hours, with profuse sweating, and the patient who has been restless, or, if a child, perhaps delirious, falls into a tranquil sleep. 2. In the synochal b form- — so-called from its continuance — the febrile movement is more prolonged and the symptoms are more acute and severe, while they belong to the same category as before. From time immemorial a tendency of this fever to terminate on odd a Autochthonous, indigenous. From Gk. avT6x^a>v, sprung from the land itself, of native stock. I.e., continued; from Gk. awoxh, a holding together. 236 SIMPLE FEVER. days — the 3rd, 5th, 7th, or 9th — has been observed, so that these are sometimes called critical days. Modes of Crisis. — The crisis in ephemera and synocha may take place in one or more of many ways — namely, sweating, copious epistaxis or nose-bleed, haemorrhage from the womb or rectum, an attack of vomiting, a sudden diarrhoea, diuresis with a dense deposit of lithates in the urine, or the development of a crop of herpetic vesicles on the lips (herpes labialis) or about the nostrils, hence the term " Herpetic Fever." Simple Fever is not attended by any skin-eruption. In a few cases Davasse a observed pale bluish spots — the taches bleudtres of French writers — which are also occasionally met with in typhoid fever, acute pneumonia, and other diseases. There is nothing characteristic about these markings, which are supposed by Striimpell b and German writers generally to be connected with the irritation of lice. This view is gaining ground in British Medical literature, for Jamieson, writing in the British Journal of Dermatology (Volume I., No. 10), includes among the rarer effects of the presence of pediculi the development of maculce c&rulea} (taches bleuatres) upon the skin. Facing page 516 of the third edition of Murchison's Treatise on the Continued Fevers there is a beautiful tinted litho- graph, representing these taches bleuatres in enteric fever. In several instances he saw them distributed along the course of the small subcutaneous veins. The Ardent Continued Fever of the tropics is merely an ex- aggerated form of the synocha of Great Britain and Ireland. Murchison gives a graphic account of it as he observed it among the European troops at Calcutta in 1853 and in Burmah in 1854. In many cases the symptoms commenced immediately after in- cautious exposure to the direct rays of the sun. Hence Scriven's name for it: "Sun Fever." It appears to be a very formidable fever indeed. About the fourth or fifth day there was often acute a Des Fievres Ephemere et Synoque. Paris, 1847. P. 23. b Text-book of Medicine. By Adolf Striimpell. English Translation. London : 'H.K.Lewis. 1887. Page 16. J. B. Scriven : On Indian Fevers. Indian Annals of Medical Science, No. 8, 1857. SIMPLE FEVER. 237 delirium, followed by more or less unconsciousness, contracted pupils, and sometimes complete coma. Between the sixth and the ninth day, death took place by coma, or there was a copious per- spiration, followed by a rapid fall of the pulse, an increased flow of urine, an abundant deposit of urates, and convalescence. The subsidence of the fever was, however, occasionally followed by sudden, or even fatal collapse. 8. The Adynamic or Asthenic Simple Fever may run on for two or three weeks, with increasing weakness. Murchison frequently observed attacks of this kind after great mental or bodily fatigue, and Alfred Hudson b had a similar experience. " At the same time," says Murchison, " it must be remembered that cases of this sort are never fatal, and that enteric fever often assumes characters very like those now described." Diagnosis. — This is often a matter of difficulty, or even impos- sible. From typhus and typhoid fevers it is ultimately distin- guished by its short duration and the absence of an eruption. An outbreak of herpes on the face about the fifth day of a feverish attack would suggest simple fever in the absence of pneumonia or of typhus. Resembling the first paroxysm of relapsing fever by its intensity, simple fever is distinguished from that malady by the comparative insignificance of the muscular and arthritic pains which accompany it, and by the absence of enlargement of the spleen and liver, and of jaundice. Besides, it occurs at times and in places other than those selected by relapsing fever. Prognosis is almost invariably favourable in this country, unless some complication should arise. The ardent fever of the tropics is stated to be a serious and often fatal disease. Pathology. — There is no special lesion. Murchison observed great congestion of all the internal organs in the fatal cases of ardent fever examined in India. Treatment. — The simple continued fever of this country re- quires no special treatment beyond rest in bed, a suitable diet, a MurchiRon : On the Climate and Diseases of Burmah. Edinb. Med. and Surg. Journ., Jan. and April, 1855. b Lectures on the Study of Fever. Dublin : 1867. P. 262. 238 SIMPLE FEVER. and attention to the bowels, kidneys, and skin. As to the ardent fever of the tropics, all writers on Indian diseases advise venesec- tion or leeches to the head, followed by cold effusion, the continued application of cold to the shaven scalp, purgatives, and diaphoretics. 8. For the asthenic form Murchison recommends quinine and the mineral acids, with a nutritious diet and wine. a Cf. Morehead : Clinical Researches on Diseases in India, 1860. Second EditioD. Page 166. Also, Sir Kanald Martin : Influence of Tropical Climates. 1856. Page 208. 239 CHAPTER XXVI. Typhus Fever. Nomenclature — Literature — Definition — Geographical Distribution — ^EnoLOQY — Exciting and Predisposing Causes — Facts known relative to the Specific Poison of Tjphus : 1. Modes of infection ; 2. Its striking distance not great ; 3. Poison readily absorbed by " fomites ; " 4. Period of infec- tiousness : Convalescence ; 5. Non-inoculable ; 6. One attack confers immunity ; 7. Of light specific gravity ; 8. Destroyed by dry heat ; 9. Typhus not an epizootic — Murchison's doctrine of the spontaneous generation of typhus — Proofs of its infectiousness — Arguments for and against its spontaneous origin — Predisposing Causes : Sex, Age, Season, Temperature and Moisture in the Atmosphere, Occupation, Idiosyncracy, Intemperance, Bodily Fatigue, Mental Fatigue and Depressing Emotions, Previous Illness, Recent Residence in an infected district, Overcrowding and defective Ventilation, Destitution and deficient Alimentation — Conclusions. Nomenclature. — No fewer than 98 names for this form of Con- tinued Fever are specified by Murchison in his elaborate account of the disease. Of these I can here give only a selection : — Typhus.— (Boissier de Sauvages, 1760; Cullen, 1769; and all modern British writers) Gk. Tvo a cr "wd. TYPHUS FEVER. 249 I venture to dissent from this doctrine of the de novo or spon- taneous generation of typhus on the following grounds: — 1 . It is opposed to all analogy, so far as the specific fevers are concerned. No one suggests that smallpox, or scarlatina, or relapsing fever, arises de novo. Why, then, should it be thought that typhus or typhoid does so arise ? 2. Notwithstanding what Murchison says on the point, such a doctrine denies the microbic origin of typhus, which I am well aware is not yet proved. 3. Typhus did not arise in certain extreme cases of over- crowding, to which Murchison himself refers, such as the " Black Hole of Calcutta," the case of the Irish steamer Londonderry, and the tragedy of Ujnala. He explains the failure of typhus to appear in these instances by saying there was not sufficient time for its development. 4. The doctrine is beset with difficulties greater than those it is designed to explain. For example, in an account of an out- break of typhus fever which took place in Bristol during the year 1867, Mr. D„ Davies, then Medical Inspector for that city, expresses himself in no uncertain terms on the question under con- sideration. He remarks' 1 : — "I would as soon believe in the spon- taneous generation of human beings as I would in the spontaneous generation of typhus fever." 5. The theory is unnecessary, if we assume the microbic origin of typhus and remember the vitality of the resting spores of patho- genic micro-organisms to which reference has already been made. [See page 16]. Even Dr. Cayley, the able Editor of the posthumous third edition of Murchison's Treatise, dissents from this doctrine, for he com- ments upon it thus : — " Judging, however, from analogy with relapsing fever and other contagious diseases, it seems probable that typhus is due to a specific microbe which requires conditions of overcrowding and imperfect ventilation to develop its virulent and contagious properties." b a Medical Times and Gazette. October 19, 1867. b Loc.cit. Third Edition. 1884. Page 119, 250 TYPHUS FEVER. " If we reflect," says Mosler, a of Greifswald, " that the contagious matter may remain latent for years in rooms or on furniture, should we not then give up the belief in the spontaneous origin of such a disease? Unsuspected ways in which the poison has successively passed from individual to individual, from the cottage to the palace, are being daily brought to light. Again, every possible means of communication in the whole civilised world must be taken into consideration. Attention is seldom paid to all the dangers of transport. A carrier of the contagium rarely meets with an obstacle in its passage from the sick room to the healthy. Coins and bank tokens never meet with the fate of annihilation. One cannot tell whether the money previously belonged to one who was healthy or diseased. As to paper money, which is composed of organic masses, there can be no doubt but that it might take up infectious matter. Small coins, also, especially those of nickel, which lose their smooth surface when long in circulation, become thickly coated with particles of dirt, and impregnated with infectious matter, particularly as they often serve as playthings for sick children. Having regard to all the possible ways in which transference of the infection may be effected, can we any longer cling to the doctrine of the spontaneous origin of typhus ? " " The hypothesis of a ' spontaneous generation ' of infectious diseases," wrote Niemeyer, b " in the sense that their cause is a new agent induced by injurious influences is, of course, to be rejected, for in that case we should be inferring a generatio cequivoca, which has been disproved." II. To those circumstances, which in themselves are insufficient to generate the disease, but which render the body more liable or susceptible to the influence of the primary exciting cause — that is, the essential or specific poison, virus, or contagium — and without which the latter would often prove inert, the term " predisposing causes " is applied. a Real-Encyclopadie der gesammten ETeilkunde. Wien und Leipzig : Urban und Schwarzenberg. Vol. VII. Art., " Fleoktypbus." b A Text-book of Practical Medicine. London : H. K. Lewis. 1880. Revised Edition. Page 615. 300 3000 Diagram A., shows the Ages of 18,138 ccoses of Typhus Fever, a-dmitted; uito the JLoTidoTb Fever Ho spilc/t, with ike riwrrvb eaxzfa cu/e TYPHUS FEVER. 251 Murchison discusses the following predisposing causes of typhus : — 1. £ex. — This does not in itself predispose to this fever. Out of 18,268 cases of typhus admitted to the London Fever Hospital during the twenty-three years, 1848-1870, inclusive, 8,946 were males, and 9,322 were females. The excess of females was, thus, 376; but this is accounted for by the pre- ponderance of that sex in the total population. Lebert, the writer of the article on "Typhus " in von Ziemssen's "Cyclopaedia of the Practice of Medicine," found from accurate records of 740 cases observed in epidemics at Breslau that 55'68 per cent, of the patients were males, and only 44*32 per cent, were females. 2. Age. — No period of life is exempt from typhus, but it is for the most part a disease of adult age. Murchison ascertained that the mean age of 3,456 cases admitted into the London Fever Hospital in the ten years, 1848-57, was 29-33 years. The accompanying Diagram (A) has been copied from the third edition of Murchison's "Treatise on the Continued Fevers of Great Britain," with the sanction of the Editor, Dr. William Cayley, F.R.C.P., and by the kind permission of the Publishers, Messrs. Longmans, Green, & Co. A careful study of this instruc- tive diagram will show (1) the incidence of typhus in each lustrum of life ; (2) the remarkable influence which age exercises over the rate of mortality from this fever. 3. Season. — During twenty-three years, January and March were the months in which the number of admissions of typhus patients to the London Fever Hospital reached a maximum — the minimum falling in September, August, and July. This distribu- tion was from time to time disturbed by an epidemic, outbreaks of typhus commencing and advancing irrespective of season. An examination of the Registrar-General's Returns of deaths from typhus in Dublin, undertaken many years ago, led me to the con- clusion that the death-rate from typhus attains its maximum in January, and its minimum in September. The reason for this is not far to seek. Typhus is often intimately related to over- crowding, and affections of the respiratory organs are among its 252 TYPHUS FEVER. most frequent complications. Hence we should expect to meet with it, especially in the colder seasons of the year. Murchison points out that typhus does not always become more prevalent with the commencement of cold weather, nor does it decline immediately on the advent of summer. He correctly infers from this that the increase of typhus in winter and spring is not so much due to the direct effect of cold as to the continued overcrowding and defective ventilation of the dwellings of the poor in cold weather. 4. Temperature and Moisture in the atmosphere do not seem to have any marked predisposing influence on typhus, notwith- standing the opinion advanced by Dr. T. W. Grimshaw, a now Registrar-General for Ireland, in 1866, that a warm moist state of the atmosphere seemed to favour an increase of typhus, whereas dryness with cold had a contrary influence. Murchison was unable to trace any such connection, but points out that exposure to cold and wet, if long continued, depresses the nervous system and so favours the onset of typhus. 5. Occupation dees not predispose to this fever except so far as it involves actual exposure to the poison, as in the case of physi- cians, medical students, nurses, and laundresses. Dr. Alexander Tweedie considered that butchers were particularly exempt from typhus. There is no reason why they should be so, beyond the fact pointed out by Murchison, that they usually have an abundant supply of nourishing food. 6. Idiosyncrasy. — By using this term, Murchison wishes to convey that some persons show a complete natural immunity from typhus, whereas others have a peculiar aptitude for con- tracting the disease, not once but twice, as happened in his own case. 7. Intemperance not only strongly predisposes to typhus, but greatly increases its danger. This has been already pointed out. b Even a single act of intoxication may predispose to this fever. Murchison met with several instances of persons exposed to the a " On Atmospheric Conditions influencing the Prevalence of Typhus." DM. Quar. Journ. of Med, Science, May, 1866. • b See Chapter IV., pages 39 and 42. TYPHUS FEVEK. 253 poison for months who were not attacked until immediately after a debauch. 8. Bodily fatigue. — Whatever lowers vitality and exhausts and debilitates the body, like fatigue, want of sleep, and pain, predis- poses to typhus. 9. Mental fatigue and depressing emotions, such as sorrow, fear, disappointment, and anxiety, have a like effect. Cheerfulness and confidence, on the other hand, aid an individual to resist the fever poison. 10. Previous illnesses predispose to typhus. A " feverish cold " is sometimes said " to develop into typhus." This is not what really happens ; but the catarrh increases the susceptibility of the individual to the fever poison. In hospital practice, convalescents from other diseases are often attacked by typhus if the virus is about. Simple fever and scurvy strongly predispose. Yon Hilden- brand's view, put forward in 1811, that typhus rarely attacks phthisical subjects, does not rest on sure ground. 11. Eecent residence in an infected district greatly increases the risk run by an individual exposed to typhus. Persons continu- ously so exposed appear to become acclimatised in a greater or less degree. We can imagine that " typhisation a petite dose " (to use Jacquot's eloquent phrase), repeated again and again, may in time exhaust the soil for typhus as effectually as one thorough and unequivocal attack of the fever. 12. Overcrowding of human beings, with deficient ventila- tion, is one of the most powerful predisponents of typhus. To this fact testimony is borne by all the historians of epidemics of the disease. 13. Lastly, destitution and deficient alimentation are abso- lutely the most powerful predisposing causes of typhus. It is essentially a poor man's disease. Famine and pestilence "hunt in couples " in this instance, as in many others also. In conclusion, we may sum up the facts relating to the aetiology of Typhus, after Murchison, in the following sentences : — 1. Typhus is due to a specific poison, the entrance of which into the system is the prime exciting cause of the fever. 254 TYPHUS FEVER. 2. This poison is communicated from the sick to the healthy through the atmosphere, or by fomites ; but is rendered inert by free ventilation. 3. The great predisposing causes of typhus are, in the order of their aetiological importance — destitution and defective nutrition, overcrowding, bad ventilation. 4. In the presence of these factors, a small and hitherto inert dose of the fever poison may kindle a serious outbreak of typhus in such a way as to suggest that the fever has arisen spontaneously or de novo. 255 CHAPTER XXVII. Clinical Description or Typhus Fever. Stages op Typhus: (1.) Incubation— about twelve days, or less. (2.) Inva- sion — earliest symptoms referable to the Nervous System. (3.) Nervous Excite- ment (Eablier Eruptive Stage). Objective Symptoms: typhus rash, maculse, subcuticular mottling, "Mulberry Rash " (Jenner). Delirium: ferox, tremens, typbomania (Galen). (4.) Nervous Prostration (Later Eruptive Stage) — characterised by ataxia and adynamia. Petechias — the " Typhoid State " — its symptoms. (5.) Defervescence or Crisis. Modes of Crisis : sleep, slight diarrhoea, diuresis, perspiration. (6.) Convalescence. — Duration of Typhus. Blasting Typhus, or T. siderans. — Typhus kvissimus. — Relapses. — Temperature in Typhus. — Hyperpyrexia. We may most fitly consider the course of typhus fever as, for con- venience, divided into certain stages — those specified by Murchison being the most convenient of all. They are the stages respectively of— (1.) Incubation; (2.) Invasion; (3.) Nervous Excitement, Earlier Eruptive Stage ; (4.) Typhoid State, Later Eruptive Stage ; (5.) Defervescence, or Crisis ; (6) Convalescence, Nervous Prostration. "The duration of these stages," says Murchison. 3, " varies in different cases — some may be shortened or altogether absent, and occasionally it may be difficult to say when one stage ends and another begins." I. Stage of Incubation. — In typhus fever there seems to be no fixed duration for this stage. In a paper published in the second volume of the "St. Thomas's Hospital Reports" (1871), in which Dr. Murchison collected 31 cases where he had been able to determine the period of incubation, that author arrived at the following conclusions : — 1. The period of incubation of typhus varies in duration in different cases. 2. In a large proportion of cases it is about twelve days. 3. In exceptional cases it is longer than twelve days ; but it rarely, if ever, exceeds three weeks. *Loc. cit. Third Edition. Page 179. 256 TYPHUS FEVER. 4. In many cases (one-third or more) it is less than twelve days, and occasionally there is scarcely any latent period, the symptoms commencing almost at the instant of exposure to the poison. It would seem that the poison of typhus may be so concen- trated, or the system may be so susceptible to its action, that its effect may be almost instantaneous. Generally, the patients are conscious of the moment when the fever poison enters the system. In my own person, I have often suffered from a " typhus head- ache " almost immediately after exposure to the poison of this disease. In one melancholy and tragic instance I had an opportunity of estimating the duration of the stage of incubation in typhus with a certain degree of accuracy. On the night of Wednesday, December 28, 1881, my friend and colleague, Dr. Reuben J. Harvey, Physician to Cork-street Fever Hospital, died on the tenth day of petechial typhus. At the beginning of December Dr. Harvey, then thirty -six years of age, seemed to be in the enjoy- ment of perfect health. He attended a meeting of the Physiological Society in London on the evening of the 8th, and returned to Dublin on the 9th, travelling all night. On Saturday, the 10th, he attended the wards of Cork-street Fever Hospital, where there was very little typhus at the time. On the morning of the 11th, how- ever, he examined a lad who had been admitted the previous evening, on the eighth day of typhus. This patient he continued to attend daily, until his own illness had lasted at least twenty-four hours. On December 19, Dr. Harvey did not feel well; next day he suffered from severe headache. On the 22nd, he was too ill to leave his bed. Early on Friday, the 23rd, macula? appeared (4th- 5th day), and ultimately there was a profuse rash, which very soon became petechial. Almost incessant wakefulness was among the first dangerous symptoms ; but at a very early stage the heart became weak and its action rapid, and the respirations ran up to 60 in the minute without any pulmonary complication to account for this untoward symptom. The downward progress was swift, and the end came on the evening of the tenth day. TYPHUS FEVER. 257 In this case, so pathetic in its sadness, and which lost to Cork- street Fever Hospital the services of a most able, learned, and con- scientious physician, the period of incubation could not have exceeded 10 days, and was, most probably, 8 or 9 days in length. Niemeyer, in his " Text Book of Clinical Medicine," gives two remarkable examples of the contagiousness of typhus, which are also of value as contributions to the evidence as to the duration of its period of incubation. In the year 1854 two typhus patients were received into the Magdeburg Hospital from the prison, which was much crowded. For months previous there had been only a few cases of typhoid fever and not a single case of typhus in his wards. Eight days alter the reception of these patients, two others who had lain beside them were attacked by the same disease. One of the latter patients had been admitted for inter- mittent fever, the other for epilepsy. Again, in March, 1855, a tradesman from Heiligen.stadt was attacked with typhus while away from home. He was received into Niemeyer's ward, in which no typhus had been treated for almost a year. Eight days after the reception of this patient, a blacksmith's apprentice and a mechanic, lying next to him, were attacked by the fever. In Murchison's second attack of typhus, the incubation staa-e lasted exactly 5 days. Mr. Da vies, a whom I have already quoted on the subject of the spontaneous generation of typhus, states in the same paper that in 1867 four Norwegian sailors, on the ni°-ht of the arrival of their ship in Bristol from Onega, visited some typhus fever nests, and all four sickened with typhus eight days afterwards. II. Stage of Invasion. — One or two days of slight indisposition, shown by lassitude, vertigo, slight headache, and loss of appetite may precede the true onset of typhus, which is sudden. The symptoms, as usual in specific fevers, are referable to the nervous system ; they are — chilliness or slight rigors, languor, frontal head- ache, pains in the back and limbs, especially the thighs. The chilli- ness comes and goes, and complete loss of appetite, with constipation and sometimes nausea (but no vomiting), follows. The tongue is laro-e pale, and coated— first with a white, afterwards with a yellowish "Medical Times and Gazette. Oct. 19, 1867. Page 428. S 258 TYPHUS FEVER. brown fur. The urine is scanty, high-coloured, and of considerable density — 1025-1030. The pulse commonly exceeds 100 and is compressible, although rarely it is below the normal rate. The breathing-rate is accelerated in proportion. The face is flushed and dusky. The eyelids swell along their edges, the eyes water, and the conjunctivae are injected. The expression at first betokens languor and weariness, but soon becomes dull, heavy, and listless. Giddi- ness, noises in the ears {tinnitus aurium), and sleeplessness are commonly present. If sleep occurs, it is haunted by dreams, the patient talks, and his mind wanders in his sleep. A sense of complete exhaustion quickly overwhelms the sufferer, so that by the third day he is fain to take to his bed. III. Stage of Nervous Excitement (Eruptive Stage.)— This commonly extends from the appearance of the rash until the com- mencement of somnolence or stupor. Its leading features are restlessnes, wakefulness, and delirium. During this stage headache gives place to raving, and the tongue grows dry and brown, while collections of sordes gather on the teeth and gums. About the fourth or fifth day the first stage of the typhus eruption may be observed. It is a rash, or exanthem, often closely resembling the rash of measles, and, in consequence, called " mor- billiform,'' "rubeoloid," or "measly." It consists of spots, or " maculae," of very irregular size and outline, and of a dirty pink or florid colour, which appear first near the axillae and on the wrists, then on the sides of the abdomen, afterwards on the chest, back, shoulders, thighs, and arms. They are rarely seen on the face or neck, for two reasons — first, these parts are very vascular, and the general hyperemia or congestion of the fever conceals the rash ; secondly, the rash develops less quickly and less thoroughly in parts freely exposed to the air. When they first appear, and also when they are few in number, as in the milder cases, they are slightly elevated and deleble on pressure, like the velvety papules of measles. They have, however, no defined margin, but merge insensibly into the colour of the surrounding skin. Along with these superficial spots there is a characteristic marbling or mottling of the skin, caused by the presence beneath the cuticle of another crop of TYPHUS FEVER. 259 maculae. Hence the term "subcuticular mottling." The spots and mottling together constitute an eruption to which Sir William Jenner first gave the name of the "mulberry rash" of typhus. Towards the close of the first week, on the 5th day usually, the headache gives place to delirium, which is sometimes acute and noisy, like mania (delirium ferox) ; sometimes more like that of excessive alcoholism, being accompanied by muscular agitation and trembling (delirium tremens) ; and sometimes'of a low muttering kind (the typhomania of Galen.) The nervous excitement is most marked towards evening and at night, prostration taking its place in the morning. IV. Stage of Nervous Prostration— the Typhoid, Putrid, or Malignant Stage (Later Eruptive Stage.) — This is characterised by extreme nervous prostration (ataxia), and muscular and cardiac weakness (adynamia), defective cerebration, low muttering de- lirium, stupor, and unconsciousness deepening into coma. The patient lies on his back (prostrate dorsal decubitus), moaning or talking to himself incoherently, with a tendency to sink down in the bed. He is utterly indifferent to what goes on around him, looks stupid and unconscious, with inj ected ferret-like eyes, contracted pupils (the "pin-hole pupil" of Graves), teeth covered with sordes, and dry brown- crusted tongue. Deafness is not infrequent. Other symptoms are : tremors, subsultus tendinum, spasmodic twitchings of the face, and even well-marked choreic convulsions, or more commonly picking or fumbling with the bedclothes — the so-called Floccitatio a or Carphology. b Obstinate hiccough often accompanies these various involuntary movements, and is a very grave sign. Not uncommonly, also, involuntary evacuations take place from paresis of the sphincters of the rectum and bladder. The pulse is rapid, small, and soft (112 to 140), and the respirations are shallow, frequent, blowing, and noisy — the " cerebral breathing " of Sir Dominic Corrigan. Simultaneously with the supervention of the foregoing unfavour- able symptoms, the eruption changes in character, becoming a Lat. floccvs, a lock or flock of wool. b Greek Kapcpos, a dry .-talk ; Xeyus, I gather, pick up, and lay in order. Galen (A.D. 1*63) uses the word napcpoAoyia, a gathering oj chips, dec. 260 TYPHUS FEVER. darker in colour and quite indelible on pressure. The spots are no longer elevated, and in the centre of many of them dark purple or bluish points appear — the true petechise, which Murchison defines as consisting of an infiltration of dissolved haematin into the tissue of the cutis. The peculiarity of typhus, so far as the rash is concerned, consists in an eruption which, in its earlier stage, is a true exanthem due to hyperemia of the cutaneous capillaries, while in its later stages an escape of blood-pigment into the cutis is sub- stituted for this hypersemia. The rashes of other diseases may be accompanied with the development of petechia?, but are not, like the macular rash of typhus, converted into petechia. The earlier and more marked the " typhoid state " just described is, the more severe is the case. The older writers spoke of it as the putrid or malignant state. It is by no means peculiar to typhus. We have seen that it occurs in smallpox and scarlatina, and, indeed, any idiopathic fever, or blood-poisoning, or local in- flammation, may pass into this state. In such a dire strait the patient may lie for many hours, or several days, life trembling in the balance, until the stupor passes into profound and fatal coma, or sudden engorgement of the lungs with asphyxia supervenes, or the heart fails, with coldness and lividity of surface and profuse sweating — death ensuing from syncope and coma combined. V. Stage of Defervescence or Crisis. — Happily, such is not always, or even frequently, the end of an attack of typhus. More usually, on or about the fourteenth day there is a more or less sudden improvement. The patient falls into a quiet and prolonged sleep, from which he awakes at first, it may be, bewildered and confused ; but he quickly recognises those around him, and for the first time is conscious of his profound weakness. Pulse and temperature fall, the tongue becomes moist and begins to clean, slight perspiration sets in, or the bowels are relaxed, or the urine becomes abundant and deposits lithates (urates) in abundance. In few acute diseases is crisis so marked as in typhus. In 1810, J. von Hildenbrand a stated that the disease abated " after a very rapid a Ueber den ansteckenden Typhus. Wien. 1810. Plate Y CHARTS OF TEMPERATURE RANGES IN TYPHUS .F^.Z- Typhvis. f after E i£< ric Fever. 3wuf 5 ff 7|«|^|^|//|« , |«|a'|«|« ' ' /^ ji ly iwn 98 ± v~d 6 — S -, ffft ! ._..._■■ Fig.Z flavor ,. „ Disease ° ° ' O y 10 11 /s /i # top . 1 . \—A-- Inlft 1 1/1 » F «UJ ../, I -I- 4 1 7 W /.Efctt ... . /«/• ^-) ! M ....... _ i r /'?'••'' _i_-,l_L... . r^S V * 93° . » 1 z ~ t \ Ai 3z 3=S*====== ^-_zptf ._" ir^E^EG ^ ^ ^ r* _ __zL ^*.,._.3L,_, +- ± Fig. 3. &f e * 7 6 a 10 /I & t3 14- 105° — -J 1 W +TT- ntm t 4 JL^ ._ ~ W-fcj j ,, , .,, . LS V- * J W 3""=§="EE==""== j t «ri===|== — EE= E^== - //7/?» _ _.«. W I - BH tq #•==== = -ji— ---- = - = - «*= z\z~z*zz] :i-:~i-Sz^E3=5EE: fl -=— =-=— z— ? J :r ^ cE_ B -Jpfo. -^ fe£ 7 8 s * /; « '* * /J /tf /<#" I s //;•;- 3 JL m ~i I ^J h l 04 I j_- /a? ; i j ~ 1 .... » ■■■ iOl>-- tl 53--- 4 _ ■ /00° — — — — — 9$°- — 1- _- = — £====== = 15 «w 3 a---- ^ q □ + + \ i- t-5 £ w *r=~= = == = :ii=«z ==== - = * * _^ ; #r l -f- ■ TYPHUS FEVER. 2()3 the heart required tonics and some stimulants. The temperature charts of this case (Fig. 1) and of three others which were somewhat similar are reproduced in Plate VI. Traube, a of Berlin, in 1853, revived Galen's doctrine of critical days, according to which the fever should terminate on one of the odd days, and not on the intervening even days. Murchison's observations do not support this doctrine in reference to typhus ; but both this fever and typhoid or enteric fever tend to terminate at or near the close of a weekly period. Relapses are extremely rare in typhus. Neither Sir William Jenner, nor A. P. Stewart, nor Murchison, has ever seen a case of true relapse. Out of 18,268 cases of typhus reported at the London Fever Hospital during 23 years, only one example of a true relapse was observed (by Dr. Buchanan), although in several instances a genuine has been preceded by an abortive attack. Buchanan's case was that of a nurse in the hospital, aged forty- two, who passed through an undoubted typhus fever, lasting two Weeks. After a week's interval, a relapse took place, with a recur- rence of eruption, lasting upwards of a fortnight. A very similar case is recorded by W. Ebstein, b of Breslau, where there was an interval of 25 days between the two attacks. Temperature. — The facts to be fixed in the memory relative to the behaviour of the temperature in typhus are the following: — 1. A sudden rise of the thermometer takes place at the outset, culminating in a fastigium which is generally reached on the evening of the fourth day, or earlier, but may be postponed to the seventh day, or later. In this fastigium the thermometer may mark 105°, or upwards, or it may not exceed 103°. 2. A more or less pronounced remission of fever or pseudo- crisis, occurs at some time between the seventh and tenth days, except in severe cases. In mild cases, this fall of temperature at the beginning of the second week may prove complete and final — a true crisis cutting the fever short, as in the cases of short dura- tion already referred to. On the other hand, in grave cases, a a Uebcr Krisen und kritische Tage. Berlin. 1852. b Die Recidive des Typhus, Breslau. 18b9. 264 TYPHUS FEVER. gradually rising temperature at this very period may culminate in a fatal hyperpyrexia. Of this I will presently quote an example. 3. A renewed rise of temperature in the second week culminates about the eleventh day in a second fastigium, which in favourable cases does not attain the height of the initial fastigium of the first week. This second increase of fever may be absent, the tempera- ture gradually falling during the second week, until about the fourteenth day, when it rapidly sinks to or below normal. 4. Defervescence is sudden in a majority of cases. Preceded very often by a final evening exacerbation on the 12th or 13th day — which Wunderlich calls a " critical perturbation " — defer- vescence is often " precipitous," the temperature falling 3° to 5° F. or more in a single night, then rising some 2° in the evening, and finally reaching the normal point for the first time next morning. Such is the crisis of typhus. It is, in fact, very like the critical fall of temperature in both measles and acute pneumonia (pneumonic fever), except that it occurs at the end of the second week of the fever instead of at the end of the first week, as in the two diseases named. In severe cases, with cerebral symptoms (ataxic typhus), tem- perature ranges high all through the first week, there is no remission about the seventh day, and, worst of all, the thermometer continues to rise in the second week. This last occurrence often points to the advent of some complication which may postpone defervescence indefinitely, or it may usher in excessive fever or hyperpyrexia as already mentioned. On the other hand, in adynamic cases, with heart failure and pulmonary obstruction, the range of temperature may be moderate — not exceeding 103°, or irregular, with spiking, or the fever may be continuous with absence of morning remissions, or a fall of temperature may be observed with a rise of pulse-rate, without any improvement in the general symptoms. In his "Lectures on Fever," a Dr. William Stokes quotes an old and well-founded opinion that all anomalous circumstances in fever are to be feared. The aphorism runs: "Pulsus, vultus, et urina bona; oeger moritur." And it is a London : Longmans, Green, & Co. 1874. Page 361. TYPHUS FEVER. 265 true. Fatal cases of typhus are generally preceded by high temperature from the very beginning, yet even in such cases it is not so much the intensity as the continuance of the fever which determines the mortal result. Just before death and in the death agony, both Wunderlich and Murchison describe a rise of tempera- ture as a very constant phenomenon. According to the former authority, the temperature is seldom as low as 104° during the agony, more usually it ranges between 105-8° and 107-6° F., and once it reached 109*4° F. In the Dublin Journal of Medical Science for February, 1878, I published a case of typhus with hyperpyrexia, in which the exceptionally high reading of 109-1° was recorded during the death- agony of the patient, a woman, aged thirty-eight, who succumbed on the 19th day of a typhus fever of the nervous or ataxic variety. The following is a brief history of the case : — Margaret T., aged thirty-eight years, married to a shoemaker, and residing in Cuffe-street, Dublin, was admitted to the Meath Hospital on the afternoon of Wednesday, September 12th, 1877. It is worth noting that a young man from the same house was under treatment for severe typhus in Cork-street Fever Hospital from July 18th to September 8th. There was no special medical history previously to her present illness, which commenced on Tuesday, September 4th, 1877, with a shivering fit, followed by- chilliness so great as to oblige her to hang over the fire the greater part of the day. She also suffered from pains in the limbs. She fought against her illness until the following Friday (4th day), when she took to bed, as she was getting much worse. On Saturday, severe pain in the small of the back, and, next day, vomiting of " watery stuff " were superadded to obstinate constipation, which was an early symptom. From the outset also she was very sleepless. She did not come into hospital until the afternoon of the ninth day. In the evening her pulse was 120, her respirations were 28 per minute, and the axillary temperature was 104-9°. Next morning her face presented a dusky, congested appearance ; the eyes were heavy, and the conjunctivae deeply suffused ; her tongue was heavily furred, but moist ; both it and the lips were 206 TYPHUS FEVER. exceedingly tremulous. There was a marked " nervousness " of manner. A profuse mulberry eruption covered nearly all parts of the body — the original maculae had become true petechias, which were unusually distinct and dark in colour. Her pulse was 124, not strong; respirations, 24; temperature, 104*3° (at 10 a.m.). The heart's action was rapid and weak, but both sounds were audible, and the impulse could be felt in the normal situation. Treatment. — It was decided to free the bowels by a simple enema of olive oil and warm water, to support the strength by strong beef- tea and abundance of milk, four ounces of port wine and moderate doses of quinine. September 14th (11th day). — The enema acted twice, bringing away dark, solid faeces in considerable quantity. There was a slight remission of fever, the morning temperature being 103°. September loth (12th day).— She spent a sleepless night, being very restless and moaning constantly. The heart was becoming rapidly weaker — the impulse was feeble, the first sound indistinct, the second relatively strong — being thrown into relief by the sub- sidence of the systolic sound. Strychnin and digitalis were added to the quinine mixture; and the port wine, which had been increased to 8 ounces the previous day, was further increased to 12 ounces, with 4 Ounces of whisky. The heart's action was impeded by tympanites, to combat which a turpentine enema was administered. It acted once, with some relief to the patient. The persistent sleeplessness and increasing head symptoms led me to try, cautiously, tartar emetic and opium, as recommended by Dr. Graves. Only two doses, however, were taken — too small a quantity to induce sleep on the one hand, or to be accused of injuring the patient on the other. One-sixth of a grain of tartarated antimony and 10 minims of tincture of opium alone were given. September 16th (13th day). — She passed a sleepless night, with much muttering delirium. The tongue was moist ; but there was progressive failure of the heart. Its action was very weak — quite foetal in character. Port wine, §xii. ; whisky, §vi. Towards evening the temperature began to fall with an attempt at crisis. At 7.30 p.m. there were marked cerebral symptoms ; but in the TYPHUS FEVER. 2G7 night the bowels moved, and both diaphoresis and diuresis occurred, so that an evident effort at crisis was made. September 17th (14th day). — The morning temperature was moderate— 102° ; but this one favourable symptom was accompanied by a rise in the rate of both pulse and respirations— a circumstance of evil omen. The rash was on this day evidently fading from the anterior aspect of the body, although it remained very petechial even in this situation. September 18th (15th day). — The temporary remission of pyrexia was now succeeded by an exacerbation in the symptoms — a morning temperature of 103*7°, constipation, commencing retention of urine, and persistence of the rash. The increased meteorism obliged us to order another turpentine enema, which operated once. September 19th (16th day). — Another pseudo-crisis occurred on this day, with profuse diaphoresis, and a fall of temperature to 101 '7°. Again there was a complete want of accordance in the symptoms — the respirations remained as fast as ever (48 per minute), the pulse fell only four beats per minute, there was com- plete retention of urine. The pulse could scarcely be counted, owing, first, to weakness ; secondly, to the intensity of the sub- sultus which was present. The urine was now slightly albuminous, and the urea was partially decomposed — the fresh urine, drawn off by the catheter, effervescing briskly on the addition of dilute nitric acid. September 20th (17th day). — In no way better, in some respects worse ; temperature rising ; bowels costive, with tympanites. September 21st (18th day). — Morning temperature, 104*8°; pulse, 122 to 126 ; bowels have not acted ; no return of power over the bladder ; the urine is drawn off by catheter every eight hours, or oftener. A turpentine enema was ordered, and to omit the 3-minim doses of liquor strychnine which she has been taking. In the evening a third abortive attempt at crisis reduced the temperature to 103*2°, but the pulse remained unaffected. September 22nd (19th day). — Much worse in every particular ; unconscious, with coma vigil ; pupils contracted and sluggish to stimulus of light ; considerable albuminuria ; morning temperature, 268 TYPHUS FEVER. 106*4°. Ordered : one grain doses of camphor and musk every second hour. At 6*45 p.m. I visited her again. She was bathed in a cold perspiration ; the extremities were cold, her eyes fixed, with coma vigil ; bronchial rales heard universally over the chest ; axillary temperature (taken twice with two reliable thermometers) was 108'6°. She was manifestly dying. At 7 30 p.m. the last observation on the temperature was made ; it was found to be 109 - 1°. Three hours later she was dead. Unfortunately no observation was made after death. This was partly owing to the late hour at which she died. Clinical Chart of Temperature, &c. M. T. ; Age, 38 ; Disease, Typhus Fever; Result, Death on \§th day. Day of Month Sept. 12 I8 77 13 H 15 16 '7 18 19 20 21 22 - Day of Disease 9 IO II 12 13 14 15 16 17 18 | 19 - w* ►J < CO CO H s ss a 5< t* ri as & H -9! M W EL, g w 110° 109° 108° 107° 106° 105° 104° M. E.IM. e.Im. e.|m. e.'m. e.|sc. e.Im. e.|m. r.|m. E.Im. e. m k Ik. e. "I" •• •• •• .. •• .. » m r^ •/ :: J 5 » » " « ::\ :/ V .. •/ *T •• •• 106 102° - •■ - •• / " It- Pulse {*; Resp. £■ 120 124 120 120 123 126 13+ 1 36 136? 130 136 128 134 124 124 118 124 122 124 120 I48? — 28 24 30 28 30 3+ 40 44 48 48 48 44 53 48 5° 4S 53 46 48 44 48 — Motions 2 I I I I 1 ? - TYPHUS FEVER. 2l>9 Authenticated temperatures as high as those noted in this in- stance — namely, 108'6° and 109"1° — are so rarely recorded that I was induced to bring forward the foregoing " Clinical Record." So far as I am aware, no such temperatures had been observed in the Meath Hospital since the modern introduction of Medical Thermo- metry. In a valuable appendix to Dr. Stokes' work on Fever, my colleague, Dr. Arthur Wynne Foot, gives a resume of thermo- metrical observations in the medical wards of that hospital during the three years, 1871, 1872, and 1878. Among 9,248 observations, the highest reading noted was 107"2°. He says : — " On 27 occa- sions temperatures of 105° Fahr. or upwards were registered in typhoid fever in 15 patients, and of the 15 patients in whom the temperature on one or more occasions reached 105° Fahr. or upwards, five died." The highest temperature recorded was in " a girl aged 16 ; temperature on 30th morning 107 - 2° Fahr. ; died on the 31st evening. Her mean temperature (51 observations) during the twenty-six days she was in hospital was 103*l o Fahr. The morning temperature, 107 '2°, was coincident with severe rigors, preceded by violent pain in the abdomen, ushering in peritonitis, not due to perforation, but to propagation outwards of the irrita- tion arising from numerous and extensive ulcerations of the intestinal glands." Dr. Murchison, 8, speaking of the temperature in typhus, observes that " a severe case is often characterised, not merely by a high temperature in the first week, but by an anomalous or irregular range in the second ; for example, by an absence of the morning fall, or by a sudden fall with rise of pulse, or with no improvement in the general symptoms. In fatal cases there is usually a rise of two or more degrees just before death or in the death-agony" I have italicised the latter part of this passage, as it bears so directly on the present case, and is so fully illustrated by it. Wunderlich b remarks that " Fatal cases of exanthematic typhus generally announce themselves even from the very beginning by a The Continued Fevers of Great Britain. Third Edition. 1884. b Medical Thermometry. Translated by W. Bathurst Woodman, M.D. The New Sydenham Society. 1871. Page 331. 270 TYPHUS FEVER. the enormous height of the temperature (41*2° C. = 106*16° Fahr., and even more). The transient remission at the end of the first week is wanting in these cases. Death may occur in the second week with continual high temperatures. If the case enters the third week, some remission may show itself on the fourteenth day, but this must not be regarded as a favourable symptom, and is very soon compensated. " Yet even in fatal cases the temperatures in the third week are not so high as at the earlier periods, at least till near the death-agony. The daily maxima do not exceed 40*8° C. (105-44° F.), but are, for the most part, moderate. The danger to life during this third week is indicated not by the height of the fever, but by its continuance. " Just before death, and in the death-agony, the temperature constantly rises in exanthematic typhus. In all my cases in which it was possible to make observations, there was a rise of temperature during the agony of at least 1*25° C. = 2*2° F., in one case of even 3*6° (6-48°); and on an average about 1-8° C. (3*24 F.). During the agony the temperature was seldom so low as 40° (104° F.) ; more usually it was about 41°— 42° C. (105*8°— 107'6° F.), and once 43° C. (109-4° F.)." The curves of temperature in this last case are given in Table IV. at the end of Wunderlich's book, and are also to be found in Dia- gram VII. in Murchison's work, where the case is described as one of " Typhus fatal on 17th day, with very hiqh temperature (109*4° F.) before death? The chart is strikingly like that which is the subject of the preceding " Clinical Record." The dread significance of such temperatures is aptly expressed by Wunderlich in his definition of " Hyperpyretic Tempera- tures" a — those " which in every known disease, except relapsing fever, in all probability indicate a fatal termination — 107*6° F. (42° C.) or more." a Loc. cit. Pasre 7. 271 CHAPTER XXVIII. Analysis of the Chief Symptoms of Typhus. The Surface : Fades typhosa. — Skin : maculae or petechiae, sudamina, herpes, poisonous odour, which is most infectious ; branny desquamation, atrophy of nails, laches bleudtres, purpura spots, vibices, profuse sweating — an ominous form of crisis. — Circulatory System : Pulse, vital condition of the Heart — Dr. Stokes's views — Question of stimulants. — Respiratory System : Rate of breathing — varieties of respiration — Hypostatic congestion — Breathing offensive. — Digestive System : Anorexia, boubmia in convalescence — Condi- tion of the tongue — " Parrot Tongue " — Sordes —Diarrhoea. — Urinary System : Characters of the urine. — Nervous System : Headache, delirium, mental state, wakefulness, " coma-vigil " (Chomei), " coma-vigil " (Jenner), loss of muscular strength, decubitus, muscular paralysis, agitation, rigidity, general convulsions. — Lesions op Organs op Special Sense : The eye, ear, nose, taste, sensibility of the skin. We will now briefly consider the different parts or systems of the body as affected by typhus. I. The Physiognomy. —The expression of typhus — the facies typhosa — is characteristic. From the outset the patient looks dull and heavy. Afterwards the aspect is vacant and bewildered, sometimes wild and defiant. The face is flushed, with a dusky, earthy, or leaden hue. The conjunctivae are suffused, the tongne is dry and brown, sordes coat the lips, gums, and teeth. Such is the physiognomy of bad typhus. II. The Surface. — The skin is covered with macula? or petechiae in proportion to the severity of the attack. "The quantity of the eruption," says Murchison, " its depth of colour, and the earliness with which it becomes livid or petechial, are in a direct ratio to the severity of the case." All writers on typhus are agreed as to the ominous significance of a copious, livid, and petechial rash, and as to the mild nature of non-maculated cases. The skin is of a dirty congested hue, deepening into a leaden or livid tint along the sides of the body and over the back. Sudamina,* or sweat vesicles, and local eruptions of herpes are not uncommon. a Lat. Sudamen, sweat. 272 TYPHUS FEVER. A poisonous odour hangs about the skin of the typhus patient after the first week. It is most infectious. Lind compared it to the smell of rotten straw. Gerhard well described it as " pungent, ammoniacal, and offensive." Barrallier likened it to the odour developed by rubbing the leaves of rue between the fingers. Murchison thinks it more correct to speak of it as a smell sni generis. This typhus odour is strongest in damp weather and when the ventilation is deficient. The forms which the true typhus eruption assumes have been already described, as well as the date on which it appears, and the percentage frequency of its presence. It only remains to mention that the rash comes out once and for all, not in successive crops, like the rose-spots of typhoid, and that the spots remain visible for a week or ten days. Desquamation takes place in fine branny scales, especially when the skin has presented a general erythema- tous blush. A, Vogel a has described and figured a white band and a furrow which often appear at the lunula of the nails four to six weeks after the commencement of the fever and gradually advance to the tip. The hair usually falls off in convalescence. The occa- sional appearance of the so-called taches bleudtres is of no clinical importance. Purpura spots aud vibices are also seen in certain bad forms of typhus, especially when complicated with scurvy. This often hap- pened in the Crimea, according to Jacquot. The purpura spots are independent of the characteristic petechias of typhus, although both are subcutaneous ecchymoses. The skin is generally dry and hot from an early stage until crisis, which is often accompanied by moderate perspiratiou. A profuse sweat is an ominous form of crisis. In several cases, for the most part fatal, Murchison found that, on evaporation, the sweat left a white efflorescence upon the eyelids and face. This consists of rod-shaped and stellate crystals, composed of a free acid, fatty matter, and a large proportion of chlorides. Barrallier made a similar observation in the Toulon epidemic of 1861. a Die Nagel nach fieberhaften Krankhtiten. Deutsch. Arch, fur klin. Med. 1870. Page 333. TYPHUS FEVER. 273 III. Circulatory System. — The circulation is much disturbed. The pulse is at first full, but soft and compressible, and moderately quickened, to 108, 112, or 120 beats per minute. Occasionally it is abnormally slow — down to 48, 40, and even 30 beats. This is often a sign of debility. The impulse of the heart and the pulse beat do not always correspond in rate, some of the systolic waves failing to reach the radial artery, so that tlie heart may beat twice for every stroke of the radial pulse. The pulse always becomes more rapid and less full when the patient sits up or attempts to stand, positions which should never be assumed by the typhus patient. In severe cases the pulse becomes undulatory or dicrotous in the second week. This is an indication of very low arterial tension. The vital condition of the heart is profoundly altered in this fever. It is to Dr. Stokes that we are indebted for a full clinical account of febrile weakening of the heart. a According to Louis, the typhous softening of the heart preponderated in the left ventricle. Hence, the first sound was weakened. Sometimes both ventricles were engaged, and then the first sound would disappear. In a case of " malignant fever," observed by Dr. Stokes in the Meatli Hospital many years ago, the patient (a woman) became pulse- less at the wrist, while the heart beat rapidly and forcibly. Trans- fusion of human blood was tried, and the patient rallied. The experiment not being repeated, death took place. Dissection showed that the body was absolutely bloodless. From this obser- vation Stokes concluded that the blood passing through the ven- tricle had very little to say to the making of the first sound. Weakening of the heart generally commences about the fourth or fifth day of typhus, and begins to subside about the tenth day. The first symptom is a diminished cardiac impulse, even when the patient lies partly on the left side, so as to bring the apex of the heart in contact with the chest wall. The impulse, in the next place, fails altogether, while the first sound diminishes in loudness. a Cf . Researches on the State of the Heart and on the use of Wine in Fever. Dubl. Jour, of Med. Science. Vol. XII. 1839. Also Diseases of the Heart and Aorta. 1854. Page 366. And Lectures on Fever. London : Longmans Green & Co. 1874. Pages 185, et sea. T 274 TYPHUS FEVER. These signs are most apparent towards the left side, because the left ventricle is most affected. Occasionally the first sound is accompanied by a temporary bellows-murmur. The third stage is disappearance of the first sound, the heart beating with only one, and that the second sound, which by contrast may appear to be even accentuated. It may, however, be positively increased owing to tension in the pulmonary artery. In a yet more advanced stage of cardiac weakness both sounds are equally diminished in loudness, and become equi-distant, while the heart beats with great rapidity (140-160 per minute). To this state the term foetal heart is applied, because in its weakness and quickness it resembles the heart-beat of the foetus in utero. This condition indicates extreme debility. The last stage of all is silence of the heart, a sign of impending dissolution — as Stokes observes, a con- dition which is almost invariably fatal. It should be remarked that the influence of a very muscular or a very fat chest-wall must be allowed for, if present, when a physical examination of the heart is made. When loud bronchial rales and rhonchi are audible the heart sounds may also be concealed. Should the patient recover, the physical signs alter in the inverse order. Coincidently with the return of the first sound, the pulse should fall in rate, otherwise the prognosis is bad. After the fever symptoms have vanished the pulse often falls much below the normal rate — even as low as 30 beats in the minute, and then slowly recovers itself. Dr. Stokes points out that in fatty degeneration of the heart, or after a bite from the rattlesnake, wine may be taken in almost any quantity without producing head symptoms. From this he adduces an argument for the free use of wine in fever. At the same time he shows that when recovery of the heart coincides with an increasing rate of the pulse, stimulants are almost certainly doing harm— they must be omitted and at once. IV. Respiratory System.— (1). As is well known, the ratio which the respirations bear to the pulse-rate is in health 1 to 4— that is, 18 respirations per minute correspond to a pulse-rate of 72 per minute. In typhus, where there is no pulmonary complication TYPHUS FEVER. 275 of account and where the nervous symptoms are not pronounced, this ratio is commonly maintained. Thus a pulse of 120 would mean 30 respirations a minute. In grave cases, however, certain abnormal characters of respiration may arise from cerebral disturb- ance independently of any pulmonary complications. Thus the breathing in such cases is hurried, sighing, irregular, spasmodic, 'or jerking (Murchison). There is, as Hudson a expresses it, a besoin a respirer, what the Germans call Lujthunger. This irre- gularity of breathing, independent of any pectoral affection, Graves 1 - was in the habit of calling " cerebral respiration." In other cases the breathing is irregular, blowing, or hissing, while the mouth is kept closed, the cheeks puff out, and the nostrils dilate with each expiration — this is the " nervous or cerebral respiration " of Sir Dominic Corrigan. A third variety is the rising and falling breathing, to which the name of " Cheyne-Stokes respiration " has been given. (2). Hypostatic Congestion takes place in the most dependent parts of the lungs in consequence of impaired innervation (para- lysis of the pneumogastric nerves), impaired nutrition of the blood vessels, and lessened heart power. Its occurrence is largely de- termined by the way in which the patient lies — as, for example on the back {dorsal decubitus). At the same time serum is effused into the pulmonary tissue (serous oedema of the lungs), and effusion also takes place into the bronchi and bronchioles. This dangerous state of things, as a rule, betrays its development by neither cough nor expectoration, the chief symptoms being rapid, laboured breath- ing (30, 40, 50, or even 60 respirations each minute) and cyanosis due to defective aeration of the blood. The surface is livid cold and clammy, and the patient passes from stupor into coma. Physical examination of the chest day by day affords timeliest warning of the stealthy approach of this perilous condition, and should never be neglected in typhus. The patient should not be raised in bed for this examination, but gently and slowly turned a Lectures on the Study of Fever. Second Edition. 1863. P. 100. b Clinical Lectures on the Practice of Medicine. New Sydenham Society Edition. Vol. I., page 177. 1884. 276 TYPHUS FEVER. * from side to side, while still in the recumbent position. Further, in order to protect himself from infection, the physician should allow fresh air to play for a moment about the patient's person before applying his ear to the back of the chest. A stethoscope with a long double stem should also be employed for auscultation. The physical signs are — First, a few coarse crepitating rales with, it may be, abnormal clearness on percussion probably due to' relaxation of lung tissue. The rales are then heard all over the back and front of the chest, and increasing dulness on percussion may be detected with feeble, but not tubular breathing. The breath of a typhus patient is offensive, heavy, and pungent, with a smell which has been likened to that of yeast. The propor- tion of carbon dioxide (C0 2 ) in the expired air of typhus was shown by Dr. A. Malcolm, a of Belfast, in 1843, to be considerably below the normal amount. This anomalous result is explained by Vierordt's observation that, even in health, the proportion of car- bonic acid in the expired air diminishes as the respirations increase in frequency. Leyden of Kbnigsberg b also, while confirming Malcolm's statement that the percentage of carbon dioxide in the expired air of typhus is diminished, found the absolute quantity increased by one half. In severe cases the breath has often an ammoniacal odour, and Murchison's observations led him to think that both in uramiia and in typhus the expired air may contain ammonia independently of the condition of the mouth and pharynx. He figures some very beautiful dendritic (tree-like) crystals of chlo- ride of ammonium obtained by holding a glass rod moistened with hydrochloric acid before the mouth and nostrils of typhus patients. V. Digestive System. — The appetite fails completely from the outset, and this anorexia c persists until crisis, when a return of appetite is one of the first signs of approaching convalescence. In fact, there is an intense craving for food and an enormous appetite a Edinb. Monthly Journ. of Med. He. Vol. III. 1843. b E. Leyden. " Ueber die Respiration im Fieber." Deutsch. Arch, fur Klin. Med. 1870. Page 536. c Gk. avope^ia, want of appetite. From av-, priv., and opt^is, a longing or yearning for anything. TYPHUS FEVER. 277 (boulimia) a during recovery. The tongue is at first large, pale, and coated with a white fur, which soon becomes yellowish brown ; it afterwards shows a dry, brown streak in the centre. At a still later stage of the bad cases it is thickly studded with sordes, becomes black and shrunken, and cannot be protruded, but catches behind the lower teeth. In this condition it is described as the " parrot tongue" of typhus. Occasionally it is red, with enlarged papilla?, but scarcely ever is it glazed and fissured like the tongue of typhoid or enteric fever. The amount of dryness and darkness of the tongue is, according to Murchison, a fair criterion of the severity of the case. When stimulants, however, are given in excess the tongue is apt to become dry and brown. The sordes which gather on the lips, gums, and teeth, as well as on the tongue in the second \veek, consist of pro- liferated epithelium, which has desquamated quickly, fragments of food, various micro-organisms, dried mucus, saliva, and blood. This mixture becomes black from desiccation. Nausea and vomiting are rare in typhus, so also is meteorism or tympanites. Gurgling (gargouillement) in the ileo-caecal region, tenderness on pressure in this situation, intestinal haemorrhage, and diarrhoea, are all exceptional in typhus. Sometimes, however, the bowels are loose, especially about the time of crisis. Consti- pation, however, is the rule in typhus. Both liver and spleen may be enlarged, as in other acute infective, or specific, diseases. When diarrhoea prevails, the motions become strongly alkaline in reaction, and contain many prismatic crystals of triple (ammonio-magnesian) phosphate. VI. Urinary System. — The renal secretion is much diminished at first. It is acid, dark-coloured, and of high density (1024-1030). The coloration is due partly to concentration but still more to escape of blood-pigment, the result of typhous dissolution of the blood. Towards the close of the fever there may be diuresis, with a copious precipitation of urates or lithates. Urea is increased in quantity at first, but afterwards falls below normal. This is due, notwith- standing the disintegration of the nitrogenous tissues, to low diet a Gk. 0ov\tfjLia, ravenous hunger. L'<8 TYPHUS FEVER. and imperfect elimination. In a " Note on the Relation between Urea and Fever," communicated to the Tenth International Con- gress at Berlin, Professor Horatio C. Wood and Professor John Marshall, of the University of Pennsylvania, stated that it seemed to them " not yet definitely decided whether increase of urea elimi- nation is an integrant part of the fever process, or whether it is an indirect outcome, caused by the action of the excessive heat upon certain organs, or other disarrangements of the bodily functions." In their paper, the authors point out one important fallacy which must be guarded against — namely, the tendency to consider tem- perature as a measure of fever, using the term " Fever " in its proper sense to express " the abnormal nutritive process, the out- come of which is often elevated temperature." 8. There is reason to believe that the presence of urea, or some other derivative of albumen, in the blood will give rise to delirium, stupor, and coma, as well as. to the ammoniacal odour given off by the skin. Albuminuria is often present, but this does not necessarily imply renal disease, for in excessive blood-changes such as occur in bad typhus, the blood-serum may find its way into the urine. Tube- casts, however, are not uncommonly found on microscopical exami- nation. Murchison suggests that possibly, in some cases, the albuminuria may be due to the presence of albumen in excess in the blood from disintegration of the tissues, which the glandular structures have been unable to convert into urea. Chlorides gradually diminish from the outset, so that absence of chlorides from the urine cannot be regarded as pathognomonic of acute pneumonia, as has been supposed. Uric acid is usually increased, and both Frerichs and Murchison have detected leucin (C 6 Hi 3 N0 2 ) and tyrosin (C 9 H U N0 3 ), two products of the disintegration of albumen or fibrin in the urine of typhus. VII. Nervous System. — Frontal headache is an early and con- stant symptom. It is a dull, aching, heavy pain — rarely acute, darting, stabbing, throbbing, or bursting. It is the most charac- a Verhandlungen des X. Tntemationalen medieinisrhen Congresses. Band II. Abtheilung II. : " Physiologie und physiologische Chemie. " 40. TYPHUS FEVER. 279 teristic nervous symptom during the first week of typhus. Vertigo and rheumatoid pains in the back and limbs, are also present during the earlier periods of the fever. Mental confusion or actual delirium takes the place of headache towards the close of the first week. Hence typhus lias been often called " brain fever." The mind becomes blunted and dull, memory lapses, and cerebration is slow and defective. Hence the term " typhus." a The delirium varies in character. Three types, in particular, are described — (1.) A quiet, listless, low muttering delirium — the typhomania of Galen and early writers — well defined as "affectus ex phrenitide et lethargo mixtus." The patient is easily roused from it so as to give either coherent or rambling answers, but soon relapses into a torpid or semi-unconscious state. (2.) A more busy form of raving, with prostration, restlessness, and tremors of the limbs, muscles of the face, and tongue — like the delirium tremens of the drunkard. (3.) An acute, noisy and violent or maniacal frenzy, in which the patient's strength appears super- natural for a time, but the outburst is succeeded by profound prostration or fatal collapse. In this form — called delirium ferox — the patient may exhibit a homicidal or suicidal tendency. Of the three foregoing types the first is the most common, the last is the least common in typhus. One form may pass into another, or one form may merge in another. "The mental state of the delirious typhus patient," writes Murchison, " is peculiar, and well worthy the study of the meta- physician. As a rule, the memory is first and most affected ; judgment and power of connected reasoning often remain after the memory has entirely gone. The mind may labour under the strangest delusions, and often it appears to revolve obstinately around some fixed idea. The patients rave about objects which have greatly engrossed their attention, either immediately preceding the attack, or years before, and which are now jumbled with persons, scenes, and events, with which they have had no connec- tion." He gives some very graphic illustrations of these mental phenomena from his own experience and that of other authors. a Gk. Tvfos, smoke, or vapour. 280 TYPHUS FEVER. Wakefulness is a common symptom in early typhus. It is apt to be followed by extreme nervous agitation and prostration, or by somnolence, deepening into complete coma, and terminating in death. Sometimes a patient awakes from a prolonged sleep and insists that he has never closed his eyes. This condition is the " coma-vigil" of Chomel a — not of necessity a bad sign. But this term is, unfor- tunately, apt to mislead, for with more propriety it has been applied by Sir William Jenner to another condition of most ominous import. In the " coma-vigil" of Jenner the patient lies with his eyes wide open, with a vacant gaze, his lips parted, his face pallid and ex- pressionless ; the pulse rapid and feeble, or imperceptible ; the breathing hardly to be detected ; the skin cold and clammy or bathed in sweat. Although awake, the sufferer is insensible and surely dies. Loss of muscular strength is an early and constant symptom. The patients are not only weak, but from the first complain of a feeling of feebleness and lassitude. The decubitus is dorsal. In bad cases the patient sinks down in the bed, his head gliding from the pillow. Various muscular paralyses are observed in typhus. Thus, paralysis of the neck of the bladder, coming on about the 10th or 11th day, will lead to involuntary dribbling of urine; paralysis of the sphincter ani, to incontinence of faeces. The coats of the bladder may lose their power from over-distension, causing reten- tion of urine. Incontinence and retention may even co-exist. Meteorism is due to paresis — that is, partial paralysis — of the walls of the intestines. The orbiculares palpebrarum may be paralysed, so that the patient cannot close his eyelids — so causing keratitis and sloughing of the cornea from exposure. Aphonia, inability to protrude the tongue, and dysphagia, are other examples of typhous paralysis — the last-named being the worst of all, and usually the forerunner of death. Muscular agitation indicates great prostration. It is observed in the old and infirm, in the intemperate, and in brain- workers. a Lemons de Clinique Medicale. Paris. 1834. Tome I. TYPHUS FEVER. 281 The forms it takes are — Tremulousness of the hands, tongue, or whole body; rapid oscillatory movements of the eyeballs (nystag- mus a ) ; choreiform movements of the extremities ; twitchings of the tendons (submltus tendinum) of the wrist and facial muscles ; choreic convulsions (Murchison, one case ; Barrallier, one case) ; picking at, or fumbling with, the bed-clothes (floccitatio or carphology), and obstinate hiccough (singultus). All these symptoms are of grave import, and are best marked in ataxic typhus. Muscular rigidity is a much rarer phenomenon than muscular agitation, although equally unfavourable. The fingers may be clenched or the forearms flexed. Tonic spasms of certain muscles have been observed, or even trismus or strabismus. Well-marked opisthotonos, with the head bent back and the limbs rigid, was once observed by Murchison and once by Perry — both cases proving fatal. General convulsions are most dangerous in typhus. They occur in about one per cent, of the cases, and with rare exceptions are of uraemic origin. In most cases there is albuminuria, with scanty or suppressed secretion of urine. Kidney disease is often present, or there may be an intemperate history. Occasionally, simple retention of urine determines an attack. Uragmic convulsions do not usually appear before the middle or end of the second week. The fit is commonly preceded by unwonted drowsiness or delirium, occasionally the patient may seem to be convalescing. Death may take place during the fit, and in 41 out of 51 cases observed by Murchison it happened in less than twenty-four hours. If life is prolonged, coma or a renewed attack may follow the first fit. Hippocrates b regarded convulsions as most dangerous in fever, and all writers agree with this opinion. Occasionally, however, recovery does take place. In Murchison's note-books there were records of 69 eases of typhus with convulsions. Of these 61 were fatal, and 8 recovered. a Gk. vva-Tayfi6s, nodding, or drowsiness ; from v vtrrdfa, to nod in sleep. b Aphorisms. Bk. IV. 66, 67. "E.v rolffi irvpeToiaiv ol e/c twv vttvwv (p40ot, % <7iraa-fxo\, ko,k6v. 'Er roifft irupiToiai rb irvevfia irpoffKoirTOf, Kaicbv, (nrao-/xbv yap 282 TYPHUS FEVER. In Cork-street Fever Hospital during the year ending March 31, 1881, ursemic convulsions proved fatal in three instances, in two at least of which there was a distinct history of alcoholism. It is more than a coincidence that there was a marked tendency to cases of this kind in January, 1881 — that is, after the Christmas holidays, and during a period of intense cold. Retention of urine may give rise to epileptoid convulsions, in which case judicious treatment may afford immediate relief. Sir Dominic Corrigan, in his " Lectures on Fever," a gives a striking instance of this ; but the following quotation from Dr. Stokes's " Lectures on Fever " b will prove even more interesting. He says : — " The most long-continued attack of convulsions I ever witnessed was in the case of a student of this (the Meath) Hospital, who had gone on to the thirteenth day of fever. The distended bladder could be felt, but such was the violence of the convulsions, attended with extraordinary priapism, that all attempts at cathe- terism were futile. It was also impossible to get the patient to swallow anything, or to use an enema, and under these desperate circumstances we determined to employ chloroform inhalation. The greatest difficulties attended the administration ; but, at last, the effect was produced. The convulsions ceased like magic, and sud- denly a jet of urine sprang upwards to a great height from the still erect penis, the stream continuing to flow until the bladder was empty, when the priapism disappeared. " We see, therefore," adds Stokes, " that where the uraemic con- dition and its accompanying convulsions depend on mere retention of urine, we have a ready and efficacious remedy in careful and judicious evacuation of the bladder by the catheter." VIII. Lesions of Organs of Special Sense. — 1. The Eye. — The conjunctivae are generally injected with dark blood, hence the expression, " the ferret-eyes " of typhus. The pupils are, as a rule, contracted, sometimes to a mere point — the pin-hole pupil of Graves. This is noticed in cases of acute deli- rium. When stupor is profound or has deepened into coma, the a Dublin : Fannin & Co. 1853. Page 43. b London : Longmans, Green & Co. 1874. Page 421. TYPHI'S FEVER. 289 pupil dilates, and is insensible to light, and slight strabismus occurs. Dr. Cayley observes that inequality in the pupils is by no means an infrequent symptom in both typhus and enteric fever. It may occur at any time, and is apparently without prognostic signifi- cance. He offers no explanation of the phenomenon. Photophobia also is not of uncommon occurrence. 2. The Ear. — During the first few days, and also in convales- cence, tinnitus aurium and noises in the head are often present. After the fifth day, deafness of one or both ears may occur, either as part of the general anaesthesia of the fever, or as a result of typhous softening of the intrinsic muscles of the ear, according to Dr. Stokes. In some cases, otitis may be the cause of the deafness, and otorrhoea will solve the question. Fracastori (1546) regarded deafness as a favourable symptom — " Surditas salutem portendit" and Alison, of Edinburgh (1849), was of the same opinion. But it is only relatively true, morbid acuteness of hearing, or intole- rance of sound being distinctly a bad sign. 3. The Nose. — The sense of smell is blunted, often from catarrh. Epistaxis, or nose-bleeding, is very rare in typhus. Murchison met with it about a dozen times in 7,000 cases, and even then it was generally scanty. This is a point of diagnostic importance be- tween typhus and typhoid fever. 4. Taste. — This sense is perverted from the outset, and in advanced and severe cases is abolished. Acids are longest relished, but after a time cold water is preferred (Murchison). 5. Sensibility of the Skin. — This is usually lessened, or may be lost towards the end in grave cases (anaesthesia). On the other hand, the opposite condition, hyperesthesia, is occasionally observed. 284 CHAPTER XXIX. Complications and Sequelae of Typhus. Causes of Complications in Typhus. Complications affecting (1) the Res- piratory Organs : Bronchitis, pneumonia, gangrene of the lung, pleurisy, tuberculosis, haemoptysis, laryngitis. (2) The Blood and Circulation : Acute haemophilia, pyaemia, venous thrombosis, phlegmasia dolens, arterial thrombosis and embolism, heart diseases. (3). The Nervous System : Meningitis, mental disease, paralysis, neuralgic and rheumatoid pains. (4). The Organs op Digestion : Erysipelas of the pharynx, haematemesis, diarrhoea, dysentery, intestinal haemorrhage, jaundice, peritonitis. (5). The Urinary Organs : Nephritis, vesical catarrh, haematuria. (6). Diseases of the Integuments and Bones : (Edema, bed sores, gangrene, noma or cancrum oris, '' hospital gan- grene," buboes. (7). Other Specific Diseases : variola, scarlet fever, diph- theria, erysipelas, typhoid fever. Complications and Sequelae of Typhus. — The chief determining causes of the complications which modify the course of typhus are: — (1). The weakened state of the heart ; (2). The impure state of the blood ; (3). Constitutional peculiarities and family idiosyncrasies ; and (4). The " epidemic constitution " at a given time or place. I. Diseases affecting the Respiratory Organs. — " The advent of pulmonary complications in typhus is most insidious, for the ordinary symptoms, cough and expectoration, may be slight or absent, and the patient is unable to complain of pain " (Murchison). Hence the necessity of a daily careful inves- tigation of the chest in this fever. 1. Bronchitis, or, as Stokes preferred to call it, the " Bronchial Affection " of typhus, is one of the commonest complications of this fever — hence the names " Catarrhal Typhus," given to the disease by Irish writers, and " Broncho- Typhus," or "Pneumo- Typhus," of Rokitansky. a " A Manual of Pathological Anatomy. Vol. IV., page 23. Sydenham Society. London. 1862. Translated by Dr. Day. TYPHUS FhVER. 285 Bronchial catarrh may usher in, accompany, or succeed an attack of typhus. It is a dangerous complication, particularly in winter — first, because it is almost certain to be associated with more or lesa hypostatic consolidation in the lungs; secondly, because the bron- chial secretion is likely to accumulate in the tubes and asphyxiate the patient in consequence of his inability to cough, coupled with the impaired nutrition and paralysis of the muscular fibres of the bronchi. Although Stokes a denied to the bronchial affection of typhus the name of "bronchitis," he practically admitted that it was bron- chitis when he spoke of it as " a special condition of the air-passages, secondary to the fever, the result either of the typhous deposit or of the vascularity with turgescence to which I have already alluded." He adds : "I do not know any characteristic difference between the physical signs which may occur in ordinary idiopathic bronchitis and those which present themselves in typhus when the air-tubes are engaged." Surely this is conclusive. 2. Pneumonia is a rare complication or rather sequela of typhus. It may end in recovery, or in abscess, gangrene, tubercular phthisis, or fibroid condensation (cirrhosis). It may be distinguished from hypostatic congestion (with which, however, it is sometimes asso- ciated) by the fact that the dulness is unilateral and by the presence of tubular breathing and rusty sputa. Dr. Stokes, b in his " Lectures on Fever," long ago drew attention to a peculiar form of pneumonia which occasionally seemed to replace — as it were — the symptoms of fever, and to which, accord- ingly, he gave the name of "aborted" or "arrested typhus." But his very graphic and striking description exactly corresponds to acute pneumonia of the apex ; and, in the light of modern in- vestigations, his cases of supposed arrested or aborted typhus read much more like pythogenic pneumonia or pneumonic fever than typhus. It should also be borne in mind that this consolidation is described as taking place as early as the fourth or fifth day of the supposed typhus, when as yet there is no typhus rash, and at a a Lectures on Fever. London : Longmans, Green, & Co. 1874. Page 131. b Loc. cit. Page 157, et seq. 286 TYPHUS FEVER. time when consolidation and even crisis are not uncommon in acute pneumonia. 3. Gangrene of the Lung, easily recognised by the abominable foetor of the breath and expectoration, and by the ghastly and pinched look of the patient, is a rare and fatal complication. It is apt to occur in the most destitute patients. In one or two cases observed by Murchison it was secondary to extensive bedsores over the sacrum, being evidently of embolic origin. 4. Pleurisy is a rare and latent complication. The effusion is generally purulent from the beginning as in other specific fevers. 5. Tuberculosis of the lung is also a rare sequela of typhus, notwithstanding Stokes's opinion to the contrary, based upon his observations of "fever" cases which were probably typhoid, not typhus. 6. The occurrence of haemoptysis must be considered as excep- tional. It results either from tubercular deposits or from acute haemophilia (Murchison). 7. Laryngitis is an infrequent but dangerous complication. In Germany, Rokitansky gave to the disease the name of Laryngo- Typhus. It may be croupal in character or show itself as acute oedema of the glottis. When the inflammation involves the car- tilages, it is called " perichondritis laryngea." II. Diseases of the Blood and Circulatory Organs: — 1. Acute Haemophilia. — Typhus patients, like smallpox patients, may from "dissolution of the blood" become "bleeders" — the defibrinated and devitalised blood escaping from the vessels with unwonted ease. Hence the formation of purpura spots and vibices, and the occurrence of epistaxis, haemoptysis, haematemesis, melsena, menorrhagia, and hematuria, as well as other haemorrhages. This tendency to bleed is most marked with coincident scurvy and typhus, as in the French Army during the Crimean War and in the Epidemic of 1847-1848, at Edinburgh and elsewhere. 2. Pyaemia, with purulent deposits in the joints, is a rare and very fatal complication about the period of the crisis, or it occurs as a dangerous sequela during convalescence. It is ushered in by TYPHUS FEVER. 287 repeated rigors, and is accompanied by extreme prostration, heart- failure, jaundice, and profuse sweating. 3. Venous Thrombosis occurs as an occasional sequela, causing Phlegmasia alba dolens, or White Leg. Stokes held that this lesion was to be expected when the pulse continued quick in con- valescence with no pulmonary or abdominal complications to account for its doing so. In ten years only one case per 800 was observed in the London Fever Hospital ; but it used to occur much more frequently. It is not always a painful affection. The left leg is most usually affected, perhaps owing to compression of, and conse- quent slowing of the circulation in, the left iliac vein by the right iliac artery. The swelling is firm and brawny, and at times enormous. The skin is pallid, hence the term " alba." Besides venous thrombosis, obstruction of the lymph channels (J. Warburton Begbie a ), or inflammation of the subcutaneous areolar tissue (diffuse cellulitis) may also cause phlegmasia. The swelling is then rugose and painless, as well as firm and brawny. 4. Arterial Thrombosis and Embolism are occasional, but serious, complications or sequels of typhus. They cause local gangrene, cancrum oris, osseous necrosis, abscess or gangrene of the lungs, and splenic infarctions. 5. Heart Diseases. — Both pericarditis and endocarditis are extremely rare complications. Hence, Dr. Stokes could not believe in the inflammatory nature of the affection which led to weakening of the heart in typhus. Murchison met with only two examples of pericarditis, and one example of endocarditis, in this fever. Notwithstanding the views put forward by Stokes, no doubt is now entertained as to the organic nature of the changes which take place in the myocardium in typhus. It is an acute granular disintegration of the muscular tissue of the heart, such as has been described above in the account of the pathology of scarlet fever. (See Chapter XVIIL, page 178.) a Edinb. Med. Journal. September, 1872. 288 TYPHUS FEVER. IIL Diseases of the Nervous System. — 1. Meningitis is, undoubtedly, very rare in typhus ; but cases have been recorded by Corrigan and Hudson a in Dublin, J. B. Russell b in Glasgow, Jacquot c in the Crimea, Roupell d and Murchison e in London. The cerebral symptoms of this fever are, however, almost invariably independent of inflammation. 2. Mental Disease — Temporary Fatuity and Mania are rare, and very sad, sequelae of typhus. Both at the Meath Hospital and at Cork-street Fever Hospital I have known mania to occur after this fever, necessitating the removal of the patient to a Lunatic Asylum. Happily, recovery generally follows at last, usually in two or three months. 3. Paralysis also is a rare sequela. It is most commonly ob- served as hemiplegia, when it perhaps depends on " arterial throm- bosis of the central organs of the nervous system" (Murchison). Hudson f mentions the occurrence of paraplegia, but gives no illus- trative case. About the year 1880, two cases of this sequela occured in the practice of the Meath Hospital — one of dorsal, the other of cervical, paraplegia. Both patients were males, and recovery followed in each instance. Dr. Henry Kennedy 5 observed a case of general paralysis after petechial typhus, the patient being a woman aged forty-four. 4. Muscular Fains sometimes occasion much distress in conva- lescence, and protract recovery. They are sometimes of a neuralgic character, but often resemble muscular rheumatism. The former *ype may be the precursor of phlegmasia, gangrene of the feet, or paralysis (Murchison). In some cases, the pains are probably symptomatic of peripheral neuritis, which is now known to occur after specific fevers. 5. An interesting phenomenon sometimes observed in typhus or a Lectures on the Study of Fever. By Alfred Hudson, M.D. Dublin. 1868. Second Edition. Pages 252 et seq. b Glasgow Med. Journal. February, 1869. c Du Typhus de V Arm.ee de I 'Orient. Paris. 1858. a A Treatise on Typhus Fever. London. 1839. Pp. 108, 217. e Lancet. 1865. Vol.1. Pp. 417, 482. ' Loc. cit. Page 248. * Ibidem. TYPHUS FEVER. 289 during convalescence from this fever is the development of the pathological deep reflex known as "ankle-clonus," and the exaggeration of the physiological deep reflex called the "knee- jerk " or " patellar reflex." IV. Diseases of the Digestive Tract. — 1. Erysipelas of the Pharynx is met with in some cases, causing dysphagia and — it may be — oedema of the glottis, and so endan- gering life. 2. Hsematemesis, or vomiting of blood, is occasionally observed. It may be profuse and so prove fatal. In these cases the rash on the skin is unusually abundant and dark. 3. Diarrhoea is sometimes so severe as to constitute a complica- tion. In some epidemics it is more common than in others. 4. Dysentery complicates typhus in camps and sieges. It pre- vailed also in some of the Irish epidemics of typhus. The poisons of the two diseases are, doubtless, developed under somewhat similar circumstances. 5. Intestinal haemorrhage is very rare but very fatal in typhus. It is due to a liquefied state of the blood, and is often associated with haematemesis and other haemorrhages. Its aetiology, therefore, is different from that of intestinal bleeding in typhoid. 6. Jaundice also is rare but fatal in typhus. Sir William Jenner never met with an instance, but 15 cases came under Mur- chison's notice. In 3 of these the jaundice was due to consecutive congestion of the liver ; in a fourth case, it resulted from gastro- duodenal catarrh. In the remaining 11 cases, of which 9 proved fatal, the jaundice co-existed with the rash and was evidently due to some abnormal state of the blood, as in pyaemia, yellow fever, snake-bite, and other blood-poisonings. Bile pigment was present in the urine, so there was true jaundice. 7. Peritonitis is almost unknown as a complication of typhus. Sir William Jenner and Dr. Alexander Collie have each recorded a single instance of the occurrence of acute idiopathic peritonitis in convalescence. Murchison saw two cases — the causes being, respectively, the bursting of a softened embolic infarct in the spleen and tuberculosis of the peritoneum. U 290 TYPHUS FEVER. V. Diseases of the "Urinary Organs. — 1. Nephritis — whether primary or secondary, acute or chronic, is a most serious complication of typhus — often inducing uraeraic convulsions. 2. Catarrh of the Bladder (Cystitis) sometimes occurs in con- valescence, especially after retention of urine and over-distension of the bladder. 3. Hematuria may result from : — (1.) acute haemophilia, (2.) nephritis or congestion of the kidneys, (3.) cystitis. VI. Diseases of the Integuments and Bones. — 1. (Edema, if slight, is generally the result of debility. General anasarca may occur from nephritis. Both appear in convalescence, when the patient begins to walk. In this stage, also, I have repeatedly witnessed extreme suffering from painful feet — the cause apparently being non-removal of the epithelium from the soles of the feet, and consequent obstruction of the sweat ducts. 2. Bedsores (gangrene of the integument) occur in protracted cases from : — (1) pressure, as over the sacrum, trochanters, heels, occiput, ears, elbows, and so on; (2) early neglect and want of skilled nursing ; (3) impaired innervation. 3. Spontaneous gangrene, independently of pressure, is probably brought about by arterial thrombosis. It affects the toes and feet, the nose, penis, scrotum, and pudenda in the female. It occurs in badly-fed patients, and is ushered in by severe shooting pains, numbness, coldness, and lividity. In my "Medical Report" of Cork-street Fever Hospital, for the year ending March 31, 1879, I mentioned the case of a typhus patient who died on the fourth day of the fever from gangrene from the fingers. 4. Noma, or Cancrum Oris (gangrenous stomatitis), is a very destructive and fatal variety of gangrene, which attacks the cheek, mouth, tongue, and face of delicate, badly-fed children, about the end of the second week of typhus. It is not peculiar to this disease, for it occurs also in smallpox, scarlatina, and measles. According to Rilliet and Barthez, not more than one in twenty cases of noma recover. It is regarded by Hutchinson as allied to, or identical with, "hospital gangrene." The first sign is usually TYPHUS FEVER. 201 a brawny swelling in the substance of the cheek. This becomes purple, softens and breaks down, and then the gangrenous ulcera- tion may spread in all directions, causing perforation of the cheek, and involving the lips, tongue, alse nasi, and eyelids, and even causing exfoliation of the teeth and jaws. I have myself seen two cases of this terrible complication. In one, a large gaping cavity opened through the cheek into the mouth, and the smell of the breath was indescribably foetid. 5. Hospital Gangrene attacks wounds and ulcerated surfaces in persons under the influence of typhus. It is a contagious form of gangrenous inflammation which attacks a raw surface, and is identical with, or closely allied to, acute sloughing phagedena. The wound, on invasion, ceases to discharge and becomes coated with a gray tenacious slough extending from the centre towards the margin. The patient usually sinks exhausted. The disease is micro -parasitic, and its ultimate extinction may, therefore, be looked for in time. 6. Inflammatory Swellings or Buboes are not infrequent in typhus, especially in the parotid and submaxillary regions, about, or after the time of crisis. They form rapidly, and are very painful. According to Drs. Craigie a and Graves, b the inflamma- tion has its seat mainly in the subcutaneous areolar tissue, and not in the substance of the glands. In some cases, they have seemed to Murchison to originate in extravasations of blood. The same author considers that these inflammatory swellings constitute a con- necting link between typhus and Oriental plague, or bubonic fever. He goes so far as to say that " typhus is probably the plague of modern times." These bubonic swellings may terminate in purulent infiltration and abscess, or may recede without suppurating. In the former case especially they are a formidable complication of typhus. VII. Other Specific Diseases. — 1. Variola; 2. Scarlet Fever; 3. Diphtheria ; 4. Erysipelas; a Fevers. Edinburgh. 1837. P. 301. b Clinical Lectures on the Practice of Medicine. New Syd. Soc. 1886. Vol. I., page 223. 292 TYPHUS FEVER. 5. Typhoid or Enteric Fever — are all known to have complicated or closely followed upon typhus. Murchison reports the case of a girl aged fifteen, ill of varioloid, who was conveyed to the Smallpox Hospital in a carriage used for the removal of typhus patients. While still going through her illness a typhus rash appeared. In 18G2, Dr. Peacock reported in the Lancet a case in which the rashes of typhus and scarlatina actually co-existed. Both Murchison and W. T. Gairduer, of Glasgow, have seen typhus complicated with, or followed by, diph- theria. Erysipelas of the face is, according to the former author, an occasional complication of typhus, appearing, perhaps, as early as the third day, but more commonly towards the close of the second week, or during convalescence. It was noticed by Murchison, in 92 out of 14,676 cases, or once in 159 cases. Lastly, the co-existence of typhus and typhoid fevers admits of no question, and, in my opinion, the frequency of this accident led to the confounding of these two fevers and to the view that they were to be regarded as merely modified forms of the one essential disease. 293 CHAPTER XXX. Typhus — (continued). Varieties op Typhus : Inflammatory, nervous or ataxic, adynamic, ataxo- adynamic or congestive, Typhus siderans, Typhus levissimtts, abortive, catarrhal. Diagnosis : from relapsing fever, enteric fever, " jungle fever," purpura, measles, meningitis, delirium tremens, asthenic or " typhoid " pneumonia, uraemia — Prognosis and Mortality : Bad signs in typhus ; death-rate influ- enced by age, sex, condition of life and habits, season, pregnancy, fatigue, priva- tion, late treatment — Pathological Lesionb : (1) General; (2) Special, affecting the integumentary, respiratory, circulatory, nervous and digestive systems of the body — Pathology of the " Typhoid State." Varieties of Typhus. — The following, among many other varieties of this fever, have been described : — 1 . Inflammatory Typhus, characterised by much febrile reaction in the young and robust, and in patients of the upper class — a rare form, having occurred in only 40 out of 1,302 cases observed by Barrallier. 2. Nervous or Ataxic Typhus, in which nervous symptoms pre- dominate. The eruption is generally copious, dark, and petechial. This form is also described under the names, " Typhus Comatosus " and "Brain Fever." It was observed by Barrallier in 109 out of 1,302 cases. 3. Adynamic Typhus, accompanied by great muscular and cardiac prostration, involuntary evacuations, and a tendency to collapse. The skin may be cool and the pulse slow. Barrallier noted this form in 92 out of his 1,302 cases. 4. Ataxo-adynamic Typhus, or the Congestive Typhus of Armstrong. This is a combination of the ataxic and adynamic forms, and is by far the most common variety, having occurred in 810 out of Barrallier's 1,302 cases. Typhus Siderans, or " Blasting Typhus," very acute, and fatal within a few hours or days. 204 TYPHUS FEVER. 6. Typhus Levissimus, or "Mild Typhus," observed by Barrallier in 235 out of 1,302 cases. " Typhus levissimus " was described by von Hildenbrand in 1810 under this name. 7. Abortive Typhus. Jacquot gave the name " Typhisation a petite dose " to cases in which symptoms occurred in persons exposed to infection without developing into actual typhus. Of this incomplete form Niemeyer observed some cases in the Magde- burg Hospital, and a large number of observations made in the Prague epidemics of 1843 and 1848 exactly correspond with his. The patients — who, in his cases, had always been exposed to typhus poison — complained of rigors, great depression, lightness of the head, frontal headache, weakness of the limbs, loss of appetite, and other symptoms common to the incubation stage of typhus, renewed and stronger chills, slight delirium, and catarrhal symptoms. Towards the close of the first week, the constitutional disturbance, fever, and catarrhal symptoms disappeared, and the patients began to con- valesce. They recovered very slowly, suffering much from prostra- tion. Niemeyer called the affection kt a rarely-mentioned abortive form of typhus." a 8. Catarrhal Typhus, an Irish appellation for the disease, because it is so often complicated with bronchial catarrh. In Germany, the names "Broncho-typhus" and " Pneumo-typhus " were intro- duced by Rokitansky, as already mentioned. Diagnosis. — The rash is pathognomonic of typhus. Before it appears, we have grounds for a differential diagnosis in a history of exposure to the infection, of such symptoms after exposure as rheumatoid pains, headache, and early prostration. It may be necessary to distinguish typhus from the following diseases, or diseased conditions, or vice versa : — 1. Spirillum Fever (Relapsing Fever). 2. Typhoid or Enteric Fever. 3. Tropical Remittent Fever (" Jungle Fever "). 4. Purpura. 5. Measles. a Text-Book of Clinical Medicine. Revised Edition. 1880. Vol. II., page 622. TYPHUS FEVER. 2'J5 6. Meningitis : Encephalitis. 7. Delirium Tremens. 8. Asthenic, or Typhoid, Pneumonia. 9. Uraemia. 1 & 2. It will be convenient to postpone the diagnosis of Typhus from Relapsing Fever and Typhoid or Enteric Fever until those fevers have been described. 3. The " Typhoid-Remittent " Fever of the tropics — or " Per- nicious Malarial Fever" (Hirsch) — commonly called "Jungle- Fever " in India — is a miasmatic disease, caused by malaria. It is non-contagious, independent of overcrowding, prevails in tropical climates, and in warm and rainy seasons. The spleen is much enlarged, and quinine often acts specifically. Petechias may be present, but the macular rash of typhus is wanting. 4. Riverius long ago (1648) distinguished the petechia sine febre (purpura) from typhus (febris petechialis). Purpura is non-contagious ; as a rule, apyrexial ; is unaccom- panied by cerebral symptoms, but is attended with haemorrhages from the mucous membranes. The spots, too, are larger than the petechias of typhus. 5. Measles is distinguished from typhus by the history of ex- posure to the poison of measles, the prevalence of an epidemic, the prodromal catarrhal symptoms, the brighter tint and greater abundance of its rash, the presence often of diarrhoea, and the early defervescence. The bronchial catarrh of typhus appears late and in the lighter cases the rash is not abundant. 6. In Inflammation of the Brain (Cerebritis, or Encephalitis) or its membranes (Meningitis), delirium is present from the very first, and is accompanied by excruciating headache. The senses are morbidly acute, whereas they are dull and blunted in typhus. The pulse is bounding. The eyes have not the heavy, dull look of typhus, nor is the rash of that disease present. Loud cries and screams (cri cerebral), as well as strabismus, ptosis, opisthotonos, and partial palsy, characterise meningitis. There is extreme in- tolerance of light (photophobia) and of sound. Nausea and vomiting 296 TYPHUS FEVER. are common. A red streak is left upon the skin after pressure by the finger (tache cere'brale, or cerebral stain). 7. The Delirium Tremens of the drunkard differs from that of typhus in setting in with sleeplessness and delirium, without shivering, headache, or pains in the limbs. The tongue is moist and coated with a creamy fur, the skin is moist and cool, there is no eruption, and the temperature is not high. 8. In Asthenic or Typhoid Pneumonia the apex of the lung may be chiefly affected, when the symptoms of the local disease may be masked by the constitutional state (latent pneumonia). The differ- ential diagnosis will, under such circumstances, turn on the presence of physical signs in the lung and the absence of eruption. 9. In Uraemia from chronic renal disease, the " typhoid state" may be fully developed, leading to great difficulty in diagnosis. But it is in chronic interstitial nephritis (contracted granular kidney — renal cirrhosis) that uraemia chiefly occurs. This form of kidney disease usually occurs in advanced life, especially in gouty subjects or persons suffering under chronic lead-poisoning (plumbism), and the temperature is normal or subnormal. This last circumstance Murchison calls "the grand point of distinction." Finally, the typhus rash is, of course, wanting in uraemia. Prognosis and Mortality. — The unfavourable signs in a given case of typhus are : — (1) A presentiment of death, often entertained by physicians when ill of typhus ; (2) a soft and compressible pulse in rate above 120 in an adult ; (3) absence of cardiac impulse, and lessened or silent first sound of the heart ; (4) hurried respirations, particularly if no pulmonary lesion exists to explain this symptom ; (5) sleeplessness and delirium ; (6) complete coma-vigil of Sir William Jenner ; (7) the presence of the pin-hole pupil of Graves ; (8.) great pros- tration; (9) convulsions; (10) muscular tremors and hiccough; (11) relaxation of the sphincters before the tenth day; (12) tym- panites or meteorism ; (13) lividity of the face and surface gene- rally ; ^14) abundance and darkness of the rash; (15) persistent high temperature ; (16) profuse sweating after the tenth or twelfth clay; (17) the presence of any serious complication. TYPHUS FEVER. 297 When death takes place, it occurs from asthenia, with heart- failure ; or from ataxia, nervous symptoms deepening into coma ; or from some intercurrent complication or sequela. Mortality. — There is reason to believe that the death-rate from typhus among the community taken all round does not exceed 10 per cent, of those attacked. Hospital statistics show a much higher rate. Thus, in 23 years ending with 1870, of 18,268 patients admitted in typhus to the London Fever Hospital, 3,457 died, giving a mortality of 18*92 per cent. The mortality since 1862 has been less than it had been previously — 18*22 per cent, compared with 20*89 per cent. As in the case of other epidemic diseases, the mortality is greater immediately after the outbreak than in the later stages. The last serious epidemic in the Annals of Cork-street Fever Hospital occurred in the years 1880-82, immediately in the wake of the smallpox scourge of the years 1876-80. So far back as January, 1880, typhus showed an epidemic tendency in Dublin, the female department of the North Dublin Union Workhouse being the chief focus from which the disease spread in the first instance. Out of 57 cases of typhus admitted to Cork-street Fever Hospital in the three months ending March 31, 1880, not fewer than 40 came from the female division of the North Dublin Union. The outbreak attained its greatest violence in the last quarter of 1880, during which the admissions rose to 217. It finally died out in the early part of 1882, the admissions falling to 28 in the first three months of that year. In all, 675 patients were treated during the epidemic, and of these 71 died, the resulting death-rate being 10*5 per cent. As usual, the disease was much more malig- nant at the beginning of the epidemic than it was in its later stages. It is interesting to recall the fact that this — the last serious out- break of typhus in Dublin — followed not only in the wake of a prolonged epidemic of smallpox, but also in that of the disastrous year 1879, the continuous cold and wet of which led to unparalleled and general distress throughout Ireland. With the assistance of Dr. John Marshall Day, the Resident Medical Officer of Cork street Fever Hospital, I have tabulated the 298 TYPHUS FEVER. number of cases of typhus admitted to the hospital annually in the twenty years ending March 31, 1891, as well as the deaths from this fever which occurred in each of the same twenty years. I find that the total number of cases admitted was 2,895, of which 363 proved fatal. These figures give an average mortality of 12*6 per cent., or nearly one in eight. It is worthy of note that the wards of Cork-street Hospital are splendidly ventilated — indeed almost to excess in winter. I have no doubt that this free ventilation contributes largely to so low a death-rate from typhus. Age influences the mortality from typhus in a most remarkable way. This is shown in the accompanying Diagram (B.j, copied from Murchison's "Treatise on the Continued Fevers of Great Britain," by permission of Messrs. Longmans, Green & Co. It shows the variations — according to age~of the percentage death-rate of 18,132 cases of typhus admitted to the London Fever Hospital. Accord- ing to this diagram, the mortality during the first five years of life was 6-69 per cent.; in the second lustrum, it fell to 3*59 ; between 10 and 15 it was only 2-28 per cent., between 15 and 20 it rose to 4*46 per cent. After 20, it progressively increased until of those — Above 30 years of age 35*39 per cent. died. 40 » 43-48 50 j» 53-87 60 11 67-04 70 11 79-00 80 11 100-00 And yet typhus is not invariably fatal in advanced life. The fol- lowing is quoted from the " Medical Report of Cork-street Fever Hospital," for the years 1820-21, written by Dr. William Stoker, grandfather of Mr. William Stoker, now one of the Professors of Surgery in the Royal College of Surgeons in Ireland : — " A very remarkable case of malignant typhus fever passed through the wards under my care in the month of January (1821). It was that of a man of the name of Owens, 104 years of age, husband to the woman of that name, whose death is given in the foregoing tabular obituary. This man's fever continued for three weeks, 100 I 100 1 — 9i }|l| 95— 90 — 85 90 rpi 85 — 80 " s 30 _ — 75 | 75— 70 | 70 — 65 60 '!' . 1 1 i &-4 — 55 m ■ 1 60 I rwr lliiiii 1 1 I 50 Iflillfl 1 ill 1 ! :; 'i [■"■'" lilHII I ' | 'i i ill :■!'• ,' I .1 : 1 ll *? I ' j:"-' -45 ill 1 i ii J Hi 1 ||i| j :l!'|l! ¥5 — 40 if ||j f 1 : 1 ' 1 1 18 1 1 nil ■] II ;| j 1 |ft| 1 I,.;,! pit 1 ';jl;j ftf I -35\ [, r SI ii i r- i ! 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TYPHUS FEVER. 209 through a greater part of which time he was delirious, his limbs tremulous, his body covered with petechia?, and his extremities livid. The crisis of his illness was sudden and decisive, and his convalescence rapid ; so that in a few days afterwards he was able to walk to the House of Recovery, whence he was dis- missed in as perfect health as was compatible with his time of life within a week from the commencement of his convalescence." Sex. — Men die of typhus in greater numbers than women, per- haps, because the average age of male typhus patients is greater than that of the females, but more probably, because men are more muscular as well as more intemperate. Disintegration of tissue by the fever process would, under these circumstances, go on more rapidly in men than in women, while elimination would be checked, owing to the morbid changes in the liver and kidneys, brought about by alcoholism. The intemperate, the sickly, the obese, or the very muscular, the hard-worked, whether bodily, or mentally, but especially the latter, run the worst chance if attacked by typhus. As regards months and seasons, the mortality from typhus drops to a minimum as summer advances, and rises to a maximum in the late winter and spring. During twenty-three years (1848-1870), the mortality at the London Fever Hospital was considerably less (16 "2 per cent.) in the last five than in the first seven months of the year (20*7 per cent.). This is, no doubt, the result of increased destitution, overcrowding, and defective ventilation in winter on the one hand, and of plenty and a more open-air life in summer on the other. Pregnancy adds little to the danger of typhus, but suckling induces anaemia and increases the chances of death by asthenia. Fatigue and privation greatly increase the mortality from this fever, and so does neglect of treatment in the early stages. Lastly, too late removal to hospital is most prejudicial. This was insisted upon by Dr. Alison, of Edinburgh, in 1844 and 1849, and I have had repeated opportunities of verifying the correctness of his obser- vations. In the year ending March 31, 1884, fifteen deaths occurred in 300 TYPHUS FEVER. Cork-street Fever Hospital before the deceased patients had been forty-eight hours under treatment in the hospital. Six out of these fifteen cases were suffering from typhus. " Dying on admission " is a grave indictment against those who were responsible for the removal of the unhappy sick to hospital in their last hours. On July 5, 1882, I drew the attention of the Managing Committee of Cork-street Hospital to the circumstances under which the first death which occurred in the hospital within the official year, beginning on April 1, had taken place. On the afternoon of July 1, a married woman, aged forty, was sent in on the fifteenth day of bad petechial typhus with bed-sores, and in an extremely prostrate condition. She lived for four and a half days after admission. At the time, I expressed the opinion that a patient, of middle age also, so far advanced in typhus of a severe type, could not be safely moved to hospital, and should have been treated and nursed at home. On August 7, 1883, I again called the attention of the Committee of the Hospital to a very similar case. A married woman, aged forty- nine, was sent in on the tenth day of severe typhus, during a violent thunder-storm. She died twenty-four hours after admission. Can anything more deplorable be imagined than the want of judgment exhibited in this and other " cases sent in when beyond recovery ? " Pathological Lesions. — Cadaveric rigidity is of short duration in typhus, and putrefaction takes place rapidly. Emaciation is considerable, but much less than in typhoid fever. Speaking of the anatomical lesions met with in fatal cases of typhus fever, Murchison says that the patient usually dies before the body has had time to become much emaciated. Dr. Cayley, however, quotes Dr. Hermann, of the Obuchow Hospital, St. Petersburg, to prove that a considerable loss of weight takes place during an attack of typhus. That physician found that the average daily loss of weight ranged from £ lb. to 3 lbs. The greatest total loss was 31 lbs. A widespread congestion (passive hyperemia) is the most constant and noticeable post-mortem appearance in typhus. In connection with the several systems of the body, the following additional pathological appearances may present themselves : — TYPHUS FEVER. 301 1. The Integumentary System. — The petechia; of typhus remain visible after death. Bedsores may occasionally be observed, and less frequently spontaneous gangrene. Rarely, lymphatic and bubonic swellings may be present. There is much livid discolora- tion of the surface, and the green tinge of decomposition sets in very early after death. 2. The Respiratory System. — The chief features are traces of a widespread catarrhal inflammation of the air passages (catarrhal laryngitis, tracheitis, and bronchitis), hypostatic consolidations in the lungs, rarely pneumonic consolidations, and pleuritis with purulent effusion. 3. The Circulatory System. — The blood is profoundly altered, being feebly coagulable, often staining the endocardium and the intima vasorum. Lebert a says that the blood found in the heart and larger veins usually forms a black pultaceous, soft clot, in which there is but little distinctly coagulated fibrin. Examined under the microscope, rouleaux are found wanting, and the red blood- corpuscles are crenated and misshapen. The muscular tissue of the heart is softened and friable. Rokitansky b held that this softening was " a simple diminution of consistence, not depending upon any disturbance of texture." But cloudy swelling and granular fatty degeneration have been observed by all modern pathologists. The appearances have been already described (see Chapter XV1IL, page 178). 4. The Nervous System. — The membranes of the brain are highly vascular, but this is not to be regarded as a token of in- flammation — the congestion is, in fact, passive or mechanical, and depends on heart-failure or pulmonary obstruction. In rare in- stances deposits of lymph or pus, no doubt, indicate the presence of recent inflammation. Murchison, Stokes, and other authorities rightly hold that no relation exists between the vascularity of the cere- bral membranes and the cerebral symptoms observed during life. " The assumption of inflammation of the brain in the presence of a Von Ziemssen's Cyclopaedia of the Practice of Medicine. Art. " Typhus Fever." Vol. I., page 335. b Pathological Anatomy. Sydenham Society. 1852. Vol. IV., page 171. 302 TYPHUS FEVER. violent nervous symptoms in fever," wrote Dr. Stokes, a " consti- tutes one of the greatest dangers to which young physicians are exposed, when they come to deal with the most formidable com- plication of the disease — aye, and old physicians, too, whose clinical education has been imperfect. I have known of the application of leeches to the head in an advanced case of cerebral fever with delirium ferox to be followed by sudden sinking and death." Increased effusion of serum within the cranium is, according to Murchison, one of the most frequent morbid appearances in typhus. The most common seats of this effusion are beneath the arachnoid and in the lateral ventricles, and sometimes in the cavity of the arachnoid. The serum is transparent or sometimes apparently opalescent, owing to slight opacity of the superposed membrane. It may be colourless or straw-coloured. It does not contain flakes of lymph or exudation-corpuscles. There is no relation between the amount of effusion and the in- tensity of the symptoms of brain trouble, nor is the increased serosity a sign of inflammation. Murchison thinks that in typhus the brain wastes from malnutrition and the effusion takes place to fill up space. It would be more correct to say that from the con- gested vessels, with badly-nourished walls, and owing to lessened pressure upon them by the shrunken brain, effusion takes place. The cerebrum and cerebellum are generally healthy. They may be highly vascular, a condition shown by diminished consis- tence, a darker tint of the grey matter, and numerous blood-points on section of the white matter. Softening of the brain has been occasionally observed, and Barrallier b has called attention to a re- markable indistinctness of the arbor vita; of the cerebellum in some cases. Similar appearances to those described in connection with the brain are less frequently seen in the spinal cord. Nothing definite has yet been ascertained as to the condition of the sympathetic system of nerves in typhus. Marmy found many of the ganglia softened, and Beveridge found the cervical ganglia a Lectures on Fever. London : Longmans, Green & Co. 1874. Page 279. b Du Typhus epidemique a Toulon. Paris. 1861. Page 106. TYPHUS FEVER. 303 enlarged and dense from the deposit of an amorphous granular matter. 5. The abdominal viscera. — The characteristic lesions of enteric fever are wanting. The kidneys are not uncommonly hyperaemic and enlarged, while the tubes are engorged with blood and stuffed with granular epithelium. Acute nephritis is thus unmistakably present in not a few instances. The pathology of the " Typhoid State " is not yet clearly made out. Murchison thinks it is very possible that the condition to which this name is given may have a common origin in all the diseases in which it shows itself, or may be due to the accumulation in the blood of the products of disintegrated tissue as the result of the primary malady. The connection between the typhoid state and the presence of urea, carbonate of ammonia, or other nitro- genous detritus in the blood is, according to Murchison, a subject which deserves further investigation. James Andrew a considers that the chief primary cause of the condition may be the injurious influence of a high internal tem- perature upon the central nervous organs, but this same tempera- ture acts directly also upon the parenchyma of glandular organs, and upon the muscular fibre both of the heart (Stokes) and of the voluntary muscles (Zenker). The disorder of the nervous centres must be greatly increased by, if not sometimes decidedly due to, the changes in the composition of the blood, and in the forces of the circulation. Murchison admirably sums up the pathological appearances in typhus as follows : — " 1. There is no lesion constant in, or peculiar to, typhus. " 2. The intestines never exhibit the peculiar lesions [almost] invariably present in typhoid fever, and the mesenteric glands are not enlarged. "3. No evidence of acute inflammation is found in the brain or its membranes, to account for the cerebral symptoms. "4. The chief morbid appearances are: a fluid condition of the a Quain's Dictionary of Meaicine. 1883. Art. "Typhoid State." 304 TYPHUS FEVER, blood, atrophy of the brain, with increase of intra-cranial 8uid, granular degeneration of the sympathetic nerves ; atrophy, with granular or waxy degeneration of the muscles and heart ; enlarge- ment and congestion of the liver, spleen, pancreas, and kidneys, with a swollen, granular state of the gland-cells ; bronchial catarrh and pulmonary hypostasis. The relative frequency of these lesions varies at different times and places ; none are of constant occur- rence, or peculiar to typhus." 305 CHAPTER XXXI. The Treatment of Typhus. Prophylactic and Curative Treatment (or " Management "). Preven- tive Measures : Personal cleanliness, good food and air-space, ventilation. Management : hygienic measures adopted at Cork-street Fever Hospital, Dublin. Nursing. Medicinal treatment must be purely symptomatic. Water Treatment. Quinine. Alcoholic Stimulants. Food. — Treatment of Compli- cations and Sequels : Pulmonary congestion, bronchitis, paresis, incontinence of urine, convulsions, bedsores, phlegmasia and thrombosis, oedema. Con- valescence : costive bowels. Tonics. Change of Air. This topic has already been dealt with in detail in the Chapters on the General Principles of Treatment. "It is easier to prevent Typhus than to cure it," said Murchison, and if thorough effect could be given to all the preventive measures described in Chapter IV., typhus fever would, in all probability, soon cease to exist. Nothing is more striking than the diminution of this fever of late years — even in those countries (such as Ireland), and towns (such as Cork, Dublin, Glasgow, and Liver- pool), where the repeated epidemics in the past caused it to rank as an endemic disease. In the recognition of the facts that destitution, overcrowding, and deficient ventilation, enormously predispose to typhus, lies the key to the prophylaxis of the disease. Personal cleanliness, an abundant supply of good, wholesome, food, a sufficient cubical air- space per head of the population (500 cubic feet, at least), and free ventilation, which means the supply of 3,000 cubic feet of fresh air per head every hour, are the best preventives. Those sick of typhus should be treated in large airy wards or rooms — 1,500 to 2,000 cubic feet being allowed to each patient — - and the beds should be at least six feet apart. We have already seen that, if a single fact is well established in the life-history of the contagium of typhus, it is that the virus is most readily destroyed or rendered inert by contact with atmo- X 306 TYPHUS FEVER. spherical air, presumably through oxidation. If this is so, what vast magazines of typhus-poison might be rendered powerless for mischief in every gentle breeze, not to speak of a more violent tempest, provided only doors and windows are not too closely barred. After thus referring to the destruction of the virus of typhus fever by oxidation, through the natural agency of the currents of the atmosphere and of strong winds, it may be of interest to describe the therapeutical means adopted by my colleagues and myself during the last epidemic in Cork-street Fever Hospital, with a view of neutralising the fever poison, when it was actually at work in the patient's system. First, attention was constantly directed to the ventilation of the fever wards. In severe cases, where the eruption was copious and dark (petechial), a strong current of fresh air was allowed to blow over and around the patient whenever the state of the weather at all permitted it. Lebert a says on this point that in a recent epidemic at Breslau he found it to be an excellent plan, even during the severest cold of winter, to keep the windows open during part of the day and night. The patients bore it well so long as the fever lasted, though they proved very sensitive to cold after the defervescence. The weight of bed-clothes was reduced to a minimum, so that the fresh air might easily reach the surface of the whole body. It might be supposed that the exposure would give the patients cold ; but experience proves that this is not so, and I am convinced that in a vast majority of cases the bronchial catarrh and other pulmonary affections of typhus are not the result of cold, but of passive hyperemia of the bronchial mucous membrane and of the parenchyma of the lungs — that, in fact, these lesions belong to the essential pathology of the disease. Secondly, directions were given to the nurses in all bad cases, with profuse eruption, to sponge the entire surface of the body twice or three times a day with vinegar and warm water. a Art. "Typhus Fever," in von Ziemssen's Cyclopaedia of the Practice of Medicine. TYPHUS FEVER. 307 Thirdly, solution or tincture of the perchloride of iron, chlorate of potassium in moderate doses, or quinine, was given in nearly all such cases, either separately or in combination, and with re- markably good results. Under this hygienic treatment several very grave cases pro- gressed favourably, and it is an interesting fact connected with my own practice in the hospital, that I seldom felt called upon to order for these patients any large quantity of alcoholic stimulants. Bearing in mind the early and great prostration of typhus, the patient should take to bed as soon as possible in a cheerful, large, airy apartment, with two bedsteads in it — one for day and one for night. The best form of bed for a typhus patient is a hair-mattress laid upon a woven-wire spring mattress. The bed-clothes should be light. The patients' head should be kept as cool as possible, but his feet should be warm. There is no disease in which the services of a trained, expe- rienced, strong, and judicious nurse are more needed than in typhus. In the ninth of his " Clinical Lectures on the Practice of Medicine," Dr. Graves gives excellent advice on this point. He says : — " You should never, if possible, undertake the treatment of a case of fever where the friends or relations of the patient supply the place of a regular fever nurse. The mistaken tenderness of relatives and their want of due firmness, presence of mind, and experience, will frequently counteract your exertions and mar your best efforts. Affection and sorrow cloud the judgment, and hence it is that very few medical men ever undertake the treatment of dangerous illness in the members of their own families. . . . Again, it will not do to have a nurse who has been usually employed in other diseases ; your assistant must be a regular fever nurse, and the man who undertakes the treatment of a long and dangerous case of fever without such an assistant will often have cause to regret it. . . A fever nurse has a vast deal in her power ; if an enema is to be administered, the patient will be much less disturbed and annoyed than if it were given by an unskilful person. The mere handling of a patient — the moving of him from one bed to another — the 308 TYPHUS FEVER. simple act of giving him medicine and drink — the changing of his slieets and linen — the dressing of his blisters — and a thousand other offices, can be performed with advantage only by an ex- perienced nurse. Always bear in mind that it is of the utmost importance to economise the patient's strength in fever. The very act of lifting him up, or removing him from one side to another, tends to produce exhaustion. In the advanced stages of fever, the services of a properly qualified nurse are inestimable. Then there is the moral management of the patient, and this is an office which no one can undertake unless qualified by experience, and a correct knowledge of the habits of persons labouring under such forms of disease. Everyone admits the value of moral superin- tendence in the treatment of the insane. Now there are very few patients who are not in a state analogous to insanity, for a longer or shorter period, during a course of typhus fever. There is a necessity for moral management in fever as well as in insanity, and this is understood only by an experienced nurse." Both in hospital and private practice, the nurse, or nurses — for there should be a day nurse and a night nurse — should keep a written record, for the information of the physician, of the times at which food and stimulants have been given, the bowels have moved or water has been passed; of the changes in the nature and character of the symptoms from visit to visit of the physician ; and of the behaviour of the temperature and the rate of the pulse and respirations at stated intervals already agreed on. So far as the physician is himself concerned, every case of fever should be visited at least twice a day — morning and evening — during the acute and critical stages, for a few hours may mean life or death to the sufferer. The medicinal treatment of typhus is purely symptomatic, for as yet we possess no specific for this disease, if we except fresh air. " Although," says Murchison, " many practitioners have at diffe- rent times proposed to cut short an attack of typhus by such heroic remedies as blood letting, the cold affusion, emetics, and quinine, we possess as yet no such specific" as will arrest its progress or shorten its duration. TYPHUS FEVER. 309 Von Hildenbrand, early in the nineteenth century, observed — " No method yet known, whether rational or empirical, can cure the contagious typhus, either in a direct or in an indirect manner, or even abridge its ordinary and natural course, which is about four- teen days." To the same effect Stokes a declared that " the treatment of fever, whether it be typhus or typhoid, is reducible to a simple formula, and is essentially the same in both types of disease. We know of no cure for fever; no man has ever cured it. It is, however, curable spontaneously. If you leave it to its own course, it is capable of curing itself. It will spontaneously subside. Remem- bering the law of periodicity, the great object of the physician should be to gain time, preserving the patient from the dangers which threaten him, which belong to this special state of life. If he can be kept alive to the 14th day, the 21st, the 36th, or even the 60th day, recovery will probably ensue. Every day, every hour of existence preserved and sustained is a great gain. The risks that he runs are due to debility or to the influence of the secondary affections. We, so to speak, cure the patient by pre- venting him from dying. . . . Herein lies the secret of the treatment of fever. We watch the progress of the disease through- out its varying phases ; we meet by judicious treatment, as they arise, the symptoms of secondary and local malady ; we sustain the system as far as practicable ; we preserve the sufferer at the least expense to the constitution ; and we wait patiently until the hour shall strike when, in accordance with the mysterious law of periodicity, the fever shall have departed and convalescence shall have begun." Murchison employs a striking metaphor when, to the same effect, he says — " A patient with typhus is like a ship in a storm ; neither the physician nor the pilot can quell the storm ; but by tact, knowledge, and able assistance, they may save the ship." Mosler, of Greifswald, says that he has up to the present tried the methods mentioned by Murchison for the treatment of typhus : the water treatment, the use of large doses of quinine, alcoholic * ^ectures on Fever. 1874, Pages 83 and 84. 310 TYrHUS FEVER. stimulants, and nourishing food. Suitable combinations of these measures are recommended by him as the best way of dealing with typhus, and by means of them he obtained brilliant results in an epidemic observed by him in 1867, when only 8 deaths occurred among 94 patients, the mortality being 8*7 per cent, compared with the average laid down by Griesinger as ranging between 15 and 20 per cent. In the same epidemic, before suitable treatment had as yet come into use, of 36 patients 20 died, which gave a death-rate of 55 per cent. We are, therefore, justified in concluding that even the mortality in typhus may be reduced to an inconsiderable figure by a persistent water-treatment, carried out with the aid of the thermometer, especially when combined with the use of quinine and of the other remedies already mentioned. The administration of alcoholic stimulants in typhus should not be a matter of routine. The sagacious physician owes it to his patient and to his own reputation to decide, in each case after full consideration, whether these remedies — potent for evil no less than for good — are to be prescribed or withheld. Stokes's views on this subject, contained in the twenty-seventh of his Lectures on Fever (Edition of 1874,) are thoroughly sound and philosophical. After pointing out that, in his practice, cases had occurred in which either no wine was used, or it was sparingly employed, or it was not ordered until after the middle period of the fever, he goes on to speak of the anticipative treatment by stimulants — that is, their administration at an early stage of fever, when the sagacity of the physician enables him to foretell the occurrence of great prostration of nervous energy. Under such circumstances he gives stimulants oy anticipation. In adopting this practice we follow the old maxim, " venienti occurrite morbo," and we take into account the character of the prevailing epidemic, and the previous medical history of the patient. The effect of each dose of alcohol should be carefully watched and noted. The management of some of the complications and sequelae of typhus remains to be discussed. 1. Pulmonary Congestion and Bronchitis are best treated by poulticing, dry cupping, and the application of stimulating liniments TYPHUS FEVER. 311 to the chest by rubbing — for example, compound camphor liniment, acetic turpentine liniment., and so on. Iodine may also be applied in the form of an oleate, or in combination with water and glyce- rine — the stronger preparations destroy the absorbent power of the skin. Internally, the most useful remedies are iodide of potassium and bark (in convalescence), quinine and iron, quinine and arsenic in pill, digitalis. In gangrene of the lung, free stimulation, chlo- rate of potassium and borax, large doses of quinine, guaiacol (which is obtained by the destructive distillation of guaiacum resin and is contained in beech creasote to the amount of 60 to 90 per cent.), and antiseptic inhalations of carbolic acid, creasote, tar vapour, &c, are the most suitable remedies. 2. Paresis after the fever requires a generous diet, mineral tonics, strychnin, and massage, with galvanism, shower-baths, and sea- bathing in summer. Tincture of perchloride of iron is an excellent remedy in incontinence of urine, and in the female this infirmity is often at once relieved by cauterising the orifice of the urethra with nitrate of silver. 3. In addition to the measures suggested in Chapter V. (page 63) for the relief of convulsions, it is right to mention that Hudson, in 1837, recorded a case of recovery after two severe fits of convul- sions in typhus, the treatment adopted consisting in the abstraction of ten ounces of blood by wet cupping from the neck and purging with calomel. In a case of typhoid fever in a lady, complicated with epileptoid convulsions, the treatment adopted by Hudson consisted in withholding wine, cutting off the hair, applying cold to the head and leeches behind the ears ; also, in the exhibition of grain doses of calomel at short intervals. This lady recovered perfectly. She never had epilepsy before her fever, nor did she afterwards suffer from it. 4. Bedsores may be avoided to a large extent by careful nursing and by the use of an annular air-cushion, a water bed, or a spring bed. The threatened parts should be protected by being kept dry, and painted twice a day with a solution of one part of sheet gutta- percha in eight parts of pure chloroform, or equal parts of white of egg and rectified spirit, or equal parts of collodion and castor-oil. 312 TYPHUS FEVER. When the sores have formed, they should be washed and dressed antiseptically. An excellent stimulating application is composed of two parts of castor-oil and one of balsam of Peru spread on lint, or carbolised-oil (1 in 40, that is, 2-| per cent.). These dressings should be protected by a layer of oiled silk, or else covered with some poultice less septic than linseed meal, such as the yeast, carrot, chlorine, or charcoal poultice. 5. When phlegmasia or thrombosis of the femoral veins occurs, the foot and leg of the affected side must be raised, and a long wide flannel bandage should be applied from the feet upwards. If thrombosis is present, denoted by a hard painful cord in the situa- tion of the femoral vein, strips of lint smeared with equal parts of glycerine and extract of belladonna may be laid along the affected part, and covered with the flannel swathe as before. 6. (Edema of the lower extremities generally yields to a generous diet, and tonics like iron and quinine and strychnin. The dieting of a typhus fever patient should be conducted on precisely the same principles as those which guide us in managing an enteric fever patient. The reader is, therefore, referred to the Chapter on the " Curative Treatment of Enteric Fever," where the subject is considered in detail. During convalescence, the patient recovering from typhus should be warned against assuming the upright position too soon, or exposing himself to cold. The returning appetite should be held in check for the first two or three days. On the third day, with a clean tongue and a quiet pulse, a piece of boiled white fish, or chicken, or the hollow part of a tender mutton chop, may be allowed. Costive bowels should be relieved by sipping water in mouthfuls frequently, or by the administration of enemata of cold water. Tonics may be given with advantage ; but of these the most potent are exercise in the open air, and change of residence to the country, the seaside, or the mountain slope. 313 . CHAPTER XXXII. Relapsing, Famine, or Spirillum Fever. Nomenclature— Definition — ^Etiology (historical sketch) — Mode of Preva- lence —Predisposing Causes — Geographical Distribution — Exciting Cause- Bacteriology — Spirillum, Obermeieri — Inoculation Experiments — One Attack of Relapsing Fever confers no immunity against a second. In describing this form of Continued Fever, I am at the serious disadvantage of never having seen a case of the disease in my hospital or private practice. This fact, after well-nigh twenty years' experience in two hospitals — one of them, Cork-street Fever Hospital, the great epidemic hospital of the south side of Dublin — leads me to dispute in the strongest manner the accuracy of Hirsch's unqualified and dogmatic statement that " there can be no doubt that the disease is endemic in Ireland." a Although this disease is personally unknown to me, the descriptions of relapsing fever by Murchison, H. Lebert, C. A. Ewald, and others, are so admirable that it becomes possible to picture to oneself what this form of continued fever must be in its clinical aspect. Nomenclature — Relapsing Fever, Famine Fever, Spirillum Fever (Vandyke Carter, 1882), Typhinia (Farr, 1859), Bilious Typhoid Fever, Yellow Fever of the British Islands (Graves and Stokes, 1826), "A Five Days' Fever with Relapses" (Rutty, 1770), Synocha (Cullen, 1769), Miliary Fever (Ormerod and Watson, 1848). Germ. — Recurrens (Ewald), Ruckfallsfieber, recurrirendes Fieber Die Hungerpest, Armentyphus, Febris, vel Typhus Recurrens (Hirsch, 1859), Riickfallstyphus (Lebert, 1870), Das wiederkeh- rende Fieber (Obermeier, 1869). French — Fievre a rechute, Typhus a rechute, Fievre recurrente, Fievre a recidive. * Handbook of Geograph. and Historical Patholoyy. New Syd. Soc. Vol. I., page 614. 31 i RELAPSING FEVER. ltal. — Febbre a recidive, Febbre ricorrente. Span. — Fiebre recidiva. Swedish. — Recurreuta Feber (Cf. Forhandlingar vid Svenska Lakare-Sallskapets, 1865, p. 110, and 1868, p. 73). Norwegian or Danish. — Recidiv-Feber, Galbefeber. Dutch. — Galkoorts (i.e., Biliary Fever). Definition. — A specific contagious febrile disease, characterised by the presence in the blood during the febrile paroxysm of a spiral bacterium, called after its discoverer the Spirillum Obermeieri ; by a critical defervescence after 5 or 7 days, which is followed by a remission lasting 7 or 8 days, and by a relapse on or about the fourteenth day, lasting some 3 days. This fever prevails chiefly in the form of an epidemic during seasons of scarcity and famine. It is unaccompanied by an eruption, but jaundice is present in some 20 per cent, of the cases. The death-rate is not high, being from 5 to 7 per cent. After death, the liver and spleen are com- monly found enlarged. A second, or even a third relapse may occur. iEtiology. — The first minute account of an epidemic of Relapsing Fever dates from the years 1739 and 1741, and we owe it to Dr. Rutty . a He described it as " a fever of six or seven days' dura- tion, terminating in a critical sweat. . . . ; here the patients were subject to a relapse even to a third or fourth time, and yet recovered." It followed hard upon the scarcity caused by seasons of unexampled severity in the years 1739-40. " It was far from being mortal," adds Rutty, who goes on to say — ' ; I was assured of seventy of the poorer sort at the same time in this fever, aban- doned to the use of whey and God's good providence, who all recovered, while those who had generous cordials and great plenty of sack perished." In an historical sketch of the fevers which were " epidemical " in Ireland during the last and at the commencement of the present century, Drs. Barker and Cheyne, writing in 1821, observed: " Certain it is, that the fever in 1800 and 1801 very generally a A Chronological History of the Weather and Seasons, and of the Prevailing Diseases in Dublin, with their various Periods, Successions and Revolutions, during the space of forty years. Dublin. 8vo. 1770. RELAPSING FEVER. ?>lf> terminated on the 5th or 7th day by perspiration ; that the disease was then very liable to recur ; that the poor were the chief sufferers by it ; and that it was much more fatal amongst the middling and upper classes in proportion to the number attacked." Barker and Cheyne a were the historians of the great epidemic of 1817-1818; Graves and Stokes of that of 1826-1828. Other outbreaks occurred in Great Britain and Ireland in 1842-1843 and 1847-1848 ; as well as in Silesia in the last-named years (Diimmler and von Barensprung). A very full and excellent account of the epidemic of 1847 in Ireland will be found in the 7th and 8th Vols, of the New Series of the Dublin Quarterly Journal of Medical Science (1849). There was a great epidemic at St. Petersburg and Odessa in 1863, and a second epidemic occurred in Silesia in 1867 and 1868. In the latter year relapsing fever reached Berlin for the first time, frequently recurring up to 1873. In 1868 relapsing fever re-appeared in Great Britain also, an epidemic beginning in London in July of that year, and lasting until June, 1871. In Liverpool relapsing fever caused 355 deaths in 1870, 207 deaths in 1871, and 25 deaths in 1872. Seventy-seven deaths from relapsing fever were registered in England in the ten years 1880-89. Of these, 33 occurred in males and 44 in females. A few deaths occurred every year in Scotland up to 1879. So far as Ireland is concerned, the Registrar-General, Dr. T. W. Grimshaw, has kindly furnished me with the following Return of the Number of Deaths from Relapsing Fever, registered in Ireland during the ten years, 1881-90 : — 1881 ... 1 1886 ... 3 1882 ... 1 1887 ... 1883 ... 1 1888 ... 5 1884 ... 2 1889 ... 2 1885 ... 4 1890 ... 3 In reference to this table, it is to be remembered that the Regis- a An Account of the Rise, Progress, and Decline of the Fever lately Epidemical in Ireland. Dublin : Hodges & M'Arthur. 1821. 316 KELAPSING FEVER. trar-General is not responsible for the diagnosis, and the eminently contagious nature of relapsing fever suggests grave doubts as to its accuracy in the cases embodied in the return. As regards its mode of prevalence, Murchison draws the fol- lowing conclusions from the history of the disease: — 1. Relapsing fever is an epidemic disease in a stricter sense than even typhus. It may disappear entirely for years from those places where at other times it rages most fiercely. 2. Epidemics of relapsing fever have usually co-existed with epidemics of typhus, and have always appeared under circum- stances of distress or famine. 3. In mixed epidemics the relative proportion of typhus and relapsing cases has varied at different times and places ; but, as a rule, the proportion of relapsing cases has been much greater at the commencement than towards the close of the epidemic, and with the advance of the epidemic typhus has taken the place of relapsing fever. Predisposing Causes. — Hirsch a shows clearly that the preva- lence of relapsing fever is not dependent upon climate, is little influenced by weather or season, and seems to bear no relation to the soil, as regards altitude, configuration, geological formation, and the like. The disease, further, shows no preference for race or nationality. As regards sex, of 2,115 cases admitted into the London Fever Hospital in twenty-three years (1848-70), 1,279 were males, and only 836 were females. Murchison thinks that this curious result is due to the fact that far more males than females belong to the class of tramps and vagrants, who constitute a large proportion of the cases of relapsing fever. This disease attacks all ages — in the London Fever Hospital the youngest patients were two boys aged 5 months, the oldest was a man aged 75. The percentages of all the cases were — under 15 years, 18*9 ; from 15 to 25 years, 35*9 ; 25 years and upwards, 45-2. The mean age of typhus patients was (as already men- a Handbook of Geographical and Historical Pathology. New Syd. Soc. Vol. I., pages 606, et seq. RELAPSING FEVER. 317 tinned) 29*33 years, or about 3 years above the mean age of the whole population ; but the mean age of relapsing fever patients was only 24-41 years, or two years under that of the population at large. While its area of distribution, as we will show presently, is much more limited than that of typhus, it is an undoubted fact that relapsing fever and typhus often coincide remarkably in time and place, relapsing fever appearing to be associated in a very conspicuous manner with epidemics of typhus. But, as Hirsch points out, the most striking analogy to typhus which relapsing fever manifests, comes out in the relation of the origin of the disease to all those conditions of social misery which play so decided a part in the history of typhus outbreaks. As Engel a says of it in his account of " the Bukowina Fever," relapsing fever is peculiarly a " morbus pauperum." As regards the Geographical Distribution of relapsing fever, in Europe, the British Islands (and particularly Ireland), Russia, and Germany (with the exception of the south), Austria, the Levantine States, and the islands of the Eastern Mediterranean, have been mo.«t frequently and most severely visited. On the other hand, Scandi- navia, Switzerland, France, Italy, and the Iberian Peninsula, seem to have been hitherto exempt, or nearly so, from visitations of the disease. From Norway, however, Danchersen reports {Norsk Magazin for Lcegevidenskaben, 1865, xix., p. 76) the preva- lence of epidemics from 1858 to 1861, and again in 1865, in the medical or dispensary district of Vadso, inhabited by a poor fishing population. In Ireland, during the epidemic of 1826-28, relapsing fever often assumed the character of bilious typhoid, so much so that Graves and O'Brien b were constrained to explain cases of that kind as yellow fever. Outside Europe, one of the most extensive centres of relapsing fever and of bilious typhoid is India. a Oest. med. Jahrb. 1847. Vol. III., p. 249. b Transactions of the Med. Assoc, of the King and Queen's College of Physicians in Ireland. 1828. 318 RELAPSING FEVER. An extensive epidemic, described by Dr. Vandyke Carter, 8, who gave the disease the name of " Spirillum Fever," occurred in 1877— 78-79 in Western India, coincident with a period of famine due to prolonged drought and complete failure of the rice-crop. The disease also occurs along the North African Coast, including Egypt and Algeria, as well as in Abyssinia. In 1864-65 it pre- vailed in certain parts of China. Since 1844, it has occasionally appeared in some of the Eastern States of the North American Union. Central and South America, Australia, and Polynesia, have apparently escaped the disease up to the present. Exciting Cause. — That there is a specific poison in relapsing fever, communicable from the sick to the healthy, is proved beyond all doubt by evidence similar to that which has been adduced in the case of typhus. At one time (in 1847) Virchow held that the disease was not contagious, but he must have abandoned this heresy, for Hirsch b says: "There exists no doubt whatever in the expe- rience of all observers, and according to the experimental inocu- lations, that relapsing fever (or bilious typhoid) is contagious." Bacteriology. — Since Obermeier's discovery in 1873, c no doubt remains that for relapsing fever, at all events, there exists a specific germ, or (as Lebert calls it) a protomyces. d Obermeier's spirilla differ onlv in size from similar filaments originally discovered in stagnant water by Ehrenberg in 1838, and named by him Spiro- chete plicatilis {airelpa, a coil; yavr% a hair). Another spiro- chete was found in the mucus of the gums by Steinberg in 1862. This he named Spirillum buccale. It has since been described by F. Cohn under the name Spirochete denticola. The three forms are closely allied and may be regarded as different species of one genus or different varieties of one species (Murchison). The following excellent account of what is now known as the Spirillum a Spirillum Fever of Bombay. 1877. b hoc. cit. Page 614. c Vcrkommen feinster, eine Eigenbewegung zeigender Fdden im Blute von Re- cur renzhranken. Ueber Pilzparasiten im Blute bei Recurrens, x., 1873. Loc. cit. Centralblatt fur die med. Wissenschaften, xi., 145. 1873. d Gk. vpunos, first ; (ivk7)s, a fungus. RELAPSING FEVER. 319 of Eelapsing Fever, or the Spirochete Obermeieri(Cohn)is given by von Jaksch : a — The spirillum was first noticed by Obermeier in the blood of a patient suffering from relapsing fever. It has since been seen by many observers, but most authorities are agreed that it is to be found only during the paroxysms of the disease, and that as the temperature falls the bacilli disappear^ When a specimen of blood containing them is placed under the microscope, the bacilli appear as long and very delicate unsegmented threads twisted into spirals. Their average length is about six or seven times the diameter of a red blood-corpuscle. They have a brisk vibratile movement in the direction of their long axis. This motion, when the blood is examined with a low power, gives to the eye a peculiar impression of disturbance, and will immediately lead the practised observer to look for the presence of spirilla. If he then increases the power, and still better, if he employs an oil immersion lens with Abbe's condenser and a small diaphragm, the spirilla come clearly into view. These bodies are extremely sensitive to reagents of all kinds. Even the addition of distilled water will cause them to disappear. The number of spirilla which are to be seen together in a speci- men of blood varies greatly, and often bears no relation to the in- tensity of the fever. If the blood is examined in the intervals of the disease, provided another paroxysm be impending, it displays peculiar refractive bodies resembling diplococci, which are especially numerous when the paroxysm sets in ; and just as it begins, they even seemed to von Jaksch, in certain cases to grow out, as it were, into short thick rods, from which the spirilla were finally evolved. Before those of von Jaksch similar observations had been made by Sarnow c ; and, pending further confirmation, it seems probable that these bodies are the spores of spirilla which have so long been sought for. a Clinical Diagnosis. By Dr. Rudolf v. Jaksch. Translated from the second German edition by James Cagney, M.D. London : Charles Griffin & Co. 1890. Pages 30 and 31. b In opposition to this view, see Naunyn. Centralblatt filr Bacterioloc/ie und Parasitenkunde. IV. 376. 1888. c Der Ruckfallstyfjhus in Halle a. S. im Jahre, 1879-81. Inaugural Dissertat Leipzig. 1882. 320 RELAPSING? FEVER. Since both the spirilla and the forms just mentioned have been met with as yet only in the blood of persons suffering from re- lapsing fever, their great importance as a clinical test is apparent. Monkeys have been inoculated with success from man, a but inocu- lations of mice, rabbits, sheep, and pigs gave negative results. The spirilla were found in the blood of the inoculated monkeys in great numbers, and also in the brain, lungs, liver, kidneys, spleen, and skin. They are believed to be the cause of the disease (Crookshank). Moschutkovsky, b of Odessa, was the first to attempt to produce infection by inoculating the blood of relapsing fever patients on healthy men, and he proved not only the communicability of the disease, but also the specific pathogenetic significance of the para- site. A further result of his researches was to prove the identity of relapsing fever and the so-called " bilious typhoid," a view already maintained by Griesinger and the Russian physicians on anatomical and pathological grounds. The period of incubation in the inoculated cases was never more than 8 or less than 5 days. In monkeys, Vandyke Carter found it to vary from 30 hours to 5 days. When the disease is taken in the natural way, its latent period is on the whole shorter than that of typhus. According to Lebert, it varied at Breslau from 3 to 7 days — it was, however, oftener over than under 5 days. Murchison analysed 32 cases, and found that in not one instance did the stage of incubation exceed 12 days, while in 13 it did not exceed 5 days. In 3 cases the attack was immediate on exposure to the infection. One attack of relapsing fever confers little or no immunity from a subsequent visitation. This was proved in all the great epidemics of the present century both at home and abroad, but a classical observation is that of Sir Robert Christison, Bart., who in the out- break of 1817-19 experienced no fewer than three separate attacks within fifteen month sin his own person. a H. Vandyke Carter. Lancet, 1879. Vol. I., page 84 ; and 1880, Vol. I., page 662. See also Koch. Deutsche med. Wochenschrift. 1879. Nos. 16, 27, 30. b Centralblatt fiir die med. Wissenschr. 1876. No. 11. Petersb.med. Wochen- schrift. 1878. No. 27. Archiv. fur Hin. Med. 1879. XXIV., page 80. c Edin. Med. Journal. January, 1858. Page 583. 321 CHAPTER XXXIIL Clinical Description of Relapsing Fever. Sudden onset. — High Temperature. — Abrupt crisis. Intermission. — Re- lapse. — Low mortality. — " Bilious Typhoid " (Griesinger). — " Yellow Fever of the British Islands" (Graves). — Heart murmurs. — Stages and duration. Temperature. — Complications and Sequelae. Relapsing Fever usually begins with great suddenness. In some cases, indeed, the actual outburst of the disease may be preceded by such prodromata as malaise, weariness, pain and heaviness in the head, flying pains in the extremities, and thirst. Whether such prodromata have occurred or not, the patients are suddenly seized with chills or rigors, frontal headache, and pains in the back, neck, and limbs. They complain of giddiness and noises in the ears (tinnitus). The vertigo rather than their weakness compels them to take to bed at once. This cold stage is quickly followed by a reaction, characterised by flushing of the face, epistaxis in many cases, a dry, hot skin, increase of pains, throbbing headache, and burning thirst. The appetite is, in most cases, completely lost ; but there may be voracious appetite (boulimia). This was noticed in the epidemic of 1843 in the prac- tice of the London Fever Hospital, and also in that of 1847, in Ireland, especially by Mr. Kelly, a of Mullingar, Co. Westmeath, The pulse becomes very quick, reaching 120 as a rule, or far exceeding even this rate. It is generally full and firm, and its rapidity is not of evil omen. On this point, Niemeyer says that the pulse is more frequent in relapsing fever than in almost any other disease. The tongue is large and moist, rarely becoming dry, cracked and brown. The bowels are constipated ; tenderness at the epigastrium is complained of. Nausea and vomiting are not uncommou a DM. Journ. of Med. Science, New Series. Vol. VIII., page 64. 1848. Y 322 RELAPSING FEVER. symptoms. A slight catarrhal jaundice may be present, but this is to be distinguished from the much more serious hgematogenous jaundice which not infrequently renders the disease malignant (bilious typhoid). The vomited matter may consist of green bile, or else of blood like coffee-grounds (black vomit). Sleeplessness is a common and distressing symptom ; but delirium is much less usual than in typhus. The urine is scanty and high-coloured, and, according to Obermeier, shows that parenchymatous nephritis exists. When jaundice is present, the urine contains bile-pigment and bile-acids. Physical examination reveals considerable enlargement of both liver and spleen even at an early stage. There is no eruption of a specific kind, but a roseolar rash has not infrequently been observed, as well as true petechias in certain cases and crops of sudamina in or after the sweating stage. The fever runs very high in relapsing fever — temperatures between 105° and 108*7° being quite common shortly before the crisis. The thermometer at the beginning rises so abruptly that within twelve or twenty-four hours of the earliest symptoms it may reach 104° to 106° F. Towards the close of the first week — sometimes as early as the third, or as late as the tenth day — more usually on the fifth, sixth, or seventh day — all the symptoms subside like magic. In a few hours — eight or nine — the pulse sinks to 70, 60, 50, or even lower, and the temperature runs down from its acme of 106° to 108° to several degrees, it may be, below normal. This sudden crisis is ushered in by profuse sweating — the patients being literally bathed in perspiration for some hours ; more rarely by diarrhoea, epistaxis, menstruation, or intestinal haemorrhage. The perspiration which accompanies crisis has an acid reaction and " a characteristic dis- agreeable smell " (Cormack, 1 843). Occasionally a brief spell of frenzied delirium immediately precedes the critical defervescence. During the next few days, while the pulse remains slow, the temperature gradually rises towards normal, the tongue cleans, appetite returns, and the patients feel and declare themselves well. In most cases, however, on or about the seventh day from the RELAPSING FEVER. 323 crisis, without warning or assignable cause, the relapse sets in. This is, in fact, a repetition of the initial symptoms of the first attack. Sometimes this secondary paroxysm is even more severe than the first, so far, at all events, as high temperature is con- cerned ; but the febrile movement is generally of shorter duration, lasting only three or four days, and terminating by another crisis, with its attendant phenomena. Now and again, there is a second relapse, coming on about the 21st day, and lasting two or three days. Rarely, even a third or a fourth relapse may occur ; but, on the other hand, there may be no relapse at all in exceptional cases, the passing off of the first paroxysm terminating in convalescence without further suffering. By far the most common ending of relapsing fever is in recovery. The death rate in most epidemics is only 2 or 3 per cent., and it rarely exeeeds 6 or 8 per cent. When death does occur, it is the outcome of — (1) collapse and general paralysis during the paroxysm ; (2) exhaustion during the interval ; (3) some com- plication or secondary affection — such, for example, as acute pneu- monia or nephritis with urasmia. Pregnant females invariably abort, and often die, in relapsing fever. i Bilious Typhoid (Griesinger). — " Under certain influences, still unknown," writes Niemeyer, a " possibly, merely as a result of the action of a particularly intense contagion, relapsing fever assumes a very malignant character. The appearance of the disease is especially modified by excessive participation of the biliary appa- ratus, and in most cases death appears with severe symptoms. Griesinger describes this malignant form of relapsing fever from his observations made in the East, and terms it ' Bilious Typhoid.' The St. Petersburg epidemic of 1864 to 1866, where, besides simple recurrent fever, there were numerous cases of bilious typhoid, especially at its commencement, fully confirmed Griesinger's description of the disease, as well as his opinion that it was a severe form of recurrent fever." We have already seen above a Text-Booh of Practical Medicine. Revised Edition. London : H. K. Lewis. 1880. Vol. II., page 662. 324 RELAPSING FEVER. that this view is altogether borne out by the inoculation experi- ments of Moschutkovsky and others. According to Zorn, a the fever does not run so high in this bilious form as it does in the simple variety. It is not uncommon for peripheral parts to feel even cold, a very dangerous symptom. The same writer also states that the second attack or relapse occurs in only about one half of the bilious cases. Under the heading, " Yellow Fever of the British Islands," Graves b detailed a number of cases of the severe form of Relapsing Fever, just now described. Nearly twenty patients died at the Meath Hospital of the disease, prominent symptoms of which were hardness and tenderness of the abdomen about the epigastrium and hypochondria, a knotted feel of the abdominal muscles, general jaundice of a bright yellow colour, uneasiness and anxiety of coun- tenance, a very quick and hurried pulse, coldness of the extremities, and deep purple coloration of the tip of the nose, the cheeks, and sometimes of the toes (local asphyxia). Another notable symptom was abdominal spasm, to which the hospital nurses gave the expressive and (as it proved) appropriate name of "twisting of the guts," for recent intussusceptions or invaginations of the intestines were among the most constant pathological conditions noticed after death. The purple coloration of the nose superadded to the jaundice imparts a weird and frightfully repulsive appearance to the patient sinking under this malignant form of relapsing fever. In the epidemic of relapsing fever of 1847, Dr. Stokes made a number of observations in the Meath Hospital on the condition of the heart in the disease. He found little evidence of softening of the heart, but " a bellows murmur, or, in some cases, a prolonga- tion of the systolic sound, was common, especially in the relapse ; but this did not result from carditis." Dr. Stokes's observations were borne out by his colleague, Dr. Cathcart Lees. The murmur was systolic in time, basic, and travelled not infrequently into the a Petersburg Zeitschrift. IX. 16. b Clinical Lectures on the Practice of Medicine. New Syd. Soc. EditioD. Vol. I., page 323. 1884. RELAPSING FEVER. ' J >25 great vessels. It generally diminished in intensity when the patient sat up, and Dr. Stokes regarded it as of anaemic origin. Stokes's researches on the subject have been amply confirmed by R. D. Lyons, of Dublin (in 1861) ; G. P. Tennent, of Glasgow (in 1871) ; W. Zuelzer, of Breslau (in 1867) ; and Obermeier, of Berlin (in 1869). When cerebral symptoms occur in relapsing fever, they are generally, as in typhus, independent of inflammation of the brain or its membranes, and depend either on cholaemia, or uraemia, or some other form of blood-poisoning. Stages and Duration. — Four well-defined stages may be recog- nised in the course of relapsing fever: they are those of — (1) the primary paroxysm, (2) the intermission, (3) the relapse, and (4) convalescence. In 100 consecutive cases under Murchison's care, and accurately noted by him in his case-books, the average duration of the primary paroxysm was 5*96 days; that of the intermission was 7'82 days ; that of the relapse was 3*45 days — total duration, 17*23 days. Under ordinary circumstances, when there are but two paroxysms, the duration of relapsing fever to the commencement of permanent convalescence is, according to Murchison, about 18 days. Temperature. — The thermometer begins to rise before the initial rigor and while the pulse is still normal. It reaches, or may reach, 104°-106° F. within from twelve to twenty-four hours. An acme, or fastigium, is attained shortly before the crisis (105°-108'7°). During the paroxysm there are usually daily remissions of one or two degrees Fahrenheit — mostly in the morning, and best marked in children. Crisis is sometimes ushered in with a rigor, when the temperature falls to or below normal — a fall of 8°, 9°, 10°, or even 13°, occurring in a few hours. In one case the thermometer fell 14-4° in twelve hours! For two or three days after the crisis the temperature is commonly sub-normal (96°, 94°, or even as low as 92°). So constantly is this the case, that this low tem- perature is a useful diagnostic sign. In the relapse the maximal temperature of the whole attack is generally recorded, but the hyperpyrexia is of shorter duration than in the primary paroxysm. 326 RELAPSING FEVER. The high temperatures in relapsing fever entail little or no danger to the patient, nor do they produce serious cerebral symptoms. In Plate VI., are two charts of the temperature ranges in relapsing fever — one copied from Wunderlich's " Medical Ther- mometry," the other from Murchison's " Treatise on the Continued Fevers of Great Britain." Complications and Sequelae. — 1. Pneumonia is said to be more common in relapsing fever than in typhus, but Murchison observed this complication in only 4 or 5 out of 600 cases. 2. Sudden collapse may prove rapidly fatal, and has been known to occur at any stage of the disease. The pulse becomes small, irregular, or imperceptible, the heart's impulse fails, and its sounds are blurred or obliterated, the whole surface is cold and livid, and the patient often becomes quite insensible. This fatal syncope is, in some cases, due to haemorrhage ; in others, to pre-existing organic disease. 3. Haemorrhages from various parts are not uncommon, and may occur at any stage. The most usual kind of haemorrhage is epistaxis ; but bleeding may also take place from the womb, stomach, bowels, kidneys, and ears. 4. The spleen is commonly much enlarged. It may rupture or become the seat of thrombotic abscesses. 5. " One of the most remarkable features of relapsing fever," says Murchison, " is the frequent occurrence during convalescence of a peculiar disease of the eyes. This sequela has been observed in almost all epidemics, but is never met with after typhus or enteric fever." Among other writers on the subject we find Dr. Arthur Jacob, of Dublin, who contributed to the fifth volume (that for 1828) of the " Transactions of the Association of Fellows and Licentiates of the King and Queen's College of Physicians " a paper entitled " On internal Inflammation of the Eye following Typhus Fever." The disease, as described by Dr. Mackenzie, of Glasgow (1843) presents two distinct stages — the amaurotic and the in- flammatory. J. A. Estlander, in a paper published in 1869 — flate VR CHARTS OF TEMPERATURE RANGES IN RELAPSING FEYER fiff.I Relapsing fever Fak 107 6 105 8 mo I0Z 2 100-4 98 6 96 S C 2 3 4 S 6 7 8 & /0 H 12 J3 H IS IS 7 18 9 W *V «"—::- :::z:=:::=:::::=S:::::::::-:: z =5iE~==EEEEEEE==EEE=E=~lE;E========E=l ^^feEzEE^ :: -ttlz z z :B:± z±: * Aquae, ad §vi. • M. ft. mist. Signa : " One sixth part every fourth hour." To fulfil the same indications as the foregoing, Dr. Cheyne's " mild anti-febrile and gently stimulant diaphoretic " (as Graves a calls it) may be prescribed : — $. Ammonii Carbonatis, gr. 60 ; Succi Limonis, §ii. ; Syrupi Aurantii, |ss. ; Aquas, giiiss. M. ft. mist. Signa : " One-sixth part every third or fourth hour." a Clinical Lectures. New Syd. Soc. 1884. Vol. I., page 318. 332 RELAPSING FEVER. Graves improved Cheyne's prescription by substituting carbonate of sodium for carbonate of ammonium — thus, in a modern form : — fy. Sodii Carbonatis, gr. 60 ; Succi Limonis, §i., 5vi. ; Misce et adde — Tinct. Aurantii Recentis, 3ii. > Syrupi Aurantii, §ss. ; Aquae, ad §vi. M. ft. mist. Signa : " One sixth part every third or fourth hour." Graves says nothing can be more agreeable in flavour than this mixture. The citrate of sodium which is formed "determines gently to the kidneys, tends to keep up a soluble state of the bowels, and forms a most grateful and refreshing beverage." If a weaker solution is preferred, a drachm of the carbonate of sodium may be dissolved in five, instead of four, ounces of water. As a placebo, Lebert gives small doses of phosphoric acid. This formula would, probably, meet his approbation : — ]$. Acidi phosphorici diluti, 3iss. ; Elixir. Glusidi (Saccharini), 3ss. ; Aquae, ad §iv. M. ft. mist. Signa : " A tablespoonf ul every second or third hour." Bleeding (venesection) is inadmissible in relapsing fever for reducing temperature or any other purpose. Niemeyer sets his face even against cold* baths, on the ground that relapsing fever, in spite of the high temperature, has a low mortality. He thinks it well to limit ourselves to sponging the body with cold lotions, and — if the cerebral symptoms are severe — to the application of ice to the head. Lebert is quite in accord with Niemeyer on this point and recommends the very same measures. Should they fail to relieve headache and procure sleep, Murchison says recourse must be had to opium or hydrate of chloral. When collapse threatens, Lebert orders an ammoniated tincture of musk as follows : — RELAPSING FEVER. 333 I£. Moschi, gr. 60 ; Ammonii Carbonat., gr. 30 ; Olei Mentha?, min. v. ; Alcoholis, §ii. ; Aquae Destillatae, §v. Of this mixture, thirty drops are to be taken in a tablespoonful of sugar and water, or wine, every hour. Obstinate diarrhoea is to be combated by alum, tannin, nitrate of silver, and opium (Lebert) ; or by small doses of laudanum in decoction of logwood, or an astringent mixture containing kino or catechu with opium (Murchison). For dysentery the best remedies are ipecacuanha and opium. They may be prescribed in the form of " Twining's Pill " a (ipeca- cuanha, blue pill, and extract of gentian), or as follows (Mur- chison) : — !E|. Pulv. Ipecac, gr. 2 ; Pulv. Ipecac. Comp., gr. 5 ; Hydrargyri cum Creta, gr. 3. Misce, Fiat Fulvis. Signa : " One four times a day." An enema of starch and opium should be used from time to time, if there is tenesmus ; and occasional doses of castor-oil are useful if the stools are scanty and the abdomen is distended. Should dysentery not yield to these means, the pharmacopoeial solution of the pernitrate of iron with small doses of opium will be found an excellent remedy. Severe epistaxis should be controlled by plugging the nostrils and posterior nares. For the post-febrile ophthalmia, in its earlier stages, a liberal diet, tonics (such as quinine and iron), and blisters behind the ears, will do good. When iritis declares itself, Mackenzie b recom- mends leeching the temples, continued dilatation of the pupils with solution of belladonna or atropin, blisters behind the ears, a nutri- a Cf. Twining. Diseases of Bengal. 1832. b Loc. cit. 1843. 334 RELAPSING FEVER. tious diet, and one of the following powders every four or six hours until the gums are touched : — #. Hydrargyri Subchloridi, gr. 12 ; Quininae Sulphatis, gr. 12-24; Pulv. Opii, gr. 3 ; Sacchari Albi, q.s. ut fiant pulv. xij. In "bilious typhoid," Griesinger recommends large doses of quinine (10 to 30 grains daily) — a mild purgative of salts, castor- oil, or cream of tartar (acid tartrate of potassium) having been first given at the beginning of the attack. During the convalescence of patients who have become exceed- ingly exhausted, Lebert considers that a good invigorating fare is best supplemented by tincture of cinchona, or mild preparations of iron, particularly of the lactate. This last may be given to the amount of three to eight grains daily, in pill form, with extract of gentian. 3&5 CHAPTER XXXV. Enteric, or Typhoid, Fever. General Considerations. — Essential difference between typhus and enteric fevers not recognised in the past — reasons for this. — Evils of not differentiating between typhus and enteric fevers. — Fundamental distinctions. — Liebenneister's views. The day has now long passed by since the doctrine of the identity of typhus and enteric fever attracted any number of adherents among the great thinkers of the Medical Profession. But there was a time when this doctrine did obtain credence, and even the commanding genius of William Stokes clung to this faith with what in one less distinguished would, perhaps, be regarded as obstinate infatuation. Writing so recently as 1874, a he used such expressions as these : " The inexpediency of drawing hard and fast lines of distinction between what are termed typhus fever and typhoid fever." b " Fever has been somewhat arbitrarily divided into two classes, or placed under two great headings — typhus and typhoid." c " Do not these facts point to the conclusion that there is but a slight tension, so to speak, in the individuality or separate cha- racters of the various forms of fever, and that in their essence and from a practical point of view, they may be looked on as species rather than genera — the genus being fever, that condition on which anatomical investigations, in the words of Graves, throw but a negative light ? " d I think there are three chief reasons why in the past the essen- tial differences between typhus and enteric fever were not recog- nised. a Lectures on Fever. London : Longmans, Green & Co. 1874. b Loc. cit. Page 44. c Loc. cit. Page 78. d Loc. cit. Page 89. 336 ENTERIC FEVER. First, in presence of the defective hygiene of former days the " typhoid state," of which mention has so often been made in these pages, was much more commonly observed than it is now. It complicated enteric fever no less than typhus. Secondly, there can be no reasonable doubt that enteric fever was of much less frequent occurrence before the days of water closets and of water carriage of " night soil." Murchison especially alludes to the fact that enteric fever has much increased in Edin- burgh of late years, 3 and his explanation is that this increase of the fever, "followed the introduction of new sanitary arrange- ments — the substitution for the scavenger and niglitmen of drains opening into the interior of the houses, but with a water supply insufficient to prevent the escape of sewer emanations." b Thirdly, from the non-recognition of the separate identity of typhus and typhoid, it followed almost as a matter of course that cases of both these fevers were treated in the same wards — nay, in adjoining beds, perhaps, sometimes in the same bed. The natural consequence was that the typhoid patients contracted typhus, which soon declared itself with its stupor and macuhe — thus rendering confusion worse confounded." The evils which accrue from non-recognition of the essential difference of typhus and typhoid as regards their origin are clearly shown by Mr. J. Spear, in his report to the Local Govern- ment Board on appearances of typhus fever in various parts of England during the year 1886-87. c In Leeds, Hartlepool, Carlisle, Middlesborough, Oldham, Newcastle-on-Tyne, and Flint, typhus gained a footing through the neglect of unrecognised cases ; and in Liverpool this is the common experience with respect to constantly recurring localised outbreaks. In a previous year (1885), Mr. Spear met with an outbreak in Workington. The disease spread by a demonstrable chain of cases to several adjoining villages and a Treatise on the Continued Fevers. Third Edition. 1884. Pp. 443 and 444. b Cf. W. T. Gairdner, M.D. Public Health in relation to Air and Water, Edinburgh. 1862. c Sixteenth Annual Report of the Local Government Board. 1886-87. Page 269. ENTERIC FEVER. 337 towns, localised epidemics of considerable importance resulting. In each one of these several invasions the disease had been regarded as typhoid or enteric fever, with the result that inefficient measures for preventing its spread had been applied. In 1883, Mr. Spear in- vestigated a notable outbreak of typhus in a large charitable insti- tution at Hammersmith. The disease had been spreading for three months amongst the children, infecting at least nineteen of them, as well as several of the Sisters of Mercy and two priests from outside, before its true nature was recognised. The priests were supposed to be suffering from " typhoid." From his experiences Mr. Spear was led to conclude that con- siderable outbreaks of typhus might occur without medical recogni- tion, the disease being mistaken for typhoid fever or (in children) for measles, influenza, &c, and that the result of such diagnostic failure was not merely official mis-information, but often the unchecked spread of the disease. He observes — " It is a matter the extreme importance of which to the general community has not yet been sufficiently appreciated, or practical instruction in the diagnosis of fever would occupy a more prominent place in medical education." a Liebermeister ° puts the matter very well when he says, " In fact, the only likeness between typhus and typhoid fever, except that they are both infectious diseases, is that in both diseases many of the cases are attended with severe and long-continued fever. In every other respect they are different. Typhus fever has many more analogies with smallpox, measles, and scarlet fever, than with typhoid fever. Typhoid fever, in its aetiology and mode of propa- gation, resembles dysentery and cholera much more than it does typhus. " The real fundamental difference between the two diseases is this : Typhus fever is a purely contagious disease ; typhoid fever belongs to the miasmatic-contagious diseases. Typhus can be transmitted directly from person to person; its contagion is as a Loc. cit. Page 287. b Von Ziemssen's Cyclopaedia of the Practice of Medicine. Vol. I., page 41. Art. "Typhoid Fever." 338 ENTERIC EEVER. intense and evident as is that of the acute exanthemata. Typhoid fever, on the contrary, is never [directly] transmitted from person to person. There can be no doubt that this profound difference in the mode of propagation depends upon an essential difference in the poison producing the two diseases. Every classification, there- fore, which is grounded on scientific principles, must separate these two diseases widely from each other." As we shall see in the sequel, Liebermeister is too dogmatic in absolutely denying the transference of typhoid or enteric fever from person to person, but there can be no doubt that the disease belongs, as he supposed, to the miasmatic-contagious rather than to the contagious group. That is, an affected body furnishes, indeed, the morbific germs of typhoid fever, but these germs must undergo a further development after they leave that body, most probably in immediate relation to sewer gas or the products of decomposition (putrefaction), before they attain their complete infecting power and become capable of reproducing the disease in another body to which they have gained access by one or other of the recognised channels of infection. 339 CHAPTER XXXVI. Enteric Fever (confined). Nomenclature. — Synonyms. — Definition. — Literature and History. — Geographical Distribution. — ^Etiology : Predisposing causes : sex, age, defec- tive sewerage and drainage, season, temperature and moisture, soil and under- ground water. — Immunity. — Exciting cause. — Bacteriology : Bacillus typho- sus (Eberth). — Supposed spontaneous origin of enteric fever. — This doctrine is now untenable. — Resting spores. — Paths op Infection : currents of air, drinking water, milk, meat. —Mode of invasion. Nomenclature. — Probably there is no other disease which has so many, and at the same time such unsuitable, names. Objections can be raised on etymological, pathological, and etiological grounds respectively to each of the three names by which this fever is best known to English authorities. It is not like typhus, and therefore the term " Typhoid " in its literal sense is inapplicable to it. The fever is not in any sense the result of the characteristic intestinal lesions of the disease, and so the term " Enteric " is unsuitable from a patho- logical point of view. Lastly, mere putrefaction is certainly not the proximate cause of the fever, and so Murchison's ingenious name of " Pythogenic Fever," derived from what he endeavoured to show was the cause of the fever {Trvdo Professor of Medi- cine in the University of Berlin ; Karl Liebermeister, c Professor of Clinical Medicine in Tubingen ; and Wilhelm Zuelzer, a of the University of Berlin, in Germany ; and Charles Sraart, e Major and Surgeon, U. S. Army, in America. In the work of the last-named author, the section on Pathological Anatomy is profusely illustrated with a series of most beautiful photo-reliefs, heliotypes, photographs on steel, and chromo-lithographs. In these the pathological ap- pearances of the intestines in typhoid or enteric fever are shown in perfection. I venture to say that such another collection of draw- ings does not exist. Geographical Distribution. — Enteric fever prevails all over the world. The sketch of its geographical distribution given by Hirsch justifies the designation of an ubiquitous disease. Its incidence is as wide as the globe. Until recently, the Tropics were supposed to enjoy an immunity from it, but this is not so, although the disease is, no doubt, less prevalent in lower latitudes than in higher. This fever is met with in India — often obviously lying hidden behind the " continued and remittent fever of the Anglo- Indian physicians — in Burma, Cochin China, Reunion, Mauritius, Madagascar, Tahiti, Senegambia, Bermudas, the West Indies, Cayenne, and Brazil — all tropical or sub-tropical localities. It would seem, then, that climate does not, in and by itself, exert a determining influence on the occurrence of enteric fever (Hirsch). This disease is endemic in the British Islands. It is apparently most common in England, more common in Ireland than in Scotland, and in the last-named country more common on the west than on the east coast (Mnrchison). It is also endemic in nearly all parts of the Continent. In Iceland, where it is known by the name of " Landfarsot " (sickness of the country), it is met with every year — a The Principles and Practice of Medicine. Art. " Enteric Fever." 1886 and 1891. b Handbook of Geographical and Historical Pathology. New Syd. Soc. Trans- lation. 1883-1886. c Von Ziemssen's Cyclopaedia of the Practice of Medicine. Vol I. 1875. & Real-Encyclopadie der gesammen Heilkunde. Art. "Abdominal Typhus." e The Medical and Surgical History of the War of the Rebellion. Part. III. Volume I. Medical History. Washington, 1888. ENTERIC FEVER. 345 not infrequently in an epidemic and malignant form. In Africa it is not wanting. It prevailed extensively among the British troops in the Zulu, Egyptian, and Soudan campaigns, and among the French troops in Tunis. Brigade-Surgeon Albert A. Gore, M.D., contributed to the Dublin Journal of Medical Science a series of papers on enteric fever in Egypt since the British occupation of that country. In North America the disease is endemic from Greenland to Mexico. It has been observed throughout Central and South America also, as well as in most parts of Australasia. ./Etiology. — General considerations lead us — for the most part with Murchison — to the following conclusions : — 1. Enteric fever is either an endemic disease, or its epidemics are circumscribed (and local). 2. It is most prevalent in autumn and after warm weather. 3. It is independent of overcrowding, and attacks rich and poor indiscriminately. 4. It sometimes arises apparently independently of a previous case, in the presence of fermentation of faecal and perhaps other forms of organic matter, in which presumably the " resting spores " of its conlagium vivum have lurked. 5. It may be communicated by the sick to persons in health, but even then the poison is not like smallpox, given off from the body in a virulent form, but is developed by the decomposition of the excreta after their discharge. Dr. Cayley expresses the opinion — based upon observations made at the Middlesex Hospital — that the period required for the development of the infectious properties of the stools in this fever does not exceed twelve hours, and may be shorter. He holds that the fresh stools are incapable of communicating the disease, a point which may well be regarded as settled, notwithstanding the opinion to the contrary put forward, in 1880, by Dr. Collie, of the Homerton Fever Hospital. 6. Consequently, an outbreak of enteric fever implies poisoning of air, drinking water, milk, or other ingesta, with decomposing excrement. 346 ENTERIC FEVER. I have ventured to change the wording of the fourth of these propositions, because I cannot •assent to the doctrine of the de novo or spontaneous origin of enteric fever which is implied in Murchison's original words — viz., " It may be generated inde- pendently of a previous case by fermentation of faecal, and, per- haps, other forms of organic matter." a While we admit the propriety of using the term " endemic " in connection with enteric fever, we agree with Dr. Hilton Fagge that " there could be no greater mistake than to suppose that its diffusion is, like that of ague, independent of the movements of human beings and of their intercourse." The analogy is rather between enteric fever and cholera. Of late years enteric fever has shown a greater tendency to an epidemic prevalence than was formerly the case. This is notably so in Dublin, where an epidemic of this fever has prevailed every autumn since 1887. The Registrar-General for Ireland, Dr. Grimshaw, has furnished me with accurate statistical facts bearing upon the prevalence of both typhus and enteric fever in Dublin during the past twelve years. From Table II., in which this infor- mation is embodied, the rapid decline of typhus and the still more rapid increase of enteric fever in the Irish metropolis are clearly apparent. The Table includes the number of cases of typhus and of enteric fever admitted to hospital each quarter and of deaths from these diseases in the Dublin Registration District during the twelve years, 1879-1890, inclusive. a Murchison. Loc cit. 1884. Page 499. Table II. — Showing for each Quarter in the 12 years, 1879-90, the number of cases of Typhus and of Enteric Fever admitted into the principal huh 1 in. hospitals ; the number of Deaths in these Institution* from each of the diseases named,, and the number of Deaths from those causes registered in, the whole of the Dublin Registration District. Years Quarters Typhus Enteric Fever No. of Admissions to Hospitals Deaths in Hospitals Total Deaths Registered in Dublin Registration District No. of Admissions to Hospitals Deaths in Hospitals Total Deaths Registered in Dublin Regist ratio' District 1879 March 70 16 25 143 21 83 June 57 13 20 72 8 51 September December 43 49 9 6 21 23 71 81 2 5 34 37 Total 219 44 89 367 36 205 1880 March 159 19 26 94 11 47 June 129 32 44 67 4 63 September December 141 470 21 44 32 55 107 109 4 4 32 46 Total 899 116 157 377 23 188 1881 March 470 72 85 51 7 42 June 357 42 54 35 2 28 September December 246 147 31 18 36 19 31 52 6 7 31 22 Total 1,220 163 194 169 22 123 1882 March 126 19 25 34 3 28 June 96 16 19 44 2 33 September December 124 245 11 18 17 23 49 75 2 2 29 45 Total 591 64 84 202 9 135 1883 March 351 51 57 42 3 46 June 253 28 48 30 3 27 September December 100 125 17 9 23 13 34 76 3 9 26 33 Total 829 105 141 182 18 132 1884 March 141 22 30 64 8 29 June 122 20 21 48 3 29 September December 103 103 9 14 12 20 34 72 6 12 30 46 Total 469 65 83 218 29 134 Table IT. — continued. 1885 1886 1887 1888 Quarters 1889 1890 March June September December Total March June September December No. of Admissions to Hospitals Deaths in Hospitals Total March June September December Total March June September December Total March June September December Total March June September December Total 78 70 54 45 247 38 16 38 31 123 33 32 28 42 135 51 27 21 179 46 24 27 35 132 48 36 14 61 159 Total Deaths Registered in ! Dublin Registration District Enteric Fever No. of Deaths Admissions in to Hospitals Hospitals Duul'n Registration District 15 14 6 4 39 9 3 7 3 22 14 7 3 5 5 20 4 3 3 18 5 5 1 9 20 17 17 14 6 54 18 4 11 39 5 10 5 4 24 9 7 5 10 31 7 5 3 3 18 25 58 48 73 86 265 75 32 55 101 263 65 57 75 79 276 65 39 91 170 365 126 127 176 354 783 4 155 7 135 2 106 12 240 636 3 5 5 9 22 9 4 7 15 35 28 5 25 44 12 13 16 38 79 23 8 16 19 66 1600 7600 _ PI 1500 /500 „ 14-00 14-00 J300 1300 . izoo :':...; i^il noo 1 | //0t> — II II |j 1 1 woo 1 1 7006 7- 900 1 1 H 9C0 — 800 1 i Stf0 100 1 1 100 600 II ji mmmt 600 nil 1 WO I j f|| 500 — 1 100 1 too — 300 1 I 1 I 300 __ ZOO li || 1 H I ^pinger, c and these have been confirmed by the researches of Robert Koch, Meyer, and Friedlander, and more recently by Gaffky and very many others (von Jaksch) — in our own country, by Coats and Crooke. d Gaffky conducted a series of most accurate investigations on the subject in the laboratory of the Imperial Office of Public Health, Berlin, with the result that, in twenty-six out of twenty-eight fatal cases of enteric fever examined, the typical bacillar masses were present in the mesenteric glands, or in the spleen, liver, or kidneys. From this fact Eberth considers that the view that these organisms are in reality the cause of the typhoid process, has, without question, increased in probability to a high degree. Moreover, the bacilli do not apparently proliferate after death, as they would do had they anything to say to putrefaction. When animals have been infected by inoculation with these bacilli, they manifest symptoms of enteric fever, and the researches of E. Frankel, M. Simmonds, e and C. Seitz, f seem to leave no doubt as to their pathogenic character, although Beumer and Peiper g have come to a different 8 Reports of the Medical Officer of the Privy Council and Local Government Board. London. 1875. b Virchows Archiv. LXXXIII., 486. 1881. c Klebs' Bandbuch der pathol. Anatomie, 7 Leiferung, bearbeitet von Prof. Eppinger. d Brit. Med. Journal, March 12 and July 1, 1882. e Centralbl. fur klin. Med. VI., 737. 1885. f Bacterial. Studien z. Typhus-atiologie. Munich. 1886. e Zeitschrift jur Hygiene, I., 489, 1886, and II., 110, 1887. ENTERIC FEVER. 3f>3 conclusion. Gaffky has not succeeded in producing the disease in animals with his cultivations. Bacilli have of late years repeatedly been found in the blood of typhoid patients, and von Jaksch a says " they are doubtless the exciting cause of the disease." Rutimeyer b and Neuhaus experimented upon the blood taken from the rose-spots, and succeeded in cultivating bacilli from it. Bozzolo, d in three atypical cases, was able to demonstrate the presence of Eberth's bacillus in the blood, and thus determine that he was dealing with typhoid septicaemia. He considers bacterio- logical examination of the blood of great diagnostic importance. Neumann, e again, has found the Bacillus typhosus in the urine in six out of twenty-three cases investigated. Karlinski, of Cracow, examined the kidneys and urine in six fatal cases of enteric fever and the urine in thirty-eight other cases of the same disease. Bacilli were found in all the kidneys examined. In twenty-one specimens of urine Eberth's bacilli were found, all these urines being albuminous. When albuminuria was transient or absent, no bacilli were found. Colonies rapidly increased in albuminous urine, and preserved their vitality for a long period ; in urine containing bile, the bacilli died in five days. An important question arises as to the passage to the foetus from the mother of the micro-organisms of enteric fever. Eberth in particular has raised an objection to the experiments made by Reher, Nenhaus, Chantemesse, and Vidal, f which went to demon- strate the presence of the Bacilli typhosi in the blood of foetuses derived from typhoid mothers. Eberth is of opinion that a confu- sion must have arisen between the bacteria of typhoid and the bacteria of putrefaction. In one of his later communications, 8 a Clinical Diagnosis. Translated by James Cagney, M.D. London : Charles Griffin & Co. 1890. Page 33. b Centralbl. fur klin. Med. VIII., 145. 1887. c Berlin, med. Wochensch. XXIII., 89 and 389. 1886. d Deutsche med. Zeitung. Berlin. Aug. 28, 1890. Sajous' Annual of the Universal Medical Sciences. 1891. Vol. I., H.-52. e Berlin, med. Wochensch. XXV., Nos. 7-9. 1888. f Recherches sur le bacille typhique et I'etiologie de la filvre typhoide. Wiirz- burg. 1888. ' Centralblatt fiir die med. Wissensch. 1889. Juni 1. 2 A 354 ENTERIC FEVKR. however, Eberth admits the correctness of the observations; and still more recently, Dr. Joseph Giglio, a of Palermo, in an original paper, entitled " Ueber den Uebergang der mikroskopischen Organ- ismen des Typhus von der Mutter zum Fotus," as a result of his experiments, comes to the conclusion that the bacillus cultivated by him is the genuine Bacillus typhosus. To confound it with saprophytes is out of the question. Gaffky's results agree entirely with the descriptions given by Eberth, Koch, and Meyer in regard to the shape and appearance of the bacilli. On the average the rods are about thrice as long as they are broad ; their length corresponds to about the third part of the diameter of a red blood corpuscle. The rods are 2 fi. broad, and form filaments up to 50 /*. long. In isolated spots one may see somewhat longer threads, which on more thorough examination are seen to be made up of several segments. The extremities of the bacilli are distinctly rounded off. In several of the cases examined by Gaffky, the bacilli found in the internal organs contained unmistakable spores, which appeared as round portions, remaining unstained and occupying the whole breadth of the bacilli. The Bacillus typhosus occurs in the stools of enteric fever, but it is impossible to recognise it with the microscope alone, owing to' the vast number of microbes constantly to be found in the dejec- tions of this disease. Nor does it stain well for diagnostic purposes. Hence it is necessary to obtain pure cultivations for its complete recognition. The difficulty of staining this organism, and its occurrence in solitary isolated clumps, enabled it for a long time to elude the vigilance of observers. In connection with this, Dr. German Sims Woodhead mentions a plan which may prove useful to inquirers. " These bacilli,'' he writes, 6 " are said to be stained with difficulty, but I have found that if the sections in which they are present are first allowed to remain for about ten minutes in a one-fifth per cent, solution of corrosive sublimate, and then stained by Gram's method, the bacilli are most deeply stained, although Frankel and other a Centra'blatt fii>- Gynacohgie. 1890. No. 46, page 819. a Bacteria and their Products. London : Walter Scott. 1891. ENTERIC FEVER. 355 observers state that the colour is invariably discharged if Gram's method be used." This, however, is only part of the difficulty, for although the bacilli are found in clumps in the adenoid follicles, in the spleen, and commonly in the mesenteric glands, it is only, as Fliigge says, " after the examination of a large number of sections that one or several of these follicles can be found." The Bacillus typhosus develops readily in a medium of nutrient gelatin — the cultivations appearing after twenty-four hours. Rods and threads appear under the microscope, and they seem to be endowed with an evident and peculiar motion. The parasite develops to an extraordinary extent on prepared potato at a tempera- ture of 37° C. (98-6° Fahr.). Spores form after three or four days. On microscopical examination the inoculated mobile bacilli are found in surprising abundance. The whole surface seems to consist almost entirely of bacilli, which stain only with moderate intensity with aniline dyes. A globulin substance, behaving like myosin, seems to be the nutrient material in the potato. Typhoid bacilli also grow luxuriantly on sterilised blood serum of sheep, in solidified blood serum around punctures made with the platinum needle, in meat infusion, as well as in some vegetable infusions (Gaffky). A discussion has lately taken place as to the mode of origin of enteric fever in India and other tropical and subtropical climates, and is referred to by Dr. Cayley in the Third Edition of Murchi- son's Treatise on the Continued Fevers. In this discussion there seemed to be a general consensus of opinion that the disease may arise de novo, and two theories were put forward as to the mode of origin — the entogenous and the ectogenous. The former theory implies that the disease may be generated in the system, without any infection from outside the body, from the effects of climate, changed modes of life, or even the decomposition of fasces in the intestinal canal. This apparent mo'de of origin I myself long since recognised, chiefly in relation to retention and decomposition of the faeces in the bowels, but I prefer the term " autogenous " or perhaps " autochthonous," to " entogenous," as an adjectival prefix to enteric fever arising in this way. 356 ENTERIC FEVER. However, since the discovery of Eberth's Bacillus typhosus, and. the establishment of its causal relation to enteric fever, the doc- trine of the de novo or spontaneous origin of the disease, whether without (pythogenic) or within (autogenic) the body, has become untenable. My opinions, therefore, have of necessity been modified, and the doctrine I now hold is this — Enteric fever arises only when the spores of the specific microbe already named enter the body, and especially the intestinal canal, of a susceptible individual. But the state of health which accompanies habitual constipation, with fgecal decomposition in the intestines the result of that consti- pation, enormously increases the susceptibility of an individual, and, in fact, acts so powerfully as a predisposing cause as almost to appear to be the exciting cause of an attack of the disease. I believe that under such circumstances a very minute dose of the specific poison will suffice to kindle an attack of enteric fever, which might consequently seem to be of independent or spontaneous origin — to be, in a word, autogenous or autochthonous. 8. Enteric fever probably arises in the following way: — The specific bacilli, or rods, form spores inside the organs of one sick of the disease, especially in the mucous membrane of the small intestine. The micro-organisms are then discharged with the motions in their most resistant condition — i.e., as resting spores — and thus pass into faulty or leaky drains or cesspools, or into the ground. In these situations they may remain quiescent, and therefore harmless, for a long time for want of suitable nourishment or of a suitable temperature. At last these resting spores arrive by chance in a body capable of being infected, and there they develop into bacilli, and begin anew their cycle of existence as pathogenic microbes. Gaffky further shows that it is highly probable that the development of the spores does not occur a These several terms are derived from the Greek, namely : — "Entogenous," from ivrSs, within; yevvdw, I beyet or produce. " Ectogenous," from £kt6s. without; ynvvdw. "Autogenous," from avros, srtf ; yevvdoi. " Autochthonous," from o.vt6x6o» / , sprung from the soil itself {L&t. terrigena), indigenous. From avr6s, self ; x^ v > the earth, ground. ENTERIC FEVER. 857 only in the human organism, but that — as in case of the bacilli of splenic fever (Bacillus anthracis) — they may sprout and form bacilli in favourable circumstances even outside the animal economy, in- creasing enormously in numbers, and in the warmer part of the year forming spores afresh. Paths of Infection. — In Gaffky's opinion— and he is no doubt correct in his view — the most diverse paths stand open to the infecting germs for admission into the human organism, and it would be one-sided to fix one's attention solely on one or another of these. Besides the air which we breathe, and the water which we drink, our food may be the carrier of the typhoid virus. I. The poison maybe transported by currents of air. Murchison cites remarkable instances of such an occurrence — outbreaks of enteric fever having been caused by exhalations from drains, or sewers, or water-closets. Such outbreaks took place at the Peckham police station in 1859, at Chatham in 1872, in the School and Abbey Cloisters at Westminster in 1848, and at a school at Clapham in August, 1879. Under these and similar circumstances pneumonic fever, called by Dr. T. W. Grimshaw and me " Pytho- genic Pneumonia," a is also apt to arise. II. The poison may be, and probably most usually is, conveyed by drinking water. Of this Dr. Hilton Fagge specifies not fewer than 1 1 very striking and conclusive examples. The most singular of these was an outbreak at Lausen in the Valley of Ergolz in the Jura in August, 1872, when 130 out of a population of about 800 people were attacked, all of whom used the water of a public fountain, fed from two sources. One of these was a spring into which water percolated from certain meadows in another valley, separated from the Ergolz Valley by a mountain, the Stockhalder. In that other valley two cases of enteric fever occurred in July, 1872. The discharges from the patients were thrown into an adjoining stream. In the middle of the month just named the water of this stream was used to irrigate the meadows, and three weeks later the epidemic at Lausen began. fl Dull. Journ. of Med. Science. 1875. Vol. LIX., page 399. 358 ENTERIC FEVER. III. Milk may be contaminated with the poison, and when used may give rise to the disease. The first epidemic traced to such an origin occurred in Islington in 1870, and was investigated by Dr. Edward Ballard. Similar outbreaks took place at Armley, near Leeds, in the summer of 1872, and in the St. Marylebone District, London, in the summer of 1873. About Christmas, 1878, a remarkable epidemic was caused by infected milk in the Pembroke Township, Dublin. This was thoroughly investigated by Sir Charles Cameron, who published an excellent account of it in the Dublin Journal of Medical Science for July, 1879 (Vol. LXVIII., No. 91, Third Series). All the house- holds affected were supplied with milk from a particular dairy, the owner of which had been ill with " fever " since the middle of December. Two children had also been ill with fever of some kind during the same month, and all the patients had remained in a small house attached to the dairy. The excreta were daily thrown out on a dung-heap close to the cow-sheds, and the milk-pails were so placed that they could hardly escape being infected by means of particles of matter from the dung-heap carried by the wind. The bibliography of milk-epidemics of enteric fever is rapidly increasing. In the " Transactions of the Second Intercolonial Medical Con- gress of Australasia," Dr. Allen records the occurrence of an out- break at Melbourne in the spring of 1879. The son of a milkman died of enteric fever. Of 93 households supplied with milk by the milkman in question, 23 were visited by enteric fever. Forty persons were attacked, of whom 3 died. In the middle of June, 1889, enteric fever suddenly appeared in a community of 3,000 inhabitants in Sweden. One hundred and four cases with 11 deaths occurred in less than four months. It was discovered that those attacked received their milk from the same dairy. The milk was gathered from various sources and redistributed. Two persons ill of fever, presumably typhoid, were probably the starting point of the outbreak. In the Edinburgh Medical Journal for 1890-91 (Vol. XXXVL, ENTERIC FEVEK. 359 pages 801-814), Dr. H. Littlejohn reports an outbreak of typhoid fever due to milk infection. To the American Lancet, Detroit, 1891 (New Series, XV., pages 121-128), E. P. Christian contributes a paper, entitled "Cows' Milk and Typhoid Fever." In 1890, A. Vincent a published a "Note sur une ^pid^mie de fievre typho'ide propag^e par le lait." IV. There is some reason to believe that meat may, under exceptional circumstances, convey the poison of enteric fever. Dr. Cayley b states that several outbreaks from this cause have been reported from Switzerland, where cattle are, according to Huguenin, c not uncommonly affected by true enteric fever. The most remarkable outbreak of this kind was one which took place at Kloten, near Zurich, in 1878. Upwards of 700 persons were attacked in consequence of eating decomposed veal from a calf, which Huguenin believes to have been affected by enteric fever. Legrain {Ann. de la Policlin. de Paris, October, 1891, and Brit. Med. Journ., November 7, 1891) says that the problem of the origin and propagation of enteric fever is probably solved by the discovery of Eberth's bacillus and by the finding of this micro- organism in the water suspected of conveying the disease, Three theories have been put forward — (1) autotyphisation, and the identity of the B. coli communis with Eberth's bacillus lends some strength to this idea ; (2) direct contagion ; and (3) the presence of the germ in external media, especially in water, and its trans- mission in that way. This last is the most generally accepted theory. Brouardel in 1887 admitted that though the disease could be propagated by water, air, the patient's linen, or the hands of those looking after him, yet in 99 out of 100 cases it was through the medium of water. The author then gives the details of an epidemic occurring in a home for idiots and the weak-minded. After describing the insanitary condition of the river, M. Legrain draws attention to the increasing prevalence of gastro-intestinal "Geneve. Taponnier et Studer. 1890. Page 15. b Crnonian Lectures, 1880. c Correspondem-Blatt fur tchweiz. Aerlze. No. 75. 1878. 360 ENTERIC FEVER. affections in the home. Thus among an average of 170 treated yearly, there were 25 such cases in 1887, 57 in 1889, and 84 in 1890, the epidemic taking place from January to May of the last- named year. Two conclusions are drawn — (1) that the highest figure representing the gastro-intestinal disturbance and that representing enteric fever corresponded, and (2) that the epidemic was the climax of a preparatory period of gastro-intestinal disorders. The author agrees with Chantemesse that gastric disturbance with fever, apart from simple indigestion, may be abortive enteric fever. Mode of Invasion. — A question arises as to the organ in which the typhoid germs that have once entered the body first settle, and afterwards extend from this their primary seat of invasion, so as to bring about the general disease. Eberth lays stress upon a case observed by Meyer, a in which death ensued on the second day of illness. In this case there were found at the post-mortem examination hyperemia of the lungs, spleen, and kidneys ; in the lower portion of the ileum marked swelling of the solitary follicles and Peyer's patches, but nowhere any trace whatever of necrosis or of loss of substance. None of the mesenteric glands were swollen. In this recent case, microscopical examination revealed an exceptionally large deposit of the bacilli of Eberth and Koch in the cells of the submucosa and in the intermediate muscular layers. Eberth concludes from this case that the bacilli are first localised in the intestinal mucous membrane, that thence they pass into the mesenteric glands, thence into the blood-stream and accumulate again in the spleen, and, as Gaffky would add, in the other organs. Eberth further points out that anatomical investigations have afforded no evidence of the admission of typhoid germs through the lungs. On this point Gaffky does not agree, for he considers it as highly pro- bable — or at least the possibility cannot be contested — that the lungs may occasionally represent the seat of invasion. Be this as it may, there is no doubt that a close correlation exists between enteric fever and that variety of acute pneumonia, or pneumonic fever, to which the term " Pythogenic Pneumonia " is now applied. a Der Typhus-Bacillus unci die intcstinelle Infection. Volkmann's Klinische Vortrage. 1883. No. 220. ENTERIC FEVER. 301 At the time of writing (November, 1891), there is under my care in the Meath Hospital a young woman with characteristic typhoid stools, and whose urine gives a striking reaction with Ehrlich's test; but whose illness began with right apex pneumonia, with rapid breathing, cough, glutinous expectoration (not, indeed, deeply coloured when the patient was first seen by me), dulness on per- cussion, and, finally, the most typical crepitus redux. Towards the end of October, 1882, the following remarkable out- break of disease came under my notice. On the 12th of that month a lad, aged thirteen, was admitted into Cork-street Fever Hospital from 6 Malpas-street, Dublin, suffering from acute pneumonia. Malpas-street is very unhealthy — the houses are old and dirty, ill-drained and dilapidated. The street runs down to the bottom of a valley, through which a small tributary of the Poddle river flows sluggishly. The district is a prolific hotbed of disease. On Oct. 31 the boy's father (John C), a boatman, aged thirty-six, came in with the same disease. On the 20th of the same month two girls, both aged fourteen, were admitted to the Meath Hospital in enteric fever — one from 11 Malpas-street and the other from No. 13. On Nov. 27 a girl, aged twenty, was admitted to Cork- street Hospital in enteric fever from 7 Malpas-street, next door to the house from which the two cases of pneumonia had come a few weeks previously. On Dec. 12, John C, was again admitted to the Meath Hospital from 6 Malpas-street with " renal dropsy." It was he who suffered from pythogenic (?) pneumonia in the pre- vious October, as narrated above. Another coincidence occurred in March, 1883. On the 18th of that month Winifred N., aged nine- teen, came into Cork-street Hospital from 6 Malpas-street in an attack of " f ebricula," and the following day Anthony L., aged twenty-seven, was admitted from the same house with left basic croupous pneumonia. A very similar instance of the correlation existing between enteric fever and pneumonia came under my observation in the autumn of 1881. Four cases of illness occurred in a Training College in Dublin within a few weeks. Two of the four patients suffered from true enteric fever ; a third, from an attack of acute 362 ENTERIC FEVER. gastro-intestinal catarrh or — as some may think — from an abortive enteric fever ; and a fourth from acute pneumonia, reminding one of Laennec's " epidemic pneumonia," which in recent times has received the names of ' v sewer-gas " or " pythogenic " pneumonia. The drinking-water was proved by Sir Charles Cameron a to be the source of the sickness in all the four cases. " Whether it be," writes Gaffky, " that the spores of the typhoid bacilli are taken up in drinking water, or, in rare cases, along with articles of food ; whether it be that they are inspired with the air breathed, remain attached to the mucous membrane of the mouth and throat, and are afterwards swallowed, in all probability they pass without damage through the stomach, sprout to form bacilli in the alkaline contents of the intestine, multiply there and penetrate into the intestinal mucous membrane at those spots which are most adapted for their reception— viz., the Peyer's patches and solitary follicles. Afterwards they arrive in the mesenteric glands, where they form the very numerous characteristic masses, and are then carried away in the blood-current into the other organs. Becoming fixed here and there in these, they multiply to form those group.«, the almost constant presence of which in the spleen, liver, and kidneys, has been described in detail in the earlier part of this work. Obviously the infection will be more certain to ensue the greater the number of spores taken into the body." Virchow b maintained that infection in enteric fever most fre- quently took place by means of drinking water. He wrote : " The striking limitation of the anatomical changes to a deeply situated portion of the intestine, the lower end of the ileum and caecum, seems to indicate that a local action of the morbific matter takes place, as these are exactly the situations where the contents of the intestine are relatively most frequently retarded, where therefore the longest con- tact with the mucous membrane occurs. This consideration harmo- nises best with the inception of the typhoid matter in drinking water." a Dull. Journ. of Med. Science. February, 1882. b " Canalisation oder Abfuhr. Eine hygienische Studie." Virchow's Archiv^ Band 45. Heft 2. Side 294. 363 CHAPTER XXXVII. Clinical Description of Enteric Fever. Stage of Incubation or Latent Period— Stage of Invasion — Stage of Glandular Enlargement — Ulceration and Sloughing — Amphibolic Stage — Stage of Lysis — Convalescence — Duration of the Fever. As in the case of Typhus, we may most conveniently consider the clinical history of Enteric Fever as the disease passes through the different periods or phases of its development — the stages, in fact, of incubation, invasion, glandular enlargement, ulceration or slough- ing of the intestinal glands and lysis, and convalescence (Murchison.) I. Stage of Incubation. — From elaborate researches, Murchison was led to conclude that — 1. The period of Incubation of enteric fever is most commonly about two weeks ; 2. Instances of a longer duration are more common than in typhus or relapsing fever ; 3. It is often less than two weeks, and may not exceed, one or two days. Liebermeister admits that the period of incubation is difficult to be determined, because " it is hard to fix the exact date of the infection, and often hard to fix that of the commencement of the disease," He considers that, according to our present (1875) experience, the average period of incubation is three weeks. In a paper, " Ueber die Incubationzeit des Abdominaltyphus," published in 1875, Professor Quincke, 8 of Berne, gave some cases — due to drinking contaminated water— in which the duration of incu- bation was very accurately ascertained. In these eases the shortest period was eight days, the longest certain period between sixteen and eighteen days. In the Marylebone milk epidemic of 1873, a child was taken ill five days after drinking the infected milk (Cayley). Hilton Fagge is responsible for the statement that a Correspondenz-Blatt Jiir schweizer Aerzte. 1875. No. 8. 364 ENTERIC EEVER. it has been conjectured the incubation is shorter when the poison is inhaled with the breath, longer when it is swallowed in drinking water. During this latent period, the patient may feel quite well, or, on the other hand, he may complain of being "out of sorts ; " there may be languor, a tendency to diarrhoea, and vague feelings of discomfort and chilliness, with headache and loss of appetite. II. Stage of Invasion. — This lasts from the first marked feeling of illness until decided febrile symptoms have developed. It is a badly defined period, for the advent of enteric fever is essentially gradual and insidious in most cases. It lasts, according to Murchison, for one or more days. Of late years the classical insidious onset of enteric fever has in many instances given place to a more abrupt and vehement advance, characterised by decided rigors, violent headache, and rapid rise of temperature. This, at least, has been our experience in Dublin during and since the epidemic of 1889. In a word, the whole course of the disease has become more typhus-like than formerly. The earliest symptoms are, headache and pains in the limbs, with irregular chills, giddiness, and languor. Sometimes nausea and vomiting are prominent symptoms, and still more frequently there is urgent diarrhoea, particularly if the patient has taken a saline aperient while under the impression that he is suffering from a mere bilious attack. III. Stage of Glandular Enlargement. — This overlaps the inva^ sion, and extends to the twelfth or fourteenth day. The pulse now increases in frequency, temperature rises, especially in the afternoon or evening, the fever being of a remittent type, the skin is hot, the tongue is furred and red at the edges, and epistaxis is apt to occur. The nights are restless and disturbed, and the patient feels weak, but not to anything like the same extent as in typhus. Indeed it is quite usual for the sufferer from enteric fever to pursue his ordinary avocations during the whole of the first week of his illness, or even longer. So far there is nothing absolutely pathognomonic of enteric fever, ENTERIC FEVER. 305 but Murchison points out that the concurrence of diarrhoea or gastric disturbance, with an evening temperature of 103° or 104° F. and prostration, in a young person, ought always to make the practi- tioner suspect that this is the disease which he has to combat. In very rare instances enteric fever sets in with sudden maniacal delirium (Hilton Fagge). On the other hand, a person may ail for one, two, or three weeks, after which a definite attack of this fever may begin and run its usual course. At the close of the first week and during the early days of the second, the symptoms are more or less headache, prostration, loss of appetite, diarrhoea with liquid motions of an ochrey-yellow colour, a frequent soft pulse liable to great variations in rate and strength, fever of a variable remittent type. There is a warm, dry skin, with occasional clammy sweating. The pupils are dilated, and the conjunctivae are clear, the nose bleeds from time to time, there is a clear complexion with a hectic flush upon the cheek, so that the patient is like one in pulmonary consumption. The tongue is at first covered with a creamy fur, through it the enlarged papillae begin to show, and a triangular red space appears at the tip. The edges also are red. The epithelium is subsequently shed, and the surface of the whole organ in severe cases becomes red, glazed, dry, and transversely fissured and sore. Occasionally the tongue becomes cracked, dry, and brownish. In most cases, but not invariably, the area of splenic dulness is increased. Tym- panites, or meteorism, is commonly observed, sometimes to an extreme degree. There is tenderness on pressure over the abdomen, with gurgling (gargovillement) in the iliac fossae. Intestinal haemo- rrhage may occur. Occasionally constipation prevails and may even be obstinate. The Rose-Rash. — Between the seventh and twelfth days an eruption of isolated, elevated, rose-coloured spots first appears, chiefly over the abdomen and back. The soft papules, of which this almost pathognomonic rash consists, are deleble on pressure, vanishing to reappear when pressure is removed. They come out in successive crops for ten days or a fortnight, or longer, each crop lasting for two, three, or more days. There may be only three or 366 ENTERIC FEVER. four rose-spots, but on the other hand they may be counted by hundreds. This stage of the fever derives its name from the enlargement of the intestinal and mesenteric glands which is proceeding apace during the first fortnight of the disease. IV. Stage of Ulceration and Sloughing. — This stage extends from about the twelfth or fourteenth day to some time between the twenty-first and twenty-eighth day (Murchison). In mild cases cerebral symptoms may be wanting, but in the severer forms of enteric fever headache gives place in the third week to somnolence, increasing delirium, particularly at night, and progressive nervous and muscular prostration. Inordinate tremor is regarded by Sir William Jenner as indicative of the pre- sence of deep ulceration of the intestine, such as is likely to lead to perforation or haemorrhage, and Murchison held the same opinion. In these serious cases also sordes collect on the teeth, diarrhoea persists, the tongue is dry, glazed, red, and fissured, and bed-sores are apt to form over the sacrum and near the great trochanters. The patient daily loses strength and wastes rapidly, and at last the " typhoid " or " ataxic state," of which I have so often made men- tion, may be developed, the patient either dying of coma or slowly improving towards the close of the third or in the fourth week. In many instances, the typhoid stage is never reached. Yet the patient is not free from danger, for, apart from pulmonary or other complications, he may succumb in the third or fourth week to one or other of the perilous results of the intestinal lesions — exhausting diarrhoea, haemorrhage, or — most perilous of all — perforation of the intestine, and peritonitis — with or without perforation — local or general. The duration of this stage is uncertain, and for a time there may be a period of uncertainty, or of changing fortunes (Murchi- son), to which Wunderlich a has given the name of the amphibolic b stage. This doubtful period usually follows the acme, or fasti- gium, of the fever, and in it the range of temperature is more or " Medical Thermometry. New Syd. Soc. 1871. Pa»e 315. b Gk. a/x/atelW. CHARTS OF TEMPERATURE RANGE'S IN ENTERIC FEVER. Fml- Normal Enteric Fc £■'■■ ' Fy.2.-J\ brmal Anterrr Fever. w\ :ii|||||j||E| = : : . :L .": [ _.__ g_ 1 [LP j Tg^-i- jr ■ . j=~H: .: ^-^---ff !p|i| SEE :||g^||=pE| --i-U-4 ! Jl-i *- : --4— ^-W:: ^41. rW r^- _rj-- ltpi|rE|E TT] — ^ _.:.Ii.-^-[. -fllip - :-Tp..nE-:f: n( t ^U Bill - + Jf fffP ff f f -ff 7 S —Jint< -■'/'.■ F''yrr. With /i\-.-r'/,Y.\'-,-F.^:--- J-U7.J 1-En.Urie /-ever, tvith XUo.ps* I /•iy ^ ■ -Enteric r'rter, wtfh f&i-i{- > u/t ', /n-Vy'.-Wv ENTERIC FEVER, &>3 104° and 10o'8°. It may rise to hyperpyretic degrees, but not easily above 110°. In one of Dr. Reuben J. Harvey's cases — that of a young woman, aged twenty, who died in Cork-street Hospital on March 17, 1880, apparently on the eighteenth day of ataxic typhoid fever — the temperature in the axilla a few minutes before death registered lO^S . The chart is given in Plate VIII., Fig. 7. Except in fatal cases, however, it is rare to meet with temperatures above 106-7°. At the beginning the temperature rises in a zig-zag fashion, in such a way that during the four days or so occupied by the pyrogenetic or initial stage the thermometer rises about 2° or 2 # 5° Fahr., from morning to evening, falling again from evening to morning only 1°, or at most 1'5° Fahr., with the result that about the fourth evening a reading of 104° is reached or slightly exceeded. From this time onward for seven or eight days, the course of the temperature is tolerably uniform — slight morning remissions being followed by moderate evening exacerbations in this stage, the fastigium of the fever. It will be observed that, so far, we have had to deal with a remittent type of fever during the pyrogenetic stage, and a continuous or sub-continuous type during the fastigium. In the middle of the second week, between the 9th and 12th days, slight and severe cases show a marked difference. In slight cases the fastigium then shows a tendency to terminate — its short daily curves are gradually converted into the steep daily curves of the period of convalescence. The temperature ranges begin : to "spike," and the fever-type is once more remittent. In such cases the temperature approaches to normal in a zig-zag fashion in the course of from 6 to 10 days : defervescence is gradual — by lysis. Recollect, however, that even in these mild cases, at any moment the even tenor of the temperature range may be inter- rupted by the supervention of some complication. We may expect a severe course of the fever when the morning temperature is persistently above 103°, and the evening temperature touches 105°, when any irregularity of temperature occurs in the 394 ENTERIC FEVER. second week, when moderation of the temperature does not occur, at least about the twelfth day. Increasing fever towards the close of the second week is always an ominous sign of coming trouble. The same remark applies to a rising temperature in the third week, or to a temperature which is higher in the third than it was in the second week. Complications commonly occur about this time. They generally raise the temperature, and abolish or mask the morning remissions. Profuse haemorrhage or perforation of the intestine may cause sudden and considerable fall of temperature. In these severe cases, a period of changing fortunes — a period of uncertainty — often intervenes. This is called the amphibolic stage, and has already been explained (see page 366). It some- times lasts only three or four days ; generally a week, or ten days, sometimes even longer. In fatal cases, in the death agony, or at the moment of death, the temperature may be subnormal, but more usually it is high or excessive— 107-6° to 110°. Sometimes the amphibolic stage terminates in a protracted fever (lentescirende Process — Wunderlich), of quite indefinite duration and depending upon continued ulceration in the bowels, or bronchorrhoea, or marasmus. Although defervescence generally takes place gradually in enteric fever — that is, by lysis, yet it may occur suddenly — that is, by crisis. Dr. H. T. Bewley, F.R.C.P.I., has kindly permitted me to publish a clinical chart of such a case. (See Plate VIII., Fig. 9.) Complete recovery is to be admitted only when the temperature shows complete freedom from fever in the evenings — when, in fact, it has been normal for at least two successive evenings. For a short time the thermometer may fall below normal, but trivial causes — such as change of diet, excitement, and so on — may cause it to rise afresh from time to time in convalescence. Young children show a very remittent type of temperature in enteric fever. In middle-aged and elderly subjects, the intensity of the fever as marked by the thermometer is less pronounced than it is in children and adolescents. Dr. Cayley supplements Murchison's account of the behaviour of ENTERIC FEVER. 395 the temperature in the disease by a paragraph on apyrexial or afebrile enteric fever. He writes : — " Cases or even epidemics of Enteric Fever have been observed in which the temperature throughout has not risen above the normal point, and has often been subnormal, though the disease has been of a severe type, with weli-marked intestinal lesions. This ab- normal range of temperature seems to have always been due to the patients having previously been exposed to great hardships and insufficient food." — (Murchison's " Treatise on the Continued Fevers." 1884. Page 518.) An epidemic of this kind is described by Dr. Struve as having occurred among the German troops besieging Paris in 1870, and another similar epidemic was recorded by Dr. O. Frantzel in the Zeitschrift fur klin. Medicin for 1880. Complications and Sequelae. 1. The Eespiratory Tract. — 1. Bronchitis is rarer in enteric fever than it is in typhus. Murchison noted its presence in 21 out of 100 cases. It may occur early or late in the fever, but most commonly both bronchitis and hypostatic consolidation of the lungs supervene in the fourth week, when these complications either kill or indefinitely prolong convalescence. 2. Pneumonia is more common than in typhus. Murchison noted it in 13 out of 100 cases, and Austin Flint (according to P>artlett a ) in 12 out of 73 cases. It commonly occurs in the third or fourth week, but may usher in the disease. In this latter case its presence is probably an indication that the enteric fever poison has entered the system through the lungs. It is most commonly a lobular pneumonia, but occasionally it occurs under the form of croupous pneumonia. When there is an unusual tendency to pneumonia and pleurisy in enteric fever, the disease receives the name of the "thoracic form." 3. Pleuritis is more usual than in typhus. It may terminate in empyema, or in an interlobar pleural abscess (Murchison). Pleurisy was observed in the hospital at Basle 64 times in 1,743 cases of enteric fever. Twenty-one of the 64 cases, or nearly one-third, " The Fevers of the United States. Fourth Edition. Philadelphia. 1856. 396 EXTERIC FEVER. terminated fatally. In most of the fatal cases (14) the pleurisy was dependent upon some affection of the lungs — such as hemor- rhagic infarction, gangrene, pneumonia (Liebermeister). 4. Pulmonary Tubercle is a more common sequel of enteric fever than of typhus. This is due, according to Murchison, to the longer duration of the fever and to the greater emaciation which accompanies it. But surely the chief causes are the unhealthy state of the glandular system, which often predisposes to enteric fever, and is certainly intensified by it ; and the infiltrated condi- tion of the lung tissue in this fever. This is apparently the view, taken by Liebermeister , a who says — " The cases under considera- tion (of general miliary tuberculosis) occur in persons who have the specific poison of tubercular phthisis lying latent within them, and the fever, with its sequelae, only serves as an exciting cause for the development of these processes." Murchison b states that tubercle should be feared when hectic fever and bronchitis persist after the fourth week, and Stokes taught that a quick pulse-rate in convalescence indicated — (1) tuberculosis in the lungs and other parts ; (2) " secondary reactive inflammation in the mucous glands of the intestines ; " (3) phlegmasia dolens. At the same time Stokes held that the bronchial affection of fever often simulated phthisis, especially in those cases where the patient lost strength, and grew pallid and emaciated.* 3 5. Laryngitis is a serious complication, more common on the Continent than in Great Britain and Ireland. Ulceration and, partial destruction of the epiglottis appeared to Louis to be such characteristic secondary anatomical lesions in enteric fever that he said — " Si on venait a les observer chez un sujet qui aurait suc- combe" a une maladie aigue, elles annonceraient d'une maniere presque certaine, et sans aller plus loin, que l'affection est une fievre typho"ide."at. Med. Congresses. Berlin. Band II. Abthei- lung V. Innere Medicin. 210. ENTERTC FEVER 407 of Spleno-typhoid which occurred in my practice in the autumn of 1880. Further allusion will be made to this case at page 422. 5. In certain instances the fever is very acute, and death may occur in the first, or early in the second week, before ulceration has commenced in the bowel. Trousseau a describes this variety as la forme inflammatoire, and Murchison gives several examples of it in his work on Fevers. Some years ago I witnessed a case of this kind in the Epidemic Wards of the Meath Hospital. 6. Infantile Remittent Fever, often called " Worm Fever " or " Gastric Fever," is now known to be identical with the enteric fever of adults. According to Murchison's experience, idiopathic remittent fever in children is almost invariably enteric. An excel- lent account of the fever will be found in Dr. Charles West's work on the " Diseases of Infancy and Childhood." b It is to this author that we are principally indebted for establishing the identity of infantile remittent and enteric fever. 7. Senile Enteric Fever may be veiled or latent. The abdominal symptoms are often but slightly marked, and temperature does not range high. The fever, however, is protracted and collapse is not uncommon. Hilton Fagge suggests that the atrophy of the lym- phatic organs in old age, including those of the ileum, may be an anatomical condition which is unfavourable to the reception and multiplication of the enteric microbe. The same line of thought would explain the special features of the disease as it presents itself in elderly patients. 8. The afebrile or apyrexial form is of rare occurrence. Although the general symptoms, and especially the nervous symptoms, as delirium and stupor, may be well marked and rose-spots are present, yet the temperature remains normal throughout, or may even be subnormal. The intestinal lesions are usually slight, and the disease often terminates at the end of a fortnight. An outbreak of this type occurred in the German army besieging Paris in the winter of 1870-71, and has already been mentioned at page 395. *■ Clinique Med.de VH6tel Dieu. Paris. 1865. Tome I., p. 241. b London : Longmans, Green & Co. 1874. Sixth Edition. Pages 769, et eeq. 408 CHAPTER XLII. Enteric Fever (continued). Dia gnosis — Prognosis and Mortality— Pathology. No single symptom pathognomonic of Enteric Fever. — Diagnosis depends on aetiology, course of the disease, and particularly the temperature. — Ehrlich's Test. Diseases apt to be confounded with Enteric Fever : Typhus, relapsing fever, remittent fever, scarlatina, smallpox, pyaemia and puerperal fever, gastro-intestinal form of influenza, tuberculosis, trichiniasis, ulcerative endocarditis, acute rheumatism, &c. Prognosis and Mortality : Influence of age, sex, season, station in life, recent residence in an infected locality, intensity of the poison, family constitution,' personal constitution and habits, previous diseases. — Modes of Death : Coma, syncope, asthenia or anaemia, hyperpyrexia (rarely). — Fatal Complications. — Pathological Anatomy : Specific Lesions — Non -Specific Lesions : affecting muscles, heart, liver, kidneys, nerve-cells, salivary glands, pancreas, larynx. " There is not a single symptom belonging to typhoid fever which can be characterised as pathognomonic." So writes Liebermeister. Yet the diagnosis is tolerably certain in most cases, and absolutely so in well-marked cases. Due consideration having been paid to the circumstances under which the illness arose, to the age and condition of the patient as regards pregnancy and so on, the diagnosis turns upon the course of the disease, particularly as regards the behaviour of the tempera- ture, upon the enlargement of the spleen and the abdominal symptoms, and upon the presence of the rose-spots. Probably it is to the temperature that we are to look with most confidence for a diagnosis in the early days of the fever. Wunderlich considers that one is justified in positively diagnos- ticating enteric fever in attacks of moderate severity during the fastigium, when previously healthy persons of youthful or middle age, after being ill about five days or a week, exhibit evening temperatures of 103'5° to 105°, alternating with morning temperatures which are 1*4° to 2'7° Fahr. lower. He qualifies this statement by adding : — " Unless some other disorder of any ENTERIC FEVER. 409 sort can be discovered to explain the height of the fever, or unless they have been the subjects of gross neglect immediately before coming under observation." Wunderlich further thinks that we may with great probability assume that enteric fever is not present, when even on the first day or on the second morning the temperature rises to 104° F. ; when, between the 4th and 6th days, the evening temperature in a child, or adult under middle age, never reaches 103° F., and indeed if it has failed to do so two or three times ; lastly, when as early as the second half of the first week considerable or progressive diminu- tions of the evening temperature are met with. Ehrlich's Test. — In 1882, Ehrlich a announced the fact that it is characteristic of the urine in enteric fever, measles, and acute tuber- culosis to yield a deep-red colour with diazo-benzene-sulphonic acid— one of the anilin derivatives — whereas normal urine gives only a- yellowish colour (like sherry or brown vinegar) with this reagent. Ehrlich obtains the reaction, not with the acid in ques- tion itself, but with sulphanilic acid. In applying the test two solutions are used — A, a saturated solution of sulphanilic acid in dilute hydrochloric acid (1 in 20) ; _B, a 0*5 per cent, solution of sodic nitrite in distilled water. A is prepared by making up 50 cubic centimetres of hydrochloric acid to 100U cc. with water and adding sulphanilic acid to saturation. To 200 cc. of this mixture 5 cc. of a ^ per cent, solution of sodium nitrite are added. The action of hydrochloric acid upon the nitrite of sodium forms nitrous acid, which, in the presence of sulphanilic acid, is converted into diazo-benzene-sulphonic acid. This is added to the urine in equal parts. Ehrlich has recently P recommended that 5 to 6 times the volume of absolute alcohol should be added to the fluid to be tested, and the reagent, prepared as above, should be added drop by drop to the filtrate. The urine thus treated should be rendered alkaline with strong ammonia. When the test is applied to the urine of a patient with enteric fever, the colour rapidly turns red, the tint varying from the yellowish-red of bichromate of potassium solution « Zeitscb. fur klin. Med. V. 285. 1882. b Cl.arite-Anualen. XI. 139. 1886. 410 ENTERIC EEVER. through ruby-red to the colour of port wine. On shaking the test tube a froth is produced, which usually assumes a delicate and very characteristic pink colour. Dr. Frederick Howard Taylor, a of the London Hospital, has recently (1889) submitted this diagnostic sign of enteric fever to a careful trial at that hospital. He finds that the reaction is not always given until the latter part of the first week, but in every case it is forthcoming during a great part of the febrile period. It is this fact which constitutes the great value of the test. Unfor- tunately, however, in exceptional cases, the reaction is given in other diseases. Herein lies the weakness of the test. Dr. Taylor arrives at the following conclusions : — 1. The absence of the reaction is practically proof positive that the case in question is not one of enteric fever (provided that the disease has lasted six days or more, and that the temperature has not yet fallen to normal). 2. Its presence suggests, but does not prove, that the case is one of typhoid — the probability being greater the deeper the tint pro- duced. 3. As the other diseases in which it occurs least seldom are not those which most closely resemble typhoid, but the reverse — for example, measles and phthisis pulmonalis — the significance of these exceptions is very much lessened. On November 5th and 6th, 1891, I had the advantage, through the kindness of Professor Emerson Reynolds, and with the aid of Mr. Emil Werner, of testing the diagnostic efficacy of this very striking test in a series of specimens of urine. Two of the series were non-typhoid urines, two others were from enteric fever patients, and the fifth was the urine of a gentleman, aged 29, on the 13th day of well-marked enteric fever, he having suffered from equally well- marked enteric fever 14^ years previously, when a lad of 15 years. In all cases a change of colour in the urine was observed on applica- tion of the test. In the non-typhoid urines only a deeper yellow was produced ; in the undoubted primary typhoid urines a beautiful rose coloration developed. In the case of recurrence, changes interme- a Lancet, May 4, 1889. Plate IX. CHARTS OF TEMPERATURE RANGES IN RECURRENT ENTERIC FEVER. J? f'^'T^ i 'C s ^ f: ^ vc . Jc, . e ^: pH ^: 1, ^ « 1' | I "I I 4 i § I 1 8 a -s « Diagram>D shorn the vanolwns, according to Age, in the rate of Mori/My of 5911 cases of Enteric Fever, admitted into the London, Fever Hospital, ( Compare wcthDiagr: B- Only 47 of patients were above 55 years) ENTERIC FEVER. 415 At the London Fever Hospital, in twenty-three years (1848- 1870), out of 5,988 cases, 1,034 died, making a death-rate of 17*26 per cent., or of 1 in 5*79. The mortality, in fact, was about the same as that of typhus. In the same hospital, in the years 1871-82, since the exclusion of the pauper patients, 144 deaths occurred among 905 patients, the death-rate being 15*9 per cent. (Wm. Cayley). The statistics which I have culled from the Registers of Cork- street Fever Hospital, Dublin, with the aid of Dr. J. Marshall Day, the Resident Medical Officer, compare very favourably with these results. In the twenty years ending March 31, 1891 (1871-1890 inclusive), 1,405 cases of enteric fever were treated in the hospital, of which 121 proved fatal. These figures give a death-rate of 1 in 11-6 or 8 '6 per cent. — only one-half the mortality in the London Fever Hospital up to 1870. The influence of age on the mortality is shown in Diagram D., copied by permission from the Third Edition of Murchison's work. It will be seen that the rate of mortality is much more uniform at all ages than it is in typhus. At Guy's Hospital the mortality under 5 years of age was 1 in 7, or 14-3 per cent. ; between 5 and 15 years, it was rather less than 12 per cent. ; between 15 and 30, it was a little more than 16 per cent.; between 30 and 40 a little more than 26 per cent., and above 40 nearly 50 per cent. (Hilton Fagge). Up to forty years of age enteric fever is proportionately a much more fatal disease than typhus. The reason why the latter fever has a gross mortality greater than that of enteric fever is correctly stated by Murchison. It is because a much larger proportion of typhus patients exceed forty years of age, and the death-rate after that period of life is much in excess of that in enteric fever. Sex. — The death-rate in the London Fever Hospital was about 1 per cent, higher among females than among males. Season and Station in Life do not materially affect the death- rate, but recent residence in an infected, locality raises it consider- ably, and so do the intensity of the poison and family constitution. In this last particular, enteric fever is akin to scarlatina (page 181). 416 enteric fever: Lastly, the prognosis is bad in the obese, the very muscular, the intemperate ; as well as in those who are the subjects of gout or of kidney disease. Death is brought about by coma, or by syncope, most commonly by the end of the second, or early in the third, week; by asthenia or anaemia, in the third or fourth week, or even later ; and only rarely by hyperpyrexia. At a meeting of the Pathological Society of Dublin, on January 15, 1876, Dr. James Little a showed the intestinal lesions in a case of acute enteric fever in a young woman who sickened on January 2, with sore throat and vomiting, and died on the 8th — that is, on the seventh day of her illness. The complications which most frequently terminate fatally are : perforation, peritonitis, intestinal haemorrhage, pulmonary congestion, pneumonia, bronchitis, and diarrhoea. Pathological Anatomy. — Enteric fever differs from both typhus and relapsing fever in the almost invariable presence of specific lesions, particularly in the glandular structures of the ileum and of the mesentery. But this fact is in no way subversive of the doctrine that enteric fever, like typhus or relapsing fever, is an essential disease. The words of Fordyce, quoted by Graves, t> are exactly applicable: — "Fever is a disease which affects the whole system ; it affects the head, trunk, and extremities ; it affects the circulation, absorption, and the nervous system ; it affects the body, and it affects the mind; it is therefore a disease of the whole system, in the fullest sense of the term. It does not, how- ever, affect the various parts of the system uniformly and equally, but, on the contrary, sometimes one part is more affected than another." k ' In several specific fevers," says Hilton Fagge, c " we find, in addition to the universal 'intoxication' with the poison, that it fixes itself peculiarly in certain foci, as we may call them, where it a Dubl. Journ. of Med. Science. Vol. LXII., page 60. 1876. b Clinical Medicine. New Syd: Soc. 1884. Vol. I., page 121. ' c Text- Book of the Principles and Practice of Medicine. Third Edition. Vol. I., page 151 Loudon: J. & A. Churchill. 1891. ENTERIC FEVER. 417 produces definite local lesions. Thus measles particularly affects the respiratory mucous membranes, and scarlet fever the throat. But nowhere is this localisation of the disease so remarkable as in enteric fever. In fact, so striking and clinically important are the local lesions that it was possible for Broussais and his school to regard them as the primary disease, and the fever as merely a symptomatic result. Probably the ' typhoid deposits,' as they used to be called, in the intestine, are to be regarded as infective granulomata, produced, like the products of tubercle and lepi*osy, by the local action of specific bacilli." The morbid anatomy of enteric fever is thus epitomised by Murchison : — 1. The agminated or solitary glands of the ileum, the mesenteric glands, and probably the spleen, are invariably diseased. 2. Many other secondary lesions are found, which are not constant or essential. The chief of these are — peritonitis, granular or other degenerations of the liver, kidneys, heart and voluntary muscles, ulcerations of various mucous surfaces, pneumonia, bronchitis and hypostatic congestion of the lungs, and an increase of intra-cranial fluid. There are no signs of inflammation in the brain, or of its membranes, to account for the cerebral symptoms. 3. There is no specific typhous exudation, and no evidence that the secondary lesions are due to the deposit of a material like that found in the intestinal and mesenteric glands. 4. The enlargement of the intestinal and mesenteric glands is not due to any attempt at elimination, but to inflammation, which is probably excited by absorption of a poison in the bowel. In 1864, Zenker a pointed out two kinds of degeneration in the fibres of voluntary muscles in enteric fever. Some of these fibres become granular ; others undergo conversion into a glassy-looking (hyaline) b substance, in which no striae can be recognised, and which splits up transversely into discs. The change is especially a Ueber die Vcranderungen cler wilkuhrlichen Mttskeln im Typhus ahdominalis. Leipzig. 1864. b Gk. vdKtvos, of crystal, or glass, from vaAos, any kind of clear, transparent stone, hence glass (Lat. vitreum). 2 E 418 ENTERIC FEVER. marked in the adductors of the thighs and in the recti abdominis. Daring life, muscles thus affected become soft and pliable. Hoff- mann has shown that similar forms of degeneration occur in the tongue, accounting perhaps for its tremulousness. Zenker himself remarked that the changes now described are not peculiar to enteric fever, but may take place in other febrile diseases, if sufficiently severe and protracted. The heart is soft and pale in fatal cases, with dilatation of the right and sometimes of the left ventricle. Its muscular fibres are more or less granular and may have lost their transverse striation. Zenker a once observed hyaline degeneration. The liver is softened, on section presenting a pale or " clayey " look. Examined microscopically, its cells are found to be granular and disintegrating. Minute gray nodules are, according to Wagner and other German pathologists, often found in the substance both of the liver and of the kidneys; the epithelium of the last-named organs are the seat of cloudy swelling and granular degeneration. Hoffmann described the nerve-cells in the great basal ganglia of the brain as being deeply pigmented. He also found an enormous overgrowth of cells in the acini of the salivary glands and of the pancreas, which structures, according to this authority, feel un- usually hard and dense. The larynx is sometimes ulcerated. Hoffmann observed such a state of things in 28 out of 250 cases. This lesion has been already described (see page 396). It will be necessary to treat of the more specific lesions of enteric fever in a separate chapter. a Loc. cit. See also Chapter XVIII., pages 178 & 179. 419 CHAPTER XLIII. Intestinal and Splenic Lesions of Enteric Fever. Specific Lesions of the small intestine, mesenteric glands, spleen. — The stomach, duodenum, and jejunum usually healthy or seat of non-specific lesions. — Neighbourhood of ileo-caecal valve, the chief seat of disease in both ileum and caecum. — "Entcrica sine enlcritide.'' — " Infective Granuloma" (Hilton Fagge). The Intestinal Lesion : its four stages— (1.) enlargement and infiltration (2.) softening and ulceration; (3.) "typhoid ulcer;" (4.) cicatrisation. — Plaques dures et molles (Louis). — Plaques reticidees et gaufrtes (Chomel). — Characters of the "Typhoid ulcer." — " Atonic ulcers." — " Shaven-beard " appear- ance {I'etat pointille). — Perforation of the peritoneum. — Lesions of the Mesenteric Glands.— Lesions of the Spleen : Putrilage, abscess. As the brun£ of the onslaught of the specific poison falls in scarla- tina on the throat, in measles on the respiratory mucous membranes, in smallpox on the skin, and — shall I add — in pneumonic fever on the lungs, so in enteric fever the battle-field is first and chiefly the small intestine, the neighbouring mesenteric glands, and the spleen. The stomach, notwithstanding the frequent occurrence of anorexia, nausea, and vomiting, in many cases escapes all pathological change ; in others the morbid appearances which it may present — for example, increased vascularity, softening, mammillation, 11 and superficial ulceration (Murchison) — are inconstant and non-essential. They may be observed with equal frequency after death from other diseases. Louis long ago pointed out that "la fievre typhoide" had no more claim to the name of gastro^enterite, than pneumonia had to that of gastro-peripneumonie. The duodenum and the jejunum are usually healthy in enteric fever, and so also may be the greater part of the ileum. But, starting from the ileo-ccecal valve, morbid changes are found to extend upwards into the caecum and ascending colon in about one-third of the fatal cases ; but more particularly and much a Lat. Mamilla, a nipple. Fr. mamelonnation, the condition of bein°- mam- millated, that is, of having (or presenting) nipple-like prominences. 420 ENTERIC FEVER. more frequently — backwards into the ileum, in some instances only for a few inches, in others for two or three feet, or further. These morbid changes affect both the solitary glands and the agrainated glands (Peyer's patches) of the ileum, and also the solitary glands of the colon. But the distribution of the lesions is most variable. In some cases the solitary glands entirely escape ; in others, the glands of the ileum are alone attacked ; in others, those of the caecum suffer ; in a few the lesions can be traced to the sigmoid flexure or even to the rectum (Hilton Fagge). In very exceptional cases, Peyer's patches remain unaffected, and the solitary glands bear the whole brunt of the disease. Murchison saw two examples of this variety, which Cruveilhier designated la form pustuleuse. More commonly, Peyer's patches are the selected seat of the morbid changes, but even then the diseased processes seem to start from the ileo-csecal valve, and to extend backwards into the ileum only for a comparatively short distance. This apparent caprice of distribution of pathological changes suggested to Dr. Hilton Fagge the question whether there may not. be some cases of enteric fever in which no glands suffer at all. In a specimen exhibited by him to the Pathological Society of London in 1875, the only lesions in the intestines were the following : — " One ill-defined purplish red patch, of about the size of a shilling, situated a foot above the valve ; and a little higher up another patch, presenting similar characters, except that in its centre there was a darker spot the size of a pea, with a breach of surface, visible only when it was examined under water." 11 Hilton Fagge considered that it is by no means unlikely that in mild cases of enteric fever, such as never could prove fatal except by some accident, the intestinal lesions are often very slight, and may possibly in rare cases be altogether absent. This view is, of course, diametrically opposed to the dogmatism of Murchison, b who speaks of " the specific lesions, which are invariably present" *A Case of Enteric Fever ivith extreme ulceration of the Larynx, and hut little affection of the Ileum. Trans, of the Path. Soc. of London. 1876. Vol. XXVII., page 40. h Treatise on the Continued Fevers. Third Edition. 1881. Page 617. ENTERIC FEVER. 421 But is such dogmatism philosophical, or in accordance with analogy ? Sure, if we may have Variola sine variolis, Scarlatina sine angina, Morbilli sine catarrho, we may expect occasionally to meet with Enterica sine enteritidc. Dr. Stokes," no doubt, went too far when he said : " It would be more philosophical to say that no form of fever has any special anatomical change ; that where such does take place it is of a secondary character ; and that, when it arises in the digestive system, it is more frequently observed in one form of fever than in another." Yet there is a kernel of truth in such a statement, and so long as the essential or specific nature of each febrile disease is admitted, so long must we look upon the local lesions as secondary, and therefore accidental rather than essential. At a meeting of the Societe des Hopitaux de Paris, March, 1890, Dr. Vaillard described the following case : — A soldier after an attack of influenza became very ill, suffering from stiffness in the neck, headache, coma, constipation ; temperature, 104° F. Death on the 10th day. At the autopsy were discovered hyperemia of the meninges and lungs, and enlargement of the spleen, while the intestines were perfectly healthy. Cultivation experiments showed the presence of an organism, which appeared to be the bacillus of typhoid, in the spleen, lungs, and medulla. A streptococcus was also present. Vaillard believes that this was a case of enteric fever without the usual symptoms. In the discussion which ensued, Dr. Chantemesse stated that he had found the typhoid bacillus in a dead-born foetus, whose mother aborted during an attack of typhoid. Its intestine was perfectly healthy. It had died of typhoid septicaemia. In another case which he had observed a man died of typhoid. Many typhoid bacilli were found in his organs, but the intestine was perfectly healthy, with the exception of one ulcer of the size of a lentil. These observers therefore conclude that there may be in rare cases a typhoid septicaemia without any local lesions. On January 23, 1891, Dr. Sidney Phillips b submitted to the a Lectures on Fever. 1874. Page 238. h Trans, of the Clin. Soc. of London. Vol. XXIV., page 104. 1891. 422 ENTERIC FEVER. Clinical Society of London notes of two cases of typhoid fever, fatal at a late period of the disease without ulceration of the intestine. On November 27, 1880, I laid before the Pathological Society of Dublin specimens from a case of enteric fever in which there was no disease of the glands of the ileum, while the spleen was extremely large, soft, and friable, and in a state of putrilage. The ileum was carefully examined. In places the mucous membrane was congested to the extent of two or three inches, but there was not the slightest trace of past or present disease of the agminated or solitary glands. Peyer's patches were, indeed, apparently less distinct than usual. They were not hyperbaric, and did not present the "shaven-beard" appearance. This was, no doubt, an example of what is now known as " spleno-typhoid." (See page 406.) At the same time, in an overwhelming majority of cases, charac- teristic lesions are certainly present in the intestines of enteric fever patients. These I will now try to describe as briefly as may be. Certain facts led Dr. Hilton Fagge to the belief that during the period of incubation the invading Bacilli typhosi produce a local "infective granuloma," and that this remains latent until they (or their spores) leave the intestinal follicles by the lymphatic channels, and overspread the entire organism in swarms. Be this as it may, the primary local lesions in the intestines run a course somewhat parallel to that of the symptoms, and with Bretonneau (of Tours), Trousseau, and Liebermeister, Ave may divide the history of the development and retrocession of these lesions into four several periods of seven days each, or weeks ; or, with Murchison, we may describe the lesions as passing through four stages, although the disease is often arrested at the end of the first. These stages closely correspond with periods of seven days each, so that there is no contradiction between the several autho- rities I have just named. The stages are: — 1. The stage of enlargement of the intestinal glands (Fr. Engouemenf). 2. The stage of softening and ulceration (Fr. JOetage furonculeuse). 3. The stage of the genuine " typhoid ulcer " (Fr. Le boarbillon). 4. The stage of cicatrisation. ENTERIC FEVER. 423 I. The first stage probably begins with the disease, perhaps even in the closing days of the period of incubation. The solitary and agminate glands in that portion of the ileum nearest to the ileo-caecal valve swell, and become the seat of what Liebermeister calls a medullary infiltration. The neighbouring mucous mem- brane is usually, but not necessarily, hyperamiic. These changes go on through the first week, so that by the eighth day or so Peyer's patches are, in cases which have proved speedily fatal' found indurated and elevated from half a line to two lines above the surface of the bowel. The hardness of the diseased patches or plates varies. If marked, the patches form the plaques dures of Louis. If the enlargement is only slight, and the consistence of the patches is soft, they are the plaques rnolles of Louis. These are the plaques reticulees (the network plates), and the plaques gaufrees (the honeycombed plates) of Chomel. Dr. T. J. Maclagan endeavoured to show that the plaques molles are always excited by a secondary inoculation with poison thrown off by a plaque dure — in other words, that the plaques dures are primary, and the plaques molles are secondary lesions. This view has not been confirmed. As is well known, a Peyer's patch is a roundish or elliptical area, situated at the free border of the intestine, I'd centimetres in length, 7'2 centimetres in breadth, with its long axis corre- sponding to that of the intestine (at least, in the ileum), and con- sisting of twenty or more lymph follicles grouped together and separated from each other only by thin prolongations of the sub- mucous tissue (E. Verson a ). In enteric fever, the proper structure of a Peyer's patch first becomes enlarged by a proliferation of its cellular elements, the surrounding connective tissue next becomes involved, until, at last, the whole patch is converted into a conti- nuous mass of altered gland-tissues. This, according to Murchison, is what happens in the case of the plaques dures. In the plaques molles the morbid process stops short of this-^the glandules become enlarged, but not to such an extent as to run into one another. n Manual of Human and Comparative Histology. Edited by S. Strieker. Vol. I., page 5G5. New Syd. Soc. 1870. 424 ENTEEIC FEVER. II. The second stage is nearly completed by the end of the second week. The infiltration of Peyer's patches gradually pro- gresses, and some of the swollen patches ulcerate and become partially or wholly necrotic — the process leading to the formation of sloughs stained a bright ochre or yellow by the bile (Lieber- meister). Wm. Budd a considered that "this yellow matter is the peculiar ' typhoid matter,' whose presence is typical of the disease, and whose formation and elimination constitute the essence of the intestinal process." This view is not now entertained by any authorities on enteric fever, so far as I know. Ulceration seems sometimes to begin as an abrasion of the surface of the diseased follicles, and gradually to extend through their substance ; much oftener, however, the whole or most of the infil- trated tissue dies in a mass, forming a soft, shreddy, flocculent slough of a bright ochre colour as above (Hilton Fagge). The former process affects the plaques molles, the latter the plaques dures (Murchison). III. The stage of the " typhoid ulcer " is, in Murchison's words, that which intervenes between the commencement of ulceration and the commencement of cicatrisation. It is impossible to fix its limits, as they vary in different patient?, and in different ulcers of the same bowel. For the sake of convenience, however, we may say that ulceration usually takes place after the 9th or 10th day, and in the third week sloughs fall off, the cleaning off of the ulcers being in general well-nigh completed by the 21st day or so. " Typhoid ulcers" are distinguished by the following characters : — 1. Situation. — In the lower third of the ileum, chiefly near the iieo-ca3cal valve. 2. Size. — They vary in diameter from one line to an inch and a half. 3. Form. — If their seat is a Peyer's patch, they are elliptical; if a solitary gland, circular ; or they may be irregular from the coalescence of several ulcers. a Typhoid Fever : its Nature, Mode of Spreading, and Prevention. By William Budd, M.D., F.R.S. London : Longmans, Green & Co. 1873. Page 47. ENTERIC FEVER. 425 4. Anatomical Relations. — The elliptical ulcers are always opposite the attachment of the mesentery, and their long diameter corresponds to ihe longitudinal axis of the gut. 5. Outline. — Their margin is formed by a well-defined fringe of mucous membrane, of a purple or slaty-gray colour, one line or more in width, detached from the submucous tissue. There is no thickening or hardening of the edge, as in the tubercular ulcer. 6. Base. — This is formed by the submucous tissue, or by the muscular coat of the intestine, or by the peritoneum. As the sloughs fall off, losses of substance of variable extent and depth take place, involving, it may be, the muscular coat, and even the peritoneum. In the latter case, of course, perforation occurs. IV. At some time during the fourth week, the reparative process called cicatrisation begins, and may continue for a long time — in the case of an individual ulcer it occupies about a fortnight. Cicatrisation begins in the ulcers nearest the caecum, and proceeds upwards. The floor of the ulcer becomes covered with a thin, gray, shining layer of granulation tissue, which is dove-tailed, so to speak, between the muscular coat and the detached fringe of mucous membrane. The ulcer then heals by a gradual growth of mucous membrane from the edges towards the centre — an epithelial covering being slowly formed over the ulcer, adherent at first, but afterwards becoming movable on the submucous coat. The gland-structure which has sloughed away is not regenerated. The cicatrix is slightly depressed, firmer, less vascular, and smoother than the surrounding mucous membrane. When held up to the light, the bowel appears thinner at the part. There is no sur- rounding puckering, and the calibre of the gut is not narrowed (Murchison). According to Chomel, a all traces of the ulcers disappear after a short time, but Rokitansky b has recognised them thirty years after an attack of enteric fever. Occasionally the process of cicatrisation is much prolonged, owing to the ulcers becoming chronic, or, as some pathologists say, a Lerons cle Cliniquc Mtdicale. Tome I. Paris. 1834. b Path.Anat. Syd. Soc. London. 1852. Vol. II., page 73. 426 enteric fever. atonic. These chronic or atonic ulcers after the fourth week may cause severe diarrhoea, or may lead to fatal perforation. The pathological changes just described may proceed simulta- neously in different parts of the small intestine — being most ad- vanced near the ileo-csecal valve, where cicatrisation may have already begun while fresh infiltrations are only taking place in portions of the bowel at a distance from that centre of disease. This state of things is beautifully shown in the coloured Plate which forms the Frontispiece to this work. The original drawings, from which the lithograph was skilfully and artistically produced by Mr. John Falconer, of 53 Upper Sackville-street, Dublin, were executed in water-colours at my request by my friend and pupil, the late Mr. Edmund P. Henn, at the Meath Hospital and County Dublin Infirmary. They faithfully represent the appearances in a fatal case of enteric fever under my care in the year 1879. Fig. 1 shows two Peyer's patches and four solitary glands in the first stage of the typhoid disease in the ileum at a distance of some two feet from the ileo-ccecal valve. Fig. 2 represents the com- mencement of the second stage — that of ulceration — at a lower level in the ileum. It will be seen that at two points the tumefied Peyer's patch is beginning to ulcerate, and already a bright yellow coloration is commencing to show itself. Fig. 3 represents 4 inches of the ileum nearest to the valve, and also the neighbouring mesen- teric glands — the latter greatly swollen. In this case the slough is fully formed, and is about to be cast off from a patch between two and three inches from the valve ; while the slough from a large ulcer close to the valve itself has already been detached in part and cast off. One is not to suppose that, in every case of enteric fever, the local lesions in the intestines run through all the four stages which have been just described. On the contrary, the instances are not few in which retrograde changes may occur as early as the close of the first week. In the milder cases, the swelling (or, engouement) of Peyer's patches may gradually subside by degeneration and absorp- tion until both patches and separate follicles return to their normal state. If the follicles of a Peyer's patch retrograde faster than the ENTEKIC FEVEK. 427 interstitial tissue, this latter may for a time form a projecting net- work {plaques a surface reticulee). Frequently, the swollen follicles soften and break down, so that the patches again present a reticu- lated' appearance. Especially in this case, but sometimes with simple swelling, numerous little ecchymoses occur, so as to pro- duce a punctate pigmentation of the patches. This gives a dotted appearance to the patches — the shaven-beard appearance of English, the etat pointille of French writers. Hilton Fagge denies that this condition is peculiar to enteric fever — in this opinion he is borne out by Murchison, who has seen this change in case3 of typhus, cholera, phthisis, and so on. Perforation of the peritoneum may take place, according to Murchison, in one of three ways. 1. It may be due to disintegration, or to an extension of the ulcerative process. The opening is then always minute and circular, just large enough to admit a pin or a stocking wire. This is the most common form of perforation. 2. A portion of the peritoneum may slough, and perforation may result from the partial or complete detachment of the slough. The openings are, in this case, many and of considerable size. 3. The perforation may result from rupture of the denuded peritoneum at the base of one of the destroyed Peyer's patches. Among twenty-nine cases of perforation, of which Murchison had accurate notes, the first form was present in fifteen, the second in ten, and the third in four cases. Dr. Robert S. Archer, a formerly Physician to the Netherfield Fever Hospital, Liverpool, in narrating the clinical histories of six cases of perforation of the intestine in enteric fever, very properly draws a distinction between perforation in the proper sense of the term and rupture of the peritoneal coat at the base of an ulcer. In the case of perforation, the process would seem to be a gradually progressive necrotic one, involving in order all the coats of the gut from within outwards, the peritoneal coat at length suc- cumbing to the destructive change. The perforation is in this case usually more or less circular, and its edges are somewhat a Dull. Journ. of Med. Science. Vol. LXXXIV., page 90. 1887. 428 . ENTERIC FEVEK. thickened by lymphy deposit. Its size may vary from a pin-hole opening to one half an inch or more in diameter. Lymph is thrown out around the opening, and adhesions are in process of formation. In rupture of the peritoneal coat, on the other hand, the ulcera- tive process seems to stop suddenly at, or has not extended to, the serous membrane, and the latter gives way from the pressure of fasces or gas. In this case the opening takes the form of a more or less regular angular slit, with little or no deposit of lymph, and the edges may be brought together with considerable accuracy. The Mesenteric Lymph-glands are very commonly enlarged in enteric fever — no doubt from absorption by the lacteals of contagion from the affected parts of the intestines (Hilton Fagge). Hence it is that the swelling of the glands is most developed in these parts of the mesentery which correspond to the diseased portions of the intestine. The swollen glands may not be larger than a hazel-nut, but some may be as large as a horse-chestnut, or a pigeon's egg, or even a hen's egg. At first the swollen glands are hyperaamic, rosy red or bluish-red, tense ; afterwards, they become paler, assuming a pinkish or grayish tint. Suppuration sometimes occurs, while caseation or the deposition of calcareous salts forms part of the ordinary retrograde process. Examined histologically, the enlarged glands show a cellular hyperplasia — or numerical hypertrophy — with hypertrophy of the interstitial connective tissue (Liebermeister.) Fig. 3 in the Frontispiece exhibits very well the great enlarge- ment of the mesenteric glands near the ileo-cascal valve, which is so often present. In some cases other lymphatic glands are engaged also. For example, the retroperitoneal glands, the bronchial glands, and others — but these are secondary and accidental phenomena, usually due to non-specific irritations. The Spleen is commonly enlarged and softened, being the seat of changes which are strictly analogous to those observed in the intestinal follicles and the mesenteric glands. The enlargement begins early in the fever, and can be detected after the middle of the first week. At this period, the organ is tense, firm, and hyper- aemic. The spleen increases in size up to the third week and sub- ENTERIC FEVER. 429 sides again in the fourth week. The enlargement is most marked in young subjects, and may be wanting in elderly persons. Louis found the spleen softened in thirty-four out of forty-six cases, and in seven it was reduced to a mass of " putrilage " a (JMurchison). According to Rokitansky, the enlarged, softened spleen is liable to spontaneous rupture. Bacilli have frecpjently been found in the spleen in enteric fever. Their discharge into the general circula- tion when the organ suddenly subsides may account for some of the cases of relapse which have been recorded. Rarely, abscess of the spleen occurs. Murchison's vast ex- perience gives only two cases of this lesion, and he quotes five others from different authors. In the Buhl. Journ. of Medical Science for February, 1880 (Vol. LXXXI., page 109), will be found an interesting case in a boy, aged fourteen, which was reported by Dr. Robert S. Archer, then Physician to the Netherfield Hospital, Liverpool. Such are the primary local lesions of the disease before us. The secondary local lesions are principally of the nature of a parenchymatous degeneration with cloudy swelling of various organs — such as the liver, heart, and voluntary muscles {Myositis typhosd) — which is not in any way characteristic of enteric fever, but which is forthcoming in all febrile affections in which pyrexia is sufficiently intense and persistent. a Pultaceous or pappy matter, which forms in the course of certain necrotic or gangrenous affections. Lat. putrilago — rottenness, corruption, putrefaction. 430 CHAPTER XLIV. The Prophylaxis or Enteric Fever. Measures to be adopted for Checking the Development of the Fever Poison : Efficient drainage system. — Improved water-closets. — Drinking water to be taken direct from the main. — Use of chemical disinfectants. — Measures for Preventing the Propagation of the Fever Poison : Disinfection of excreta. — Treatment of bedding and body linen. — Ventilation of sick room. — Trace origin of first case of fever in each outbreak. " A man," says Liebermeister, a " who avoids breathing the exhalations of privies and sewers, who does not handle linen foul with typhoid dejections, who does not drink unboiled water from infected springs, is as safe in a place where a typhoid epidemic is raging as in one where not a case of the disease exists." This aphorism of Liebermeister places in our hand the key to the preventive treatment, or prophylaxis of enteric fever. The subject may be considered under two headings — 1. The measures to be adopted for checking the development of the fever poison. 2. The measures to be adopted for preventing the propagation of the fever poison. I. A careful study of Chapter IV., and particularly that portion of it which deals with the subject of disinfection without and with- in the body (page 31-38), will place the reader in possession of full information as to the best means at our disposal for achieving the first end in view — the checking or prevention of the growth and development of the specific poison of enteric fever. It is a popular error to suppose that this poison is an offensive gas which can easily be smelled. On the contrary, it is probably quite inodorous, although often accompanied by bad smells, the result of putrefaction of the retained contents in defective drains. a Von Ziemssen's Cyclopcedia of the Practice of Medicine. Art. " Typhoid Fever." Vol. L, page 71. ENTERIC FEVER. 431 1. The first essential is that there should be an efficient drain- age system — consisting of (a.) flushing apparatus, (/3.) properly laid, well-ventilated, and securely trapped house-drains, discharging into (ry.) well-constructed public sewers. This is not the place to enter into details on the subject of house- drains and public sewers (I use these terms in their strictly legal, or technical and accepted sense). But a few remarks will, perhaps, prove useful. They are based upon an excellent description in Mr. Winter Blyth's "Manual of Public Health." A house-drain should be constructed of glazed socket pipes, made of pipe-clay or a mixture of fire and pipe-clay — salt or glass-glazed. These drain-pipes should each be provided with a collar or socket at one end, so as to receive the spigot end of the next pipe, the joints being carefully filled in with Portland cement, unless a patent joint, such as Stanford's, is used. In this a sort of ball joint is made, and a little grease renders all tight. All joints should be water-tight. For ordinary ten-roomed houses, 4-inch pipes are ample. Larger houses require pipes of 5 or 6 inches diameter, and country mansions may require for the main drain a 9 -inch pipe. The pipes should be laid on a concrete bottom, with a fall of at least one in forty-eight — that is, 4; inch to a foot. When one drain joins another, the junction should be at an acute, not a right angle ; or in the form of a curve — a larger pipe must receive a smaller, not vice versa. Of late years, special lengths of pipe, gradually lessening in diameter from 9 to G inches, or from 6 to 5 or 4 inches, have been used for making such junctions. Drain pipes should not, if possible, be laid under a house. When a drain changes its direction, means of inspection should be provided. Every drain should have an " inspection chamber " at its lower end, before it enters the " intercept ng-trap," which cuts it off from the public sewer, as well as a " fresh-air " inlet in this same situa- tion, and a " ventilating shaft," carried above the dwelling-house at the highest point of the drain. In this last-named situation also a " flushing-tank " should be provided, capable of discharging into the drain through a 4-inch pipe not less than 40 gallons of water at least once a day. It is a great mistake to shut up a city 432 ENTERIC FEVER. residence for two or three months in the summer season, and to return to it in autumn without first causing the drains to be repeatedly flushed and thoroughly cleansed and disinfected. I am sure mischief to health is often caused by inattention to such details. In addition to the house-drains, water-closets require attention. They should be placed at the back of the house, and if in structural connection with it a short lobby or corridor should be interposed to secure cross-ventilation. There are three chief types of water- closet — the pan-closet, the valve-closet, and the hopper-closet. Of these, I mention the first two only to condemn them . The hopper- closet differs from both in having no mechanical parts. It is simply a funnel terminating in a siphon — a good flush of water sweeping the contents away. An improved form of the hopper- closet is known as the " wash-out closet." It is often made of glazed stoneware cast in a single piece, and is cleansed after use simply by a good flush of water. The most modern closets have neither " safe " nor wood casing. The " safe " is a lead tray on the floor to prevent any overflow soaking through. " Soil pipes," connecting the closet with the drain, should be constructed of lead, 4 inches in diameter, and run down outside the house, if feasible. Each soil-pipe should be freely ventilated by being carried full bore, without curves or bends, to a few inches above the roof-ridge. Under no circumstances should drinking water be drawn from a water-closet cistern or tank — indeed, each closet should be fitted with an automatic patent flushing tank of small size, used for the purpose of flushing alone ; while drinking water should, in every instance, be taken direct from the water-main. 2. Whenever drains or cesspools are disturbed for purposes of cleansing, chemical disinfectants should be freely used, and the household should certainly vacate the house for the time being. The disinfectants in most request are : — carbolic acid (phenol), in solution, one part in 40 parts of water (2£ per cent.) ; copperas (or ferrous sulphate), 2 ozs. to one pint of water ; Burnett's fluid (solution of chloride of zinc) ; chlorinated lime, commonly called ENTERIC FEVER. 433 "chloride of lime;" Condy's fluid (a powerful oxidiser and deodo- riser); chloralum ; and dry charcoal. The three last named are disinfectants, but not antiseptics (see Chapter IV., page 31). II. With the view of checking or preventing the propagation of the poison of enteric fever, the following means should in all cases be adopted :— •* 1. The Excreta should be disinfected as soon as they are dis- charged from the body. Both the freshly passed evacuations from the bowels and the urine should be mixed with a sufficient quantity of a solution of carbolic acid (1 in 40) or of ferrous sulphate, before they pass into the house drains or public sewers, or can permeate into the sources of drinking water. Carbolic acid is especially useful for this purpose because of its power of arresting fermentation. For the thorough disinfection of fluid or semi-fluid stools, Prof. Uffelmann recommends the following methods : Sulphuric, or hydrochloric acid, diluted with double the quantity of water, should be mixed with equal parts of the faecal matter, and allowed to stand, in the case of the former acid, for two hours ; in the case of the latter, for twelve hours. Jfn using carbolic acid, a 5 per cent, solution should be added to the stools in equal parts and left for twenty-four hours. Corrosive sublimate should be employed in a solution of 2 per 1,000, with half a part per 1,000 of hydro- chloric acid. An equal quantity of this solution is added to the motions and set aside for at least half an hour, but preferably for twenty-four hours. Quick-lime ought to be added to the stools in the proportion of 1\ parts per cent., and allowed to remain twenty- four hours. In the case of lime-water, a similar time should be allowed and the disinfectant should be employed in the proportion of 2\ parts to one of fasces. 2. The bedding and body-linen from the patient should be soaked in carbolised water (4 ounces of carbolic acid to a gallon of water). It is a good plan, also, to boil or bake these possible fomites before they are sent to the laundry to be washed. 3. The sick-room should be freely ventilated — the purity of the air in the chamber may be tested by exposing solution of per- manganate of potassium in saucers. The air is impure in direct 2 F 434 ENTERIC FEVER. proportion to the rapidity with which the beautiful purple colour of this solution changes into a dirty rusty brown tint. 4. When the first case of enteric fever occurs in a given house, every effort should be made to trace it back to its original cause. I am confident that the day is not far distant which will place in our hands an unfailing weapon of defence against the successful invasion of the body by the Bacilli typltosi of Eberth. A careful perusal of the discussion on " Immunity," which took place in the Section of Bacteriology at the Seventh International Congress of Hygiene and Demography, held in London, August 10th to 17th, 1891, will convince the reader that we stand on the threshold of a great discovery — the isolation of the substances which produce an acquired immunity in the case of each of the infective micro-parasitic diseases ; and these, of course, include enteric fever. In that discussion, Dr. Hans Buchner expressed the opinion that these protective substances were most probably albuminous bodies of very unstable constitution, and of a very complicated structure, which was specifically different in different cases. He proposed for these the name of "alexins" (Greek, ake^co, I ward off, defend). Mr. E„ H. Hankin, B.A., Fellow of St. John's College, Cam- bridge, said that the discovery of the bacteria-killing power of blood serum had led to the view that immunity was caused by a bactericidal action exerted by the blood and lymph of an immune animal. This bactericidal power was due to the presence of cer- tain bacteria-killing substances, to which the name " defensive proteids" had been given. These are the "alexins" of Buchner. They are divided into "sozins" a and "phylaxins." b Sozins are defensive proteids present naturally in the normal animal. Phy- laxins are present in animals which have artificially been made immune against a disease. The view of immunity suggested by the discovery of these defen- sive proteids or alexins by no means excludes Metschnikoff's pha- gocyte theory, because they can be obtained from cells which were, or could become, phagocytes. (See Chapter III., page 22.) a Greek : ca>£a>, to save alive, to preserve. b Greek : tp{\v£, a protector, from tyvXarrw, to guard. CHAPTER XLV. Curative Treatment or Enteric Fever. No Specific for Enteric Fever. — Principles of Treatment apply equally to this fever and to typhus. Curative Treatment or Management: Hygiene, Diet, Stimulants, Antiseptic Drugs: — Iodide of potassium, calomel, arsenic, antimony, /3-naphthol, salicylate of bismuth, salicylate of magnesium, carbolic acid, the sulphites, turpentine, free chlorine, quinine, oil of eucalyptus, cam- phor, creasote, thymol, naphthalin, salol. " There is no specific for enteric fever," writes Alurchison, "any- more than for typhus." But he adds : " Although we cannot cure the disease, Ave must treat it." While deprecating the nimia dili- gentia medici, by depletion on the one hand, or by over-stimulation on the other, he says that it must not be thought that the best treatment is one of mere expectancy. He quotes, however, with approval Baglivi's a remark on " mesenteric fever" made two cen- turies ago — "Sed cpiod pra? cieteris animadverto, in nullo morborum genere, tanta opus est patientia, expectatione, cunctationeque, ad bene et feliciter medendum, tanquam ad bene curandum febres mesentericas." The fact is that while the great principles of treatment of enteric fever are precisely the same as those which guide us in our manage- ment of typhus, there is no other disease which in the same degree taxes to the uttermost the resources of the physician. Of every "turn" in enteric fever, of every day or hour which marks its course, it may truly be said : " Latet anguis in herba." The atti- tude of the physician must be one of " armed expectancy," to borrow the expressive phrase given by Dujardin-Beaumetz b in 1889 to that form of symptomatic medication, which has also been described under the name of " the medication of indications." The Curative Treatment, or, rather, the Management of Enteric Fever falls under certain convenient headings, such as — Hygiene, Diet, Stimulants, Antiseptic Drugs, Antipyretic Treatment, Treat- ment of Complications and Sequelae, Management in Conva- lescence. a Opera Omina. Eomae. 1696. Ed. Sext. Lugduni. 1704. Page 54. b Le Bulletin Medical. Paris. Feb. 8, 1889; and Sajous' Annual of the Universal Medical Sciences. 1889. Vol. I., page H-55. 436 ENTERIC FEVER. I. Hygiene. — The patient should take to bed, as soon as possible after symptoms show themselves, in a large, airy, quiet, well- warmed and well-ventilated room. Irreparable mischief is done by men struggling against their illness day aftejr day, trying to " walk it off." In the Franco-German war of 1870-71, railroad travelling espe- cially was proved to exert a very prostrating influence on enteric fever patients. Physicians, who should know better, when they are themselves attacked by this disease, are wont to fight against it and refuse to admit that they are sick. Liebermeister a has known jDhysicians to make calls during the morning, when the evening before they had themselves seen that their own temperature was 104° F. in the axilla. Not only should the patient take to bed as early as possible, but he should not be allowed to sit up again until the evening tempera- ture has been perfectly normal for from three to six days at least. The hygiene of the sick room has been discussed at pages 44 and 49, and it only remains to emphasise the necessity for free ventila- tion. Even in winter, a window should be kept open during a great part of the twenty-four hours, at all events in the adjoining room to that occupied by the patient. " Even a strong draught of air, for a time, is harmless," for, adds Liebermeister, b " a patient with a high fever temperature cannot take cold." Attention to personal hygiene is of the first importance in enteric fever. The bed and body-linen should be changed as often as they are soiled. The body of the patient should be kept scrupulously clean. The whole surface should be carefully sponged with vinegar (1 part) and tepid water (3 parts) several times a day. Particular care should be paid to the state of the teeth. A good antiseptic and detergent tooth-paste is the following : — ~fy Pulv. Saponis Duri, gr. 60 ; Acid. Carbolic. Purissimi Liquefacti, 5 ss ; Olei Eucalypti, Si ; Cretse Prascipitata?, ad §i. M. ft. dentifricium. a Von Ziemssen's Cyclop, of the Pract. of Med. Vol. I., page 229. 1875. b Loc. cit. Page 231. ENTERIC FEVER. 437 Should erythema show over the nates, or sacrum, or great trochanters, the affected part should be relieved of pressure by a water-cushion or an air-cushion, and, as a routine practice in all cases, the surface should be gently sponged with spirit of camphor. In this way, and by paying attention to cleanliness, the occurrence of bed-sores may be averted. II. Diet. — The dietetic treatment of enteric fever is of the first importance. There can be little doubt that many patients are over- fed rather than under-fed in this fever, with the result that symptoms are aggravated, and diarrhcea in particular is increased. Let us reflect for a moment on the diseased state of a not inconsiderable portion of the digestive tract, and it will at once be evident that no solid food is admissible even if the patient did not turn from it with loathing. But, further, the powers of digestion are seriously im- paired, and the assimilation of food is well-nigh at a stand still. Our object, in the face of such conditions, should be to give the patient just so much nutriment as will keep him alive and enable him to combat the disease which is making such inroads on his strength. To secure these ends, the food should be liquid, very nourishing, easily assimilable, and exhibited in moderate quantities at rather short intervals. Von Ziemssen, in his lectures on the treatment of enteric fever, points out that no pure albuminous food and still less fatty food should be given. Frequent change and variety of flavour and consistence of food is desirable. Starch, dextrin, and sugar may be exhibited. Milk is the most complete mixture of albumen, fat, and carbo- hydrates, and is an excellent food in enteric fever. Von Ziemssen does not give more than one pint as a rule in 24 hours. Freshly expressed meat juice, consisting of serum, lymph, and blood, forms an acceptable and highly digestible food. Frozen meat-juice is also well borne. If eggs are given in clear meat broths, not more than three should be administered during 24 hours. Jellies prepared from fresh calves' feet with white wine, are refreshing and grateful. According to Stromeyer, the best thing to give to enteric fever patients is oaten grits, cooked for three hours, and given without sugar (Liebermeister). 438 ENTERIC FEVEE. The nearest approach to an ideal food for a fever patient is milk. In making this statement I do not wish to be misunderstood. There are some patients who cannot tolerate a milk diet. In other cases, patients are, as it were, poisoned with milk given in excessive quantities. Here, as in all other things, we must judge each case on its own merits. The fact remains that in an overwhelming majority of instances, a milk diet is the best and safest for a fever patient. It is scarcely ever necessary to exceed the amount of one quart of milk in the 24 hours — that is, 40 fluid ounces. This quantity should be given in divided doses at regular intervals of one, two, or three hours, either plain, or, preferably, mixed with warm water. If it passes through the bowels in the form of lumpy, undigested curd, it should be peptonised, with liquor pancre- aticus, or Fairchild's zymine peptonising powders. Or, it may be boiled and mixed with lime-water in the proportion of three parts of milk to one part of lime-water. The " liquor calcis saccharatus'" of the Pharmacopoeia maybe substituted for the lime-water in pro- portionate parts, the lime-water containing half a grain of CaO in the ounce, whereas the saccharated solution contains 7*11 grains. Four ounces of milk for a meal would give 10 feedings a day, at intervals of nearly 2i hours. Some of the milk, however, may be given in freshly-made tea in the morning, and some of it may be given as junket, or rennet, or in the form of custard, or blanc- mange (made with isinglass and milk), or cream. In the earlier stages of the fever, the feeding should be chiefly by day ; afterwards, the meals must be given by night as well as by day, unless the patient is in a wholesome sleep (not somnolence or coma). Besides milk, animal broths may be allowed to the extent of one pint in the 24 hours. Four such broths may be mentioned — beef -tea, chicken broth, or chicken jelly, veal broth, and mutton broth. Of these, the first and last are laxative, and, therefore, should not be given when diarrhoea is present. Beef-tea is parti- cularly valuable because of its stimulating power, especially upon the heart. It may be flavoured with a little tomato juice or a stick of celery, I have often found it a good plan to mix beef -tea and chicken jelly in equal parts, when a patient tired of either singly. ENTERIC FEVER. 439 Also, towards convalescence, tapioca, sago, or well-boiled rice, may be added to the broth in moderate quantities. The laxative effect of broth is lessened by adding a little isinglass (gelatin) or arrow- root to it. In very prostrate conditions, Liebig's beef- tea, prepared by macerating lean meat, chopped very fine, with hydrochloric acid, and a little salt, will be found a valuable food. A receipt for thifl preparation will be found at page 513 of Dr. F. W. Pavy's " Treatise on Food and Dietetics " (1874). If it is desired to give stimulants and food together, a tea- spoonful of brandy or whisky may be added to each teacupful of warmed milk, or the excellent egg and brandy mixture of the Pharmacopoeia (mistura spiritus vini gallici) may be prescribed. As a beverage, pure water may be taken without stint. All through the fever cold water is the most grateful drink. When the tongue is furred and dry, a teaspoonful of glycerine or of glycerine of borax may be added to each tumblerful of drinking water ; or the tongue, gums, and mouth generally may occasionally be painted with a linctus like the following, which will prevent or check the formation of sordes : — 1^ Potassii chloratis, gr. 30 ; Acid. Borici, gr. 20 ; Glycerini, Succi Limonis, aa §ss. Fiat Linctus. Other diet drinks or tisanes, for occasional use according to circumstances are : — Toast and water, barley-water flavoured with oil of lemon (lemon rind), red or black currant jelly in hot or cold water — very grateful where sore throat is present, or strained tamarind tea (Hilton Fagge). Ice may be sucked, but it some- times parches the mouth and lips rather than affords relief. Von Ziemssen recommends thin oat- and barley-water, the flavour being varied by the addition of sugar, cinnamon, wine, &c. Seltzer water, or other similar mineral waters, the mineral acids in water, with or without sugar, thin milk of almonds (mistura amygdalae), and a thin decoction of parched rice (especially where 440 ENTEKIC FEVEE. there is a good deal of diarrhoea) are added to the diet drinks by Liebermeister. In advanced stages of this fever, or where tympa- nites is a troublesome symptom, aerated waters are contra-indicated. III. Stimulants. — The rules already laid down for the admi- nistration of alcohol in acute disease apply in general to enteric fever (see pages 58 and 310). On the whole, stimulants are not so much required in enteric fever as in typhus, because the patients are often younger, and the heart is less affected. But it is often necessary to prescribe them — never as a matter of routine, but in definite doses and at specified intervals, just like any other medicine. Failure of the circulation, pulmonary congestion, and general depression are the indications for the giving of stimulants. Brandy in milk, or diluted and sweetened, agrees best with young children. Burgundy, port, and good claret suit adults, and old people are bene- fited by whisky, brandy, or champagne. The presence of albuminous urine, and, still more, of other evidences of nephritis, is an indica- tion for the very cautious administration of alcoholic stimulants. IV. Antiseptic Drugs. — As yet, we possess no specific for the prevention or cure of enteric fever. At the same time, certain drugs appear to have a distinctly beneficial effect in the disease where judiciously and properly administered. Passing by the treatment by means of iodide of potassium, ad- vocated by Sauer in 1840, and revived by Magonty in 1859, and von Willebrand in 1866 — the last-named using a solution of one part iodine, two parts iodide of potassium, and ten parts water, giving three or four drops in a glass of Avater every two hours, we find calomel in large, or small and repeated, doses recommended by many distinguished authorities, such as Lesser (1830), Traube, Wunderlich, Liebermeister, and von Ziemssen in Germany ; and Bouchard in France. Liebermeister has given this remedy, with but few exceptions, to every case of the fever (about 800 in number) admitted before the ninth day of the disease, in three or four eight- grain doses during the first twenty-four hours of treatment. In his hands, the death-rate fell from 18*3 per cent, among 377 patients treated non-specifically to 11*7 per cent, among 223 patients put on the calomel treatment. Further, he found that the use of calomel ENTERIC PBVBK. 441 materially shortened the duration of the disease and diminished its intensity. Bouchard considers that general antisepsis is secured by mercurial preparations. During four days, only at the begin- ning of the fever, the patient should take daily twenty pills of 2 centigrammes of calomel (6 grains in all). On November 16, 1883, I reported to the Medical Section of the Academy of Medicine in Ireland the case of a man, aged twenty, a grocer's assistant, who was admitted into Cork-street Fever Hospital on September 28, 1883, on the eighth day of a severe attack of enteric fever. The fever ran a course of four weeks, and was characterised by a succession of high temperatures during the first twenty days, ataxic symptoms, obstinate constipa- tion, hypostatic congestion of the lungs, and right basic pneumonia. Furthermore, treatment of a decidedly active kind Avas employed, and apparently with marked benefit to the patient. On five sepa- rate occasions twenty grains of quinine were given as an antipy- retic in two quickly succeeding doses of ten grains each ; twice the wet " pack" was employed for two hours at a time to control the pyrexia ; and on three occasions, at intervals of forty-eight hours, ten-grain doses of calomel, guarded with a grain of opium, were administered as an antiseptic aperient. The administration of calomel in large doses in enteric fever is nothing new, and is much thought of in Germany at all events. 3, "-After the accurate observations of Wunderlich," says Niemeyer, b " we can scarcely doubt that by this remedy we may, in some few cases, cut short the disease (according to Wunderlich one or two five-grain doses are enough), and that in the great majority of cases where this remedy is given during the first week, and before the occurrence of much diarrhoea, the course of the disease is rendered milder and shorter. The experience of Pfeufer's clinic, as well as my own, perfectly agrees with Wunderlich's. We shall not attempt to say whether the calomel has a favourable influence on the typhous intestinal disease by opposing the sloughing and n Cf. Von Ziemssen's Cyclopaedia of the Practice of Medicine. Vol. I., page 200. "Acute Infectious Diseases." b Loc.cit. P. -647. 442 ENTEEIC FEVER. ulceration, and whether, consequently, we can expect benefit from it only in the first weeks of the disease, when these changes have not yet taken place." Niemeyer's observations have recently gained additional weight in an unexpected and interesting manner. Dr. Wassiljeff some years ago studied experimentally, in Hoppe-Seyler's laboratory, the influence of calomel on fermentation and bacteria. He found that the presence of one part of calomel in from twenty to one hundred parts of fibrin or fat, did not interfere with the action of the unorganised ferments of the saliva, gastric juice, and pancreatic juice ; but the calomel did prevent the formation of certain decom- position products — as indol, phenol, skatol, creasote, and hydrogen sulphide. The calomel also prevented butyric acid fermentation. The action of calomel upon bacteria or micrococci was next studied, according to the Buchholtz-Wernick method. It was ascertained that the drug destroyed these organisms and prevented the appear- ance of new ones. From this it seems that calomel destroys organised ferments, but is without effect upon the unorganised ones. So far, all the experiments had been outside the body. Now, ex- periments were made on three dogs. They were given one grain of calomel each, and after some hours were killed. The intestines were ligated in the upper part of the duodenum and in the lower part of the colon, and the entire contents were carefully examined. In no case could the putrefactive products, indol, skatol, hydrogen sulphide, &c, be detected. It would seem from this that much of the good which calomel is known to accomplish in various intestinal troubles is due to its aseptic properties. 3. Remembering, then, these aseptic or antiseptic properties of calomel, I felt no small degree of confidence in prescribing it in combination with opium — itself an antiseptic — in a case where persistent, constipation during an attack of enteric fever, charac- terised by very high temperatures, was only too likely to lead to the formation of decomposition products in a diseased intestine. Other antiseptics, among very many which have been recom- a The Physician and Surgeon, and Dublin Journal of Medical Science for October, 1883. Page 327. F.XTKKK FKVKl;. 443 mended, are — arsenic, by Dr. Frederick Kirkpatrick a ; antimony, by Surgeon-Major Edward Lawrie, b Residency Sm*geon, Hydera- bad ; /3-naphthol, by Prof. Boucbard, of Paris ; hydronaphthol, by Michell Clarke ; c carbolic acid, by Dr. F. Sidney Gramshaw, d of Easingwold, Yorkshire ; tbe sulphites, strongly recommended by Professor Polli, of Milan ; and, above all, turpentine — an old- fashioned and most valuable remedy, free chlorine, and quinine. Arsenic usually controls diarrhoea ; it is a heart-medicine, and helps the patient to combat the adynamia of the fever. It may be given with acids in the form of the hydrochloric solution — 1 to 5 minims for a dose thrice daily. Surgeon-Major Lawrie gives the antimony as recommended by Dr. Kent Spender, e of Bath, in frequently repeated small doses — one-sixteenth of a grain of tartar emetic every hour or every two hours. He finds that it cuts enteric fever short " with such certainty that it almost appears doubtful whether the lesion of typhoid is specific, or is not rather incidental or adventitious." Professor Bouchard f uses and recommends /3-naphthol, reduced to a fine powder and mixed with salicylate of bismuth. One hundred and fifty grains of /3-naphthol are mixed with 75 grains of salicylate of bismuth, and this is divided into thirty powders. From three to twelve of these are given in the 24 hours, enclosed in a wafer, and swallowed with the food. The /3-naph- thol, insoluble in water, glycerine, or alcohol, reaches the intestine in consequence, and there acts as a powerful disinfectant, certainly deodorising the evacuations (J. Burney Yeo). Dr. Leroux leaves out the bismuth from this combination when diarrhoea is not urgent ; and if, on the contrary, there is constipa- tion, he substitutes for it salicylate of magnesium until the bowels are free. It was Huchard, of Paris, who first recommended this a Dull. Joum. of Med. Science. Vol. XCL, page 420. 1891. b Report oil the Civil Medical Department of His Highness the Nizam's Government for 1888 (1279, Fasli). Hyderabad. 1889. Page 18. The Practitioner, December, 1888, and Journal de Med. et de Chir. d The Lancet, June, 23, 1888. e The Practitioner, March, 1885. f Therapeutique des Maladies Infcctueuses. Paris. 1889. 444 ENTERIC FEVER. salt instead of bismuth salicylate. The drug acts both as an anti- pyretic and as an antiseptic in doses of 50 to 100 grains daily. Its laxative action is not great, so that its use is not contra- indicated in cases where diarrhoea is copious. The formula of the salt is as follows : — (c 6 H 4 ^ C ^) 2 Mg+4H 2 0. It contains 74*6 per cent, of salicylic acid (Pharra. Post, March 18, 1888). Dr. J. Michell Clarke, of Bristol, recommends hydronaphthol in the treatment of enteric fever. It is a grayish-white crystal- line powder, with a slight iodine odour, of somewhat indefinite composition, but yielding on repeated crystallisation a substance corresponding to /3-naphthol. Dr. Clarke finds that it agrees with patients who are on an exclusively milk diet, although with other diets it is very apt to disagree. He prescribes 2 or 3 grains in gelatin capsules, or simply suspended in milk, or in a keratin- coated pill. This dose may be given, when diarrhoea is present, every two hours for the first three to six doses ; afterwards every three or four hours. For children under one year the dose is half a grain, older children may take half a grain to one grain every hour, every two hours, or less often. Carbolic acid is ordered in a mixture, of which this is the formula : — fy Acid. Carbol. Purissimi (Calvert) Liquefacti, min. xii ; Tinctura? Iodi. (B. P.), min. xvi ; Tincturoe Aurantii Cort., 3iss ; Syrupi Simplicis, 5iii ; Aqua?, ad Sviii- Dose : One ounce every four hours for the first fortnight, or until the urgent symptoms yield, and then three times a day. If vomiting is excited, the dose of carbolic acid should be reduced, and a small quantity of dilute nitro -hydrochloric acid should be added to the mixture. Dr. Gramshavv rarely noted carboluria as a result of the treatment, which causes diarrhoea to cease. The sulphites, recommended by Polli, seemed to Murchison to excite diarrhoea in some cases, and not to be of much use. Twenty ENTERIC FEVEK. 445 grains of sulphite of sodium, or from 1 to2 drachms of sulphurous acid, largely diluted, may be given every four hours. Dr. Wilks, of Asli- ford, in a paper published in the Brit. Med. Journal, so long ago as 1870, claimed for sulphurous acid that it arrested the further develop- ment of the poison of enteric fever, and was, in fact, an antidote. Turpentine is an excellent diffusible stimulant, and an antiseptic of great value. It relieves chest complications, controls diarrhoea, checks meteorism, and stays intestinal haemorrhage. To secure the last-named object, it may be prescribed Avith ergot, according to the formula already given at page 124. In other cases, and for other purposes, 5 to 10, 15 or 20, minims of rectified spirit of tur- pentine may be given every second or third hour in capsule, or r perle, or mixture. Should albuminuria, or nephritis be present, turpen- tine must be administered with caution. Years ago this remedy was given with good results in adynamic fevers in the Meath Hospital in the form of " Turpentine Punch." It was introduced by Mr. Parr, the apothecary to the hospital. A good way of prescribing it is with spirit of nitrous ether as follows : — fy Spt. Terebinth. Rectificati (or Olei Terebinth.), 3ii ; Spt. iEtheris Nitrosi, 3i ; Spt. Chloroformi, 5ii 5 Misturae Amygdalae, ad gvi. Misce. Ft. mist. Signa : " Half an ounce for a dose." The Confection of Turpentine of the British Pharmacopoeia may be prescribed in 60 grain doses with peppermint water ; or the official oil of turpentine emulsified with yolk of egg may be given with spirit of chloroform and peppermint water. According to Dr. W. Whitla, a Dr. E. Nelson prescribes the drug thus : — B Olei Terebinth, 3iii ; iEtheris, 3i" '■> Syrupi Tolutani, ^i; Mucilaginis Acaciae, |i; Aquae Menthae Piperitae, ad ^viii. M. ft. mist. Signa ; " Half an ounce for a dose." a Elements of Tharmacy, Materia Medica, and Therapeutics. By William Whitla, M.D., J.P. 1889. Page 520. 446 ENTERIC FEVER. Professor Horatio C. Wood, of New York, bears eloquent testi- mony to the usefulness of oil of turpentine in enteric fever. He gives his uncle, Dr. George B. Wood, the credit of introducing this drug into the treatment of enteric fever. Professor Wood adopts the following formula : — r^ Olei caryophylli, min. vi ; Olei Terebiuthinaa, 5iss ; Glycerin i, Mucilaginis acacia?, aa, $ss ; Syrupi et aquae, aa ad giii. M. ft. mist. Signa : " A dessertspoonful to be given every two hours during the day." In intestinal haemorrhage, 20 minim doses of oil of tui'pentine every hour or every second hour is an efficient remedy. Both Sir Thomas Watson and Murchison, and quite recently Burney Yeo, a highly recommend free chlorine as a useful anti- septic in this fever. The liquor chlori of the Pharmacopoeia may be prescribed in 20 minim doses with the mineral acids, or we may prepare a fresh solution of chlorine gas as recommended by Dr. Yeo. " Into a twelve-ounce bottle put thirty grains of powdered potassic chlorate, and pour on it 40 minims of strong hydrochloric acid. Chlorine gas is at once rapidly liberated. Fit a cork into the mouth of the bottle, and keep it closed until it has become filled with the greenish yellow gas. Then pour water into the bottle, little by little, closing the bottle, and well shaking at each addition until the bottle is filled." . . . "To twelve ounces of this solution for an adult, I add twenty-four or thirty-six grains of quinine, and an ounce of syrup of orange peel, and I give an ounce every two, three, or four hours, according to the severity of the case." Dr. Yeo says that this is pleasanter to take than the official liquor chlori. The tongue cleans quickly, and the foetor of the evacuations subsides. Dr. Yeo thinks that we obtain not only an intestinal but also a general antisepsis by this treatment. a Treatment of Typhoid Fever. London. 1891, Page 29. EMEIilC FEVEK. 447 Ebertli, in experimenting with the Bacillus typhosus, found that quinine checked its culture. This observation enhanced the opinion long entertained that this substance was not only an antipyretic but an antiseptic in enteric fever. W. Vogt, of Berne, Iiebermeister, of Tubingen, Bouchard, of Paris, and Clement Cleveland, of New York, all recommend that the system should be rapidly saturated with quinine early in the fever. To adults Liebermeister usually gives from 22^ to 45 grains of the sulphate or hydrochlorate of quinine, in powders of 1\ grains each, every ten minutes. He does not repeat these large doses for 48 hours. Quinism is genei-ally produced to an extreme degree. Bouchard gives 30 grains every third evening, in four equal doses of 7^ grains each every half hour during the first fortnight. In the third week, the 30 grains are reduced to 22^ grains, and in the fourth week to 15 grains every third day. Dr. Clement Cleveland a gives from five to ten grain doses every fifteen minutes for two hours. At other times he gives from 5 to 10 grains every two or three hours. When this treatment agrees, the patients seemed to him to recover more quickly and perfectly, and Avith fewer sequehe. He Avas also impressed with the fact that the death-rate is much loAver Avith the quinine treatment than with the expectant plan. Professor Grancher, of Paris, gives a child, aged five, from 15 to 22|- grains, divided into three doses, e\ T ery half hour at about 5 or 6 p.m. The child usually sleeps after these large doses. Dr. Grancher believ T es that quinine has a specific antiseptic action in enteric fever. Burney Yeo, as already mentioned, gives moderate doses in com- bination with chlorine. The foregoing by no means exhausts the list of antiseptics recommended in the treatment of enteric fever. Dr. Burney Yeo quotes the folloAving additional remedies : — Mr. Kesteven, of Brisbane, in the Practitioner of May, 1885, and of April, 1887, wrote in Avarm praise of the value of oil of eucalyptus in this disease. He gave it in 220 cases, many of whom a Neic Turk Medical Record. Nov. 20th, 1886. 448 ENTERIC FEVER. had a " bad start," and lie had only four deaths. The dose employed was from 5 to 10 minims, in emulsion with mucilage every four hours. He combined with each dose half a drachm of sal volatile, half a drachm of spirit of chloroform, and half a drachm of glycerine. Dr. Janeway, of New York, highly recommends camphor, not only as an excellent antiseptic, but also as a cardiac stimulant. In the Dublin Journal of Medical Science for November, 1879 (Vol. LXVIII, page 411), Mr. George B. White, F.R.C.S.I., reported a case of enteric fever of nine weeks' duration complicated with acute cerebral symptoms, phlegmasia dolens of the left leg, and rigors, in which a very large dose of camphor (more than 40 grains), given by mistake, was followed almost immediately by good results. In dispensing a mixture ordered to be compounded with camphor water, spirit of camphor was substituted, and the patient, a lady aged 21, swallowed 40 grains of camphor in nearly one ounce of "rectified spirit. Pe'cholier, of Montpellier, is an advocate for the administration of creasote both by the mouth and in enemata, while thymol has been given by Dr. F. Henry, in doses of a grain and a half, or two grains, made into a pill with soap, every six hours. The Italian physician, Testi, a has also given thymol in 150 cases of enteric fever with good results. L. Wolff, b in a recent paper, speaks highly of naphthalin as an antiseptic remedy. His opinion is based on its employment in one hundred consecutive cases. This remedy was proposed by L. Natanson in a communication, entitled " La Naphtaline dans la Fievre Typholde." c Edgar Hirtz prescribes salol, in combination with salicylate of bismuth, in doses of 60 grains (4 grammes) a day. It appears to act like naphthol. The stools lose their foetid odour, the tongue cleans rapidly. It is valuable from two points of view : it effects first an intestinal antisepsis, next an urinary antisepsis, for it is a Allgem. Wien. med. Zeitung. No. 9, page 90. 1889. *> Medical Nms. Philadelphia. 1891. LVIII., pages 569-572. c Bulletin de la Soc. de Med. prat, de Paris. 1891. Pages 161-163. ENTERIC FEVER. 449 broken up in the system into salicylic acid and carbolic acid, which are eliminated in the urine."' A combination of /3-naphthol with salicylic acid, known as the salicylate of naphthol, or briefly betol, has been in use for some time as a substitute for /3-naphthol. The composition of this pre- paration is, however, not constant, and it sometimes injures diseased kidneys. MM. Yvon and Berlioz, of Paris, have recently drawn attention 5 to the value as an intestinal antiseptic of benzoate of /3-naphthol, or, as they term it, benzonaphthol. It is obtained by acting on /3-naphthol with benzoyl chloride. When purified by repeated solu- tion in and crystallisation from boiling alcohol, and, finally, by means of a dilute solution of caustic soda, it appears as a white crystalline powder without taste or smell. Its formula is C 10 H 7 O (C 7 H 5 0). When introduced into the intestinal canal it breaks up into /3-naphthol, which remains in the intestine, and benzoic acid, which passes off in the urine in combination with alkaline bases, or is converted in greater or less amount into alkaline hippurates. Benzonaphthol should be given in small doses frequently re- peated — 4 to 8 grains in wafer paper, or suspended in syrup and water every three or four hours. An adult may take up to 5 grammes (75 grains), a child up to 2 grammes (30 grains) a day. Although I have felt it a duty to bring forward the foregoing long list of drugs which are now employed in the treatment of enteric fever, I thoroughly agree with Dr. Hilton Fagge when he says that " at present the most rational and successful treatment of this, as of most other fevers, is to help the patient by rest, suit- able food, and good nursing ; to watch carefully and intelligently, and to interfere when complications arise but not before." In fact, the attitude of the physician who is in attendance upon a patient in enteric fever should be that of watchful, intelligent, and armed expectancy. a La Pratique Journali ere des ffdpitaux de Paris. 1891. Page 166. b Le Proyres Medical, Nov. 14, 1891, and The Practitioner, Dec, 1891. 2 G 450 CHAPTER XL VI. Curative Treatment of Enteric Fever {Continued). Antipybetic Treatment : (1). The Water-treatment (hydrotherapy, or balneotherapy), cold, cooi, and warm baths ; immersion treatment (Dr. James Barr) — Description of Apparatus — (2). Reduction of Temperature by means of the Ambient Air (de Souza). — (3). Antipyretic Drugs : Quinine, salicin, salicylic acid, the salicylates, salol, phenazone, acetanilide, kairin, thallin, digi- talis, veratria, resorcin or thymic acid with acetanilide — Hilton Fagge's Placebo. V. The antipyretic treatment of enteric fever is based on the clinical experience that a continuous and protracted high tempe- rature inflicts grave injury upon the nervous system, the muscular tissues, and particularly the heart. It is not the mere height of the thermometer at a given moment which is harmful, but a temperature which is persistently above normal. A temperature ranging from 98° or 100° at one time of the day to 106° at another time will do less harm than a temperature which keeps continuously high at 102° or 103°. Another noteworthy fact is that childreu, as compared with adults, not only become feverish more easily and quickly, but also bear high temperatures much better. Hence, it is not necessary to take the same active steps to reduce pyrexia in the very young which we must adopt if adults are to be saved when stricken by fever. (A.) Far in advance of all other means for reducing temperature in enteric fever stands the water treatment. The reasons for this pre-eminence are given in Cantani's Address on " Antipyresis,'' to the Tenth International Medical Congress at Berlin. To this classical oration reference has already been made at page 53, and in the same place the reader will find a full accouut of the different ways in which this method of treatment may be carried into effect. First adopted by Currie, of Liverpool, in 1787, the cold water treatment of fever fell into abeyance for many years. Its revival ENTERIC FEVER. 451 was due to Ernst Brand, a of Stettin (1861) and Jiirgensen. b of Kiel (1866); and since the publication of the results obtained by these writers, this method of treatment has been widely adopted in Germany, France, America, Australia, and England. In 1880, Dr. Cayley, of the London Fever Hospital, discussed the subject at length in the Croonian Lectures, and in the third edition of Mur- chison's " Treatise on the Continued Fevers of Great Britain," he gives a full account of his practical experience of the cold bath treatment, both at the London Fever Hospital and at the Middlesex Hospital. Dr. Hilton Fagge c describes the practical application of the water treatment very succinctly as follows : — " When we have decided on bringing down the temperature, there are several ways of accomplishing it. One is to place the patient at once in a cold bath of 60° or 65° F. The shock may sometimes serve as a useful stimulus ; but it is almost always better to use a tepid bath of 90° to 85° F., and rapidly cool the water with lumps of ice. The temperature is best watched by means of a thermometer in recto, and it must be remembered that it will most likely fall considerably after removal from the bath. Another important precaution is to give brandy immediately after, or even before, the bath, so as to stimulate the heart, and further the cutaneous circulation. Currie's original plan of cold affusion is best adapted to relieving headache and delirium with pyrexia by directing a douche upon the head. The practical difficulties of a bath in the case of adult patients, and the serious disadvantage of lifting and moving them — it may be many times in a few hours — speak strongly for applying cold to the surface as they lie in bed. For this purpose the ' wet pack ' has been often used with good success. It is usually soothing and sedative as well as antipyretic, but it is less effectual than the bath, and sometimes is resented. Another plan is placing bladders of ice in the axilla and over the a Hydrotherapie des Typhus. Stettin. 1861. b Klinische Studien iiber die Behandlung des Abdominal -typhus mittelst des Jralten Wassers. Leipzig. 1866. Principles and Practice of Medicine. Third Edition. 1891. Vol. L, page 172. 452 ENTERIC FEVER. great vessels of the neck and thighs, or fixing a c<>il of Leiter's tubes in the same regions and feeding them from a receptacle of iced water placed over the patient's bed. But in many — perhaps in most — cases, the easiest and safest is also the most efficient method, namely, sponging the surface with cold water, or rubbing the trunk and limbs with pieces of ice, as the patient lies on a blanket with a waterproof sheet under it. Even when there does not appear any call for active interference, sponging the face, arms, and legs with cold water or spirit lotion, is grateful to the patients, and is often followed by tranquil sleep." According to Prof. Paul Lefort, a Parisian physicians are now practically unanimous in recommending " la Balneotherapie " in enteric fever. He quotes, as joining in a chorus of approval of this method of treatment, Bouchard, Hayem, Millard, Chauffard, Geiin-Rose, Juhel-Re'noy, and Josias. Gerin-Rose advises that the patients, in addition to having baths at 30° C. (86° Fahr.), for twenty minutes at a time, four times a day, should drink as much [water] as possible ; and Debove says : " II ne suffit pas de le laisser boire, il faut le /aire boire" adding: "Perhaps, indeed, if cold water baths have any beneficial effect, they owe it simply to the diuresis which they induce." Josias. is rapturous in his praise of cool baths, given at 18° C. (64*4° F.) every three hours and for 15 minutes at a time. These baths should be suspended only in cases of intestinal haemorrhages. Menstruation, affections of the respiratory organs (bronchitis, pulmonary congestion, pneumonia, emphysema), or of the renal organs (albuminuria), offer no contra-indication to the employment of baths. v ' Thanks to cold baths," he says, " a typhoid fever is no longer 'typhoid' except in name; patients thus treated are no longer prostrate, present no stupor, but remain lively and clear-headed ; their tongues are moist, their thirst is extreme, which permits of an allowance of some 4 to 5 litres (7 to 9 pints) of liquids, nourishing or otherwise. Excessive diarrhoea and polyuria are observed ; this diarrhoea, but particularly this polyuria, are such that the patient a La Pru^'ve Journaliere des Hdpitaux de Paris. 1391. Pages 163, et seq. ENTERIC FEVER. 453 may be considered as daily washing out his intestines and kidneys. But, in an infective disease like typhoid fever, such a flushing, carrying away all the waste of the organism, should not be regarded save as a positive advantage." An interesting discussion on the treatment of enteric fever took place before the Berlin Medical Society in the Session of 1881-85. a Senator, in opening the discussion, observed that at the General Hospital at Hamburg, between 1874 and 1877, 937 cases were treated without cold baths and 568 by means of them, the mortality for the two systems of treatment being identical, viz., 7'2 per cent. In his opinion, as a mere antipyretic, phenazone (antipyrin) and such like drugs, act better tlian a cold bath, but the latter is most beneficial as a cutaneous stimulus. Goltdammer, who advocated cold baths, stated that of 3,600 cases treated at the Bethaneum the mortality was 12'8 per cent., but that if the cases which were admitted later than the second week (of which the mortality was 36 per cent, and which, there- fore, had no baths during the most important period) were excluded, the mortality fell to 9 per cent. The mortality of cases over forty years of age was 41 per cent. During the years 1849-64 the typhoid mortality in the Second Army Corps at Stettin was 25*9 per cent. ; after the introduction in 1865 of cold bathing it fell to 8 per cent. The mortality among the cases in the Prussian Army is 10 per cent., in the Austrian 26-8, in the Italian 28*36, and in the French 36 - 5 per cent. The expectant method, Goltdammer considered, gave very bad results. Sajous, b who may be regarded as a recognised exponent of American medical opinion, writing in 1891, says that "the Brand treatment seems at last to be winning its long-deferred recognition as the method par excellence of managing enteric fever."' He quotes the favourable opinion of the method expressed by Dr. F. E. Hare, Resident Medical Officer in the Brisbane Hospital, Australia, in two a Verliandlungen der Berliner mediciniscken Geselhchaft, 1884-85, and London Medical Record, December 15, 1886, page 557. b Annual of the Universal Medical Sciences. 1891. Vol. I. H.-54. 454 ENTERIC FEVER. communications on the subject. Tn the latter of these,* Dr. Hare compares the mortality in 1,828 cases during the period of expec- tant treatment (271 deaths, or 14*8 per cent.) with that in 171 cases during a period of incomplete bath-treatment (21 deaths, or 12-3 per cent.) and in 797 cases during the period of strict bath treatment (56 deaths, or 7'0 per cent.). In the last group, 15 of the fatal cases should be deducted. Excluding these, 782 cases gave a death-rate of 5 -2 per cent. In The Lancet for 1890 (Vol. I., page 690) Dr. James Barr, Physician to the Northern Hospital, Liverpool, speaks highly of prolonged immersion in what he calls the "tank bath." He illus- trates his communication with notes of a series of cases — nine in number — in which he employed this method. In addition to these, three other cases were treated by him in the same way. All the twelve patients recovered. They were immersed for periods vary- ing from six to thirty-one days. The "tank" used at the Northern Hospital, Liverpool, consists of a well-made wooden box 6ft. long, 2ft. 10 inches wide, and 12 inches deep. It is lined with lead, which is painted white, and coated with a thick layer of shellac varnish. The shellac makes the tank, on other occasions, a convenient medium for administering electric baths. Each tank is provided with a large discharge pipe, which in the case of these tanks communicates with a soil-pipe, Which leads down to the sewer : the tank, containing 70 gallons of water, can thus be emptied in three minutes. To the tanks hot and cold water are plentifully supplied. Each tank is provided with a sheet of bed-ticking, which would almost allow the patient to be submerged, but at the head there is a strip, about a foot wide, which does not sink so deeply, and on which rests an air-pillow so as to keep the head above water. The patient is wrapped up in a blanket and completely immersed, except the head. The tank is covered with a half lid, which pre- vents the weight of the bed-clothing resting on the patient, a water- proof sheet, and bed-clothing to keep in the heat of the water. A thermometer is kept constantly in the tank. As long as the B Australasian Medical Gazette. July, 1889. Sydney. KNTEUiC FEVER. 433 patient's temperature is over 100°, the temperature of the tank need not rise above 90° to 93° ; but as the body temperature approaches the normal, so also should the tank temperature. Dr. Barr did not find it necessary to lower the temperature of the water below 90° or to raise it above 98°. By regulating the heat of the water in the tank, there is no fear of any collapse, as the temperature of the body cannot fall below that of the surrounding medium. Anxious that the patients while immersed should be as little disturbed as possible, Dr. Barr enjoined them to pass their urine and faeces into the tank. But he himself admits that there are grave objections to this, and that so far he has been unable to devise satisfactory means of rendering the water in the tank aseptic. Hence he thinks it will probably be best in most cases to raise the patient above the water while the bowels are being moved. The patients subjected to the immersion treatment were kept chiefly on a milk diet, but Dr. Barr found that in the tank they digested boiled bread and milk very well, notwithstanding the opinion of Dr. Lauder Brunton that farinaceous food in enteric fever on several occasions seemed to him " to afford a more favour- able nutrient medium to the bacilli." None of the patients had any alcohol during their residence in hospital. Also, they had very little physic. When there is constipation calomel in small doses appears to Dr. Barr to be perhaps the best purgative. Naph- thaline, as recommended by Rosenbach, was prescribed to procure intestinal antisepsis, chiefly on account of its very slight solubility. The effects of the immersion treatment were briefly the follow- ing:— 1. Temperature. — Dr. Barr considers that the tank effects a true antipyretic action, where the thermogenesis is diminished, the thermolysis regulated, and the thermotaxic mechanism is improved. 2. Circulatory System. — There is a marked improvement in the vaso-motor tone : the blood-vessels become smaller and firmer ; the pulse slower, fuller, and of improved tension ; the heart maintains its vigour. There was no intestinal haemorrhage in any of the cases, and Dr. Barr is inclined to think that the tank lessens the iability to this complication, because, without doubt, the improved 456 ENTERIC FEVER. vaso-motor tone extends to the abdominal vessels, as shown by the lessened diarrhoea, the diminution in the distension of the abdomen, and the rise in the arterial tension. 3. Respiratory System. — The rate of breathing lessens in frequency, the bronchitis and congestion of the lungs improve and soon disappear. 4. Digestive System. — The improvement in the digestive tract is, perhaps, more marked than anywhere else. The tongue becomes moist and clean, the salivary secretion increases, the appetite and digestion improve, and the diarrhoea not only lessens, but the character of the motions changes for the better. 5. Nervous System. — The delirium disappears, and the general well-being of the patient greatly improves. 6. Skin — The horny layers of the palms of the hands and soles of the feet get quite macerated ; but on the skin of the body generally there is very little effect, with the exception of a slight roughness and elevation of the papillae. 7. The Tissues in general.— There is marked diminution in dehydration of the tissues, which takes place in all febrile condi- tions. This is very apparent in the case of the tongue, which maintains its proper size and keeps moist. While he advocates the treatment of enteric fever by baths, Dr. Cayley impartially discusses three chief objections which have been advanced to the adoption of this method of treatment. These are : — First — It is dangerous to the patient, from its being likely to cause collapse, intestinal haemorrhage, congestion, and inflamma- tion of the lungs. Secondly — The great mechanical difficulty in carrying it out. Thirdly — The discomfort and pain it causes the patients, and their consequent repugnance to submit to it. Dr. Cayley shows very clearly that the first of these objections has no foundation in fact. In 2,068 cases reported by Dr. Goltdammer, there was only one instance of fatal collapse. This accident can occur only when the treatment has been deferred until the later or adynamic stages of the fever, and. may be obviated by ENTERIC FEVER. 457 raising the temperature of the water in the bath. Dr. Barr also pointed this out. The frequency of intestinal haemorrhage, again, is not increased by the bath, rather the reverse. At the same time, Cayley admits that, should haemorrhage or peritonitis occur, the bathing must be at once intermitted, as perfect quiet is requi- site. With regard to lung complications, Dr. Cayley thinks it cannot be doubted but that, when the bathing treatment is begun early enough, it has a marked effect in preventing them. The mechanical difficulties are. no doubt, hard to get over in private practice ; but they are not insuperable, and in every pro- perly equipped General or Private Hospital suitable apparatus for the purpose should be available. Dr. Cayley, in his edition of Murchison's "Treatise on the Continued Fevers," describes such an apparatus, constructed by Mr. Hawksley, the surgical instru- ment maker, of Oxford-street, London, and planned by Mr. E. A. Fardon, at the time Resident Medical Officer of the Middlesex Hospital. It consists of two uprights, which move on wheels, and a cross- bar. A kind of hammock made of strips of webbing is placed under the patient, and then attached by a suspender to the cross- bar. By means of pulleys and an endless chain the hammock is lifted from the bed, then slid along the bar till it is over the bath, and let down into it and drawn up again in the same manner. Not only does this entirely relieve the nurses of any strain, but it is both safer and more comfortable for the patient. It takes, how- ever, longer to bathe a patient in this way than by simply lifting him into the bath. In reference to the possible repugnance of the patient to the bath, Cayley observes that with judicious management he has met with very little difficulty from this cause. In a large number of cases the relief given to the febrile oppression is so great that the bath is grateful ; in other cases, though disagreeable, the patients are quite willing to submit in view of the after-relief. In all cases the temperature and duration of the bath must be adapted to the con- dition and feelings of the patient and the effect it produces. Other 458 EXTERTC FEVER. means of reducing temperature must be employed where the bath is objected to or produces unfavourable symptoms. (B.) Dr. A. de Souza a recommends lowering of the temperature in fever by means of the ambient air. This method of reducing bodily temperature is especially applicable, according to him, in enteric, hectic, and tubercular fevers. In winter he keeps the room in which the patients are from 8° to 10° C. (46-4° to 50° Fahr .), the only bed-covering being a sheet and one blanket ; if towards the end of the night the temperature of the room or of the patients falls considerably, something extra is thrown over the feet. The higher the fever, the lower is the temperature of the room to be kept. If the air of the room be gradually cooled, the patients do not notice or soon become accustomed to the fresher atmosphere. In summer even, much may be done by proper ventilation and by diminishing the bed-clothes. Cold lotions and baths may also assist. (C.) A third way of reducing temperature is by the action of drugs, called in consequence " antipyretics." Never very partial to this method, I confess that since I read Cantani's Address on " Antipyresis," already quoted on more than one occasion in this book, I have become more chary than ever in the use of anti- pyretics in fever. The views of this enlightened physician have been stated at pages 7 and 53, and need not be recapitulated here. At the same time, it is necessary to allude to some of the remedies included under the heading " Antipyretics." 1. Quinine deservedly occupies the first place in the list. It may be given in suspension in water, or in milk with 3 to 5 grains of camphor, in 5 -grain doses every third hour, or in still larger doses (10 grains) every ten minutes until the desired quantity — 20 to 40 grains — has been taken. This remedy is particularly useful in the later stages of the disease, when the fever has a remittent type. Children bear quinine well (Barthez and Rilliet, 1853). 2. Salicin, salicylic acid, the salicylates, and salol are not trustworthy antipyretics in enteric fever. Salicylate of sodium in repeated doses of 10 to 20 grains has, at the Meath Hospital, pro- * El Monitor Medico. September, 1886. ENTERIC FEVER. 4")'.) duced toxic symptoms, with temporary depression of the heart's action and delirium. Albuminuria has also been observed else- where after its free administration. 3. The great group of coal-tar derivatives may next be con- sidered. Of these, the best known is phenazone (antipyrin), now official, but objectionable as an antipyretic in fever because of its depressant action. To children it should be given with the greatest caution. Acetanilide (antifebrin), also official, is an excellent febrifuge, particularly when prescribed with quinine — 3 grains of antifebrin and 2 grains of quinine, repeated every third or fourth hour, while necessary. Kairin (C 10 H l3 NO) was introduced into practice as an antipyretic by Dr. Wilhelm Filehne, a in 1883. He recommended doses of from 7 to 15 grains, repeated hourly until temperature falls. Its taste is horrible — saline, bitter, and per- sistently nauseous — so it should be prescribed either in pills, with glycerine of tragacanth, or in cachets (Martindale). It is efficient, but its effects are evanescent, and it is apt to depress the heart and cause collapse with cyanosis. Thallin (the sulphate of tetrahydro- paramethyloxychinolin !) in 3 or 4 grain doses, reduces temperature readily; but this remedy, also, is not free from danger, and is contraindicated in cardiac weakness or kidney disease. 4. Digitalis in large doses has a powerful action in reducing temperature, and is highly recommended by Liebermeister, b Wun- derlich, Thomas, and other German physicians. Liebermeister prescribes it in powder or in pills, giving from 1 1 to 22 grains in 36 hours, and following it up by a k 'full dose" (30 to 45 grains) of quinine. " Its use in these large doses," says Cayley, " can hardly be regarded as quite free from danger." Even Liebermeister states that it is to be used only where there is no considerable degree of cardiac weakness, and where the pulse is not yet extremely frequent. He adds — hardly for our encouragement — " The impending para- lysis of the heart is not prevented by the use of this drug, but seems rather to be favoured thereby. • Berlin klin. Wochensch. 1883. Nos. 6, 16. b Von Ziemssen's Cyclopcedia of Pract. Med. 1875. Vol. I., page 217. c Ueber den Nutzen der Diyitalisanwendung beim enterischen Typhus. Aruhiv. der Heilkunde. 1862. Page 97. 4(50 ENTERIC FEVER. 5. Veratria, in comparatively large doses (j^th of a grain in pill every second hour until decided nausea or vomiting ensues), was recommended by W. Vogt, and employed by Liebermeister. It is a remedy which will not commend itself to British physicians in the treatment of enteric fever. 6. The antiseptic and antipyretic methods of treatment have recently been combined by Dr. E. Tordeus, of Brussels,* who gives resorcin or thymic acid as an antiseptic together with acetanilide as an antipyretic. The dose usually employed by Dr. Tordeus was three-quarters of a grain of thymic acid and from one and a half to two grains of acetanilide, repeated not too frequently, say every two hours. Resorcin is best administered, according to Martindale, well diluted with water and flavoured with syrup of orange or glycerine. By the doses mentioned, the temperature was reduced in enteric fever from 104° to nearly normal, without any unfavour- able symptoms accruing. This long list of antipyretics may appropriately be closed with a quotation from Dr. Hilton Fagge. " It seems to be grateful to most patients," he observes, " to take what is called ' a simple febrifuge,' such as ten drops of dilute hydrochloric acid in infusion of orange, of calumba, or of serpentary. It is probably a mere placebo, but there is every reason to please as well as to cure our patients." a Nouveau Traitement de la Fi&vre Typhoide. Journal de med., chir., tt pharma- cologic. Bruxelles. 1891. Vol. XC1L, pages 325-332. 4(51 CHAPTER XLVII. Curative Treatment of Enteric Fever (Continued). Treatment of certain Complications and Sequelae. Strong Decoction of Coffee and Caffein in Ataxia and Adynamia. — Inhalation of Oxygen in Broncho-pneumonia. — Prevention of Bedsores. — Treatment of Epistaxis.— Treatment of Intestinal Symptoms, Complica- tions, and Sequels : Constipation, diarrhoea, tympanites or meteorism, vomiting, abdominal pain, haemorrhage from tbe bowels, peritonitis, perforation, medical and surgical measures. VI. Little need be said in this Chapter about the treatment of the complications and sequelae of enteric fever which engage the systems of the body other than the digestive tract. For the rules already laid down for the management of the cerebral and cardiac affections of typhus, the pulmonary affections of measles, and the anginal and renal affections of scarlatina, apply equally to those cases of enteric fever in which similar complications may happen to arise. The great subject of the treatment of the intestinal complications which are almost peculiar to enteric fever, however, remains to be discussed. Before I take up this topic, I would like to allude to a few troublesome complications and to certain remedies which have not hitherto been mentioned in connection with the special lesions to combat which their employment is indicated. In well-marked ataxia and adynamia of fever, the administration of a strong decoction of coffee (cafe 'not?') is often followed by highly beneficial results. And, in accordance with its physiological action, the active principle of coffee called caffein is employed as a cerebral and cardiac stimulant, particularly in bad fevers. According to Huchard, of Paris, caffein, exhibited endermically, gives excellent results in ataxo-adynamie enteric fever. It is a general tonic in 462 ENTERIC FEVER. adynamic states. Caffe'in is very soluble in aqueous solutions of benzoate, cinnamate, and salicylate of sodium. These dissolve it in chemically equivalent quantities. Martindale says that the follow- ing salicylate of sodium solution of it forms an unirritating hypodermic injection : — R Caffeinae, gr. 20 ; Sodii Salicylatis, gr. 1 1\ ; Aquae destillatae, ad 3i- Dose : 1 to 6 minims. This solution contains one grain in three minims. Huchard employs two solutions — a weak and a strong. The formula? for these are as follows : — No. 1. Weak — R Sodii Benzoatis, gr. 45 ; Caffeinae, gr. 30 ; Aquae destillatae, 3> ss » Make a solution by warming. No. 2. Strong — R Sodii salicylatis, gr. 47 ; Caffeinae, gr. 60 ; Aquae destillatae, 3'ss. Make a solution by warming. Another remedy worth noting is inhalation of oxygen. In the '•Medical and Surgical Reports of Cook County Hospital, 1890," a will be found an account of inhalation of oxygen in a case of typhoid fever complicated by broncho-pneumonia. Bedsores may be prevented by scrupulous cleanliness and the use of the water-bed. The parts should be kept dry and freely dusted with some emollient powder. Daily friction with spirit of camphor, eau de Cologne, whisky, or brandy, is a good preventive. Epistaxis, or nose-bleeding, is sometimes so profuse and so obstinate as to call for special treatment. The drugs afterwards recommended in intestinal haemorrhage may be prescribed. A bladder of ice should be applied over the forehead and nose ; while " hazeline " (an aqueous solution of hamamelis), infusion of matico 'Chicago. 1891. Pages 125-127. ENTERIC FEVER. 463 or of rhatany, or a solution of alum or of tannin should be injected into the nostrils. Hot water injections may also be tried, and these measures failing, the posterior nares should be plugged. The symptoms and complications connected with the digestive system in enteric fever which call for special treatment are tlie following: — (1). Constipation; (2). Diarrhoea; (3). Tympanites, or Meteorism ; (4). Vomiting ; (5). Abdominal Pain ; (6). Haemorrhage from the Bowels ; (7). Peritonitis ; (8). Perforation. 1. In treating constipation, we should never forget the advice tendered by Baglivi, a two centuries ago, that in the treatment of " Febris mesenterica maligna," all drastic purgatives are " to be shunned like the plague." In the early stage of enteric fever, an experience of many years has satisfied me that a moderate dose of calomel (from 3 to 5 grains) is often beneficial, and effectually overcomes constipation. After the first week or ten days, calomel should be given with caution. Three other plans may then be tried either in rotation or alternately. First, diet may be so arranged as to act as a laxative — beef-tea, or strained mutton broth may be allowed ; or ripe orange juice, or a few grapes care- fully deprived of their skin and seeds. Secondly, a simple enema may be administered every thirty-six or forty-eight hours, according to circumstances. Trousseau used an enema of chamomile infu- sion. On no account, however, should a glycerine enema be ordered after the first few days of enteric fever — the increased peristalsis on which its efficacy depends might lead to dangerous consequences — inflammation, or perforation. Thirdly, an excellent remedy for constipation is castor oil in small doses, as both Trousseau and Murchison recommend. My favourite prescription is to mix a teaspoonful of glycerine with a wineglassful of warm milk, and then to add a teaspoonful of castor oil. This dose, or draught, may be repeated in six or eight hours, until the bowels are freed. It is a specially useful remedy in the constipation of convalescence. Hilton Fagge discountenances any interference with constipa- tion in enteric fever. He thinks it better to err on the side of a Baglivi. Opera omnia. Romse. 1696. Editio sexta. Lugdimi. 1704. 464 ENTERIC FEVER. caution, and to abstain from meddling with the bowels until con- valescence is established. 2. Diarrhoea. — This is not only a common symptom, but some- times a serious complication of enteric fever, and if unchecked may run down the patient's strength, and so endanger his life. Our object should be — not, as recommended by the late Dr. Todd, in 1860, to lock up the bowels, and keep them so; but to check diarrhoea, limiting the motions to two in the twenty-four hours, if possible. An excellent remedy is a small starch enema, containing ten to twenty drops of laudanum. This stays peristaltic action and gene- rally controls the milder forms of diarrhoea. Much, too, may be effected by a change of diet. The milk should be boiled and mixed with lime-water in the proportion of 3, or only 2, parts of milk to 1 of lime-water. Dr. T. W. Grimshaw a used to employ the saccharated solution of lime in proportional doses — this preparation being about 14 times stronger than plain lime- water. Beef-tea should be withheld, and to each teacupful of chicken broth a teaspoonful of stiff isinglass jelly (gelatine) should be added. Thin arrowroot may also be allowed, or rice-milk. Above all, the quantity as well as the quality of the food should be controlled. Local applications to the abdomen often do good. For example : light linseed meal poultices, turpentine epithems, mustard fomen- tations, and wet-compresses, may be tried in turn or singly. As regards poulticing in this fever, I long since gave up the applica- tion to the abdomen of bulky linseed meal poultices (which are positively dangerous from a mechanical point of view) in favour of the following: .A piece of lint of suitable size is moistened with a warmed mixture of laudanum (one fluid drachm), glycerine (seven fluid drachms), and water (seven fluid ounces), and laid over the abdomen. Oiled silk or gutta-percha tissue is then applied, over which is placed a sheet of French wadding, or medicated cotton- wool — the whole being kept in position by a soft flannel roller or a " On the Management of the Bowels in Enteric Fever." Dubl. Journ. of Med. Science. Vol- LXIIL, page 132. 1877. ENTERIC FEVER. 465 bondage, This ""glycerine poultice," or " glycerine compress," as it may be called, is at once comfortable and efficient. Trousseau* used to treat diarrhoea in dothie'nenterie by ordering in the first instance a saline purge, a neutral salt, 25 to 30 grammes of sulphate of sodium or a seidlitz powder, as an alterative or modi- fier of the intestinal secretions. Tliis treatment he considered to be especially applicable when the diarrhoea was accompanied by a certain degree of meteorism. If the desired result was not obtained, he used to prescribe so-called "absorbent powders," a mixture of 7i grains of subnitrate of bismuth with an equal quantity of pre- pared chalk — this dose being repeated three, four, six, eight times in the twenty-four hours, or even oftener according to circum- stances. He also frequently gave "la mixture anglaise," namely, R. Creta3 Prseparatffi, 5J ; • Syrupi Aurantii Corticis, §j ; ™ Aqua?, §iij. Powdered calumba root in doses of from 7^ to 15 grains was another favourite remedy with him. If these means failed, he had recourse to pills containing about one-tenth of a grain of nitrate of silver irt washed bread-crumb {mie d&pain). Of these one was to be taken every hour in the course of the day. If the " Mistura Cretae" of the British Pharmacopoeia is pre- scribed, it should be ordered to be prepared afresh, as in my experience it is a mixture which does not keep well. Instead of ordering it I much prefer to prescribe a mixture containing aromatic chalk powder, with or without opium, compound tincture of chloro- form,' powdered gum acacia, and cinnamon water. " Chlorodyne," or its pharmacopoeia! equivalent — the tincture of chloroform and morphin — may be substituted in this mixture for the compound tincture of chloroform. ' ; : - - ' Murchison gives the following favourite prescription :— • R. Acid. Sulphurici Aromat., min. xx; Liquor. Opii Sedativi (Battley) min. iij ;- " Tincturae Catechu, 3 -*s ; Aquas Menthas Piperita?, -gj. a Clinique Medicate de VHdtel Dieu de Paris. • 1865. Tome I.$ pages 258, 259. 2 H 466 ENTERIC FEVER. M. ft. haustus. Signa: "The draught to be taken every third or sixth hour." Other remedies employed by Murchison were — Vegetable charcoal in teaspoonful doses every fourth hour (especially useful in diarrhoea accompanied by tympanites) ; powders of equal parts of Dover's powder and gray powder ; or acetate of lead in solution in doses of 2 or 3 grains every four or six hours, with or without one-twelfth of a grain of acetate of morphin. Dr. Grimshaw gave dilute sulphuric acid in the proportion of 3 drachms in an eight-ounce mixture, of which an ounce was to be taken every three hours. Sometimes he added to the mixture small quantities of solution of morphin, or of tincture of opium. In more urgent cases he employed the lead and opium pills of the Pharmacopoeia, in four-grain doses every fourth hour, with great benefit. Dr. Samuel Fenwick 8 speaks highly of sulphate of copper — one quarter of a grain with one quarter of a grain of opium every three hours. Murchison has an alternative prescription, according to which a quarter of a grain of sulphate of copper may be given in solution with sulphuric acid, quinine, and a few drops of laudanum every four or six hours. Liebermeister lets moderate diarrhoea alone ; but in severe cases he administers opium in small and repeated doses, sometimes in com- bination with ipecacuanha or nux vomica, and sometimes with tannin, alum, or other astringents. Twenty years ago, Dr. James Little asked Dr. Alfred Hudson to see a lady suffering from enteric fever in whom looseness of the bowels was the chief trouble, and he suggested a pill consisting of one-sixth of a grain of carbolic acid, one-sixth of a grain of extract of opium, and three grains of trisnitrate of bismuth, to be taken after each loose stool. Dr. Little informs me that he found this pill so useful that he has commonly used it since, employing during the past two years the salicylate of bismuth instead of the tris- nitrate. As, however, it often happens that patients in enteric fever are too ill to swallow a pill, Dr. Little has, when this was the * Outlines of Medical Treatment. Third Edition. London. 1891. Page 454. ENTERIC FEVER. 467 case, given the same ingredients in a mixture of which the formula approximately is — fy. Bismuth! Salieylatis, gr. 30 ; Pulv. Acacioe, 3i' ; Tinct. Opii, min. xvii! ; Glycerini Carbolici, min. xxx; Tinct. Lavand. Co., 5i'i i Aquae, ad §vi. Signa : A sixth part two, three, or four times in 24 hours, as required. I may state, as a matter of personal observation, that small doses of turpentine given systematically every few hours from an early stage of the fever seem to control the diarrhoea in a remarkable and satisfactory manner. 3, Tympanites, or Meteorism. — In the first place, I am strongly of opinion that the occurrence of this troublesome and often dange- rous symptom may be prevented by the turpentine treatment, com- menced early and persevered in. No heroic doses are required, but the remedy should be given steadily through the fever. Dr. George B. Wood, a of America, long ago recommended turpentine in doses of from 5 to 20 minims every hour or every second hour, in all cases of enteric fever accompanied by tympanites and a dry tongue. In atonic ulceration and protracted convalescence, with a dry, red, and smooth tongue, he regarded turpentine almost in the light of a specific. Another remedy, which controls tympanites, is nux vomica, or its active alkaloid, strychnin. These keep up intestinal "tone" and check undue distension of the bowel. Some years ago I was called to the Curragh in consultation to see a young officer ill of enteric fever with much tympanites. I advised 3 minim doses of liquor strychninae to be exhibited three times a day, because his heart was weak, and with a view of controlling tympanites. A few days afterwards intestinal haemorrhage occurred, whereupon my treatment was, I believe, somewhat unfavourably criticised. a Practice of Medicine. Sec md Edition. 1849. Vol. I., page 328. 463 ENTERIC FEVER. But surely both intestinal haemorrhage and perforation would be more likely caused by over-distension of a diseased intestine than by any increased peristalsis due to moderate doses of nux vomica or of. strychnin. As the gas collects c efly in the colon, Murchison recommends enemata containing carbolic acid glycerine (half a drachm), or six minims of creasote with half an ounce of glycerine, or an ounce of vegetable charcoal with two ounces of mucilage, or two drachms of spirit of turpentine with two ounces of olive oil, or two drachms of asafoetida with 10 minims of oil of rue— any one of the foregoing in a pint and a half of barley water (decoctum hordei). Of these formulas, the only one I object to is that containing charcoal, for this substance loses its absorbent properties when saturated with • fluid, and so is practically inert and therefore useless. The abdomen should be gently rubbed in the direction of the colon. Turpentine fomentations may be applied from time to time, or cold compresses as recommended by Liebermeister. Dr. Peter,' 3, of La Pitie\ Paris, found ice poultices — made by scattering small fragments of ice over a thick layer of dry linseed meal — most effectual for subduing the tympanitic distension. As the ice thaws, a poultice is formed which, in consequence of the slow melting of the ice, is kept at the temperature of melting ice. To Professor Monneret belongs the credit of devising and introducing to the profession this very valuable method of treating tympanites. ♦ In Dr. Cayley's Opinion,^ the application of ice to the surface of the abdomen is by far the best way of treating great distension.: It may be conveniently applied by putting small pieces between two folds of flannel. It is especially indicated in haemorrhage. By this means a considerable general reduction of temperature may be effected. ' Should tympanites not yield to the foregoing measures, O'Beirne's long enema tube should be cautiously passed up the rectum, when flatus will probably escape freely through it owing to reflex con- fraction of the bowel and increased peristaltic action. Puncturing a Brit. Med Journal. Vol. II., page 450. 1869. .'--y^ Murchison. 1884. Third Edition. Page 673. ENTERIC FEVER. 4G ( .) 'the colon with a capillary trochar and cannula has' been suggested, but such a procedure is not to be recommended. 4. Vomiting. — The clinical significance of this symptom has been already discussed (see pd. IV., p. 73: ENTERIC FEVER. I i 7 • When, on the other hand, diarrhoea persists through convales- cence; the patient should he kept in bed. Murchison advises that this atonic diarrhoea should be treated by astringents and tonics such as acetate of lead, sulphate of copper, or nitrate of silver. At the same time he draws attention, with approval, to a remark of Tronsseau a , that when there is great emaciation, especially in cases which have been treated on too lowering principles, vomiting and purging during convalescence may be of a purely nervous character, and sometimes are at once relieved by solid food. Hilton Fagge wisely observes that " stimulants should be at once diminished on the, subsidence of fever, and in many cases it is desirable to substitute an ounce or two of wine twice or thrice a day for brandy at frequent intervals. With young patients, however, after a favourable attack there is often no need for stimulants or drugs." I consider that this is sound advice. A grave responsibility rests on a physician who does not daily revise his patients' allow- ance of stimulants when recovering from aeute illness. There can be no doubt that habits of intemperance in too many instances date back to a time when a good-natured or a neglectful physician allowed his patient to remain day after day or week after week on an allowance of wine or spirit, for the giving of which there was no warrant. Another rule to be stringently carried out is, that on no account should alcoholic stimulants be taken without food — it maybe only i a biscuit; ! I hold that most fever convalescents are better without alcoholic stimulants— rrthey have had poison enough in their bodies— r but, if stimulants are given, they should be prescribed as medicine and not a la carte blanche. All modern authorities are agreed that the greatest caution must be exercised in permitting the typhoid convalescent to partake of solid food, and particularly butcher's meat. Stokes, indeed, tells a graphic and amusing story, in his " Lectures on Fever," b of a lady,. a Clinique Med. de V Hotel Dieu de Paris. 1865. Tome I., page 264. See above, page' 399. < ' ' . • • „ : : b Edition of 1874. Pages 332, et seq. ,;,,.,' ' 478 ENTERIC FEVER. recently married, who was violently delirious on the 12th or 13th day of "extremely severe petechial fever" — that is, be it noted, typhus, not typhoid — and in her delirium craved for " a rump of beef and cabbage," which were being cooked in the kitchen, and the odour of which filled the house. Her sister, who was nursing her, believing she was dying, resolved to gratify her wish from the feeling that it was right to accede to the request of a dying person. She proceeded to the kitchen, and brought up a large mess, steaming hot, to the lady's bedside, when the patient de- voured it with great avidity. Shortly afterwards her husband came in, and was told what had happened. He became terrified, and sent for physicians in every direction. Four or five assembled, each of whom had his own suggestion to offer. At length the late Dr. Harvey, then Physician-General, joined in the consultation. On proceeding to the lady's bedside, the consultant-in-chief, Dr. Harvey, found the patient asleep. She was reported to him to be comatose. His advice was : " I'd let her sleep it out." She did sleep it out, and in the course of some hours awoke much better. Her recovery was perfect. Dr. Stokes, in narrating this anecdote, was careful to show that he did not do so with the object of in- ducing physicians to feed their patients with salt beef and cabbage in fever. " No solid food," says Hilton Fagge, " should be given for a fortnight after fever and diarrhoea have ceased. The patient will bitterly complain of the restriction ; but if the physician has once lost a patient from perforation during convalescence he will be inexorable ever after. Progress to health after this disease must be slow if it is to be sure." To the same effect Murchison writes : " Notwithstanding the cravings of the patient's appetite, the diet must be at first restricted to such articles as milk, eggs, farinacea, custards, light puddings, beef-tea, chicken-tea, or calf's foot jelly. Meat ought not to be allowed for at least seven days after the cessation of pyrexia, and not even then if there be any signs of intestinal disturbance ; and before meat is given it is well to try for a day or two a piece of boiled sole, smelt, or whiting." ENTERIC FEVER. 479 In reference to the last-mentioned recommendation, I may state that a fish diet does not always agree with a fever convalescent. Indeed, it sometimes appears to produce poisonous effects, perhaps owing to the formation of one of the alkaloids produced by the decomposition of proteid substances, to which Professor Selmi, of Bologna, gave the name of ptomai'ns, by which they are now known. The result may be a recrudescence of the pyrexia. I have known this to occur in more than one case after enteric fever — the fish eaten being a sole apparently in good condition. " Of all fish," writes F. W. Pavy, a " the whiting may be regarded as the most delicate, tender, easy of digestion, and least likely to disagree with a weak stomach. It is sometimes styled the chicken of the fish tribe. The haddock is somewhat closely allied, but has a firmer texture, and is inferior in flavour and digestibility. The sole is a tender and digestible fish. It also has a delicate flavour, and deservedly enjoys a high reputatiou as an article of food for the invalid. The flounder is light and easy of digestion, but insipid. In all cases where fish is required for a weak stomach, either boiling or broiling should constitute the process of cooking. Frying is objectionable on account of the fatty matter used rendering the fish rich and more indigestible." Von Ziemssen, in his " Lectures on the Treatment of Typhoid Fever," to which reference has before been made, expresses the opinion that the diet of convalescence should follow the usual diet of health with certain modifications. The return to solid food should be as follows : — First breakfast : tea, with biscuit and one soft-boiled egg. Second breakfast : 100 grammes (3^ ozs.) of finely minced raw bacon with wheat bread crumbs. Noon : 150 grammes (5 j ozs.) of pigeon, young chicken, or partridge finely minced in soup. Later on this may be given in combination with a mild sauce and mashed potato, wine or beer being taken as a beverage. In the afternoon : tea with biscuit or cakes. For supper : " mush," — that is, Indian corn porridge — and milk, two soft eg^s and some raw bacon. This may soon be followed by calves' feet for breakfast, then an English broiled beefsteak, mutton and pre- A Treatise on Food and Dietetics. 1874. Page 156. 480 ENTERIC FEVEK. serves, and In the evening some strengthening soup'and some beer. At this stage, when the patient thinks of nothing but eating, Something hew in the way of food must be given daily. i " It is best," says Niemeyer, a " to let the patient eat frequently, but only a little food at a time, so that the slight amount of gastric juice secreted by the convalescents may suffice for its complete digestion. All indigestible food, which forms large amounts of faeces, should be strictly forbidden. An insignificant indigestion, a moderate diarrhoea, or slight vomiting, should be regarded as.a-very dangerous occurrence, because it may induce perforation of an ulcer that has not yet cicatrised." ¥. Woodbury 6 considers the different preparations of coca espe- cially valuable in convalescence from enteric fever, being superior to digitalis, for instance, in not having a tendency to cause diarrhoea. ' Hutchinson finds a too early return to solid food prejudicial to the patient. He continues the exclusive milk diet for three or four days after complete defervescence, or adds only animal broths. Then he gives soft-boiled eggs, the juice of underdone meat, with milk toast and other farinaceous articles. At the end of a week- the soft parts of oysters and fish are added to the dietary; at the end of ten days, the light meat of broiled chicken ; at the end of - two weeks, butcher's meat. All these articles of food are given in small quantities at first. , < ,: ■1 I close this subject of diet in convalescence after enteric fever with a quotation from Dr. Lauder Brunton's Lettsomian Lectures 1 on .-" Disorders of Digestion," delivered before the Medical Society of London in January and February, 1885: — '*The palate," he says, " like the appetite, sometimes makes demands which are a*pt to be misconstrued. As the late Professor Laycock observed, patients recovering from a severe illness not unfrequently have a strong desire for salt herrings, pork, or ham, things which would be almost certain to disagree with them if their appetite were a A Textbook of Practical Medicine. - Revised Edition. 1880. Vol. II., page 655. 6 Sajous' Annual of the Universal Medical Sciences. 1890. Vol. I. H.-52. c Loc. cit. - . . , > ' •• ENTERIC: FEVER. 481 indulged. But the fact is that the patients do not want the pork or herring; what they really desire is salt, and they crave for these articles because they contain salt. If salt be given to them in tin- form of a mixture, their appetite is appeased, and the harm is avoided which the herring or ham might have caused." Few, if any, medicines are required in convalescence. But if the patient's state remains unsatisfactory — if his progress towards recovery "hangs fire" — when, in a word, convalescence is slow, Murchison recommends " quinine, the mineral acids, iron, cod-oil, and change of air." The last is, to my mind, by far the most im- portant of all — particularly, should the patient have passed through his illness in the house which gave it to him owing to structural faults and defective drainage. Some years ago a young lady, almost dying of asthenia and anaemia after a protracted typhoid fever, was — by the advice of one of the first consulting physicians in Dublin — sent away in a carriage from one of the squares in Dublin only as far as the suburb of Sandymount, two miles distant. The result was that she immediately began to improve, and ulti- mately made a rapid and complete recovery. Lastly, several months should be allowed to elapse before the convalescent resumes his usual avocations — at least, if they are such as to put a strain upon either his bodily or his mental powers- It often takes six months or even a year before these are thoroughly restored. " There is no disease," observes Hilton Fagge, " not even rheumatic fever, in which it is so important for the patient to have a long period to recover his strength before returning to his ordi- nary duties." Should these rules be carried out, one would be justified in anti- cipating for the convalescent a " new lease of life," with a braced and invigorated muscular system, and a healthy, clear, and active brain. 2 i 482 CHAPTER XLIX. Infection and Immunity. Klemperer and Klemperer's researches on Infection and Immunity. — Case of acute fibrinous pneumonia. — Pneumotoxms and anti-pneumotoxins.— Dr. A. C. Abbott's conclusions. I have stated, on page 22, that the question of imm unity is still undecided. The most recent and valuable contribution to the literature of the subject is a paper by Klemperer and Klemperer, in Nos. 34 and 35 of the Berliner klin. Wochenschrift for 1891, on the nature of the infection in acute fibrinous pneumonia. For the following abstract of their researches I am indebted to an excellent review (by Dr. A. C. Abbott, First Assistant in the Department of Hygiene of the University of Pennsylvania a ), of the experimental work in connection with immunity and infection carried on during the past few years. This review was contributed to the number of the Practitioner for December, 1891. Klemperer and Klemperer's experiments bore entirely upon the nature of the infection in acute fibrinous pneumonia and have shed much light upon some of the obscure features of that disease. They found but little difficulty in affording immunity to animals that are otherwise susceptible to the pathogenic action of the organisms concerned in the production of this disease, 6 by the introduction into their tissues of the products of growth of the organisms from which the latter had been separated. The immunity thus produced is seen in some cases to last as long as six months ; again it is seen to disappear suddenly in a way not to be explained. It was seen in one case to be hereditary. a See also Medical News, Philadelphia, November 7, 1891. b Animals do not, as a rule, present the pneumonic changes seen in human beings. The introduction of the diplococcus of pneumonia into their tissues results, in the case of susceptible animals, in the production of septicaemia. INFECTION AND IMMUNITY. 4K3 The energy of the substance which has the power of affording immunity was seen to be very much increased by subjecting it to temperatures somewhat higher than that at which it was produced by the bacteria — 37*5° C. (99-4" F.) Klemperer and Klemperer found that if this substance was heated to a temperature of from 41° to 42° C. (105-8° to 107'6" F.) for three or four days, or to 60° C. (140" F.) for from one or two hours, intravenous injection was followed by complete immunity in from three to four days; whereas, if the unwarmed material was used, im- munity did not appear until fourteen days, and then only after the employment of relatively large amounts. Moreover, when the previously heated products are introduced into the circulation of the animal, the systemic reaction is of but short duration, but if the unwarmed substance is employed, immunity is manifest only after the appearance of considerable elevation of temperature, which lasts for a long time. In explanation of these differences, they suggest that, in the latter case, the high fever that is seen to occur in the animal may serve to replace the warming to which the product had not pre- viously been subjected, and which is necessary before the products of the bacteria are in a position to bring about the condition of immunity. They claim that the bacterial products employed in producing immunity in this case are not, in reality, the immunity- affording substance, but that they are only the agents that bring about in the tissues of the animals alterations that result in the production of another body that protects the animal. In support of this, their argument is that several days are necessary for the production of immunity by the introduction into the animal of the bacterial products; whereas, if the blood- serum of this animal, which is now protected, be introduced into the circulation of another animal, no such delay is seen, but instead, the animal is forthwith protected. In the former case the actual protecting body must first be manufactured by the tissues ; whereas, in the second it is already prepared, and is intro- duced as such into the second animal. The serum of immunified animals is not only capable of rendering 484 INFECTION AND IMMUNITY. other animals immune, but moreover possesses curative powers when the disease is already in progress. The serum of immuni- fied animals, when injected into the circulation of animals in which this form of infection was in progress, and in which there was a body-temperature of from 40-4° to 41° C, reduced this temperature •to normal (37'5° C.) in twelve consecutive experiments during the first twenty-four hours following its employment. Klemperer and Klemperer explain that the crisis seen in pneu- monia in human beings occurs at the moment when the poisonous products, manufactured by the bacteria located in the lungs, are present in the circulation in amounts sufficient to call forth in the tissues the reactive change that results in the production of the antidotal substance which has the power of rendering the poisons inert. At the time of the crisis in pneumonia the bacteria themselves are in no way affected. They remain in the lungs, and can be detected in full vigour and virulence, in the sputum of patients a long time after the disease is cured. They have lost none of their power of producing poisonous products, and still possess their original pathogenic relations toward susceptible animals. It is only after the crisis that their poisons are neutralised by this antidotal proteid which has been eliminated by the cells of the tissues, and as this occurs the systemic manifestations gradually disappear. Klemperer and Klemperer isolated, from the cultures of the diplococcus of pneumonia, a proteid body which is the agent concerned in producing the tissue-changes that result in the forma- tion of the protecting substance. They likewise isolated from the serum of immunified animals a proteid which possesses the same powers as the serum itself — of affording immunity and of curing the disease. The poisonous bacterial product they propose to call pneumotoxin ; the protecting body, anti-pneumotoxin. , After obtaining these results upon the lower animals they directed their attention to human beings, and found that by the subcutaneous application of the serum of immunified animals to patients suffering from acute fibrinous pneumonia the results were in the main promising. They found that while healthy individuals INFECTION AND IMMUNITY. 485 and those suffering from other forms of disease presented no systemic reaction after the injection of the scrum, in six cases of pneumonia in which the serum was employed there was a remarkable fall of temperature and slowing of the pulse within the first twelve hours after it was injected. In four of these cases the temperature fell to normal, but rose again after six hours. In two cases it fell to normal, and remained at that point. It would appear from the results obtained by these two observers that immunity against this disease, and the processes concerned in its cure, are of a chemical nature, the active poisons of the organisms, the pneumotoxins, being neutralised by the tissue- products, the anti-pneumotoxins. Results upon animals in general analogous to those of Klem- perer and Klemperer have been obtained by Emmerich and Fowitzky. a In the light of these experiments the hypothesis advanced by Buchner, that immunity was to be explained by reactive changes in the integral cells of the body, receives considerable support. As a result of his very critical and comprehensive review of the modern literature of the subject, Dr. A. C. Abbott arrives at the following conclusions : — 11 1. That, of the hypotheses that exist for the explanation of immunity, that which assumes acquired immunity to be due to reactive changes on the part of the tissues has received the greatest support. " 2. That immunity is most frequently seen to follow the intro- duction into the body of the products of growth of bacteria that in some way or other have been modified. This modification may be artificially produced from the products of virulent organisms and then introduced into the tissues of the animal ; or the organisms themselves may be so treated that they are no longer virulent, so that when introduced into the body of the animal they eliminate poisons of a much less vigorous nature than is the case when they possess their full virulence. "3. That immunity following the introduction of bacterial a Emmerich and Fowitzky : Munch, med. Wochenschr., 1891, No. 32. 48& INFECTION AND IMMUNITY. products into the tissues is not the result of the permanent presence of these substances per se in the tissues, or to a tolerance acquired by the tissues to the poison, but is probably due to the formation in the tissues of another body that acts as an antidote to the poisonous substance. " 4. That this protective proteid that is eliminated by the cells of the tissues need not of necessity be antagonistic to the life of the organisms themselves, but in some cases must be looked upon more as an antidote to their poisonous products. " $. That in the serum of the normal circulating blood of many animals there exists a body that is capable, outside of the body, of rendering inert bacteria that, if introduced into the body of the animal, would prove infective. " 6. That, in many instances, infection may be looked upon as a contest between the bacteria and the tissues, carried on on the part of the former by the aid of the poisonous products of their growth, and resisted by the latter through the agency of proteid bodies normally present in their integral cells. " 7. That when infection occurs it may be explained either by the excess of vigour of the bacterial products over the antidotal or protective proteids eliminated by the tissues, or to some cause that has interfered with the normal activity and production of these bodies by the tissues. ■■ " 8. That phagocytosis, though frequently seen, is not essential to the existence of immunity, but is more probably a secondary process; the bacteria being taken up by the leucocytes oniy after having been rendered inert through the normal germicidal activity of the serum of the blood and other fluids of the body." INDEX OF SUBJECTS. Abdominal pain, 469. typhus, 341. Abortive enteric fever, 405. typhus, 294. Abscesses, 101. Abschuppung, 27. . Absorbent powders, 465. Absplitterung, 27. Accidental erythema in enteric fever, 374. fever, 2. rashes — in enteric fever, 371. smallpox, 76, 90, 99. Acetanilide, 459. Acids, mineral, 49. Acme or fastigium, 25, 76. Acquired immunity, 22, 24. predisposition to disease, 38. Act, Public Health (England), 1875, 41. (Ireland), 1878, 38, 41, 46, 47. (Scotland), 41. Vaccination, 103, 109. A Acute desquamative nephritis, 146, 170, 174, 175, 176, 189, 281, 290, 303, 401, enteric fever, 407. " Acute furuncular diathesis," 85, 94, 191. haemophilia, 91, 92, 170, 470. parenchymatous myocarditis, 178, 287. nephritis 146, 170, 174, 175, 176, 189, 281, 290, 303,- 401. Adrianople, inoculation for smallpox at, 103. Adventitious rashes in enteric fever, 371. Adynamia, 242, 259, 461. Adynamic measles, 142, 143. simple fever, 235, 237. typhus, 264, 293. 488 INDEX OF SUBJECTS. Aerobic microbes, 15. ^Etiology — of small-pox, 70 ; chickenpox, 125 ; measles, 133 ; scarlatina, 155 ; Kbtheln, 193 ; erysipelas, 203 ; febricula, 234 ; typhus, 243, 253 ; relapsing fever, 314 ; enteric fever, 345. Afebrile enteric fever, 407. Affusion, cold, 56, 62, 451. Age as a predisponent, 125, 135, 251, 316, 349. Ague, 19. Air as a carrier of enteric-fever poison, 357. fresh, in typhus, 308. Albumen, fixed and circulating, 9. Albuminuria, 163, 177, 278, 381. Alcoholic intemperance, 39, 42. stimulants in fever, 48, 58, 59, 120, 188, 223, 221, 310, 331, 440, 441, 477. Amaurosis, 399. Ambient air for cooling fever patient, 458. Amblyopia, 399. American treatment of smallpox, 117. Amphibolic stage in enteric fever, 366, 394. Anabolism, 4. Anaemia, 416. Anaerobic microbes, 15. Anaesthesia, 283. Anasarca, 177, 402. Angina maligna, 168. pectoris vaso-motoria', 170. Animal heat, theory of, 4. kingdom, thermal nervous system in the, 5. Ankle-clonus, 289. Anorexia, 211, 276. Anticipative use of stimulants, 310. Antifebrin, 459. Antimony in enteric fever, 443. Antipyresis, 53, 450, 458, Antipyretics, 52, 452, 458. Antipyrin, 459. Antiseptics, 31, 50, 114, 440. Antiseptic treatment, 50, 114, 440. Anuria, 174, 176. ' Aperients, 52. Aphonia, 81, 95, 280. INDEX or subjects. 489 Apparatus for the continual bath, Hebra's, 121. thermal, 5. Apyrexia, 24, 388. Apyrexial enteric fever, 407. Ardent fever, 233, 235, 236. Areola of smallpox, 79. vaccina, 109, 111. Armentyphus, 39, 313. Army Medical Department, 339. Arsenic in enteric fever, 443. Arterial thrombosis, 290, 398. Ascites, 177. Asthenia, 416. Asthenic — measles, 142, 143. pneumonia, 296. simple fever, 235, 237. Ataxia, 169, 181, 240, 259, 297, 461. Ataxic symptoms of fever, 8, 61, 159. state, 58, 61, 62, 143, 260, 303, 329, 369, 376. scarlatina, 168 ; typhus, 264, 293. Ataxo-adynamic typhus, 293. enteric fever, 461. Atonic diarrhoea, 399. Atrophic keratitis, 94, 122, 146, 171. furrow in nails, 272, 375. Attenuated virus, 43, 103. Autochthonous disease, 235, 355, 356. Autogenous enteric fever, 355, 356. Autotyphisation, 359. " Autumnal fever," 340, 349. Axillary bubo — of vaccino-syphilis, 1 12. Bacillus anthracis, 23, 357. coli communis, 359. diphtherise, 168. malariae, 19; typhosus (Eberth), 342, 352, 353, 354, 355, 356, 359, 360, 422, 447. Bacteria, 14, 216. classification of, 15. Bacteriology — of smallpox, 73 ; of varicella, 126 ; of measles, 134 ; of scarlatina, 158, 192 ; of erysipelas, 203, 209 ; of typhus, 244 ; of relating fever, 318 ; of entsric fever, 351. 490 INDEX OF SUBJECTS. Bacterium catenula, 352. Balne*otherapie, 452. Balneum vaporis, 118. Baths and Wash-houses, 40. cold, 223, 379. immersion in, 54, 118, 184, 223, 451, 454, 457. Bath, warm or tepid — in smallpox, 118, 119, 120 ; in measles, 151 ; in scarla- tina, 184 ; in enteric fever, 451 ; Hebra's apparatus, 121 ; Barr's appa- ratus, 454 ; Fardon's apparatus, 457. Battley's sedative solution of opium, 60. Bedsores, 94, 290, 311, 402, 462. Belladonna in scarlatina, 183. Berlin, regulations for disinfection in, 35. Besoin a respirer, 275. " Bestuscheff's tincture," 222. " Bilious fever," 406. "Bilious typhoid" (Griesinger), 317, 318, 320, 322, 323, 328, 334. Bismuth, salicylate of, 443. Black Assizes, 247. Hole of Calcutta, 249. vomit, 322, 329. " Black measles," 143. "Black smallpox," 93. Bladder in fever, 62, 282, 290, 311, 402. " Blasting typhus," 262, 293. Bleeders, 286. Blood-letting, 52. /3-naphthol, 443, 444, 449. Boils, 94, 171. Boulimia, 261, 277, 321. Bourbillon, 422. Bovine lymph, 110. " Brain fever," 279, 293. Branny desquamation, 27, 140, 163, 375. Bristol, typhus in, 249. Bronchitis — in smallpox, 100, 123 ; in measles, 145 ; in erysipelas, 214 ; in typhus, 284, 310 ; in enteric fever, 395. Broncho-typhus, 284, 294. Bryce's test of vaccination, 111. Bubo, axillary, in vaccino-syphilis, 112. " Bubonic fever," 243, 291. Bubonic swellings, 171, 291, 403. INDEX OF SUBJECTS. 41) 1 Buchlioltz-Wernick method, 442. " Bukowina fever," 317. Bullae, 212. "Burnt holes," 129. Caecum in enteric fever, 419. Cafe" noir, 461. Caffein, 461, 462. " Calor mordax," 162. "Calor praeter naturam," 2, 9. Calomel in enteric fever, 440, 471. Camphor in enteric fever, 448. Cancrum oris, 146, 153, 290, 402. Carbolic acid hypodermically, 225. in enteric fever, 443, 444, 445. Carboluria, 445. Cardiac failure, 179. Carotids, compression of the, 152, 190. Carphology, 259, 281. Carriers of infection, called "fomites," 17, 19, 44. Catarrhal typhus, 241, 284. Cathartics, saline, 52. to be avoided, 52. "Cat's tongue." 163. Cerebral breathing, 259, 275. symptoms, 214. Cellulitis, diffuse, 168, 174, 287. " Change of air," 46. Chemical Carbon Company's cones, 45. Cheyne-Stokes breathing, 275. Chickenpox, 98, 125, 149 ; nomenclature, 125 ; definition, 125 ; aetiology, 125 ; non-inoculable, 126 ; clinical history, 127 ; incubation, 127 ; invasion, 127 ; eruption, 127; desiccation, 128; complications and sequelae, 129; diagnosis, 130; prognosis and treatment, 132. China, 103. Chloral, 61. Chloride of sodium in fever, 52, 278. Chlorine in enteric fever, 443, 446. Chorea, 171, 192, 281, 398. Chorioiditis of relapsing fever, 327. Chromogenic bacteria, 15. Cicatrices — vaccinal, 108 ; foveate^ 111. 492 INDEX OF SUBJECTS. Cicatrisation in typhoid ulceration, 422, 425. Cicatrix, or scar, of smallpox, 80. Circassia, 103. Cirrhosis of the lung, 285. City of Dublin Hospital, 120. Cladotricb.es, 14. Classification of continued fevers, 231. disinfectants, 31, 32. micro-parasitic febrile diseases, 25. smallpox, 82 ; measles, 142 ; scarlatina, 159 ; erysipelas, 210. Clavele*e, 103, 104. Clavelisation, 103. Cleft-fungi, 14. Clinical history — of smallpox, 75 ; of chickenpox, 127 ; of measles, 136 ; of scar- latina, 158 ; of Eotheln, 195 ; of erysipelas, 210 ; of febricula, 235 ; of typhus, 255 ; of relapsing fever, 321 ; of enteric fever, 363. Cloudy swelling, 97, 429. Coal tar derivatives, 459. Cocci, 14. Coffee in fever, 461. Coherent smallpox, 82, 85. Cold affusion, 56, 62, 151, 451. bath treatment — of fever, 54 ; of measles, 151 ; of scarlatina, 184, 187 j of erysipelas, 223 ; of enteric fever, 451. compresses, 186, 468, 469. water treatment, 53, 186, 450. Cohtis, 145, 152. Collapse in relapsing fever, 326, 332. stage of fevers, 26. Colon in enteric fever, 419. Coma, 280. death by, 416. "Coma vigil," of Chomel, 280 ; of Jenner, 280, 296, 382. " Common infectious diseases," 19, 68. Communicable diseases, 12. Complications and sequelae, 64, 122, 129, 143, 170, 198, 214, 284, 326, 395. Compresses — glycerine, 464, 465 ; cold, 186, 468, 469. Condy's fluid, 433. Confluent smallpox, 77, 82, 84, 89 ; treatment of, 114. Congestive hypersemia of kidneys, 175. Conjunctivitis, 192. Constipation in enttric fever, 377, 463, 476. INDEX OF SUBJECTS. 493 Constructive store-albumen, 9. Contagion — intimate nature of, 12-17 ; meanings of the word, 12. Contagious diseases, 17, 18, 19. Contagiousness of erysipelas, 205, 206, 207, 208. Contagium, 8 ; definition of, 13. vivum of typhus, 248. Continued fevers, 25, 227, 229, 230. Murchison's classification of the, 231. Convalescence stage, 27, 101, 141, 164, 220, 261, 312, 367. Convalescent Homes, 45, 46. Convulsions, 63, 144, 152, 190, 281, 282, 290, 311, 398. " Cooling regimen " in smallpox, 114. Cooling stage of fevers, 25. Copaiba rash, 99. Copenhagen, varicella at, 131 ; measles at, 135. Cork Hospital, 106. Cork-street Fever Hospital, Dublin, 78, 83, 89, 100, 106, 107, 124, 207, 213, 230, 256, 257, 265, 282, 288, 290, 297, 298, 300, 306, 313, 361, 385, 387, 393, 415, 441, 471. Corymbose smallpox, 82, 86. Costive bowels in typhus, 312 ; in enteric fever, 377. Cowpox, 104. Creasote in enteric fever, 448. Cri cerebral, 295. Crimean War, 248, 286, 288. Crisis, 8, 26, 236, 260, 264, 272, 322, 394. Critical days, 236, 262. Croup— true, 145, 152 ; false, 152. Crusts of smallpox, 80, "Crystalli," 126. Cubebs rash, 99. Curative treatment — 30, 48 ; of smallpox, 113 ; of measles, 150 ; of scarlatina, 183 ; of erysipelas, 221 ; of typhus, 306 ; of relapsing fever, 330 ; of enteric fever, 435. Cutis anserinp, 369. Cyclical course of fevers, 26. Cynanche tonsillaris, 180. Cystitis, 290, 402. Daphnia, or "water-fleas," 23. Darm-typhus, 341. Deafness — in smallpox, 81 ; in typhus, 283 ; in enteric fever, 383. 494 INDEX OF SUBJECTS. Death, sudden, in enteric fever, 403. Defervescence, 25, 27, 87, 88, 128, 140, 163, 213, 260, 264, 322, 367, 393. Definitions of fever, 2, 3, 7, 278 ; smallpox, 69 ; chickenpox, 125 ; measels, 133 ; scarlatina, 154 ; Rotheln, 193 ; erysipelas, 202, simple fever, 233 ; typhus, 241 ; relapsing fever, 314 ; enteric fever, 341. Delirium, 60, 83, 123, 143, 169, 214, 259, 279, 322, 381. ferox, 83, 259, 279. forms of, 83, 259, 279. in fever, 259. low muttering, 259, 381. tremens, 83, 259, 279, 296. De novo origin of typhus, 247 ; of enteric fever, 346, 356. Deodorants, 31. " Dermatitis gangrenosa," 130. Desiccation stage — of smallpox; 80 ; of varicella, 128. Desquamation, 27 ; varieties of, 27. in smallpox, 80 ; measles, 140; scarlatina, 163 ; Rotheln, 197 ; erysipelas, 218 ; typhus. 272 ; enteric fever, 375. Desquamative nephritis, 146, 170, 174, 176, 189, 290, 303, 401. Destitution, 39, 43, 253. Diagnosis — of smallpox, 98 ; of varicella, 130 ; of measles, 148 ; of scarlatina, 179 ; of Rotheln, 198 ; of erysipelas, 218 ; of febricula, 237 ; of typhus, 294 ; of relapsing fever, 328 ; of enteric fever, 408. Diaphoresis, profuse, 260, 267, 272. Diaphoretics, 51, 52, 53. Diarrhoea, 64, 81, 100, 123, 145, 152,'277, 289, 327, 333, 377, 399, 464, 477. Diary fever, 234. " Diazo reaction," 409. Dicrotic pulse, 273, 376. Diet-drinks, 439. Diet in enteric fever, 437. Dieting of convalescence in typhus, 312 ; in enteric fever, 477 — 480. Dieulafoy, 151. Diffuse cellulitis, 168, 174. Digestive symptoms in typhus, 289 ; in enteric fever, 399. Digitalis, 459. and opium, 61. Diluents, 51. Diphtheria, 180, 291 ; of pharynx and larynx, 145, 168, 170 ; treatmentof, 188. " Diphtheritic pock," 97. pyelitis, 177. Discrete smallpox, 77, 82, 89 ; treatment of, 114. INDEX OF SUBJECTS. 495 Disease, germ theory of, 12, 13. Diseases, communicable and non-communicable, 12. Disinfectants, 31, 432. Disinfection, 31, 47 ; general plan of Dr. Emerson Reynold* 1 , 32 ; regulations in Berlin, 35 ; within the body, 37. Dissolution of the blood, 91, 169, 286, 378. Distinct smallpox, 77, 82, 89 ; treatment of, 114. Diuretics, 51, 190. Diuretin, 51, 190. Dorsal decubitus, 275, 280. Dothie'nente'rie, 342. Drainage system, necessity for efficient, 431. Drinking-water as a carrier of enteric fever poison, 357. Dropsy, 177. Dublin — smallpox in, 72, 92 ; measles in, 135, 137 ; scarlet fever in, 156 ; typhus and typhoid fevers in, 346-348 ; enteric fever in, 349, 364. Dundee Royal Infirmary, 261. Duodenum in enteric fever, 419. Duration of typhus, 261 ; of enteric fever, 367. Dysentery, 289, 327, 333, 399. Dysphagia, 81, 211, 289, 397, 399. Dyspnoea., 81. Ear, diseases of the, 95, 145, 152, 171, 191, 283, 383. " Easel-like " temperature range, 163, 172. "Eating Hives," 129. Eaux aux jambes, 104. Ectogenous enteric fever, 35-5, 356. Ectrotic method of treatment, 225. Eczema. 146, 171, 192. rubrum, 2*19. Effervescing draughts, 469. Ehrhch's test, 409, 411. Eiterungsfieber, 88. Elimination, promotion of, 48. Emaciation — in typhus, 300 ; in enteric fever, 383. Embolism, 287. Emetics in enteric fever, 469. Emphysema, general, 397. Emunctories, the Great, 51. "■ I Enanthem, 147. - . , 4% INDEX OF SUBJECTS. Endemic disease, 1 9 ; definition of, 20. fever, 231, 346. Endocarditis, 287, 398; ulcerative (septic), 413. Enemata in enteric fever 468. ice-water, 470. EDgland, deaths from relapsing fever in, 315. deaths from small-pox in, 105. smallpox inoculation illegal in, 103. Engouement, 422, 426. Enterica sine enteritide, 421, Enteric fever, 230, 231, 292, 328, 335 ; nomenclature, 339 ; synonyms. 341 ; definition, 341 ; literature and history of, 342; geographical distribution, 344 ; aetiology, 345 ; predisposing causes, 349 ; recurrence of, 351 ; exciting cause, 351 ; bacteriology, 351 ; autochthonous, autogenous, or entogenous, and ectogenons, 355 ; paths of infection, 357 ; mode of invasion, 360; clinical description of, 363; incubation, 363; invasion, 364 ; glandular enlargement, 364 ; ulceration and sloughing, 366 ; amphi- bolic stage, 366 ; lysis, 367 ; convalescence, 367 ; duration, 367 ; analysis of symptoms, 369 ; physiognomy, 369 ; surface in, 369 ; rose-spots, 369 ; circulation, 375 ; dicrotism in, 375 ; respiratory symptoms, 376 ; digestive symptoms, 376 ; constipation, 376 ; diarrhoea, 377 ; intestinal haemorrhage, 377 ; urinary system, 3S0 ; nervous system, 381 ; organs of special sense in, 382 ; emaciation in, 383 ; relapse, 384 ; temperature, 392, 408 ; com- plications and sequelae, 395 ; sudden death in, 403 ; co-existence of other specific diseases with, 404 ; varieties, 405 ; diagnosis, 408 ; prognosis and mortality, 414 ; pathological anatomy, 416 ; modes of death, 416 ; intestinal and splenic lesions, 419 ; prophylaxis, 430 ; disinfection of excreta, 433 ; curative treatment or management, 435 ; antipyretic treatment, 450 ; laparotomy in, 472 ; management in convalescence, 475. Entogenous enteric fever, 355, 356. " Ephemera," 233, 235. Ephemeral fever, 147, 233, 234. "Epidemic Constitution " (Sydenham), 143, 149, 156, 284. Epidemic — disease, 19 ; definition of, 20 ; fevers, 231. Hospitals, 45. Epidemic rose rash, 142, 148, 193 (see " Eotheln "). Epistaxis, 145, 152, 283, 326, 333, 383, 398, 462. Ergot, 123, 124,470. Eruption, 24 ; stage of, 27 ; in smallpox, 78 ; varicella, 127 ; measles, 139 ; scarlatina, 162 ; Rbtheln, 196 ; erysipelas, 211 ; typhus, 258 ; enteric fever, 370. Eruptions, septicemic, 375. Eruptive fevers, 25, 65, 67, 229. . ; INDEX OF SUBJECTS. 497 Erysipelas, 99, 180, 202, 291, 292, 402 ; nomenclature, 202 ; etymology of the word, 202 ; definition, 202 ; aetiology, 203 ; idiopathic or medical, 203 ; trau- matic or surgical, 203 ; predisposing causes, 204 ; traumatism, 204 ; " poso- comiale," 204 ; contagiousness of, 205 ; throat affection in, 208 ; inoculable, 209 ; bacteriology of, 203, 209 ; clinical history, 210 ; incubation. 210 ; invasion, 211 ; eruption, 211 ; faucium, 211 ; defervescence, 213 ; migrans, 213, 219; pulmonum, 213; temperature in, 213; complications and sequelae, 214 ; pathology, 215 ; diagnosis, 218 ; prognosis, 219 ; treatment, 220 ; of the pharynx, 289. " Erysipele salutaire," 209 ; ambulant, 213 ; des nouveau-nes, 214. Erythema, 179, 219, 372 ; papular, 373. Erythematous accidental rashes, 76, 77, 90, 371. Essential fever, 2, 16, 18. phenomena of fever, 9. diseases, 16. Essera Vogelii, 193. Etat pointing 422, 427. Etymology of the word "erysipelas," 202. Eucalyptus oil in enteric fever, 448. Eustachian tubes in smallpox, 8 1 . Exanthema, meaning of term, 68. Exanthemata, 25, 65, 67, 68. Cullen's definition of the, 67. Exciting causes of disease, 38, 70, 126, 134, 157, 193, 205, 243, 318, 351. Excreta in enteric fever, disinfection of, 433. Expectant treatment, 184, 221. Eyes and eyelids in smallpox, 94, 122. in typhus, 282 ; in relapsing fever, 326 ; in enteric fever, 382. Facultative parasites, 14. Eacies typhosa, 271, 369. Fadenpilze, 13. Fairchild's zymine peptonising powders, 438. " Fall fever," 340, 349. Famine and pestilence, 39. fever, 39, 313 (see " Relapsing Fever ")■ False croxip, 144. Faroe Islands, measles in, 135, 137. Fastigium or acme, 25, 76, 263, 393. Fatigue, 39, 41. Fatty degeneration, 97. Fatuity — after typhus, 288 ; after enteric fever, 398. 2 K 498 INDEX OF SUBJECTS. Febricula, 231, 233, 328 ; nomenclature, 233 ; definition, 233 ; aetiology and history, 234 ; auto-infective, 235 ; clinical history, 235 ; modes of crisis in, 236 ; diagnosis, 237 ; prognosis, 237 ; pathology, 237 ; treatment, 237. Febrile urticaria, 373. Febris complicata, 6. mixta, 6. simplex pura, 6. variolosa sine exanthemate, 92. Feeding the fever patient, 57. Ferment, 13. Fermentation, 13. Fermentative bacteria, 15. Ferret-eye of typhus, 259, 282. Fever, intimate nature of, 1-11 ; meaning of the term, 1, 278 ; symptomatic or idiopathic, 2 ; primary, specific, or essential, 2, 16 ; secondary, non- specific, or accidental, 2 ; cardinal fact in, 2 ; " calor praeter naturam," 2, 9 ; definitions of, 2, 3, 7 ; a " dissolution," 6 ; pathology of, 8 ; essen- tial phenomena of, 9 ; uses of water in, 10 ; malarial or paludaL 19 ; classification of, 25, 229 ; preventive treatment of, 40 ; curative treat- ment of, 48 ; of suppuration, 88 ; non-specific, 231 ; specific, 231. Fever nurse, qualifications for a, 307. "Feverish cold," 253. Feverishness, 2. Fieberabnahme, 27. Fievre muqueuse, 406. typho'ide, 340. Fiji, measles in, 135. Fish as a fever diet, 479. Fission fungi, 13, 14. Flaky desquamation, 27, 140, 163. Floccitatio, 259, 281. Foetal heart in typhus, 274. Foetus in utero, heart of the, 274. Fomites, 17, 19, 44, 245, 254. Food, scarcity of, 39, 43. suitable in fever, 57, 478. Furfuraceous desquamation, 27, 140, 163. Furuneular diathesis, 94, 100. Gangrene, hospital, 290, 291. Gangrene of the lung, 286. skin, 215, 290, 311, 402, 462. vulva, 146, 153. INDEX OF SUBJECTS. 49'J Gangrenous stomatitis, 146, 153, 290. Gargouillement, 277, 341, 365, 376, 411. Gastric fever, 406, 407. '•Gastro -entente," 342, 406, 419. Geographical distribution of smallpox, 70 ; of measles, 133 ; of scarlatina, 155 ; of erysipelas, 205 ; of typhus, 242 ; of relapsing fever, 317 ; of enteric, 344. Georgia, 103. Germ theory of disease, 12, 13. German treatment of smallpox, 117. Germicides, 31. Glanders, 99. Glandular enlargement stage in enteric fever, 364. enlargements, 145, 153. Glasgow Royal Infirmary, 245, Globular bacteria of erysipelas, 216. Glomerulo-tubal nephritis, 175. Glossitis variolosa, 84, 95. Glottis, oedema of tue, 95, 100, 123, 181, 226, 289, 497. Glycerine poultice, 464, 465. "Golden rule," Jenner's, 109. Grafenberg ** wet-pack," 54. Gram's method of staining, 354. Granular degeneration, 97. " Grease," 104. Greece, 103. "Grippe, la," 20. " Grisolle sign," 98, 148. Guaiacum and oxonic ether test for haemoglobin, 185 Guy, Danse de St., 171. Guy's Hospital, 161, 415. Haematemesis, 289. Hematuria, 290, 401, Haemoglobin, test for, 185. Hemoglobinuria, paroxysmal, 185. Haemophilia, acute, 91, 92, 170, 286, 290, 398. Haemoptysis, 286. Haemorrhage, intestinal, 64, 289. 326, 378, 394, 452, 469. in enteric fever, 378, 394. in relapsing fever, 326. Hemorrhagic — putrid fever, 398 ; smallpox, 90-92, 98, 100 ; treatment of, 123. diathesis, 91, 92. 500 INDEX OF SUBJECTS. "Halo" of smallpox pustule, 79 ; of vaccina, 109, 111. Hair, fall of the, 85, 173, 218, 272, 373. Hampstead Hospital, 106. Hardwicke Fever Hospital, Dublin, 86, 106. " Hatching " stage of fevers, 26. Hazeline, 462. Headache, 59 ; in typhus, 256, 257, 278 ; in enteric fever, 381. Heart, effect of sipping upon the, 476. in smallpox, 98 ; in scarlet fever, 178 ; in typhus, 273 ; in relapsing fever, 324 ; in enteric fever, 418. of the fetus in utero, 274. Heat, adjusting mechanism, 5. animal, theory of, 4. discharging mechanism, 5. producing mechanism, 5. Hectic state, 26. Hefenpilze, 13. " Heil-fieber," 7. Hemiplegia, 288. Hendon cow disease, 157, 158. Hereditary predisposition to disease, 38. Herpes, 130, 271. vaccinal, 112, 146. zoster, 219. Herpetic fever, 233, 236. Hiccough, 63, 259, 382. Hoarseness, 81. Homerton Fever Hospital, 106, 345. Hornpox, 89. "Hospital gangrene," 290, 291. Hospitals, epidemic, 45. " Hot regimen " in smallpox, 113. House drain, description of, 431. Humanised lymph, 110. Hungerpest, 39, 313. " Hybrid measles," 195. scarlatina," 195. Hydronaphthol in enteric fever, 443, 444. Hygienic manangement of enteric fever, 436. Hyperemia, simple, 371. Hyperesthesia, 63, 283, 383, 398. INDEX OF SUBJECTS. 501 Hyperpyrexia or "excessive fever," 5, 7, 53, 88, 169, 181, 186, 214, 264, 265, 268-270, 325, 416. Hyphomycetes, 13. Hypnotics, 60. Hypostatic congestion of the lung, 275, 285. Ice, 122, 186, 188. Ice-cradle, 55. poultice, 64, 468, 469. water enemata, 470. Iceland, enteric fever in, 344. Icterus, 289, 328, 330, 399. Idiopathic erysipelas, 203. fever, 2. Idiosyncrasy, 252, 350. Ileo-csecal valve, 419. Ileo-typhus, 341. Ileum in enteric fever, 420. Immersion iu cold baths, 54, 454. Immunity, theories of, 21, 434, 482. acquired, 22. natural, 22. after enteric fever, 350. Impffeder, 110. Incontinence of urine, 311. Incubation, period of, 13, 26, 75, 127, 136, 159, 160, 195, 210, 255, 363. India, relapsing fever in, 317. Infantile remittent fever, 340, 407. Infection — carriers of, 17, 19, 44, 245, 254; paths of, in enteric fever, 357 ; and immunity, 482. Infections-fieber, 6, 18, 68. Infections-krankheit, 13, 18. Infectious diseases, 17, 18. microbes, 15. myocarditis, 178. Infective diseases, 13, 18. fever (Infections-fieber), 6, 18, 67, 68. granuloma, 422. Inflammation of serous membranes, 178. synovial membranes, 178. Inflammatory fever, 235. Influenza, 20, 412. 502 INDEX OF SUBJECTS. Inhalation of oxygen, 462. Initial fever of smallpox, 87. stage of fevers, 26. Inoculation, 17, 43, 102, 202, 205. for smallpox, illegal, 103 ; for measles, 137 ; for scarlet fever, 157 ; for erysipelas, 209. Intemperance, alcoholic, 39, 42, 252. Intermittent fevers, 19, 25, 229. Internal administration of water in fever, 11. Interstitial nephritis, 176, 296. Intestinal haemorrhage, 64, 289, 378, 394, 452, 469. lesions of enteric fever inconstant, 420. Intimate nature of contagion, 12-17. fever, 1-11. Intolerance of sound, 283. Inunction in scarlatina, 185. Invasion, period of, 25, 26, 28, 29, 76, 127, 138, 144, 161, 196, 211, 257, 360, 364. Ireland, Public Health Act, 1878, 38, 41, 46, 47. smallpox inoculation illegal in, 103. typhus in, 243 ; relapsing fever in, 313, 314, 315. " Irish ague," 241. Iritis, 94, 333. Iron — in smallpox, 115 ; in scarlatina, 192 ; in erysipelas, 222 ; in enteric fever, 481. Isolation, 27,29,44, 45, 47, 102, 183. Itching in Kotheln, 197. Jaeger system of clothing, 191. Jaundice — in typhus, 289 ; in relapsing fever, 328, 330 ; in enteric fever, 399. Jejunum in enteric fever, 419. Joint disease in smallpox, 96. Jungle fever, 19, 294, 295. Kairin, 459. Katabolism, 4. Keratitis, 94, 122, 146, 171, 192. Kidneys — lime deposits in, 176 ; in smallpox, 97 ; in scarlatina, 170, 174 ; in enteric fever, 418. Knee-jerk, 289. KcD/Uo aypvTTv6v, 381. " Kuhpockenimpfung," 104. INDEX OF SUBJECTS. 503 Lactation in enteric fever, 402. Lamellar desquamation, 27. " Landfarsot " of Iceland, 344. Laparotomy in enteric fever, 472, 473, 474. Laryngitis— in small-pox, 95, 122 ; in measles, 144, 145 ; in erysipelas, 226 ; in typhus, 286 ; in enteric fever, 396, 418. membranous, 145, 226, 286, 396. Laryngo-typhus, 286. Larynx in enteric fever, 418. Latent enteric fever, 406. period, 26, 28, 364. scarlatina, 167. Laxatives, 52. " Leaguer sicknesses," 241. " Leaven," 13. Leeching, 52, 192 ; contraindicated in erysipelas, 224. Leipzig, Rbtheln at, 194. Leiter's tubes, 452. Leptotriches, 14. "Lethargus," 382. Leucin, 278. Leucocytes as phagocytes, 23. Leucocytosis, 215. Levuka, measles at, 135. Lichen, 130 ; vaccinal, 112. Liebig's beef tea, 439. Lime deposits in kidneys in scarlatina, 176. Literature — of typhus, 242 ; of enteric fever, 342. Liver — in smallpox, 97 ; in typhus, 277 ; in enteric fever, 418 ; effect of sipping upon the, 476. *' Londonderry," steamship, 249. London Fever Hospital, 159, 230, 231, 245, 251, 263, 287, 297-299, 316, 321, 329, 349, 370, 388, 389, 415, 451. Hospital, 55, 188. Smallpox Hospital, 86, 106, 108, 117, 292. smallpox in, 71, 72. Lufthunger, 275. Lungs, cirrhosis of the, 285. enteric fever entering by the, 360. gangrene of the, 286. hypostatic congestion of the, 275, 285. tuberculosis of the, 286. 504 INDEX OF SUBJECTS. Lymph, 103, 110. Lymphangeiitis, 219. capillary, in erysipelas, 216. Lymphatic glands — in Kbtheln, 193, 197 ; in erysipelas, 218. Lysis, 8, 26, 367, 394. Macrophages, 217. Macuhe, 241, 258, 271, 370, 371. cserulese, 236, 370, 371. Magdeburg Hospital, 257, 294. Magnesium, salicylate of, 444. " Maitre bouton," 104. Malaise, 75. Malaria, 19. Malarial fevers, 19. Malignant smallpox, 90, 91, 100. stage of typhus, 259. Mania, 288, 398. Marasmus, 403. Marylebone, scarlatina in, 157, 158. Mater Misericord ise Hospital, 404. Maturation in smallpox, 79. fever of smallpox, 88. "Master Pock," 104. Meat as a carrier of enteric fever poison, 359. Meath Hospital, 56, 58, 83, 89, 115, 137, 160, 207, 246, 262, 265,269, 273, 282, 288, 324, 361, 383, 407, 426, 458. Measles, 98, 133, 180, 295 ; nomenclature, 133 ; definition, aetiology, and bacteriology, 133, 134- ; stages of infectiveness, 134 ; "striking distance," 134 ; epidemics in Faroe and Fiji, 135 ; seasonal prevalence, 135 ; clinical history, 136 ; incubation, 136 ; invasion, 138; eruption, 139; tempera- ture, 138, 140, 146 ; desquamation, 140 ; convalescence, 141 ; relapse in, 141 ; classification, 142; complications, 143 ; convulsions, 144 ; laryngitis, 144 ; suffocative catarrh, 144, 145 ; epistaxis, 145 ; diarrhoea, 145 ; croup, 145 ; otitis, 145 ; pathology, 147 ; diagnosis, 148 ; prognosis, 149 ; treat- ment, 150 ; " fiery," 154. Measly rash of typhus, 258, 370. " Medical erysipelas," 203. Medicinal rashes, 99, 371. " Meisterpocken," 104. Mekena, 398. Melbourne, enteric fever in, 358. INDEX OF SUBJECTS. 505 Membranous croup, 145. desquamation, 27. Meningitis, 288, 295, 398. Menorrhagia — in smallpox, 91, 124 ; in enteric fever, 402. Mental disease in typhus, 288. Mercury, biniodide, in scarlatina, 183. Metabolic theory of fever, 6. Metabolism, 4, 7. Meteorism, 63, 280, 376, 467. Mesenteric lymph glands in enteric fever, 428. Miasm, 19. Miasmatic-contagious diseases, 18 ; definition of, 19. Miasmatic diseases, 18 ; definition of, 18. Microbes, 9, 14. pathogenic and non-pathogenic, 1 4. infectious and non-infectious but toxic, 15. aerobic and anaerobic, 15. Micrococci erysipelatosi, 209. Micro-organisms classification of, 13. in fever, 8, 9 (See " Microbes"); Micro-parasitic diseases, 12, 18, 25, 68. Microphages, 217. Microspheres of Cohn, 216. "Micro-strife," 23,"217. Middlesex Hospital, 222, 345, 404, 451, 457. Milch cows, disease in, 157. Miliary eruptions, 371. Milk as a carrier of enteric fever poison, 358. Milk as a fever food, 437. Mineral acids, 49. ' Mistura cretse, 465. Mistura spiritus vini gallici, 439. " Mixture anglaise," 465. Modified smallpox, 69, 89, 90, 93. Montrose, erysipelas at, 208. " Morbific Agent," 18. Morbilli, 133. (-See Measles.) Morbilliform rash of typhus, 258. Morbilli ignei, 154. nigri, 143. sine morbillis, 140, 142. catarrho, 140, 142. 506 INDEX OF SUBJECTS. Morbillous catarrh, 145. Mortality — in confluent smallpox, 84 ; chickenpox, 132 ; measles, 149 ; scar- latina, 181 ; RStheln, 201 ; erysipelas, 220 ; typhus, 297 ; relapsing fever, 329 ; enteric fever, 414. Mottling, subcuticular, 269. Moulds, 13. Mucorini, 13. Mucous membranes — in smallpox, 80, 84 ; in measles, 138. Mulberry rash of typhus, 259, 370. Munich, enteric fever in, 350. Muscular lesions in typhus, 280, 288. Mycoprotein, 14. Myocarditis, acute parenchymatous, 178, 287, 418, 429. Myositis typhosa, 429. Nails, atrophic furrow across, 272, 375. shedding of the, 173. Naphthalin in enteric fever, 448, 455. Natural immunity, 22. smallpox, 93. Nausea, 321, 376. Necker Hospital, Paris, 130, 149. Necrosis, 403. Negroes, risk from smallpox to, 72. Nephritis, acute desquamative, 146, 170, 174-176, 189, 290, 303, 401. interstitial, 176, 296. Nervous excitement, 60, 258. prostration, 259. respiration, 376. symptoms of fever, 8, 288, 398. system, thermal, 5. typhus, 293. Netherfield. Fever Hospital, Liverpool, 427, 429. Nettle-rash, 219, 371. Neuralgia in enteric fever, 381. Neuralgic pains, 63, 381, 398. Neuritis, peripheral, 288. Neurotic theory of fever, 6. Neutralisation of fever poison, 48, 49. New York, Rotheln in, 195, 196. Nitre in relapsing fever, 331. Noma, 146, 153, 290, 402. tNDEX OF SUBJECTS. 507 Nomenclature— of smallpox, 69 ; varicella, 125 ; measles, 133 ; scarlatina, 154; Rotheln, 193 ; erysipelas, 202 ; febricula, 233 ; tvphus, 239 ; relapsing fever, 313 ; enteric fever, 339. Non-cnmmunicable diseases, 12. Non-infectious microbes, 15. Non-pathogenic microbes, 14. Non-specific fever, 2, 231. North Dublin Union Workhouse, 297. Northern Hospital, Liverpool, 454. Nose — in typhus, 283 ; in relapsing fever, 324, 326 ; in enteric fever, 383. Nose-bleeding, 145, 152, 283, 326, 333, 383, 398, 462. Nurse, fever, qualifications for a, 307. Nursing in typhus, 307. Nutrition of body to be maintained in fever, 48, 57. Nux vomica in tympanites, 467. Nystagmus, 281. O'Beirne's long tube for tympanites, 468. Obligate parasites, 14. " Ochlotic fever," 241. Odour in smallpox, 80 ; measles, 139 ; typhus, 272 v CEdema, 290, 312. of the glottis, 95, 100, 123, 181, 226, 289, 397. Onset of fevers, 25. Ophthalmia, 94, 146, 153, 326, 333. Opium, 60, 266, 471 ; contra-indications for, 61. Oriental plague, 243, 291. Otitis — in smallpox, 95 ; in measles, 145, 152 ; in scarlatina, 171, 191 ; in typhus, 283 ; in enteric fever, 399. Otorrhoea, 399. Overcrowding, 39, 241, 243, 252, 253. Oxygen, inhalation of, 462. Ozonic ether and guaiacum test for haemoglobin, 185. Pains, rheumatoid and neuralgic, 63. Paludal fevers, 19. Pandemic disease, 19 ; definition of, 21. Panophthalmitis, 94, 171. Papular erythema, 373. Paracentesis in perforation, 472. Paraplegia, 288. Parasites, 14 ; obligate and facultative, 14. Parasitic-contagious diseases, 18 ; definition of, 19. 508 INDEX OF SUBJECTS. Paralyses in typhus, 280, 288 ; in enteric fever, 398. Parenchymatous myocarditis, 178, 287. nephritis, 146, 170, 174-176, 189, 281, 290, 303, 401. Paresis after typhus, 311. Parotitis, 403. " Parrot-tongue," 277. Patellar reflex, 289. Pathogenic microbes, 14, 15. Pathology of the infective or specific fevers, 8. smallpox, 96 ; measles, 147 ; scarlatina, 173 ; Rotheln, 198 ; ery- sipelas, 215 ; febricula, 237 ; typhus, 300 jrelapsing fever, 329 ; enteric fever, 416. Peeling stage of fevers, 27. Pemphigus, 130, 219. gangraenosus, 129. Peptonised food, 57, 184. Perforation of the intestine, 394, 400, 427, 472. Pericarditis, 287, 398. Perichondritis laryngea, 95, 100, 286, 397. typhosa, 286, 397. Periodicity of smallpox, 71. Periostitis, 403. Peripheral neuritis, 288. Peritoneum, rupture of the, 427. Peritonitis, 178, 215, 399, 400, 471. in relapsing fever, 327 ; in enteric fever, 376, 383, 399, 4C0, 471. Persia, 103. Petechise, 77, 242, 260, 271. "Petechia sine febre," 295. Peyer's patches, 341, 360, 362, 378, 414, 420, 422-424, 426, 427, 475. Phagocytes, 23, 434. Phagocytosis, 7, 22, 434, 486. Pharyngitis, 122, 145, 399. Pharynx, diphtheria of, 145 ; erysipelas of the, 289. Phenazone, 459. Phosphorus, 62. Photophobia, 49, 60, 283. Phimosis, 96. Phlebitis, septic, 145, 287. Phlegmasia alba dolens, 287, 312, 396. Phlegmonous inflammation, diffuse, 219. Phylaxins, 434. Picote, 69, 105. INDEX OF SUBJECTS. 50'.) Pigment-forming bacteria, 15. Pilocarpin for uraemia, 190. " Pin-hole pupil " of Graves, 259, 282. Pitting in smallpox, prevention of, 116-118. Plague, oriental, 243, 291. Plaques dures, 423. gaufrees, 423. molles, 423. re'ticule'es, 423, 427. Plasmodium malariae, 19. Pleuritis, 95, 146, 171, 178, 214, 286, 395 ; treatment for, 191. Plumbism, 296. Pneumo-thorax, 397. Pneumotoxins, 484. Pneumo-typhus, 284, 294. Pneumonia, 95, 145, 213, 214, 237, 264, 285, 296, 326, 357, 360, 361, 395, 482. migrans, 213 ; pythogenic, 285, 357, 360, 361. Pneumonic fever, 264, 285, 360, 482. Pock, diphtheritic, 97. " Pocks " of smallpox, 69, 78 ; their life-history, 79. Potus imperialis, 51. Predisposing causes of disease, 38, 47, 71, 72, 135, 156, 204, 250, 251, 316, 349. Predisposition to disease, 38. Pregnancy in typhus, 299 ; in enteric fever, 402. Preventable diseases, 30. " Preventive Medicine," 30, 49. Preventive treatment, 30, 40, 47 ; of smallpox, 102 ; of measles, 150 ; of scar- latina, 182 ; of typhus, 305 ; of relapsing fever, 330 ; of enteric fever, 430. Primary fever, 2. Principles of treatment, 48. Prodromal fever — of smallpox, 76, 87 ; of cfcickenpox, 127; of measles, 138 ; of scarlatina, 161 ; or erysipelas, 211 ; of typhus, 258 ; of enteric fever, 364. stage of fevers, 26. Prognosis — of smallpox, 99 ; of chickenpox, 132 ; of measles, 149 ; of scarla- tina, 181 ; of Rbtheln, 201 ; of erysipelas, 219 ; of febricula, 237 ; of typhus, 296 ; of relapsing fever, 329 ; of enteric fever, 414. Prophylaxis, 30, 40, 47 ; of smallpox, 102 ; of measles, 150 ; of scarlatina, 182 ; of typhus, 305 ; of relapsing fever, 330 ; of enteric fever, 43 K Proteids, defensive, 434, 484, 4£€. Protomyces, 318. ;l ; Protoplasm, 9, 14. Pseudo-crisis in typhus, 263. . - - -'• 510 INDEX OF SUBJECTS. Psorenterie, 174. Ptomains, 15, 16, 22, 479. Ptyalism in smallpox, 83. Public baths and wash-houses, 40. Public Health (England) Act, 1875, 41. (Ireland) Act, 1878, 38, 41, 46, 47. (Scotland) Act, 41. Puerperal fever, 411, 412. state, 214. Pulmonary tubercle, 396. Pulse, dicrotic, 375, 376. in scarlatina, 161 ; typhus, 273 ; enteric fever, 375, 376. Punctiform bacteria of Ehrenberg, 216. Pupils, " pin-hole," 259, 282; inequality of, 283 ; dilated, 382. Purpura and enteric fever, 371. typhus, 272, 295. variolosa, 92. Purpuric rashes, 77. smallpox, 90, 91, 92 ; measles, 142. 143. Putrefactive bacteria, 15. Putrid stage of typhus, 259. Putrilage, 422, 429. Pyaemia, 96, 100, 171, 181, 191, 215, 286, 398, 411, 412. Pyelitis, diphtheritic, 177. Pyretologia, 83. Pyrexia — meaning of the term, 2 ; may be of use in the organism, 7. Pyrogenetic stage, 25, 26, 393. Pythogenic fever, 339, 341, 356. pneumonia, 285, 357, 360, 361. Quarantine, 27, 29, 43, 47. Quinine the best antipyretic, 50, 458 ; antiseptic use of, 115 ; in scarlatina, 186 ; in erysipelas, 222 ; in enteric fever, 443, 447, 458. Quinsy, 180. Rashes, accidental — in smallpox, 76, 90, 99 ; in enteric fever, 371. medicinal, 99. of enteric fever, 365, 369. Rattlesnake, bite of the, 274. " Ravaglione," 126. Receptivity, 28, 30, 43, 102 ; lessening, means for, 38. Recrudescences, 220, 367, 384. Recurrent measles, 141 ; enteric fever, 351. INDEX OF SUBJECTS. 511 "Red gum," 130. Reduction of temperature, 48, 52 ; in enteric fever, 450. Refuges, in quarantine, 44. Regimen, cooling, in smallpox, 114. hot, in smallpox, 113. Relapse in measles, 141 ; in scarlatina, 164 ; in erysipelas, 220 ; in typhus, 263 ; in enteric fever, 384, 429. Relapsing fever, 231, 232, 237, 313, 390, 411 ; nomenclature, 313 ; definition, 314 ; aetiology, 314 ; deaths in England, Ireland and Scotland from, 315 ; predisposing causes, 316 ; geographical distribution, 317 ; exciting cause, 318 ; bacteriology of, 318 ; no immunity conferred by, 3 ; clinical description, 321 ; stages and duration, 325 ; temperature in, 325 ; com- plications and sequelae of, 326 ; diagnosis, 328 ; prognosis and mortality, 329 ; pathological anatomy, 329 ; treatment, 330. Remittent fever, 19, 26, 295, 411 ; infantile, 407. Renal disease, 181. Repair, 4. Resorcin, 460. Respiration, cerebral, 259, 275. Chesne-Stokes, 275. in typhus, 274, 275. nervous, 275. Rest, absolute, 471. " Resting spores," 16, 232, 249, 319, 354, 356. Retention of urine, 282. Retinal haemorrhages, 94. Retinitis albuminurica, 171. Retrograde metamorphosis, 4. Re- vaccination, periodical, 108. Rheumatic arthritis, 170, 189, 414, 475. Rheumatism, acute, 170, 180, 189, 414, 475. scarlatinal, 178, 189. Rheumatoid pains, 63, 381. Rhizoporus, 244. Rosa anglica, 113. Roseola, epidemic, 142, 148, 161, 180, 193, 194. (See "Rotheln.") febrilis, 148. vaccinal, 112. variolosa, 77. simple, 149, 201. Rose-raah — epidemic, 142, 148, 161, 193 ; of enteric fever, 365, 369. simple, 149, 201. Rose's vaccinator, 110. 512 index or SUBJECTS. Rbtheln, 142, 148, 161, 180, 193 ; nomenclature, 193 ; definition, 193 ; a disease sui generis, 193, 200 ; "breeds true," 193 ; aetiology, 193 ; clinical history; 195 ; incubation, 195 ; invasion, 196; eruption, 196 ; itching in, 197, swelling of glands in, 197 ; desquamation, 197 ; temperature, 197 ; com- plications and sequelae, 198 ; pathology, 198 ; diagnosis, 198 ; prognosis, 201 ; treatment, 201. Rubeola nigra, 143. notha, 194. Rubeoloid rash of typhus, 258. Saccharomyces, 13. Saccharomycetes, 13. Salicin in enteric fever, 458. Salicylate — of bismuth, 443, 449. 466, 467 ; of magnesium, 444 ; of sodium — in erysipelas, 223 ; in enteric fever, 458. Salicylic acid in enteric fever, 458. Saline cathartics, 52. Salivation in smallpox, 83. Salol in enteric fever, 449, 458. Saprogenic microbes, 15. Saprophytes, 14. Scaphoid abdomen, 413. Scarlet fever, 98, 148, 154. (See " Scarlatina.") Scarlatina anginosa, 159, 167, 186. faucium, 166. haemorrhagica, 168, 177, 188. maligna, 159, 168, 187. simplex, 158, 184. surgical, 157, 291, 374, 411. Scarlatina, 98, 148, 154; nomenclature, 154; definition, 154; aetiology, 154 — 156; area of diffusion of, 155 ; rate of mortality, 155 ; predisposing causes, 156 ; exciting cause, 157 ; bacteriology of, 158, 192 ; clinical history : incu- bation, 159 ; invasion, 161 ; eruption, 162 ; defervescence in, 163, 172 ; desquamation, 163 ; relapse in, 164 ; irregular and aberrant forms, 166 ; abortive or rudimentary, 166 ; ataxic, 168 ; haemorrhagic, 168 ; compli- cations and sequelae, 170 ; pathology, 173; urine in, 177; diagnosis of, 179 ; prognosis, 181 ; mortality, 181 ; causes of death, 181 ; treatment, 182 ; prophylaxis, 182 ; curative treatment, 183. Scarlatinal dissolution of the blood, 169, 172, 181. Scarlatine fruste, 167. Schacht's " Liquor bismuthi," 224. " Scharlach-typhus," 169, 172, 181. Schizomycetes, 13, 14. Scotland, deaths from relapsing fever in, 315. Season as a predisposing cause of disease, 71, 126, 135, 156, 205, 251, 316, 415. INDEX OF SUBJECTS. hY?) Secondary fever in smallpox, 88. Semi-confluent smallpox, 82, 85. " Semitertian ague," 342. Senile enteric fever, 407. Septicaemia, 96, 100 ; typhoid, 421. Septicaemic eruptions, 374, 375. Septic endocarditis, 413. phlebitis, 145. Sequelae, 64, 85, 94, 129, 145, 171, 198, 284, 326, 395. Serous membranes in smallpox, 81. Sex as a predisposing cause of disease, 204, 251, 349, 415. Shaven-beard appearance in the intestines in enteric fever, 422, 427. Sheep rot, 103. Sheffield epidemic of smallpox, 74, 100, 105. typhus, 243. Simple continued fever, 98, 231-238. (S^e " Febricula.") Singultus, 281. Sipping of water for constipation, 476. Skin— in smallpox, 94, 96, 122 ; in typhus, 271 ; in enteric fever, 369. Sleeplessness, 60, 123, 280, 381. Smallpox, the paradigm of the eruptive fevers, 68, 69, 148, 180, 411 ; nomencla- ture, 69 ; definition, 69 ; aetiology, 70 ; periodicity of, 71 ; seasons and, 71 ; race and, 72 ; bacteriology of, 73 ; its " striking distance," 74 ; chief stages of infectiveness, 75 ; clinical history, 75 ; incubation, 75 ; invasion, 76 ; acci- dental rashes in, 76 ; stage of eruption, 78 ; stage of desiccation, 80 ; stage of desquamation, 80 ; classification of, 82 ; discrete, 82 ; confluent, 82 ; salivation in, 83 ; mortality in confluent, 84 ; sequelae of, 85, 94, 95 ; coherent, 85 ; corymbose, 86 ; temperature in, 87 ; modified, 69, 89, 90 ; malignant, 90 ; table of varieties of, 93 ; complications, 94, 95 ; pathology, 96 ; diagnosis, 98, 180 ; prognosis of, 99 ; prophylaxis, 102 ; curative treatment, 113. "Smoky urine," 177. Soil-pipes, 432. Solid food after enteric fever, 477, 478. Somnolence, 280. Sordes, 277. ' Spaltpilze, 13. Specific disease, 13, 16. fever, 2, 18. micro-organisms, 16. remedies, 53. Spirillum buccale, 318. fever, 313, 318, 390. (See "Relapsing Fever.)" Obermeieri, 318, 319. 2l 514 INDEX OF SUBJECTS. Spirochete denticola, 318. Obermeieri, 319. plicatilis, 318, 329. Spleen — in smallpox, 97 ; in relapsing fever, 326, 390 ; in enteric fever, 380, 428 ; abscess of the, 429. Splenic dulness in enteric fever, 365. Spleno-typhoid fever, 406, 407, 422. Sponging, tepid, 54, 306. Spontaneous origin — of fever, 232 ; of typhus, 247 ; of enteric fever, 346, 356. Sporadic disease, 19 ; definition of, 21. "Spores, resting," 16, 232, 249, 319, 354, 356. Sporulation, 16. St. Giles and St. Pan eras, scarlatina in, 157. Stimulants, use of, 48, 58, 59, 310, 440, 477. Stimulation in fever, 48, 58, 59, 274, 310, 441, 477. Stomach in enteric fever, 419. Stools in enteric fever, 377. Strabismus, 283. " Strawberry tongue," 163. Streptobacillus, 244. Streptococci of smallpox, 73 ; of scarlet fever, 158, 192 ; of diphtheria, 168 ; of erysipelas, 203, 209, 216 ; of typhus, 244. Streptococcus — scarlatinse, 158, 192 ; diphtheria, 168 ; erysipelatis, 203, 209, 216 ; conglomeratus, 192 ; pyogenes, 217. " Striking distance " of smallpox, 74 ; of measles, 134 ; of typhus, 245. Strophulus, 130. Strychnin in tympanites, 467. St. Thomas's Hospital, 131, 255. Stupor, 62. Subcuticular mottling, 259. Subsultus tendinum, 281. Sudamina, 271, 371. Sulphites in enteric fever, 443, 445. Sulpho-carbolate of sodium— in smallpox, 115 ; in erysipelas, 225. Sun fever, 233, 236. Suppuration, fever of, 88. " Surditas salutem portendit," 283. Surgical— scarlatina, 157, 291, 374, 411 ; erysipelas, 203. Susceptibility, 28, 30, 43, 102. Sympathetic system in typhus, 302. Symptomatic fever, 2. treatment, 49, 59. INDEX OF SUBJECTS. 515 Synocha, 233, 235. Synovitis acuta, 178. Syphilides, pustular, 98. Syphilis, 69 ; vaccine--, 112. ' Sweating, profuse, in typhus, 260, 267, 272. Table of varieties of smallpox, 93. Taohe ce're'brale, 296, 413. Tache scarlatinale, 162. Taches bleuatres, 236, 272, 370, 371. Taches rose'es lenticul aires, 370. Tagsore, 103. Tank-bath, 454, 455. Tartar emetic and opium, 60, 62, 266. Tartar emetic in enteric fever, 443. Taste, 283. Temperature, behaviour of, in febrile disorders, 25. in smallpox, 87 ; chickenpox, 127 ; measles, 146 ; scarlatina, 171; Rotheln, 197 ; erysipelas, 213 ; typhus, 263 ; relapsing fever, 325 ; enteric fever, 392, 408, 409. reduction of, 48, 52, 223, 450. Tepid sponging, 54. Terling, Essex, outbreak of enteric fever at, 350. Thallin, 459. Theory of animal heat, 4. disease, germ, 12, 13. fevers, 3, 4. immunity, 21, 434, 482. Thermal apparatus, 5. nervous system, 5. Thermogenesis, 5. Thermolysis, 5. Thermotaxis, 5. Thiocamf as a disinfectant, 34, 35. Thirst in fever, 9, 10 — how explained, 10 ; how relieved, 63. Thoracentesis, 191. Thoracic form of enteric fever, 395. Thrombosis, 287, 312, 398. Thymic acid in enteric fever, 460. Thymol in enteric fever, 448. Tinnitus aurium, 258, 321, 383; " Tippet-neck," 168. 516 INDEX OF SUBJECTS. Tisanes, 439. Tissue disintegration, 4. formation, 4, Tongue —in scarlatina, 163 ; in typhus, 277 ; in relapsing fever, 321 ; in enteric fever, 365, Tonsillitis, 180. Tooth-paste, antiseptic, 437. Torula cerevisise, 13. Toxic microbes, 15. Toxins, 15, 16, 22. Transfusion of blood in smallpox, 124; in enteric fever, 470. Traumatic — scarlatina, 157 ; erysipelas, 203. Traumatism in erysipelas, 203, 204. "surgical scarlatina," 157, Treatment, cold water, 53. curative, 48, 113, 132, 150, 183, 201, 221, 237, 306, 330, 435. ectrotic, 225. expectant, 184, 221, 330. preventive, 30, 40, 47, 102, 150, 305, 330, 430, principles of, 48, 113. symptomatic, 59. Tremor, inordinate, in enteric fever, 366, Trichiniasis, 413. Tubercle, pulmonary, %96. Tuberculosis, acute miliary, 129, 146, 153, 286, 396, 413. Turkey, 103. Turpentine, 467, 468; in enteric fever, 443, 445, 468. Turpentine and ergot in smallpox, 123 ; in enteric fever, 470, " Twining's pill," 333. "Twisting of the guts," 324. Tympanites, 63, 280,376, 467. " Typhisation a petite dose," 245, 253, 294. Typhoid, bilious, 317, 318, 320, 322 323, 328, 334, remittent fever, 295. Typhoid fever, 339, 340. (See " Enteric fever.") matter, 424. pneumonia, 296. scarJatima, 172. septicaemia, 421. stage of typhus, 259. state, 58, 61, 62 143, 260, 303, 329, 336, 369 y 376, ulcer, 422, 424. INDEX OF SUBJECTS. 517 Typho-malarial fever, 401, 405. Typhomania, 83, 259, 279. Typhus, 149, 229-232, 239, 328, 337, 411 ; nomenclature, 239 ; definition, 241 literature, 242 ; geographical distribution. 242 ; aetiology, 243 ; poison of, facts known about, 244, 245 ; supposed spontaneous origin of, 247 ; pre disposing causes of, 251 ; clinical description of, 255 ; incubation of, 255 invasion of, 257 ; eruption, 258 ; stage of nervous prostration in, 259 defervescence or crisis, 260 ; convalescence, 261 ; duration, 261 ; siderans, 262, 293 ; relapses in, 263 ; temperature in, 263 ; pseudo-crisis in, 263 hyperpyrexia in, 265 ; analysis of symptoms in, 271 ; physiognomy of, 271 ; odour of, 272 ; levissimus, 234, 294 ; pulse in, 273 ; heart in, 273 breathing in, 259, 275 ; breath in, 276 ; digestive system, 276; urine in 258, 277 ; nervous system in, 278 ; complications and sequelae of, 284 varieties of, 293 ; comatosus, 293 ; catarrhal, 294 ; diagnosis, 294 prognosis and mortality, 296 ; pathology, 300 ; emaciation in, 300 ; treat- ment, 305. " Typhus ambulatorius," 406. Typhus headache, 256, 278. Ty rosin, 278. Ujnala, tragedy of, 249. Ulceration and sloughing in enteric fever, 366. Ulcerative endocarditis, 413. laryngitis, 396. " Ulcer, typhoid," 422, 424. Underground water and enteric fever, 350. Uraemia, 176, 290, 296. preventive treatment of, 190. Urea, excretion of, 277. Urine, incontinence of, 311. in scarlatina, 170, 174, 175, 176, 177. retention of, 282. in typhus, 258, 277 ; in enteric fever, 380, 381. Urticaria, or nettlerasu, 219, 371 ; febrile, 373. Vaccina, 105, 111. Vaccinal — cicatrices, 108, 111 ; roseola, 112 ; lichen, 112 ; herpes, 112. Vaccination, 104, 105, 109, 110. Act, 103, 109. influence of, on whooping-cough, 2S ; on smallpox, 105, 106, 107, 108- Vaccinator, 110. Vaccine pen, 110. Vaccino-syphilis, 112. " Vaccuolo," 103. $18 INDEX OF SUBJECTS. Varicella, 98, 125, 127, 149. (See " Chickenpox.") emphysematosa, 128. gangraenosa, 129. prurigo, 130. ventosa, 128. Varieties of smallpox, 82, 89, 93 ; of measles, 142 ; of scarlatina, 166 ; of ery sipelas, 210 ; of typhus, 293 ; of enteric fever, 405. Variola, 69, 70, 291. (See " Smallpox.") benigna, 89. cornea, 89. , crystallina, 82. haemorrhagica, 90, 91. pustulosa, 92. maligna, 90. ovina, 73, 103, 104. purpurica, 90, 91. sine exanthemate, 89. sine variolis, 89. verrucosa, 89. Variolas cruentse, 93. equinae, 104. nigrae, 93. ovinse, 73, 103, 104. pusilla?, 126. vaccinae, 104. Variole modifie'e, 89. Varioloid, 69, 89, 90, 130. Venesection, 52. " Venienti occurrite moroo," 310. Venous thrombosis, 287, 312, 398. Ventilation, 41, 42, 306. constant or natural. 42. defective, 39. occasional, 42. Veratria, 460. Vertigo, 279. Vesical catarrh, 402. Vibices, 272, 371. Vienna General Hospital, 118, 122. Virus, 8, 13, 43. attenuated, 43, 103. Voluntary muscles in enteric fever, 417. Vomiting, 63, 376, 399, 469. of blood, 289. Vulva, gangrene of the, 146, 153. INDEX OF SUBJECTS. 519 Wakefulness, 280. Wartpox, 89, 90. Warts, shedding of, 173. Waste, 4. Wasting of fever — how explained, 9. Waterclosets, 432. Water, cold, treatment of fever, 53, 309, 310, 450. how to be supplied to the fever patient, 10, 439. supply, 40, 432. uses of, in fever, 10, 53, 439, 450. Wet-cupping, 52. Wet-pack, 54, 451. " White blisters," 129. Whooping-cough, influence of vaccination on, 28. Windpox, 128. " Worm fever," 407. Yeasts, 13. Yellow fever of the British Islands, 324, 328. Ziehl-Neelsen test, 413. "Zyme," 13. Zymine peptonising powders, 438. Zymogenic microbes, 15. Zymotic diseases, 12, 13, 18. INDEX OF NAMES. Abbott, A. C., 482, 485. Addison, 161. Aitken, Sir William, 132, 194, 196, 200. Alison, 58, 283, 299. Allbutt, Clifford, 403. Allen, of Melbourne, 358. Anderson, M'Call, 372. Andrew, James, 303. Areber, Robert S., 427, 429. Arrnitage, 62. Armstrong, 293. Ashby, 165. Atthill, Lombe, 124. Aulnas, Claudien, 375. Auspitz, 96. Autenrieth, 341. Avicenna, 2, 133. Baader, of Basle, 125. Babes, 134. Bacon, Lord Chancellor, 247. Baglivi, 331, 435, 463. Ballard, Edward, 136, 156, 358. Banks, Sir John, 117. von Barensprung, 97. Barker, F., 314, 315. Barlow, H. C, 343. Barrallier, 261, 272, 281, 293, 294, 302, 343. Barr, James, 454, 455, 457. Barry, 75, 100. Barthez, 165, 171, 174, 290, 379, 383, 458. Bartleet, 472, 473. Bartlett, 351, 395. Basch, 96. Basin, 372. INDEX OF NAMES. 521 Bastian, Charlton, 216. Bateman, 128, 143, 16?, 169, 239, 247. Beck, 397. Begbie, Warburton, 287. Behring, Stabsarzt Dr., 37. Bell, Hamilton, 222. BelloniuB, 340. Benson, J. Hawtrey, 120. Bertrand, 117. Beumer, 352. Beveridge, 302. Bewley, H. T., 367, 394. Bicker, 173. Biermer, 174, 176. Biesiadecki, 215. Billroth, 202, 217, 220. Binz, 222. Blane, Sir Gilbert, 241, 247. Blyth, A. Wynter, 23, 42, 74, 431. Bochefontaine, 223. Bock, 330. Bocker, 11. Boddie, G. P., 164. Boerhaave, of Leyden, 70, 78, 233. Bonfigli, 225. Bontecou, 472, 473. Borgien, 225. Borsieri, 193, 200, 203, 218, 240, 241. Bouchard, 441, 443, 447, 452. Bouchut, 162. Boyce, of Edinburgh, 126. Bozzolo, 353. Braidwood, 374. Brand, Ernst (of Stettin), 54, 451. Brattler, 380. Bretonneau, 340, 342, 422. Bristowe, J. S., 127. Brouardel, 359. Broussais, 340, 342, 390, 417. Brown, 341. Bruce, J. Mitchell, 178, 179. Brunton, Lauder, 8, 455, 476, 480. 522 INDEX OF NAMES. Buchanan, 158, 263, 350. Buchner, 485. Budd, Wm, 340, 351, 424. Buhl, 350. Burnett, 233. Burserius, 240, 241. Busk, 218. Cameron, Sir Charles A., 358, 362. Canstatt, 129. Cantani, Arnoldo, 6, 53, 450, 458. Cardanus, 240. Carpenter, Alfred, 374. Carpenter, W. B., 38, 40. Carter, Vandyke, 313, 318, 320, 329. Cayley, William, 64, 244, 249, 251, 283, 300, 329, 342, 343, 345, 355, 359, 363, 394, 397, 403, 414, 415, 451, 456, 457, 459, 468. Celli, 19. Chantemesse, 353, 360, 421. Chauffard, 452. Chauveau, 73. Cheyne, John, 314, 315, 331, 332, 340. Cheyne, Watson, *217, 351. Chomel, 218, 280, 340, 397, 406, 423, 425. Christian, E. P., 359. Christison, Sir Robert, 320. Churchill, Fleetwood, 146. Clarke, J. Michell, 443, 444. Cleveland, Clement, 447. Coats, 176, 352. Cohn, 73, 216, 318, 319. Cohnheim, 413. Collie, Alexander, 289, 345. Conolly, J., 81, 86. Copland, 195, 225, 233, 340. Cormack, 322. Cornil, 134, 211. Corrigan, Sir Dominic, 259, 275, 282, 288, 474 Coze, 158, 352. Craigie, 291, 340. Crocker, Radcliffe, 130, 371, 372, 374. Croly, Henry Gray, 168, 191. INDEX OF NAMES. 523 Crooke, 352. Crookshank, Edgar M., 15, 22, 73, 104, 134, 320. Cruveilhier, 340, 420. Cullen, 67, 68, 154, 231, 233, 239, 247, 313, 340. Curschmann, 75, 77, 78, 79, 80, 81, 83, 89, 90, 92, 96, 97, 117, 123, 124. Currie, 56, 450, 451. Czakert, 126. Dahne, 185. Danchersen, 317. Davasse, 233, 236. Davies, D., of Bristol, 249, 257. Day, John Marshall, 297, 402, 415. Debove, 452. De Haen, 92. Deiters, 174. Delavigne, Casimir, 109. Delpech, 131. Dieulafoy, 403. Dujardin-Beaumetz, 435. Ebel, 340. Eberth, 342, 352-354, 356, 359, 360, 447. Ebstein, 263. Ehrenberg, 216, 318. Ehrlich, 409. Eichhorst, 388. Eimer, 77. Eiselt of Prague, 406. Ellis, Edward, 197. Emmerich, 485. Engel, 317. Eppinger, 352. Esher, 473. Estlander, J. A., 326. Evans, 340. Ewald, C. A., 313, 330. Fagge, C. Hilton, 3, 76, 77, 79, 86, 89, 96, 97, 121, 125, 127, 128, 130, 131, 134, 138, 139, 143, 147, 150, 161, 164-166, 169, 173, 195. 204, 218, 219, 340, 344, 346, 357, 363, 365, 367, 368, 407, 414-416, 420, 422, 424, 427, 428, 439, 449, 451, 460, 463, 477, 481. Falconer, John, 426. 524 INDEX OF NAMES. Fardon, E. A., 457. Farr, William, 313. Fehleisen, 203, 209, 216. Feltz, 158, 352. Fenwick, Samuel, 54, 55, 173, 187, 188, 191, 225, 466. Filehne, Wilhelm, 459. Finlay, 414. Fleischmann, 126. Flint, Austin, 3, 189, 340, 395, 400. Fliigge, C, 351, 355. Foot, Arthur Wynne, 114, 117, 269. Fordyce, 233, 416. Forestus, 133, 340. Forget, 399. Fothergill, 168. Fowitsky, 485. Fracastori, 240, 283. Fraukel, 352, 354. Frantzel, 395. Frank, John Peter, 92, 218. Frerichs, 190, 278. Friedlander, 352. Friedrich, 472. Fiirbringer, 165. Gaddesden, John of, 113. Gaffky, 351, 352-357, 360, 362. Gairdner, W. T., 292, 397, 399. Galen, 2, 9, 83, 259, 263, 279, 342, 382. Gee, Samuel, 128, 132. Gerhard, 272, 343. Gerhardt, 126. Gerin-B,ose, 452. Gibson, 208. Giersing, 182. Giglio, Joseph, 354. Gilchrist, 340. Godelle, 182. Goltdammer, 453, 456. Goodfellow, 205. Gore, Albert A., 345. Gramshaw, F. Sidney, 443, 44 INDEX OF NAMES. 525 Grancher, of Paris, 447, 448, Grant, William, 241, 247. Graves, Kobert J., 57, 58, 60, 62, 116, 12:3, 152, 155, 166, 205, 226, 243, 259, 266, 275, 282, 291, 296, 307, 313, 315, 317, 324, 331, 332, 335, 378, 416. Gregory, 127. Griesinger, 242, 310, 320, 323, 328, 334, 341, 373, 377, 388, 400. Grimshaw. T. W., Registrar-General for Ireland, 106, 107, 135, 136, 251, 252 315, 330, 346, 349, 357, 464, 466. Griscom, 225. Gubler, 203, 204. Gueniot, 374. Gull, Sir William, 414. Gumprecht, 165. Gimther, 413. Guttmann, 380. Guyot, 373. Halm, 473. Hahnemann, 183. Haight, 218. Haller, of Vienna, 245. Hallier, 244. Hallopeau, 223, 226. Hamernjk, 389. Hardy, 372. Hare, F. E., 453, 454. Harkin, Alexander, 189. Harvey, Physician-General, 478. Harvey, Reuben J., 100, 256, 393. Hasse, 225. Hawkins, Csesar, 74. Hawksley, 457. Hayem, 397, 452. Heberden, William, 75, 126, 154. Hebra, 54, 75, 77, 90, 94, 110, 111, 118-122, 181, 137, 139, 141, 143, 147, 169, 181, 183, 184. Heim, 126. Henn, Edmund P., 426. Henoch, E., 128, 164, 178. Henry, F., 448. Henry, W., 246. Hermann, 300. 526 INDEX OF NAMES. Hesse, of Leipzig, 126. Hewett, of London, 406. Hewitt, of Minnesota, 74. Heyfelder, 220. Hicks, ill. Higginbottom, 225. von Hildenbrand, 193, 234, 239, 242, 253, 260, 294, 309, 342. Hippocrates of Cos, 2, 202, 219, 233, 234, 239, 281, 342, 381. Hirsch, 70, 73, 133, 155. 157, 204, 205, 208, 240, 242, 243, 295, 313, 316-318, 344. Hirtz, Edgar, 449. Hlava, 244. Hoffa, 157. Hoffmann, F., 230, 233, 368, 403, 418. van Hook, 473. Hoppe-Seyler, 442. Hopwood, E. O., 165. Howard, Warrington, 130. Howard, John, 241. Hoyer, 235. Huchard, 444, 461, 462. Hudson, Alfred, 117, 206, 225, 226, 237, 248, 275, 288, 311, 351, 377, 390, 391, 466. Hiiter, 216, 225. Hufeland, 182, 241. Huguenin, 177, 359. Human, 388. Hunter, John, 28, 404. Huss, 63. Hutchinson, 480. Hutchinson, Jonathan, 129, 130, 290. Huxham, 83, 118, 122, 233, 247, 340. Hyde, James Nevins, 372. Illingworth, C. R, 183. Ingrassias, 126, 154, 234. Jaccoud, 165, 388. Jacob, Arthur, 326. Jacquot, 245, 248, 253, 261, 272, 288, 294. von Jaksch, 319, 352, 353. Jamieson, 236. INDEX OF NAMES. 527 Janeway, 448. Jenkins, J. H., 470. Jenner, Edward, 105, 109, 111. Jenner, Sir William, 169, 259, 263, 280, 289. 296, 343, 366, 377, 381, 413. Jesty, Benjamin, 105. John of Gaddesden, 113. Josias, 452. Juhel-Renoy, 452. Jiirgensen, 451. Kanz, 340. Kaposi, 131. Karlinski, 353. Keating, 134, 380. Kelly, of Mullingar, 321. Kennedy, Henry, 288, 378. Kesteven, 448. Kimura, 473. Kirkpatrick, Frederick, 443. Klebs, 19, 174, 176, 352. Klein, 73, 158, 170, 175-177, 352. Klemperer and Klemperer, 482-485. Koch, 22, 209, 352, 354, 360. Konig, B., 204, 205. Korner, 164. Kronecker, 476. Kiittner, 196. Kurth, H., 192. Kussmaul, 472. Laennec, 362. Landenberger, 173. Langenbeck, Max, 187. Langrish, 233. Laptachinski, M., 390. Lawrence, 214. Lawrie, Edward, 443. Lawson, Robert, 19. Laycock, 241, 480. Lebert, H., 242, 251, 262, 301, 306, 313, 318, 320, 330, 332-334. Lees, Cathcart, 324. Lefort, Paul, 151, 224, 452. Legrain, 359. 528 INDEX OF NAMES. Lentin, 173. Leroux, 444. Lesser, 440. Levy, 217. Lewentauer, 117. Lewin, 141. Leyden, 276, 472. Liebermiester, 3, 18, 19, 55, 222, 337, 338, 344, 350, 363, 370, 372, 376, 377, 378, 379, 381, 396, 398, 399, 402, 403, 408, 422-424, 428, 430, 436, 438, 440, 441, 447, 459, 460, 466, 468, 472. Liddell and Scott, 202. Lieutaud, 233. Lind, 239, 241, 272. Lindwurm, 242. Little, James, 416, 466, 471. LitUejohn, H., 359. Liveing, Robert, 16, 99, 195, 196, 198, 200. Loeff, 73. Loffler, 168. Lombard, H. C, 343. Longmans, Green & Co., 251. Lorain, Paul, 215. Loschner, 173, 181. Louis, P. A. C, 273, 340, 343, 370, 377, 383, 396, 402, 406, 419, 423, 429. Luchhan, 327. Liicke, 225, 473. Lukomsky, 209. Lyons, R. D., 63, 325, 399. Lysons, Daniel, 62. Macalister, Donald, 3, 5, 6. Mackenzie, 26. Maclagan, T. J., 4, 5, 9, 10, 261, 388, 389, 423. MacSwiney, S. M., 385. Mahomet, 70. Magonty, 440. Makuna, 127. Malcolm, A., 276. Marchiafava, 19. Marius, of Avenches, 70. Marmy, 302. Martin, Sir Ranald, 233, 238. INDEX OF NAMES. 52i) Martindale, 459, 460, 402. Marshal], John, 278. Marson, 86, 89, 92,108, 117. Massa, N., 240. Maunsell, 340. Mayr, 54, 139, 147, 169, 181, 183. Mears, Ewing, 472. Mercatus, 20, Mertens, 144. MetschnikotT, Elias, 22, 217, 218. Meyer, J., 11, 352, 354, 360. Michel, 351, 389. Mikulicz, 473. Millard, 452. Mohl of Copenhagen, 131. Monneret, 468. Monro, D., 247. Montague, Lady Mary Wortley. 22, 103. Moore, William Daniel, 160, 350. Morehead, 238. Morgan, Campbell de, 205, 218, 222. Morton, 83, 154. Morton, of Philadelphia, 472, 473, Motschutkovsky, of Odessa, 245, 320, 324. Mosler, of Greifswald, 250, 309. Mott, 244. Moutard-Martin, 373. Muller, 110. Murchison, Charles, 2, 5, 9, 21, 39, 41, 42, 48, 49, 52, 58, 59, 61, 6a, 64, 68, 85, 149, 159, 160, 163, 195, 198, 230, 231, 235, 236, 237, 238, 239, 242, 243, 244, 245, 246, 247, 248, 249, 251, 252, 253, 255, 257, 260, 261, 262, 263, 265, 269, 270, 271, 272, 275, 276, 277, 278, 279, 281, 283, 284, 286, 287, 288, 289, 291, 292, 296, 298, 300, 301, 302, 303, 305, 308, 309, 313, 316, 320, 325, 326, 327, 329, 330, 331, 332, 333, 336, 339, 340, 341, 342, 343, 344, 345, 346, 349, 350, 355, 357, 363, 364, 365, 366, 367, 368, 369, 370, 372, 376, 377, 378, 380. 383, 384, 388, 389, 394, 395, 396, 398, 399, 400, 401, 402, 403, 404, 407, 411, 413, 414, 415, 417, 419, 420, 422, 423, 424, 425, 427, 429, 435, 446, 451, 457, 463, 465, 466, 468, 469, 470, 471, 477, 478, 481. Nageli, 13. ,: Natanson, 449. Nelaton, 208, 373. 2 M 530 INDEX OF NAMES. Nelson. E., 446. Nencki, 14. Neuhaus, 353. Neumann, 353. Niemeyer, 139, 142, 250, 257, 294, 321, 323, 332, 402, 441, 442, 480. Nixon, C. J., 404. Nothnagel, 170, 398, 399. von Noorden, 216. Nunneley, 225. Nystrom, 225. Obermeier, 159, 313, 318, 319, 322, 325. O'Brien, 317. Oertel, 168, 188. Ogston, 216. Orleans, Duke of, 103. Orlow, 193. Ormerod, 313. Orth, 209. Paget, Sir James, 403. Panum, of Copenhagen, 135, 137. Paris, M. le Docteur, 208. Parkes, Edmund A., 231, 380. Pasteur, 15, 22. Paterson, Robert, 194, 195. Paul, 351. Pavy, F. W., 439, 479. Peacock, 292. Peebles, 229, 240. Pe"cholier, 448. Peiper, 352. Pennock, 343. Perry, P., 245, 281, 343. Peter, of Paris, 64, 146, 213, 46 8 . Petit, 342. von Pettenkofer, 350.' Pfeiffer, 73. Pfleger, 217. Phillips, Sidney, 421. Piedvache, 351. Pinel, 240, 340. INDEX OF NAMES. 531 Piorry, 340. Piquer, 233. Pohl-Pincus, 158. Polli, of Milan, 443, 445. , Ponfick, 97, 215. Popbam, 243. Porter, William H., 191. Powell, Douglas, 132. Power, 157. Pringle, J. J., 203, 211, 351. Pringle, Sir John, 241, 242, 247, 340. Procopius, 70. Pye-Smith, 414. Quincke, 363. Quist, 73. Rasori, 240, 242. Payer, 77. Raymond, 373. von Recklinghausen, 352. Redmond, J. M., 387. Registrar-General for England, 71, 136, 156, 340, 349. Scotland, 340. Ireland, 106, 107, 135 136,251 252 315 340, 346, 349, 464, 466. Reher, 353. Reuss, 240, 241. Reynolds, Emerson, 32, 410 . Rhazes, 70, 118, 133. Richter, 216, 340. Ricord, 225. Ridley, John, 166. Riess, 330. Ringer, Sydney, 54. Rilliet, 165, 171, 174, 290, 379, 383, 458, Rindfleisch, 97. Ritchie, 340. Ritzmann, 214. Riverius, 233, 295, 340. Robert of Marseilles, 81. Roberts, F. T., 210, 220. .532 INDEX OF NAMES. Robinson, Bryan, 103. Rokitansky, 284, '286, 294, 301, 397, 402, 425, 429. Romberg, 189. Rosenbaeh, 455. Rossi, 239. Roupell, 229, 240, 288. Roux, E., 10. Riitimeyer, 353. Russell, J. K, 288, 470. Rutty, John, 313, ai4, 34a Sajous, 453. Salisbury, of Newark, 134. Samuel, 3, 6. Sanderson, Burdon, 73. Sarnow, 319. Sauer, 440. Saundby, 190, 372. Sauvages, Boissier de, 133, 154, 233, 239-241, 40. Scbneeman, of Hanover, 185. Schonlein, 340, 377. Schiitz, 229. Scriven, 233, 236. See, Marc, of Paris, 224. Seidl, Professor, 146. Seitz, 194, 352. Selmi, 479. Senator, 453. Senn, 473. Sennertus, 233, 240, 241. Serres, 342. Shattuek, 343, 388. Shelly, C. E„ 31, 32, 112. Simmonds, 352. Simon, G., 148. Simon, Th.,. of Hamburg, 77, Siredey, 373. Skoda, 118. Smart, Charles, 344, 401. Smith, Eustace, 129, 183. Smith, Greig, 473. Smith, J. Lewis, 126, 194-198. INDEX OF NAMES. 533 Smith, Walter G., 170, 216, 471. Smyly, Josiah, 119. de Souza, A., 458. Spear, John, 336, 337. Spender, Kent, 443. Squire, J. Edward, 405. Squire, William, 68. Stanger, 247. Starr, Louis, 185. Steudener, 215, 218. Stein, 472. Steinberg, 318. Steiner, 126. Stewart, Alexander P., 261, 263, 340, 343, 404. Stoker, William, 298. Stokes, Whitley, 129. Stokes, William, 56, 58, 84, 115, 116, 119, 120, 123, 206, 264, 269, 273, 274, 282, 283, 284, 285, 286, 287, 301, 302, 303, 309, 310, 313, 315, 324, 325, 335, 396, 397, 421, 477, 478. Stork, 245. Stromeyer, 438. Strother, 233, 234, 240, 340. Strumpell, 68, 170, 236. Struve, 395. van Swieten, 104. Sydenham, Thomas, 69, 77, 78, 82, 92, 93, 114, 133, 139, 143, 149, 154, 155, 156, 181, 247. Szadek, 192. Talamon, 118, 226. Taylor, F. Howard, 410. Tennent, G. P., of Glasgow, 325. Testi, 448. Thomas, of Leipzig, 125, 126, 127, 128, 129, 134, 138, 139, 140, 141, 142, 143, 147, 148, 149, 162, 164, 167, 169, 173, 189, 191, 193, 194, 195, 196, 201. 459. Thomson, John, of Edinburgh, 178. Thomson, Theodore, of Sheffield, 213. . Thome, E. Thorne, 350. Tillmanns, 209. Todd, 58, 62, 464. Tommasi-Ciudeli, 19. Tordeus, of Brussels, 460. 534 INDEX OF NAMES. Toussaint, 22. Traube, 3, 263, 440. Trojanowsky, 141, 164. Trousseau, 68, 77, 78, 79, 82, 83, 84, 85, 90, 94, 95, 100, 104, 109, 126, 127. 12*. 129, 130, 131, 140, 142, 144, 145, 149, 152, 159, 161. 162, 167, 187, 190, 191, 193, 194, 195, 197, 200, 203, 208. 212, 214, 215, 216, 218, 220, 221, 226, 342, 350, 368, 370, 371, 378, 397, 399, 403, 407, 422, 463, 465, 477. Trelat, 157, 374. Tschamer, 126. Tweedie, Alexander, 166, 252. Uffelmann, 433. Vaillard, 421. Velpeau, 220, 223. Verneuil, 374. Verson, E., 423. Vetter, 126. Vidal, 353. Vidu- Vidins, 126. Vierordt, 276. Vincent, A., 359. Virchow, 3, 215, 242, 318, 327, 362. Vogel, A., 85, 127, 154, 163, 272. Vogt, W., 447, 460. Voit, 9. Volkmann, 204, 205, 214, 215, 216, 218, 220, 223. Wagner, E. , 175, 176, 418. Walford, W. G., 183. Wassiljeff, 442. Watson, Sir Thomas, 73, 111, 113, 162, 203, 212, 224, 313, 446. Weigert, 73. Weil, 380. Wells, 205. Wendt, 81, 191. Werner, Emil, 410. West, Charles, 116, 152, 185, 402, 407. Westerland, 225. Whipham, Thomas, 372. White, George B., 448. Whitla, Wm., 446. Wilde, 225. INDEX OF NAMES. 535 Wilks, George, of Ashforrt, Kent, 445. Wilks, Samuel, 77, 163, 215, 340, 376, 397. Willan, 128, 140, 143, 162, 16t>. Willau and Bateman, 128, 143, 162, 169. von Willebrand, 440. Wilson, J. C, 379. Withering, 154. Wolff, 448. Wolfler, A., 226. Wood, George B., 446, 467. Wood, Horatio C, 10, 11, 278, 446. Woodbury, F., 480. Woodhead, German Sims, 41, 354. Woodman, Bathurst, 1G9, 172, 194, 211. Woodward, 405. Wright, G. A., 165. Wunderlich, 25, 26, 76, 87, 89, 138, 146, 163, 169, 171, 172. 187. 194, 213, 261, 264, 265, 269, 270, 326, 366, 392, 394, 408, 409, 440-442, 459. Wutzer, 214. Wyss, 330. Yeo, Gerald F., 390. Yeo, J. Burney, 50, 444, 446, 447, 448. Zawilski, 476. Zenker, 179, 303, 417, 418. Ziehl-Neelsen, 413. von Ziemssen, 55, 195, 204, 376, 437, 440, 441, 470, 479. Zopf, 14. Zuelzer, 204, 205, 215, 220, 225, 244, 325, 342, 344, 351, 379, 413. Printed by John Falconer, 53 Upper Sackvllle-street, Dublin. Hi ■ ■