Columbin ^uibcrsitp \^\5■ in tijc £itp of iJcb) Oorb ^tbool of IDental anb ®ral ^urgerp Reference Hibrarp Digitized by the Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/textbookofpractOOhare nOOKS BY THE SAME AVTllOli. A TEXT-BOOK OF PRACTICAL THERAPEUTICS. FIFTEENTH EDITION. Cloth, $4.00 net. DIAGNOSIS IN THE OFFICE AND AT THE BED- SIDE. SEVENTH EDITION. Cloth, $4.00 net; Leather, $5.00 net. MEDICAL COMPLICATIONS AND SKQUELiE OF TYPHOID FEVER AND THE OTHER EXAN- THEMATA. SECOND EDITION. Cloth, $3.25 nc(. MODERN TR1-;aTMENT. THE ^L\XAGEMEXT OF DISKA.SK m' MKniClXAL AXD XOX-MEDI- CINAL RK.MEDIKS. By E.minent Americ.w and English Authors. Edited by Dk. H.^re. 2 volumes: each. Cloth, $6.00 net: Half Jlorocco, $7.50 net. A TEXT-BOOK PEACTICE OF MEDICINE FOR STUDENTS AND PRACTITIONERS HOBART AMORY HARE, B.Sc, M.D. , OF THERAPEUTICS, MATERIA MEDICA, AND DIAGNOSIS IX THE JEFFERSON" MEDICAL COLLEGE OF PHIL.\DELPHIA ; PHYSICIAN TO THE JEFFERSON MEDICAL COLLEGE HOSPITAL; ONE TIME CLINICAL PROFESSOR OF DISEASES OF N^ IN THE UNIVERSITY OF PENNSYLVANIA; AUTHOR OF "a TEXT-BOOK OF PRACTICAL THERAPEUTICS," AND "dIAGNOSI^IN THE OFFICE AND AT THE BEDSIDE*' THIRD EDITION, REVISED AND ENLARGED ILLUSTRATED WITH 142 ENGRAVINGS AND 16 PLATES IN COLORS AND MONOCHROME LEA & FEBIGER PHILADELPHIA AND NEW YORK 1915 Entered according to the Act of Congress, in the year 1915, by LEA & FEBIGER, in the Office of the Librarian of Congress. All rights reserved. PREFACE TO THIRD EDITION, The preparation of a third edition of a book on the Practice of Medicine is a task almost equal to the preparation of the text of a first edition, particularly if several years have elapsed since the second edition appeared. Only those who keep themselves thoroughly abreast of all departments of medical endeavor can estimate what the changes have been in our conception of almost every disease as to etiology, pathology, and symptomatology, not to speak of treatment. Furthermore, only those who keep themselves thoroughly well informed can be as optimistic in regard to our struggle with disease as the nature of the advances justify. Every year sees an increasing army of investigators in physiology, pathology, bacteriology, protozoology, and therapeutics, meeting with occasional reverses, but as a whole moving onward to clearer ideas concerning some of the problems which but a short time ago seemed quite beyond hope of elucidation. The text of the present edition has been most carefully revised, and on almost every page corrections and additions have been made, based upon a careful study of the contributions of others and the writer's increasing experience in hospital" and private practice. An endeavor has been made to place the necessary facts in a concise form and to prepare the text so that it is easily read, rather than to resort to short, dogmatic sentences, which do not hold the attention because they do not lead the reader forward step by step. My cordial thanks are due to Dr. Aller G. Ellis, Associate Professor of Pathology, for his careful reading and revision of the sections dealing with etiology and pathology, and to Dr. G. E. Price, Associate Professor of Nervous and Mental Diseases in the Jefferson Medical College, for similar services in connection with those parts of the volume dealing with Diseases of the Nervous System. H. A. H. 'Philadelphia, 1915. (V) CONTENTS. DISEASES DUE TO A SPECIFIC INFECTION'. Typhoid Fever 1' Paratyphoid Fever 53 Typhus Fever 54 Variola 60 Vaccinia and Vaccination ~-i Varicella "~ Scarlet Fever ■ "i^ Measles 92 Rubella 98 Mumps 99 Whooping-cough 101 Influenza 106 Acute Poliomyeloencephalitis Ill Dengue 117 Meningococcic Meningitis 120 Croupous Pneumonia 128 Diphtheria 151 Gonorrheal Infection 165 Erysipelas ■ 168 Septicemia and Pyemia 1"1 Acute Rheumatic Fever 1~-1 Cholera 181 Yellow Fever 187 Plague (Bubonic Plague) 194 Climatic Bubo 200 Dysentery 200 Epidemic Gangrenous Proctitis 213 Hill Diarrhea 214 Malta Fever 215 Phlebotomous Fever 218 Anthrax 219 Hydrophobia 222 Tetanus 227 Glanders 231 Actinomycosis 233 Mycetoma (Madura Foot, Fungus Foot of India) 234 Frambesia (Frambesia Tropica, Yaws) 235 Tuberculosis ; 237 Acute Miliary Tuberculosis 243 Glandular Tuberculosis 245 Tuberculosis of the Serous Membranes 247 Pulmonary Tuberculosis 255 Tuberculosis of the Alimentary Canal 278 Tuberculosis of the Liver 281 Tuberculosis of the Genito-urinary System 281 Tuberculosis of the Fallopian Tubes, Ovaries and Uterus 285 Tuberculosis of the Heart 285 (vii) Vlll CONTENTS Tuberculosis: Tuberculosis of the Tliyioid Gland Tuberculosis of the Brain and Cord Hodgkin's Disease Ijcprosy ... Febricula Milk Sickness . Weil's Disease Glandular Fever Mountain Fever . Spottctl t>r Tick Fever Foot-and-Mouth Disease Miliary Fever Verruga (VeiTuga Peruviana) Gangosa Syphilis Hereditary Sj'philis Maliirial Infection Latent Malarial Infection and Relapse Relapsing Fever . Psorosperniiasis Trypanosomiasis . Human Trypanosomiasis (Trypanosoma Fever) African Lcthargj' (Sleeping Sickness) Kala-azar Tropical Sore .... Nematodes .... Ascariasis . Oxjniris Vermicularis Trichina Spiralis . Uncinariasis (Ankylostomiasis) . Filariasis (Filaria Sanguinis Hominis) Guinea-worm Disease (Dracontiasis) Strongyloides Intestinalis Tricocephalus Dispar Cestodes or Tapeworm Treraatodes Bilharzia Disease Distomatosis of the Lung Distomatosis of the Liver Parasitic Infusoria Chigger (Sand Flea) Myiasis .... Infection by Larva; of the Diptern Intestinal Myiasis .... Dermatobia Cyaniventris Tumbu-fly Disease 286 286 286 2S9 295 295 296 296 297 299 299 299 300 .302 302 312 316 328 329 331 331 333 333 335 336 336 336 337 337 338 343 346 348 349 350 353 353 355 356 357 357 357 3.57 358 358 358 DISEASES OF THE RESPTIt.VroiiY S^-STKM. Diseases of the Nose .... Acute Coryza .... Chronic Nasal Catarrh Atrophic Nasal Calarrli Hay Fever . Epistaxis Diseases of the La^J^lx Acute Catarrhal Laryngiti? .S59 359 360 361 362 364 .■^64 364 CONTEXTS IX Diseases of the Larj'nx: Chronic Catarrhal Laryngitis 366 Edematous Laryngitis 366 Spasmodic Larjiigitis 368 Tuberculous Laryngitis 368 Syphilitic LarjTigitis 370 Diseases of the Bronchi 370 Acute Catarrhal Bronchitis 370 Chronic Catarrhal Bronchitis 374 Bronchiectasis 375 Fibrinous Bronchitis 379 Bronchial Asthma 381 Diseases of the Lungs 386 Bronchopneumonia 386 JNIetastatic Pneumonia 396 Pneumonoconiosis 398 Emphysema of the Lungs 400 Compensatory or Acute Emph}-sema 404 Small-lunged Emphj'sema 405 Interstitial Emphysema 405 Gangrene of the Lung 405 Pulmonary Abscess 407 Congestion of the Lungs 409 Tumors in the Lungs 412 Diseases of the Pleura 413 Plem-itis 413 Dry Plem-isy 414 Pleurisy with Effusion 417 Purulent Pleural Effusion or Empyema 423 Chronic Pleurisy 427 Hydrothorax 428 Pneumothorax, Hydropneumothorax, Pyopneumothorax 429 ; of the Mediastinum 431 DISEASES OF THE CIRCULATORY SYSTE:\I. ; of the Pericardium 435 Pericarditis 435 Acute Pericarditis . . . 435 Chronic Pericarditis 440 Hydropericardium 442 Hemopericardium 443 Pneumopericardium 443 Pj'opericardium 444 Diseases of the Heart 444 Hypertrophy and Dilatation of the Heart 444 Diseases of the Myocardium 448 Degenerative Changes 448 Stokes-Adams Disease 450 Myocarditis 450 Cardiac Aneurj'sm 453 Wounds of the Heart 454 Endocarditis _ 454 Acute Endocarditis 455 Ulcerative Endocarditis 458 Chronic Endocarditis 460 Chronic A^alvular Disease as a Result of Chronic Endocarditis 461 Mitral Regurgitation .' 464 X CONTEiXTS Diseases of the Heart: Chronic Valvular Disease as a Rcsull of Chronic I'^ndooardilis: Mitral Stenosis 469 Aortic Stenosis 474 Aortic Regurgitation 476 Tricuspid Regurgitation 480 Tricuspid Stenosis 482 Disease of the Pulmonary Valves 482 Disorders of Cardiac Action not due to Valvular Lesions 487 Neuroses of the Heart 487 Palpitation 487 Tachycardia 487 Bradycardia 488 Arrhythmia .488 Angina Pectoris 491 Congenital Cardiac Defects 494 Diseases of the Arteries 495 Aortitis 495 Arteriosclerosis 496 Aneurysm 500 Aneurysm of Thoracic Aorta 501 Aneurysm of the Abdominal Aorta 507 DISEASES OF THE DIGESTIVE TRAC^T. Diseases of the Mouth 509 Stomatitis 509 Catarrhal Stomatitis 509 Aphthous Stomatitis 509 Ulcerative Stomatitis 510 Thrush 511 Gangrenous Stomatitis, Cancrum Oris or Noma . 511 Eczema of the Tongue 512 Leukoplakia Buccalis 513 Mucous Patches 513 Diseases of the Salivary Glands 513 Functional Disorders of the Salivary Glands 513 Ptyalism 513 Dry Mouth 514 Inflammation of the Salivary Glands 514 Mickulicz's Disease 514 Diseases of the Phaiynx 515 Acute Pharjmgitis 515 Ulcerative or Phlegmonous Pharyngitis 516 Croupous Pharyngitis 517 Chronic Pharyngitis . 517 Follicular Pharyngitis 517 Epidemic Sore Throat . . 5 IS Diseases of the Tonsils 518 Acute Tonsillitis 518 Ludwig's Angina 520 Vincent's Angina 521 Clu-onic Hypertrophic Tonsillitis 521 Diseases of the Esophagus 522 Esophagitis 522 Organic Stricture of the Esophagus ... 523 Dilatation of the Esophagus 523 Spasm of the Esophagus 524 Cancer of the Esophagus 525 CONTENTS XI Diseases of the Stomiich ■''25 Acute Gastric Catan-li -^25 Phlegmonous Gastritis 526 Diphtheritic Gastritis ''27 Mycotic Gastritis -^28 Chronic Gastritis ^28 Gastric Dilatation 531 Acute Gastrectasis 535 Gastric Ulcer 536 Cancer of the Stomach 545 Hypertrophic Stenosis of the Pylorus 552 Hour-glass Stomach 555 Gastric Neuroses ' 556 Cardiospasm 556 Pylorospasm 557 Gastric Hyperperistalsis 55/ Merycismus 557 Nervous Eructation 558 Hyperesthesia 558 Gastralgia 558 Bulimia 559 Anorexia Nervosa 5o9 Nervous Disorders of Secretion 559 Hemorrhage from the Stomach 559 Cyclic Vomiting 560 Diseases of the Intestines 561 Duodenal Ulcer 561 Diarrhea 56o Serous Diarrhea ''"O . Catarrhal Enteritis 566 Ileocolitis of Childhood . 566 Cholera Infantum 569 Appendicitis 572 Intestinal Obstruction 579 Congenital Malformation 579 Intussusception 579 Internal Strangulation 581 Volvulus 581 Obstruction from Foreign Bodies 582 Enteroptosis 582 Colitis 586 Acute Cohtis 586 Mucous Colitis 586 FoUiculus and Croupous Colitis 587 Pseudomembranous Colitis 588 Sprue (Psilosis) 588 Dilatation of the Colon 591 Membranous Pericolitis 592 Adhesions, Displacements, and Redundancy of Colon 592 DISEASES OF THE PERITONEUM. Acute Peritonitis 59^ Chronic Peritonitis • 598 Chronic Adhesive Sclerotic Peritonitis 598 Morbid Growths of the Peritoneum 599 Cancer of the Peritoneum 599 Other Growths of the Peritoneum 599 Ascites S^^ CONTEXTS DISEASES OF THE LIVER. Inflammation of tlie Liver 602 Acute Hepatitis or Hepatic Abscess 602 Ciiihosis of the Liver 606 Atrophic Cii'rhosis 607 Hypertrophic Cirrhosis 610 SyphiHtic Cirrhosis 611 Perihepatitis (Capsular Cirrhosis) 612 Affections of the Hepatic Bloodvessels 612 Amyloid Liver 614 Fatty Liver 614 Tumors of the Liver 614 Acute Yellow Atrophy of the Liver 616 DISEASES OF THE BILIARY TRACT. Acute Catarrh of the Bile-ducts, or Acute Cholangitis 617 Chronic Catarrh of the Bile-ducts 618 Suppurative Inflammation of the Bile-ducts 619 Occlusion and Constrictions of the Bile-ducts 619 Acute Cholecystitis 620 Cholelithiasis 621 Malignant Growths of the Gallbladder and Biliary Passages 627 Icterus Neonatorum 630 DISEASES OF THE PANCREAS. Pancreatitis 630 Acute Pancreatitis 630 Chronic Pancreatitis 634 Pancreatic Calculus 636 Pancreatic Cysts 636 Pancreatic Tumors 637 Hemorrhages into the Pancreas 637 DISEASES OF THE KIDNEYS. Malformations of the Kidneys 638 Movable Ividney ■ ■ ■ • ^38 Ciiculatory Disturbances in the Ividney 640 Acute Hyperemia 640 Chronic Hyperemia 640 Acute Nephritis 641 Clironic Nephritis 643 Chronic Parenchymatous Nephritis 645 Chronic Interstitial Nephritis 650 Amyloid Disease of the Kidneys 657 L"remia 658 Pyelonephritis and Pyelitis 662 Hydronephrosis 665 Cystic Disease of the Kidney 66 1 Tumors of the Kidney 66S Nephrolithiasis 669 Perinephritic Abscess 672 CONTENTS xui Disorders of Urinary Secretion 672 Anuria 672 Hematuria 673 Hemoglobinuria 674 Hematinuria 674 Albuminuria 6/5 Pyuria 678 Chyluria 678 Phosphaturia 679 Oxaluria 679 Indicanuria 679 Lithuria 680 Melanuria 680 Myelopathic Albiuiiosuria 680 DISEASES OF THE DUCTLESS GLANDS AND LYMPHATIC SYSTEM. 1 of the Thyroid Gland 681 Goitre 681 Swelling of the Thyroid 682 Tumors of the Thyi-oid Gland . ■ 683 Exophthalmic Goitre 683 Myxedema 688 Cretinism 689 Diseases of the Parathyroid Gland 691 Tetany 691 Diseases of the Thymus Gland 693 Status Thymol3rmphaticus 694 Diseases of the Suprarenal Gland 695 Addison's Disease 695 Diseases of the Pituitary Body 699 Dyspituitarism 699 Acromegaly 699 InfantiUsm 702 Diseases of the Spleen 702 Splenic Anemia 704 Banti's Disease 705 Gaucher's Disease 705 Hemolytic Splenomegaly 706 DISEASES OF THE BLOOD. Anemia 707 Secondary Anemia 707 Primaiy or Essential Anemias 708 Chlorosis ■ 708 Pernicious Anemia 710 Aplastic Anemia 713 Chronic Splenomegalic Polycythemia (Erythremia) . 713 Leukemia 714 Splenomedullary Leukemia 715 Lymphatic Leukemia 716 Chloroma 71S Anemia Infantum 718 Purpura 719 Hemophilia 721 CONTENTS DISEASES OF MTJilTIOX. Diabetes Mellitus 723 Bronzed Diabetes 739 Diabetes Insipidus 739 Gout 740 Acute Gout 745 Chronic Gout 746 Irregular Gout 746 Arthritis Deformans 749 Clironic Rheumatism 753 Muscular Rheumatism 754 Rickets 755 Scurvy ■ 759 Obesity 762 Adiposis Dolorosa 764 Osteitis Deformans 765 Hypertrophic Pulmonary Osteo-arthi'opathy 765 Leontiasis Ossea 765 Scleroderma 765 Ochronosis 766 Ainhum 766 Beriberi 766 INTOXICATIONS. Alcoholism 771 Acute Alcoholism 771 Subacute and Chronic Alcoholism 772 Morphinism 775 Arsenical Poisoning 777 Lead Poisoning, or Plumbism 778 Food Poisoning . 7S1 Bromatotoxismus 781 Sitotoxismus 781 Mytilotoxismus 781 Ichthyotoxismus 782 Ivreotoxismus "82 Tyrotoxismus and Galactotoxismus "82 Pellagra" "82 DISEASES OF THE NERVOUS SYSTEM. DISEASES IX WHICH THE CHIEF MANIFESTATIONS ARE IN THE BRAIN AND ITS MEMBR. Hemorrhage into the Brain, Cerebral Thrombosis, an Infantile Cerebral Paralysis . Little's Dise;ise ... .Vplia.sia Tumors of the Brain and its Monibranc .'Vljscess of the Brain .... Acute Cerebritis or Encephalitis Thrombosis of the Venous Sinuses . Cerebral Meningitis Pachymeningitis .... Pachymeningitis Interna \NES. mholi 785 795 799 799 801 809 811 812 813 813 814 CONTENTS XV Cerebral Meningitis: Leptomeningitis ^^^ Dementia Paralytica ^^'' Disseminated Sclerosis ^-^ DISEASES IN WHICH THE CHIEF MANIFESTATIONS ARE IX THE SPINAL CORD. Locomotor Ataxia 823 Friedreich's Ataxia S30 Marie's Cerebellar Hereditary Ataxia 833 Chronic Anterior Poliomyelitis °^^ Bulbar Paralysis 835 Lateral Sclerosis °3o Syphilitic Spastic Spinal Paralysis 838 Amyotrophic Lateral Sclerosis 838 Myelitis 840 Acute and Subacute Myelitis 840 Chi-onic Myelitis 842 Senile Paraplegia ....'' 844 Myelomalacia 844 Syringomj'elia . 844 Hemorrhage into the Spinal Cord 846 Hemorrhage into the Spinal Membranes 847 Compression of the Spinal Cord 848 Spinal Meningitis 851 Chronic Spinal Meningitis 853 Acute Ascending Paralj'sis (Landry's Paralysis) 854 Caisson Disease 8oo DISEASES IN WHICH THE CHIEF MANIFESTATIONS ARE IN THE NERVES. Neuritis 857 Special Forms of Neuritis 859 Cervicobrachial Neuritis 859 Obstetrical or Bu'th Palsy 860 Sciatica . 860 Multiple Neuritis • 860 Diseases of the Cranial Nerves 865 The Olfactory Nerve 865 The Optic Nerve 865 Optic Atrophy 866 Hemianopsia 867 The Third or Oculomotor Nerve 870 The Fourth or Trochlearis Nerve 871 The Fifth or Trifacial Nerve 871 Paralysis of the Sixth Abducens Nerve 873 Disturbances of Motility in the Ocular Muscles Depending on the Third, Fourth, and Sixth Nerves 873 Ophthalmoplegia or Paralysis of the Internal and External Muscles of the Eyeball 874 The Seventh or Facial Nerve 875 Facial Spasm 878 The Eighth or Auditory Nerve 878 The Ninth or Glossopharyngeal Nerve 880 The Tenth or Vagus Nerve 880 Eleventh or Spinal Accessory Nerve 882 Twelfth or Hypoglossal Nerve 883 CONTENTS DISEASES IN WHICH THE CHIEF MANIFESTATIONS ARK IN Till-; MUSCLES. Muscular Dystrophies 884 Pseudomuscular Hypertrophy 884 Erb's Juvenile Muscular Dystrophy 885 Landouzy-Dejerine Type of Muscular Dystrophy or Facioscapulohumeral Type 885 Muscular Atrophy of the Peroneal Tj^je 886 FUNCTIONAL NER\'OUS DISEASES AND DISEASES OF DISPUTED PATHOLOGY. Myotonia Congenita 886 Paramyoclonus Multiplex 887 Paralysis Agitans 888 Chorea Minor 890 Other Forms of Chorea 893 Huntington's Chorea 893 Dubini's Disease 894 Hysteria 894 Neurasthenia 899 EpOepsy 901 Petit Mai, or Minor Epilepsy 909 Jacksonian Epilepsy 909 Eclampsia 909 Infantile Eclampsia 909 Puerperal Eclampsia 910 Latah 911 Amok (Running Amok) 911 Astasia-abasia 912 Traumatic Neuroses 912 Occupation Neuroses 914 Raynaud's Disease 916 Angioneurotic Edema 916 Ervihromelalgia 917 Migraine 918 Sunstroke 920 Heat E>diaustion 922 Facial Hemiatrophy . . . ' 922 Periodical Paralysis 923 PRACTICE OF MEDICINE. DISEASES DUE TO A SPECIFIC INFECTION. TYPHOID FEVER. Definition. — Typhoid or Enteric fever, sometimes called Autumnal or Gastric fever, is an acute infectious disease due to the entrance into the body of a susceptible individual of the specific bacillus of Eberth, commonly known as Bacillus typhosus. The entrance of tbJs organism into the system results, after a period of from one to three weeks in some persons, but not in all, in the development of fever, anorexia, headache, mental heaviness, and more or less severe pain in the bowels, back, and limbs. The tongue is coated, and the bowels are loose or constipated. With these symptoms are developed enlargement of the liver and spleen, and swellings and ulceration of the IjTnphoid structures of the small and large intestines, and a rose rash on the skin. History. — ^Typhoid fever for many years was confused with tj-phus fever and malarial fever, and its very name means "like typhus." In 1813 it w-as considered as a separate disease, but this separation was not generally known by the profession until Louis, of Paris (1829), first emphasized a number of its cardinal points. Not until 18.37 was the identification complete, when Gerhard, of Philadelphia, published results achieved under the guidance of Louis which proved the malady to be a distinct entity. More than forty years later (1880) Eberth isolated the specific bacillus and proved it to be the sole cause of the disease. LTp to that time various causes had been thought to exist, but it had been recognized for many years as a "filth disease," and, therefore, preventable to some degree. Distribution. — Enteric fever is one of the diseases which may be said to be pan- demic, since it is found with some degree of constancy all over the world, its preva- ■ lence depending upon the introduction into the body of the specific bacillus, usually with water or food. It is estimated that about 150,000 cases of typhoid fever occur in the L^nited States each year, with a mortality of 25,000. Etiology. — ^The cause of this disease, as just stated, is the specific bacillus of Eberth, a short, thick, actively motile bacillus, with rounded ends and flagella, growing readily in ordinary suitable media. It is killed by exposure to 60° C. (140° F.), but it can withstand a freezing temperature for many days. Exposed to sunlight it is slowly killed, but drying, except in very thin layers, does not destroy it. It remains alive for months, and even for years, in clothing and in soil, if the conditions are favorable. It is readily destroj^ed by the stronger germicides, such as carbolic acid (1:200) and bichloride of mercury (1:2000). The bacillus of Eberth bears a close resemblance to the Bacillus coli covununl?, wdiich is alw^ays present in the intestine, and to the so-called paracolon bacillus and the Bacillus dysenterioe. 2 (17) 18 DISEASES DUE TO A SPECIFIC INFECTION The second etiological factor in the development of the disease is the mode by which the bacillus gains access to the body. Almost invariably this access is through the mouth, stomach, and intestine, more rarely by inhalation of the bacillus in dust by the lungs. Infection takes place by the mouth in a host of ways, as by infected water, or milk diluted with infected water, or chilled by infected ice; by vegetables and oysters and clams, which, when eaten raw, are often the means of carrying infection. It has recently been proved at Ogdensburg, New York, that infected ice may transmit the organism after it has been stored in an ice-house for at least nine months. In still other instances persons nursing cases of this disease get the finger-tips infected and so, on putting the fingers to the mouth, introduce the organism into the body. A very important cause of enteric fever is the so-called "typhoid carrier." A carrier is one who continues for many years after an attack, in some instances as long as thirty years, to throw off the specific bacillus in the stools although in perfect health. Usually the patient has a clear history of an attack of the malady, but in some a mild attack has never put the patient in bed and no diagnosis of typhoid fever has even been thought of. Klinger traced to this source 1.397 cases of enteric fever. Of these 1272 were infected by convalescent carriers and 12.5 cases by healthy carriers. "Typhoid Mary" in New York, a cook, apparently in perfect health, caused no less than seven outbreaks (28 cases) of enteric fever in five years at widely separated points. She denied that she had had typhoid fever, but examination of her stools showed them to be laden with typhoid bacilli. In other words, she was a chronic typhoid disseminator. Sawyer has reported ninety-three cases of typhoid fever infected by one "carrier," who prepared one dish at one meal. More and more such cases are being reported as time goes by. The bacillus of Eberth has been found in the stools of healthy attendants on typhoid-fever cases, who have never had the dis- ease, but who are, nevertheless, "carriers." Again, it has been proved beyond doubt that flies after lighting upon the discharges of a case of typhoid iever may carry the bacillus to otherwise pure food, and so spread the infection as long as twenty-three days after feeding on infected stools (Fischer). Stokes describes an epidemic in a factory employing 1.500 women and 400 men. As many as 200 of the women were ill at one time with typhoid fever, but none of the men fell ill. All the men drank beer at luncheon, whereas all the women used milk. The milk was found to ha^•e been infected by flies from a neighboring privy. Cockroaches may also spread the bacillus. Whipple states that typhoid fever is due to contaminated water in 40 jicr cent., infected milk in 25 per cent, and to contagion in 30 per cent., including fly trans- mission. Every great epidemic of the disease has been due to contamination of the water supply. In the Maidstone epidemic in England 1 person in every 17 in the town was infected; while in the Plymouth epidemic in Pennsylvania 1 in every 7 was stricken, for there were 1200 cases in a population of SOOO. As only a part of these SOOO persons used the contaminated water, the proportion of actual infection to exposure was far higher than 1 in 7. The influence of bad and good water supply is shown in Figs. 1, 2 and 3. In "iSSS the use of filtered drinking-water was begun in the French arm%-, as a result of which the morbidity of typhoid fever was diminished 49 per cent, in 1890, and the mortality .34 per cent. Prevention. — From what lias just been said it is evident that typhoid fever is an entirely preventable disease, provided that the bacilli as they escape in the feces, the urine, the sputum, and, perhaps, in the sweat, are destroyed as soon as they pass from the patient's body. The destruction of the discharges and so of the bacilli is therefore absolutely essential, and in addition careful antisepsis on the part of the attendant as to personal cleanliness and the protection of the dis- TYPHOID FEVER 19 charges from flies are to be enforced. As careless or ignorant persons do not disinfect the stools, the additional measures of prophylaxis are the boiling of all water that is to be placed in the mouth, and the use of nothing but well-cooked foods, which have not been exposed to flies or dust after cooking. The vessel which receives the discharges of the patient should contain carbolic acid (1:200), corrosive sublimate (1:2000), or chlorinated lime (a heaping teaspoonful to the pint). Formaldehyde solution (40 per cent.) may also be used. If the stool is formed, it should be broken up by stirring it with a rod, so as to expose all the fecal matter to the germicide. t- sn sa O 1 1000 1 sooo I 3000 1 iOOO 1 5000 1 6000 1 1 rooo 1 sooo 1 9000 1 IflOOO \ 1 1 1000 2000 3000 4000 3000 6000 7000 8000 9000 lOWO^^^^ fmmF Fig. 1. — Mortality in Chicago of typhoid fever. In 1891 and 1892 the water was contaminated with sewage and the death rate was about 1 to 450 to 1 to 1500. With a change in water supply the mor- tality has fallen to 1 to 6000 or even 1 to 9000. (Seibert.) Fig. 2. — Mortality of typhoid fever in Berlin before the supply of drinking-water was filtered. In the decade 1843 to 1853 the average yearly mortality was 1 per 900 of inhabitants. Fig. 3. — Mortality of typhoid fever in Berlin after water was filtered. (Seibert.) Physicians and nurses are not careful enough about the destruction of the stools, and the average individual is willing to take his chances on the use of unboiled water. Another of the difficulties is that patients may, when no longer kept^in the house by the disease, continue to cast off bacilli in the urine or feces which 20 DISEASES DUE TO A SPECIFIC INFECTION arc capable of infecting water supplies. This danger is of great importance, because at each urination or defecation the convalescent patient may produce a new source of infection. Further, it is toward the close of the attack and during convalescence that the urine contains these specific organisms in pure culture and in enormous numbers, and they may remain persistently present, not only for days but for months and even years. The patient should be told of this danger, should be directed to disinfect his discharges, and should receive daily doses of uritonc or urotropin to destroy the bacilli in the urine before they are passed in that fluid. If he is also informed that bacilluria is a danger to himself, in that it may result in secondary diseases in his genito-urinary tract, he may be interested enough to aid the physician in arresting the spread of the bacillus by adhering to a plan of careful medication. Purjesz and Perl report the finding of typhoid bacilli in tongue-scrapings and upon the tonsils (more often the former) of half the conva- lescents examined. The examinations were made at times between the fifth and forty-seventh day after active symptoms had ceased. All clothing, instruments, bedding, pillows, utensils, bath-tubs and ordinary wash-tubs, which may be contaminated by the discharges of a ])atient, should be disinfected thoroughly as soon as their function is performed. The hands of the nurses should be repeatedly disinfected. Antityphoid Vaccination. — Another preventive of typhoid fever consists in the injection or inoculation in the arm or back of the individual with dead Bacillus typhosus, the organisms being destroyed by heat. Such an injection produces no effects, or, rarely, local swelling and some pain, a sense of nausea and depression, and some febrile movement, which symptoms speedily disappear, the patient at the end of twenty-four to thirty-six hours being well again. Ten days later the individual is injected a second time and ten days later a third time, each dose being larger than its predecessor. The dose is 500,000,000 increased to 1,000,000,000 or to 1,500,000,000. The dose for a child of 50 pounds is considered to be approximately one-third of the dose for an adult of 150 pounds. This prophylactic treatment is perfectly safe and has been used successfully in so many hundreds of thousands of cases as to be assured as firm a place in medicine as diphtheria antitoxin. The Commission of the French Academy of Medicine advises that no subject shall be vaccinated in whom typhoid seems imminent or at the beginning of an attack, as vaccination may aggravate the disease. It should be practised only upon perfectly healthy subjects, free from all organic or other defects and from local or general aft'ections, no matter what their nature, especially tuberculosis, as vaccination may cause a temporary predisjjosi- tion to infection. Every person vaccinated against typhoid fever should take the strictest precautions to avoid the chances of typhoid infection by a careful watch upon the water that is drunk and the food that is eaten. The period during which such precautions must be taken has a duration of two or three weeks at the most. The group of persons designated as likc]\- to be ])articularly benefited by anti- typhoid inoculation are: (a) Physicians, medical students, male and female nurses in military and ci\il hospitals. (6) Members of families in which tyj)hoid fe\er is present or in which "bacillus carriers" have been demonstrated. (c) Young persons of both sexes who have come from salubrious regions in the country to cities in which are habitual foci of typhoid fex'cr. UJ) The population of cities where the latter flisease is frequent. (e) Soldiers and sailors (rank and file). The immunity induced lasts, so far as is known, about three years. Probably antibodies do not exist, but the body is ready to prepare them in the presence of infection. TYPUOID FEVER 21 Out of 130,000 antityphoid inoculations in the United States Army, 97 per eent. showed no disagreeable symptoms. In 1913 the general typhoid-fever morbidity throughout the United States was 12.70 per 100,000. In the United States Army it was per 100,000 under inoculation. In order to protect not only from the typhoid bacillus but also from both the Bacillus paratyphosus a and 13, a t>phoid-paratyphoid vaccine has been employed, each injection containing 500,000,000 typhoid bacilli, 250,000,000 paratyphoid a, and Fig. 4 250,000,000 paratyphoid /3. It produces little if any more reaction than the use of a single strain, but its use is probably needless unless there be present an epidemic of para- typhoid infection. Frequency. — Typhoid fever affects males oftener than females, and occurs most fre- quently between fifteen and thirty years of age. It may, however, affect infants or aged persons. It occurs more frequently in August, September, and October than any other quar- ter of the year, but is by no means limited to this period. (See Fig. 5.) Typhoid fever is becoming less and less frequent, and less severe all over the world. In Munich the mortality in the decade from 1851 to 1861 ranged from 123 in 100,000 inhabitants to 453 in 100,000 inliabitants, whereas in the years from 1890 to 1897 the mortality was from 57 or 14.8 in 100,000 people to 10 or 2.5 per 100,000; in Vienna it has fallen from 120 per 100,000 to 10 per 100,000; in Dantzig, from 100 per 100,000 to 10.5. In Massachusetts the mortality from typhoid fever in 33 cities in 1901 was only one- fourth of what it was thirty years before. In Philadelphia a similar decrease has occurred in both mortality and morbidity. In Mel- bourne, Australia, there has also been a de- crease in the mortality rate which is very noticeable, being over 50 per cent. These de- creases are due chiefly to care in regard to water supplies. The general mortality rate of the world may be said fifty years ago to have been almost universally 25 per cent., whereas it is now from 15 to 10 per cent. With advancing years of age the morbidity decreases, but the mortality greatly increases. (See Fig. 6.) That typhoid fever is still the cause of an enormous number of deaths is empha- sized by Whipple's statistics of the United States, in which it is shown that in 1910 there were 35,379 deaths due to this disease, a loss of life which was computed by him as equivalent to a pecuniary loss of §212,000,000 for that year alone. Pathology and Morbid Anatomy. — In studying the morbid anatomy of typhoid fever it must be remembered that it is not, Avhen fwHy developed, a local infection, restricted to one or more foci from which the Bacillus typhosus distributes its toxin ADMISSION AND DEATH RATES FOR TYPHOID FEVER, UNITED STATES (ENLISTED MEN) ADMISSION RATES PER 1000 Si S 3 IS ii S i =. ^ U z s 6 In i 'n' a P II II 1 1 1 1 ■ 1 DEATH RATES PER TOGO s YEARS i'iilli'ii^ili ANTI-TYPHOra VACCINATION BEGUN VOLUNTARILY IN 1909 WAS MADE COMPULSORY IN 1911 Chart showing (Jecreasing morbidity and mortality from enteric fever in the United States Army under so-called antityphoid vaccination. (Com-tesy of the Surgeon- General, United States Army.) 22 DISEASES DUE TO A SPECIFIC INFECTION through the liody. On the contrary, the typhoid infection is practically universal, and the bacillus may be found in varying numbers in every organ of the body, includ- Chart from the United States census, showing the period of the year when the mortality from typhoid fever reaches its maximum. ing the Kpne-marrow and skin. Contrary to general belief, they may not be demon- strable in the intestinal contents in large numbers until the disease is well advanced, AGE 10 11-1 f. ir,-20 51-2.-) ■;r.-30 31-3,-, 31'.- 10 ll-ir. inriO ."■,1 ■:,,:, M-m oi 50- -|^- 4-1- 1 1 1 " V- - ^LL -r~ .J .L 40- i \ J - ___ % . J ' 7 30- 1 1 i /j ^ _^ ^_ - -1-1- ^-,-:--W- 20- -- -- - i-T / ^ , / \/ -_ 1 1 ,' __ ^ 10- 0- -- _ -''-' ■-" ^ '-' /" 1 1 ^ TJ- -U.- 1 1 ±L±E±: Showing the increased mortality of tjT)hoid fever with ago. (Curschmann.) and their presence in the stools depends largely upon the intensity of the changes which take place in the intestinal lymph nodes. It is true, however, that the TYPHOID FEVER 23 agminated follicles (Peyer's patches) and the solitary follicles of the small bowel are the parts of the body which usually are the seat of the most evident and constant lesions. On the other hand, it is not to be forgotten that cases of unfloubted typhoid fever occasionally occur in which no ulceration of the intestinal mucosa takes place. The alterations from the normal in the bowel may be discussed under three heads: (1) a difl'use catarrhal inflammation of the intestinal mucosa of varying severity, but usually resulting in descjuamation of epithelium; (2) hyperemia, swelling, endothelial and lymphoid hyperplasia, necrosis, and finally ulceration of the agminated follicles or Peyer's patches; and (3) a similar change in the so- called solitary lymph follicles of the intestine, although the changes in the agminated follicles are distinctly the more conspicuous. These changes begin in the very Fig. 7 Ulceration of a Peyer patch in typhoid fever, with associated sweUing of solitary glands. earliest stages of onset, and do not wait until the symptoms of the disease are well developed. If the patient comes to autopsy at this time, the intestinal mucosa will not only be found inflamed, but in addition the lymphoid structures just named will also be found swollen and reddened by hyperemia. Their edges are not well defined, and the entire gland is hyperplastic and spongy. A little later in the progress of the disease these areas become less red in hue and begin to look some- what gray in color; they are firmer and project above the surrounding mucous membrane to a marked degree, so that they extend well into the lumen of the bowel. Sometimes the hyperplasia within the gland is so great that its edges overhang the surrounding tissue. These elevated, circumscribed masses, made up of pro- liferated lymphoid and endothelial cells, are known as typhoid nodu?es. In addition 24 DISEASES DUE TO A SPECIFIC INFECTION to being elevated ahove the surface of the intestine, these ceils extend into the wall, usually involving the submucosa and at times the muscle coat. Owing to disturbances in nutrition and the action of the tyjjhoid toxiiie the nodules become necrotic, the dead tissue sloughs, and the typhoid ulcer is formed (Fig. 7). The most extensive ulceration usually takes place in the lower part of the ileum. While ulceration of the tissues composing Peyer's patches is the usual result of this infection, necrosis does not always ensue. The gland may become red and swollen and the inflammatory process go no farther, proceeding from this state to that of resolution and healing. Not infrequently this agminated patch is not equally affected in all its parts, and this gives it an uneven appearance, which is emphasized when the portions which are most affected ulcerate, so that small ulcers are dotted over the surface of the swelling, which, if the process is severe, finally coalesce. In severe types of the disease the process is so well diffused that a huge slough forms which, when it drops off, leaves a swollen, ulcerated surface, the excavation being usually very deep. It is this type of necrosis that results in perforation, the opening in the bowel wall being usually found at a point directly opposite the mesenteric attachment. Rarely the perforation takes place between the layers of the mesentery and causes a retroperitoneal abscess. Ilarte states that in 140 cases out of 190 the perforation occurred in the small bowel within twelve inches of the cecum. If the patient survives the severer periods of the disease, the swelling of the glandular tissue gradually diminishes, granulations develop, new connective tissue largely takes the place once occupied by the gland, and the ordinary intestinal epithelium covers the exposed area. While it is true that the solitary glands are rarely so markedly affected as the agminated follicles, they may suffer much more severely and be found diseased over a larger area than are the patches of Peyer. The number of ulcers in the bowel in typhoid fever varies greatly. Usually they are limited in number, but occasionally they are many and cover very large areas. They may be more numerous in the cecum than elsewhere in the colon. Out of 577 autopsies upon cases of this disease in Hamburg and in Leipzig, the cecum was ulcerated in 510, or SS..39 per cent.; the cecum and appendix in 247, or 42.S1 per cent.; the colon in 184 cases, or 31.89 per cent.; the jejunum in 41 cases, or 7.10 per cent.; the rectum in 12 cases, or 2.08 per cent. The percentage of cecal lesions, in these statistics of Curschmann, just given, is much higher than is generally noted; 40 per cent, is more nearly correct. As already stated, the lower part of the small bowel is the area chiefly affected. Next to the changes in the intestine the most noteworthy alterations may be said to take place in the lymph nodes of the mesentery, which lie between the intestinal lesion and the general system. These tissues go through a similar process of hyperemia, swelling, and endothelial proliferation, which usuallj' falls short of extensive necrosis. Small necrotic patches are not infrequent. I\Iore rarely large foci of softening or even suppuration may occur in these nodes, and as recovery takes place small septic areas are gradually walled off by lymph, become encysted, or are absorbed. Rupture of enlarged mesenteric nodes has been observed. The spleen, in addition to its swelling, which begins early and lasts for the first three weeks or more of the illness, is full and tense, and of a darker hue than normal. Later, as the attack wanes, it becomes soft and darker in hue. The splenic blood sinuses are distended by erythrocytes, the endothelial cells proliferate, and the pulp here and there becomes the seat of small areas of coagulation necrosis. The splenic lesions may also consist in infarction and rupture, but the latter accident is very rare. Until a few years ago the presence of the typlioid liacilius in the blnnd was un- known, but we now know that this organism is present in this part of the l)ody with great constancy, probably invariably during an attack of typhoid fever. It TYPHOID FEVER 25 is usually present as early as the fiftli day and persists until the close of the third week, or even longer than this. Rosenberger collected 535 cases of typhoid fever in which the blood was examined for the bacillus. It was found in SO per cent, of these cases. In a still more recent study Coleman and Buxton obtained the following results: Second Week. Of 484 examinations made in the second week of the disease, 353 (73 per cent.) were positive. Third Week. Of 268 examinations made in the third week of the disease, 178 (60 per cent.) were positive. Fourth Week. Of 103 examinations made in the fourth week of the disease, 39 (38 per cent.) were positive. AHer the Fourth Week. Of 58 examinations made after the fourth week of the disease, exclusive of relapses, 15 (26 per cent.) were positive. The examination of the blood has therefore become of great importance in the early diagnosis of the disease. (See Diagnosis.) The bacillus probably gains access to the blood through the mesenteric lymph nodes, and the destruction of myriads of the bacilli by the blood thereby sets free their endotoxin, which produces the symptoms and many of the lesions of the malady. The liver is usually somewhat swollen, but the changes in its appearance are not peculiar to this disease. The hepatic cells manifest more or less cloudy swelling, and the areas of coagulation necrosis containing endothelial cells are present. The cells lining the bile-ducts may be swollen, granular, and, in some cases, undergo a process of desquamation. Abscess of the liver may develop or gallstones may by their presence aid in the production of a cholecystitis, but more commonly typhoid fever probably induces the formation of gallstones. (See Complications.) The heart muscle nearly always suffers from typhoid infection in direct proportion to the severity of the toxemia present. The myocardium is granular and may suffer from fatty or hyaline changes. Very rarely the endocardium becomes affected and the specific bacillus has been obtained from vegetations on the valves. The kidneys show no typical changes. They usually show cloudy swelling, and even an acute nephritis may be present. Sometimes as the result of a terminal infection multiple abscesses may form in the kidneys and a croupous exudate in the pelvis of these organs may develop. Reference is made elsewhere to the lesioiis of the respiratory tract which may complicate the course of the malady, such as laryngeal perichondritis, ulcerative laryngitis, hypostatic congestion, pneumonia in both its forms, pulmonary infarc- tion, simple pleurisy, and empyema. (See Complications.) An endarteritis (which may be a thrombo-endarteritis) has been showTi to occur in a small percentage of cases, and it is reasonable to assume that the thrombotic processes occasionally observed in the veins depend upon a similar involvement of the lining membrane of these vessels. Longcope has shown that the lesions in the bone-marrow closely resemble the changes in the lymphoid tissues of the mesentery and of the bowel. There are present many lymphoid cells, large phagocytes, and foci of necrosis. A very important factor to be recalled in the study of the pathology of typhoid fever is the presence of additional infecting microorganisms which aid the Bacillus typhosus in producing severe lesions and often are equally responsible for a fatal termination. This view is, however, based on postmortem findings, and is not supported by the results of antemortem examinations of the blood, for of 150 cases of typhoid fever in which the blood was examined during life Cole found but one in which mixed infection was present; the case was one of staphylococcemia, with multiple boils, and terminated in death. Incubation. — ^The period of incubation of the infection by typhoid fever is generally stated to be from one to three weeks. That the period of incubation may be much 26 DISEASES DUE TO A SPECIFIC IXFECTIOX shorter than this would seem to be proved hy tlie case reported l)\- Duflocci and Voisin of a girl nineteen years of age who dehherately swallowed a virulent culture of the typhoid bacillus with the intention of committing suicide. She began to feel ill on the third day, had fever on the fourth day, rose si)ots on the fifth day, and the Widal reaction appeared on the sixth day. Symptoms. — Typhoid fever usually begins with a sense of wretchedness and general illness, no particular symptom being especially well marked, unless it be more or less severe frontal headache and aching in the back and limbs. The facial expression very early in typhoid fever usually becomes listless and later stupid and heavy, and the patient is often a little deaf because his mental state is Ix-numbed rather than because there is any actual trouble with the auditory apparatus. Not infrequently there may be a considerable amount of cough without expectoration, and there may be exaggeration of the sounds of bronchial breathing on auscultation. The tongue is somewhat coated, and very early its edges become clean and red, while the central coating remains. This appearance of the tongue is very character- istic, even in mild cases. Headache, thirst, and sleeplessness are usually prominent symptoms during the first week. A viild fever develops simultaneously and nose-bleed may occur repeatedly. Usually the liver and spleen become swollen toward the end of the first week, and the belly becomes somewhat tumid and tender. The characteristic enlargement of the spleen in enteric fever may be undemon- strable because of the distention of the stomach and intestine with gas; but while the presence of an enlarged spleen is of some importance in reaching a diagnosis of typhoid fever, inability to discover any increase in its size does not negative the diagnosis of typhoid fever in any degree. An undue amount of gurgling can be felt and heard in the right iliac fossa. Gonstipation is usual in the first week, but diarrhea may be marked, and, if loose, the stools may be brownish, but later resemble okra-soup or pea-soup. M E M eIm E M E M E M E M E M E M E M E M E M E M E M E MEM e:m E M E M E M E M E 106° 104' X £ 103° 1 102° •^ 101" 100° 00° = ^y\:A/:V\y\A A7 ... Z Z z z Z z \ £ E IL -- ^ 1 p -■^Imu T ^ E E 2 Z s = - f =: V V ^\i\\\ivi — - - t ^ I ; - - tVV f- -- T -j =: : = ~ - - E -A ^ 4* I' 1/ \l \l /" _ _ _ — — _ -J _ f V U / i _ - -J — — — - — r — r- ^— , r- ■J-, -L- — oisMsc 1 ■z 3 i 5 6 7 8 10 11 12 13 li 15 16 " U 19 m 21| PULSE 90 TO 120- DICROTIC! M '--^ ^^ 1 Course of typhoid fever. (Modified from Musser.) The temperature in typhoid fever during the first week rises step by step. Each morning it is higher than on the previous morning, and each evening higher than on the night before, although the morning temperature is often lower than that of the preceding evening. (See Fig. 8.) Usually by the end of this week it reaches TYPHOID FEVER 27 in the morning 102° or 103°, and at night 103° to 104°, and remains at this level until the fourteenth or twenty-first day. The pulse is more rapid than normal, ranging from 90 to 100 beats per minute, and it is usually soft and compressible; the pulse of debility, not of vigor. Often the pulse is a little dicrotic. As the disease progresses the pulse rate usually increases to about 110, but the pulse force distinctly diminishes. At about the seventh to the ninth day a very important diagnostic sign first makes its appearance, namely, the so-called rose spots, which usually develop on the skin of the abdomen and chest, sometimes on the back, and more rarely on the limbs. These spots are small, faint macules, usually scanty in number, which lose their color momentarily when pressed upon or when the skin on which they exist is stretched between the finger and thumb of the physician. As a rule these spots are isolated, but very rareh' they may be so profuse as to produce the appear- ance of an ordinary rash. Fig. 9 105° 1 — r — r — — — — — 1 E j 5 J i i £ ; i < f. s = i i j j j j j j ^ £ j iH J 1 _ — — — 104° ^ 103° — — — — — — r— — 1 — — 1 — — — — = - - T - - - z i: - - - - zz - z X i 102° ~ ~ t c — — = \- ■~ = - - - ^ - - - 1 - i z: : — - zz - zz < 101° >- 100° ^ I ::: / - ' - - ^ a' ~ ^ - - - ^^ '1 '-M ^ zz - z ~ ~ ^^ 1 W :|: r- = ^ - - - - _ ^ 1 t \ - - I 99° 98° — ^ ^ — zz - "T ^ — V - - - A - - - - : 1 1 ' 7j— - z ^ i — — — — — zz : :| -1 -: -~ = = = 5 ± I DAY OF ^ 2 2 r; s s U 2 5 s S s s ?5 PULSE ^f^ ■9- ^, ^■'V \*' «* ^'''*. "-%* ^'^V N*V ^*^i. X^ ^- f<0' ^^ •^ RESP. ^x^ f^ f,s. f-i' ■i« _ .1, f^ ■''- -l* f^ f^ f4 554 n 5^^ DATE s ^ C! " rr " = '- to o o n 2 ** Part of a chart showing the period of steep curves from the fourteenth to the twentieth day of an attack of typhoid fever. The tongue becomes dry and it may be fissured, the mental stupor increases, diarrhea is also active, and the moderate tympanites of the earlier days becomes more marked. If the patient has received little care, or if the case is essentially severe, his condition is manifestly one of profound toxemia, and by the end of the second week he is evidently at the very acme of his infection. Death not infre- quently takes place during this period as a result of profound toxemia, hemorrhage, perforation, or pulmonary complications. Because of the toxemia delirium may be marked, and it is usually of the low muttering type, the patient seems to be in a semi-stupor, the teeth are covered with sordes, and the tongue is foul and dry. These symptoms gradually carry the patient into his third week, with increasing diarrhea, greater tympanites, deeper stupor, and more manifest signs of profound 28 DISEASES DUE TO A SPECIFIC IXFECTIOK toxemia, witli muscular tremors or true .stihsnltiis iendimim. Emaciation l)y tliis time is marked and the skin dry and harsh. The heart is feeble, its sounds distant and muffled, and myocardial degeneration is manifestly advanced. To the possi- bility of the appearance of the fatal complications named in the succeeding pages as appearing at the end of the second week are added at this time still greater danger of pulmonary hypostatic congestion and pneumonia. The patient may be so profoundly poisoned by the toxic products of the disease that he seems almost moribund. If the pathological process is not so severe that recovery is im])ossihlc, the first sign of the ending of the malady may develop at any time between the fourteenth and twenty-eighth clay, according to the severity of the disease. This consists in a slight modification of the temperature range and the develo])ment of a low morning temperature with a well-maintained high evening temperature, so that the daily range may amount to from 2° to 3°. This is called the "period of steep curves," and the appearance of these steep curves at this time in the course of the disease is usually a promise of approaching convalescence. An equally good descrijjtion of this period is that of Murchison, who called it the "stage of changing fortunes," or that of Wunderlich, who described it as the "period of ambiguity." The last stage of the acute febrile period having been reached, the temperature falls to normal during the next few days by lysis, and then may be subnormal until convalescence is well established, the patient being wasted and feeble, but usually ravenously hungry. AriPiCAL Forms. — While the train of symptoms just described may be con- sidered typical of an attack of typhoid fever occurring under conditions favorable for its full development, it is often so modified by various causes that a large pro- portion of cases do not present many of the most prominent and diagnostic symp- toms, but, in their place, manifestations so at variance with those of ordinary cases as to greatly perplex the physician. Thus, very marked variations in onset may occur and completely mislead the medical attendant if he be not on his guard. In some cases instead of manifesting itself gradually the disease has a sudden onset with a sharp chill followed, it may be, by a profuse sweat and a continued fever. This variation is perhaps most apt to occur in children. Headache may be so severe in the beginning as to rouse the suspicion of meningeal inflammation, and active delirium may be an early symptom, being severe enough to be maniacal in type. In other instances a pneumonia is the earliest sign of the malady, while in still others a severe choleraic diarrhea may begin the illness. It is also important to recall the fact that well-developed signs of appendicitis may appear, due to the swelling of the lymphoid tissues of the intestine and appendix by reason of the infection. This has frecjuently resulted in enthusiastic surgeons removing the appendix only to find it slightly diseased as part of the general lymphatic change, the speedy appearance of the rose rash and persistent temperature soon showing the true character of the case. Rarely a severe attack of vomiting begins the illness, and still more rarely acute renal disease, nephro-typhoid, or thefievre typhoide a forme renale of the French observers, develops. Although diarrhea was correctly considered at one time to be one of the most constant symptoms of enteric fever, it is now absent in more than half the cases during the whole course of the disease, and splenic enlargement in many instances is too slight to be discovered, so that it is to be borne in mind that while these two symptoms possess a positive diagnostic value when j)resent, their absence in no way contradicts the diagnosis of typhoid fever. In other instances the course of the fever greatly varies from that just described. It may rise very abruptly, and it may end equally suddenly, the lysis being com- pleted in twenty hours. Sometimes the morning temperature is the higher of the two, although this is rare. The regular course of the temperature may also be TYPHOID FEVER 29 greatly altered by intercurrent chills. (See Chills.) Very rarely, strange as it may seem, no febrile movement is present at any time in the course of the malady. The most important variations from what may be called the normal course of the temperature in the second and third week of this disease are those pro- duced by free hemorrhage from an in- testinal ulcer and by perforation of the bowel. A sudden fall of several degrees should always arouse suspicion of one of these accidents, for the drop in the fever may be noted before any of the other signs of hemorrhage or perforation manifest themselves. Marked rises and falls of temperature are also often seen in patients who are markedly anemic as the result of hemor- rhage. Abortion also causes a marked fall of the fever. The course of the temperature may resemble that of remittent malarial fever, and it has frequently misled phy- sicians into the belief that malarial in- fection and not typhoid infection was present. (See Chills.) Infectious com- plications of the disease, such as otitis media, phlebitis, furunculosis, menin- gitis, and erysipelas, may also cause sudden variations in temperature. And in cases which have been gravely ill it not rarely happens that fever continues after the typhoid infection has run its course because of post-typhoidal septi- cemia — that is, a multiple infection due to the presence of pyogenic organisms, which have found a favorable field for growth in a patient whose vitality has been impaired by the specific fever. As the stage of convalescence ap- proaches, or when it is reached, a sharp return of active febrile movement may come on for a clay or two, the temper- ature being as high or higher than ever before. It then returns to its ordinary level. This is called a recrudescence, and possesses no grave significance. It often follows mental excitement and the taking of improper or too much food. When this rise of temperature perists, it usually is indicative of some complicating malady, or of a relapse called an "intercurrent relapse" if it takes place during the continuance of the primary febrile period. (See Fig. 10.) After the fever has disappeared there may be a prolonged continuance of a slight evening rise of temperature as the result of nervous irritability and anemia, or it 31V0S J.I3HN3aHVd 30 DISEASES DUE TO A SPECIFIC INFECTION depends upon the abuse of strychnine, with the mistaken idea that it is a valuable heart tonic at this time. In other cases a subnormal temperature for the entire twenty-four hours may persist for days. This is of no importance sa\e that it indicates that the patient is feeble and needs good feedinfi; and fresh air. The other variations met with depend upon the age of the patient. Old persons often have an irregular febrile movement, and children may have marked rises and falls of temperature which do not necessarily indicate any complications. Persistence of distinct febrile movement after the fourth week in any case of typhoid fever in which a relapse has not occurred nearly always means a complicat- ing or secondary infection. The number of cases of rapid tuberculosis called typhoid fever, until the persistent loss of flesh and fever forces the correct diagnosis upon the physician, is by no means small. The possibility of ulcerative endocar- ditis, cholecystitis with ulceration, with or without impacted gallstones, and septic infection due to suppuration as causes of fever are to be borne in mind and their presence carefully looked for. (See Complications.) That a patient witli this disease may suffer not only from the infection due to the bacilli of Eberth, but from midtiple infections by other organisms which aid in decreasing his vital resistance should be borne in mind. Closely associated with the study of the temperature is that of chills. They may usher in an acute complicating inflammatory process, or be entirely without such significance. Somtimes they occur in cases which suffer from constipation, apparently as a result of the absorption of fecal poisons. (See Fig. 11.) In other cases they are due to a true coincident malarial infection, but it is a noteworthy fact that during the course of typhoid fever, even if the patient is also suffering from malarial infection, the latter usually remains in abeyance until the former has about run its course. It is better for the physician to regard such chills as being an indication of some acute complication than to consider them as malarial, unless he can prove the existence of the last possibility by finding malarial organisms in the blood. The shin is sometimes covered by a jugacioiis scarlatiniform rash in the early stages. In certain cases it desquamates in large flakes or in fine, branny scales, the latter appearing oftenest in those who have been actively bathed and rubbed. Very commonly if sweating takes place, sudamina, or tiny sweat-drops retained beneath the superficial epiderm, are found on the abdomen, chest, or limbs. Herpes about the mouth is very rare in typhoid fever, but it does occur, notwithstanriing the denial of this fact by some observers. Under the name of tciche blendtrc, or peliomata, faint blue or steel-gray spots of fairly good size, are sometimes met with. They are not due to the disease, but are found only in those who are infested with lice. The so-called tachc ccrrhralc is not characteristic of this disease, but is sometimes seen during its cour.se, and consists in a red line with white borders produced by drawing the finger-nail over the skin. It is probably due to palsy of the cutaneous vessels. Of the deeper lesions of the skin, we meet with bed-sores, which rarely occur in cases seen from the first and which recei\'e proper care. They appear usually over the sacrum. Cases of superficial (janqrene of the skin have been reported by Stahl and the author. Erysipelas occurs, usually of the face, by reason of infection through fissures in the buccal or nasal mucous membrane. Sometimes erysipelas migrans develops. In very malignant cases petechice may be present. Patients suft'ering from typhoid fever rarely suffer from other eruptive diseases, but instances of scarlet fever, chickenpox, and measles occurring as complications are on record. In women in particular the hair often falls out freely during or after an attack. Boils are by no means rare lesions, and even carbuncles may develop as a result of multiple infection. The blood in typhoid fever suffers from an increasing degree of anemia in respect TYPHOID FEVER 31 to the number of the red cells and of their richness in hemoglttbin. Indeed, the color-index is more markedly lowered than the corpuscular count. When an inadequate supply of liquids has been allowed the resulting concentration of the blood may produce an apparent corpuscular richness not actually present. ■■.-i; ~ n ~ " ~ " " ^ ~ " -- ^ «! oz •«-To < If, 81 -n-vc \ K DO 81 •«"SI 90 81 ■B-JB >d HII Oil OS ■I.'.. - •■s . ■KM C ,i HI 81 ■«i;i % ■n-r r, mi or. ■BM / 001 OJ ■B-TC SJ 001 001 05 7Z ■«KS, k ■U-.I r, \ Jll 85 'XM 9 K on K ■KM C H on t5 ■"7,1 ROl W. ■K-YB |J_,5» ci; \z ■K-V CI ■t^ ^ rni n ■R-Y 1.. J,; oJ or. n ■^nzi on \7. •it-JO S 501 05 ■"■JO ." SOI 05 ■" ,, c ■ ■ Kil 05 ■lint on 55 ■^■Y r, «. oOl 05 •W-Yll > SOI 55 ■BYC 1! 811 f5 ■>^"El . L _ - - - - 001 1-5 ■"■a 6 ^ ^ ^ KI Si- ■"■,1 [1 e u _ 1' n 1 a J r 001 00 ■1,-JS ~ >^ — L- LU ^ _ •K-JE u'l.Sfi' II '^1 " "~ ^ s 801 f5 ■"51 > SOI ^5 ■"■Y r, / on t5 ■B'Yg ^ on 55 "YC < V on 05 K"JI >\ 05 z\\ 5C ■"■JC azA \Z ■"■iO k on 85 ■it-JE / Ell 5C •"ET _ _ _ - - — -I 851 1-5 ■"■YC / on t5 •"■Y,, - — _ _ uLUll 1,1 J oci i-5 ■"■< 5 I w i: . " ■■ HI ~ ~ -■ -. .. 1YE - Gl iin 1-5 K-5t ^ o / on OC 0-0 -• OEI OC ■^■JO <. - _ 1 WC i]^\i\ rei EC ■B^as h ~'r\- - _ _ _ Ujg 1 1 1 1 1 1 g g SQg& The bacteriolytic power of the blood in severe cases is probably always dimin- ished. The leukocytes are slightly decreased in number, the large mononuclear and transitional cells are relatively increased, and, according to Thayer, the poly- morphonuclear cells are decreased. Cabot asserts that a leukocytosis, non-inflam- matory in origin, sometimes occurs. 32 DISEASES DUE TO A SPECIFIC INFECTION Complications and Sequelae.' — Circulatory Complications. — The heart, as already stated, is weakened, and if severely affected may develop enibryocardia or fetal heart-sounds. There are few, if any, diseases which do not have special predilection for the heart muscle or its valves, which so greatly interfere with this organ as does typhoid fever. A pulse rate above 125 is ominous, and one of 130 or 140 dangerous. The danger is usually in direct proportion to the feebleness of the first sound of the heart. When the cardiac sounds are those of the fcrtus in utero (enibryocardia), the prognosis is grave. A very rapid pulse and irritable cardiac action are sometimes seen in cases in which strychnine has been used to excess with the idea that it is a stimulant. A soft systolic murmur is occasionally audible, which may be hemic in origin or due to relative insufficiency of the mitral valves. Rarely it may be due to endocarditis or pericarditis, but pericarditis is a very rare complication of typhoid fever. Gaudy and Gourand state that pericar- ditis arising during the course of tj-phoid fever occurs in two forms, namely, the fibrinous, which is characterized by an abundant pseudomembranous exudation with only slight serous effusion, and the fibrinopurulent form, in which a consider- able efl'usion may occur. Pericarditis may exist alone or may occur in connection with endocarditis, myocarditis, pleuritis, or pulmonary complications. As a rule, it de\'elops very slowly and may remain latent, so that only most careful auscultation over the precordial region will reveal the presence of friction fremitus, and later careful percussion may be required to distinguish an effusion. The pathogenesis of this complication is obscure. The purulent form when it occurs may be due to secondary infection, although the fibrinous variety is probably due to a direct infection with the Eberth bacillus. Typhoid fever complicated by purulent pericarditis is always fatal, but the existence of the serofibrinous pericarditis influences prognosis slightly if at all, unless the eft'usion be profuse. Sudden cardiac failure may occur as the result of myocarditis, or of embolism or thrombosis of the coronary arteries, from heart-clot, thrombosis of the cavse and pulmonary veins or from pericarditis with effusion. Sometimes the cardiac failure is gradual when due to these causes. So far as the bloodvessels are concerned the most common lesion is phlebitis, which usually affects the veins of the left leg, especially the femoral vein. The frequency of involvement of the ^'eins in the left leg depends upon the pressure exercised by the right common iliac artery i:pon the left common iliac vein, which tends to obstruct the flow of blood. Sometimes the tendency to the formation of a thrombus is greatly increased by a local infection of the endothelial lining of the vessel, and it is not uncommon for a severe chill or chills to mark the onset of the lesion. Wright and Knapp have recently shown that the tendency to the formation of a thrombus in typhoid fever is augmented by the increase of calciiun in the blood. When milk is the exclusi\'e diet the rise in the proportion of calcium oxifle supplied to the body is very noteworthy. They also recommend that for the prevention of this state the physician add 20 to 40 grains of citrate of soda to each pint of milk taken by the patient in order to decalcify it. Thromboses of extraordinary size and number may form anil extend from the femoral vein to the vena ca\-a. When venous plugging seriously interferes with the circulation, the gangrene which results is usually moist, but in the vast majority of cases of phlebitis of the leg partial recovery takes place, although varicosity of the veins of the limb may persist after convalescence is completed. The rarity of plugging of the veins of the upper extremity is remarkable. Arterial thrombosis is much more rare than is rcnoxis thrombosis. This complica- tion usually develops after the second week of the fever, and is manifested iiy pain and tenderness along the course of the vessel affected. Usually the leg is the ' See Medical Complications and Sequelaj of Typhoid Fever, by tlie author and Bcardsley, 2d ed., Lea & Febiger. TYPHOID FEVER 33 limb involved. After a temporary increase in the force of pulsation in tlie affected vessel the pulse becomes small and may be lost. The part becomes cold and discolored, and finally gangrene ensues. In other cases, in which the vessel which is involved is small, recovery takes place by the establishment of a collateral circula- tion. Even in the mild cases the patient suffers afterward from fatigue in the affected limb on exertion, and intermittent claudication may develop. The con- dition is due to an arteritis. Thayer has published statistics which seem to indicate that typhoid fever is prone to produce early senile changes in the bloodvessels in after years. Complications in the Alimentary Canal. — The complications in the upper digestive tract are pharyngitis, which is rarely severe enough to cause much dis- comfort, and esophagitis, which is still more rare, although several observers have recorded idceraiion of the esophagxis. Inflammation of the parotid gland is a rare complication of typhoid fever, and usually occurs about the third week in cases of severe infection. This inflammatory state may be due to infection of the gland from the mouth by ordinary pus organisms, or more rarely be due to the specific bacillus. Rarely parotitis occurs in the first week. In the only case the author has seen in which this complication developed at this time there was no pain or redness, and the swelling disappeared in about ten days. It was also bilateral. In advanced typhoid fever it is usually bilateral ; is often followed by ugly sloughing, and is a very dangerous complication. The stomach in typhoid fever is rarely much affected. Digestion in this viscus is, as a rule, feeble because in all fevers there is a lack of gastric secretion, and this is particularly true of typhoid fever. Vomiting may come on usually as a result of indiscretions in food and medicine. Sometimes, however, late in the disease a persistent, pernicious vomiting develops which only ends with exhaustion and death. A few cases of gastric ulcer occurring in typhoid fever are recorded. When there are more than three or four stools a day diarrhea is to be considered excessive. When a far greater number occur, it is usually the result of improper feeding. The stools are thin and resemble pea-soup save that they are apt to be a little more yellow. They are alkaline in reaction, offensive, and may contain particles of undigested food, as curds of milk, and also small shreds of Ijiuphoid tissue from the sloughs of the bow-el. The specific bacillus usually is not to be found in the stools until about the seventh or tenth day. The significance of active diarrhea as to the gravity of the case has been much discussed, some believing that it is a sign of a severe infection. The real significance is not of severity of infection, but of severity of intestinal invoh'ement, catarrhal or ulcerative, although in some cases even the latter state does not provoke active diarrhea. General diffuse pain in the bowels is often present early in the disease, but is apt to disappear later. Hemorrhage from the bowel in typhoid fever is one of the inevitable complications in a certain percentage of cases, and usually takes place after the second week of the disease. Very rarely slight loss of blood may occur in the first w^eek. Proper treatment of the patient all through his attack may diminish toxemia and prevent a fatal terminal infection, but no form of treatment so far devised has materially diminished the frequency of hemorrhage or the mortality from this cause, although the frequency of the occurrence and mortal effects vary greatly in different epi- demics. The general average of its occurrence may be placed at 5 per cent. In 52,196 cases of typhoid fever collected from several series of cases reported by French and German physicians, and from the official reports of hospitals in the United States and Canada, England and Ireland, Germany, Austria, South Africa, and Australia, hemorrhage is stated to have occurred in 2725 cases, which gives a percentage of 5.22. The mortality in persons suffering from it is about 35 to 50 per cent., although in 271 cases of intestinal hemorrhage complicating typhoid 34 DISEASES DUE TO A SPECIFIC IXFECTIOX fever, collected from the official reports of hospitals in the Initcd States, Caiuula, England, and Germany, 71 cases proved fatal, which gives a percentage of 2().2. Hemorrhages usually arise from ulcers in the small intestine and are very rare in children. The symptoms consist of sudden fall in the temperature and it may be in the pulse rate, but this primary decrease is usually followed by a more rapid pulse than existed before the accident occurred. A diagnosis of hemorrhage is to be reached not only by the observance of the symptoms just described, but in addition by the presence of Ijlood in the stools and by examining the blood to discover a paucity of hemoglobin. The gravity of a hemorrhage depends upon the relation of the quantity of blood lost to the vitality of the patient and the frequency with which the bleeding occurs. Thus a fairly profuse hemorrhage in a strong patient may be followed by no severe symptoms, whereas repeated small hemorrhages may greatly exhaust the most lusty individual. When the patient is at the end of a long and se\'ere attack of the fe\-er, even a comparatively small hemorrhage may be fatal. The existence of small losses of blood not sufficient in size to be manifest to the eye when the stools are examined, may be discovered by the tests for occult blood. Perforafion of the bowel, the most serious of all the complications of this disease that is commonly met with, has no relation to the severity of the general symptoms, for it occurs as often in mild as in severe cases. Indeed, in nearly 50 per cent, of recorded cases this accident occurred in mild cases. The statistics of Brown indicate that 25,000 deaths occur annually in the United States from this complica- tion of typhoid fever. It takes place far more commonly in men than in women, 71 per cent, against 29 per cent, and in the majority of cases the lesion is in the ileum. Wlien perforation occurs the symptoms may be ushered in by agonizing pain, which may be severe enough to rouse the patient from a considerable degree of stupor. If the patient is not too apathetic the pain is often described as being in the lower zone of the belly near the median line, and most commonly slightly to the right. The belly-wall is sensitive to palpation, speedily becomes tense and all the symptoms of a general diffuse peritonitis may cjuickly ensue. The pain may, however, be very slight and pass away or become modifieil, as the peritoneal condition resulting from the escape of fecal matter into its cavity becomes more and more septic. The pulse l)ecomes rapid and running, and collapse may speedily assert itself. When this occurs, death speedily comes on, the patient dying in a few hours, or, again, he may rally and survive for several days. Early death is, however, the more common result. Thus in the collection of 34 cases made by Fitz, of Boston, 37.3 per cent, died on the first day, 29.5 per cent, on the second, and 83.4 per cent, in the fir.st week. During the second week 9 died, in the third week 4 died, and 2 other cases lived thirty and thirt>-eight days, respectively. If collajise does not ensue, the rally of the system results in a rise of the temperature to a point higher than before the accident, and this movement is often accomi)anic(l In- chills and rigors. Usually by the second or third day the peritoneal sym])toms become more and more marked, the condition of the patient more and more asthenic and depressed, and death results by the fourth day from a general jx'ritonitis with toxemia from the absorption of toxic materials. In other cases the onset of the perforation is insidious; the l)elly before the perforation may have been moderately tympanitic, but now becomes intensely hard and rigid ; the pain, which in some cases is so severe, does not develop, but the great fall in fever followed by a rise, and this again by rigors, it may be, give evidence of the grave accident which has occvirred. The pulse becomes increasingly rapid and running, and the res])iration more and more costal and less and less dia])hragmatic, until the patient sinks out of life, without much, if any, sufl'ering, in generally the same manner as one sees death come to a case of diffuse septic peritonitis due to a pyosalpinx or to sejitic appendicitis. In such cases the perforation is usually very small, and is so sur- TYPHOID FEVER 35 rounded by adhesions that the escape of the intestinal contents is very gradual and insidious, infecting the peritoneum without the escaping fluid being copious enough at any one time to produce great pain or reaction. In this connection it is important to note that a sudden fall in temperature is not a symptom necessary to the diagnosis of intestinal perforation. On the con- trary, there are many cases on record in which a rise of temperature has followed this accident. The diagnosis of perforation is to be reached by the following signs in addition to those just given: The hand of the physician, when lightly placed upon the abdominal wall, not only develops the fact that it is hj^persensitive, but that its muscles are unduly tense. If the perforation has occurred, the abdomen, here- tofore rather swollen and tumid, may be slightly scaphoid. There is usually a sharp increase in pulse rate. Percussion may indicate the presence of gas in the peritoneal cavity, and the liver may be pushed away from the abdominal wall in such a manner that the ordinary area of liver dulness is largely decreased. Percus- sion of the right hypochondrium is, therefore, an essential procedure in the physical diagnosis of these cases. A fallacy underlying this test is the possibility of a portion of the colon, when greatly distended with gas, slipping up between the liver and the belly wall, and thus giving resonance; but this is a rare occur- rence. In some cases, however, as intimated, the symptoms are so insidious that the absence of this sign does not negative the diagnosis of perforation. Indeed a positive diagnosis may not be possible, and cases are sometimes met with in which the perforation has not been suspected, and is found only at the autopsy. Other cases have been operated upon for perforation and no opening found. The diagnosis of peritonitis due to perforation is aided, but not confirmed, if an examination of the blood reveals a leukocytosis of polymorphonuclear cells, but the absence of leucocytes does not negative perforation. There are several conditions causing pain which must be carefully excluded before the physician can arrive at the diagnosis of perforation, even if the symptoms and signs just described are present. These are diaphragmatic pleurisy, pneumonia of the bases, appendicitis, iliac thrombosis, and intestinal obstruction. Further than this, peritonitis may develop from extension of the inflammatory process in the bowel or by reason of the migration of microorganisms through those parts of the bowel wall which have been impaired by the ulcerative process. In such cases the pain, swelling, and diaphragmatic paralysis may all be present without being due to perforation, and so closely may the symptoms of perforation be aped that operation has been performed, with the discovery that no perforation had occurred; thus in a case under the care of Herringham, nothing was found at the section and the patient recovered. Perforation may also be simulated by suppura- tion and rupture of a swollen mesenteric gland. Other causes of peritonitis are necrosis of the mesenteric glands, infarction of the spleen, or the development of abscess in an ovary or Fallopian tube. Very rarely peritonitis arises from cholecys- titis or cholangitis, with or without gallstones. Liebermeister has recorded two cases in which rupture of the gallbladder with escape of gallstones into the abdom- inal cavity took place. An ulcer in the appendix may perforate or an intercurrent appendicitis may complicate the case. The percentage of frequency of occurrence of perforations is generally stated to be about 2.2, but in 30,966 cases of typhoid fever collected by me from several series of cases reported by French and German physicians, and from the official reports of hospitals in the United States and Canada, England and Ireland, Ger- many, Austria, South Africa, and Australia, perforation is stated to have occurred in 1144 ca.ses, which gives a percentage of 3.69. The percentage of its mortality, when surgical interference is not resorted to at the most favorable time, is 90 to 36 DISEASES DUE TO A SPECIFIC INFECTION 95 per cent., and with ojjcratix'e interference it may l)c as liigli as Si] per cent. (See Treatment.) Perforation is very much more frequently seen in men than in women. Fitz ill 444 cases found 71 per cent, in men and 29 per cent, in women. In 21 cases of perforation in Basle, 15 were men and 6 were women; and Griesinger in 14 cases had 10 men and 4 women. Murchison also found in 24 cases Ki men and S women, although the general mortalitj' of the disease anioiig women was slightly higher than among men. So, too, Bristowe, of London, met with this accident in men in II of 15 cases, and, again, Niicke collected 100 perforation cases, of which 72 ■were in men and 34 were in women. Perforation is responsible for a large proportion of the deaths which occur from typhoid fever. Out of 1721 cases which came to autopsy the percentage of deaths due to perforation was 11.3, according to Murchison. According to Ilolscher, it was found in 2000 Munich cases 114 times (5.7 per cent.), and in 20 out of 80 of his cases which ended in death. In 4680 cases tabulated by different writers, Fitz found the proportion to be 6.58 per cent., which agrees with Holscher's statistics. Hoffman found that out of 250 deaths in typhoid fever 20 were due to perforation. Perforation occurs in the ileum in at least two-thirds of all the cases of this acci- dent and in the colon or appendix in about 4 per cent. It takes place most com- monly in the third and fourth weeks of the malady, but is by no means rare in the second week. It occurs most commonly in patients between twenty and thirty years of age. Elsberg has reported a case of a child of three and a half years who sufTered from this accident, but whose life was saved by abdominal section. The relation of typhoid fe\'er to appendicitis is one of great interest. It has been thought by some that appendicitis arising in typhoid fever was a mere coin- cidence; by others, that its origin depended upon a general infectious process; and, again, by others, that it was due to the direct infection of the appendi.x with the bacillus of Eberth. Probably all these views hold true in individual cases. The richness of the appendix in lymphoid tissue, and the fact that typhoid fever is particularly prone to attack such tissues, renders this organ peculiarly susceptible on theoretical grounds. That this view is correct is proved by the research of Hopfenhausen, who collected the appendices obtained from 30 cases of typhoid fever and studied them under Stilling in the University of Lausanne. She concludes that moderate changes in the appendix may be found in nearly all cases of this disease, that it is most marked in the earlier stages of the malady, and consists chiefly in cellular infiltration, specific lesions being rare and not sufficient to produce the more severe forms of appendicular disease. True appendicitis complicating typhoid fever, in the sense of inflammation of the appendix severe enough to produce abscess, is undoubtedly a very rare affection. Hopfenhausen lias collected statistics of 743 cases of appendicitis, of which 5 per cent, were due to typhoid fever. This must be a very much larger percentage than usually exists. It is a noteworthy fact that appendicular symptoms are not infrequent in early typhoid fever, and often disappear under rest in bed, and with the full ilcvelopment of the infection. Rarely the inflammation goes on to the formation of an appendicu- lar aliscess or perforation. The swelling of the lymph node in the meso-appendix and the presence of ulcers in the cecum explain why it is that pain in the appendicu- lar area is by no means rare. (See Plate I.) Sudden pain in the lower zone of the abdomen may be indicative, not of appendicitis, but of the presence of an iliac thrombosis. Tympanites in typhoid fever is always present to some degree at some stage of the disease. When very marked, it is an evil s\inptom because it indicates active fermentation in the bowel, and the presence of intestinal atony, and because the PLATE I Showing Typhoid Ulcers in Small Bowel and near the Appendix. ( Kast and Rumplep. ) TYPHOID FEVER 37 gas presses on the abdominal thoracic viscera and disturbs their functions. By distending the intestine it may also predispose the patient to a hemorrhage or perforation by the strain on a severely ulcerated Peyer's patch. Hepatic Complications. — The liver and gallbladder rarely show signs of active infection during the early part of an attack of typhoid fever. .Jaundice is one of the rarest complications of this disease. Aside from some swelling and tenderness in the hepatic region, no symptoms in the hypochondrium are usually observable. It is, however, important to note that secondary involvement of the gallbladder as a sequel of this malady is by no means rare, a true cholecystitis developing in a goodly proportion of cases as a result of infection of this viscus by the bacillus of Eberth. This cholecystitis may be severe enough to result in emp>ema of the gall- bladder and perforation of itswalls, with symptoms resembling intestinal perforation. A still more interesting fact is that such a cholecystitis due to this organism may develop many years after the attack of typhoid fever, and again the clumping of these organisms in the gallbladder may give rise to the formation of gallstones. Louis, in his work on tj^shoid fever, published in 1S36, states that changes in the bile and gallbladder occur more frequently in typhoid fever than in other acute diseases, and cites 3 fatal cases in which cholecystitis, unrecognized during life, was found at autopsy. Grisolle and Andral mention similar cases. In 3 instances French found the gallbladder of persons who had died of typhoid fever filled with turbid albuminous fluid, and Rokitansky speaks of having found "fibrin- ous exudations" in the gallbladder of several patients who died from the disease. Murchison refers to the cholangitis and cholecystitis which may accompany typhoid fever, and reports a case of rupture of the gallbladder, followed by general peritoni- tis. In 1876 Hageimauller reported 18 cases of cholecystitis complicating typhoid fever. He concluded that it was a more frequent complication than had generally been supposed. Plolscher, in the 2000 Munich autopsies, found empyema of the gallbladder 5 times. In 1889 Bernlieim suggested that typhoid bacilli might give rise to gallstones by producing alteration or stagnation of the bile. In 1893 Defourt reported 19 cases of cholelithiasis, in which the first attack of biliary colic occurred at varying periods after typhoid fever. Osier has reported a case of hepatic colic occurring for the first time in the fifth week of typhoid fever. At operation nothing could be found to account for perforation of the gallbladder, but nine months later a gallstone was discharged. Fournier found bacteria in 38 out of 100 gallstones which he removed at autopsies. The colon bacilli predominated, while the typhoid bacilli were found to be second in frequency. Milian, Chantemesse, and Horton Smith report similar experi- ences. Chiari found tj'phoid bacilli present in the gallbladder in 19 out of 22 cases, and obtained pure cultures from 15. In 9 out of 10 cases at St. Bartholomew's Hospital, London, Bacilli typhosi were found. Gushing mentions 5 cases of cholecystitis complicating tj'phoid fever, in which pure cultures of colon bacilli were obtained from the pus. Marsden reports a case in which cultures resembling Bacillus typhosus were obtained. Van Dungern obtained pure cultures of typhoid bacilli from pus surrounding the gallbladder fourteen years and a half after an attack of typhoid fever. Pure cultures have often been obtained from six to eight months after the attack (Chantemesse, Dupre). This is a fruitful source of infection. Mason thinks that the bacilli gam entrance through the biliary ducts. Council- man believes that they are carried through the blood, and that areas of necrosis in the liver afford them portals of entrance. Hagenmiiller, Mayo Robson, and Mark Piichardson believe that biliary complications, especially cholecystitis, are due to ascending infection of the ducts. Marsden is of the opinion that the most 38 DISEASES DUE TO A SPECIFIC IXFECTION important passage of bacilli into the gallljIaddeT is tliroiiuli the lilood, tlic liver, and the biliary duets. lie is undoubtedly correct. Typhoid cholecystitis during the course of the fe\er is frequently latent. In more than one-half the recorded cases, either on account of latency of symptoms or typhoidal stupor, nothing unusual was observed during life. The two most constant symptoms are pain and swelling, the former being paroxys- mal and most marked in the region of the gall-bladder and under the scapula. Maurice Richardson says that it may be in the epigastrium or over McBurney's point. According to Mayo Robson, if a line be drawn from the umbilicus to the ninth rib on the right side, there is almost always tenderness at the Ijeginning of the second third of this line. Jaundice is rarely met with, but there may be repeated chills and sweats. Genito-urinary Complications. — Albuminuria in typhoid fever is quite a constant condition, occurring as frequently as in 70 per cent, of all cases, and being most marked in the second week. Usually its presence is not associated with that of tube-easts unless the patient is already a sufferer from nephritis j^rior to the attack. When casts are present, the albumin is usually present in large amount. Albuminuria without casts is not a serious complication. Probably true nephritis is present in almost 20 per cent, of the cases, but this is usually not productive of renal symptoms. An antecedent nephritis may take on renewed activity' and a true hemorrhagic nephritis may occur, usually in severe cases only. The urine is apt to be scanty and of high specific gravity unless the physician insists upon the patient drinking freely of water. Pyuria in slight degree is common. Blumer says it occurs in 17 per cent., but it is a noteworthy fact that pyelitis due to typhoid fe\'er is almost unknown. While this is true, it is also of interest to note that enormous numbers of the bacillus of Eberth are to be found in the urine after the second week of the disease, and often far into convalescence. Petruschky has estimated that 1 c.c. may contain 170,000,000 bacilli. A profuse imlyuria is often present when the stage of con- valescence is entered upon. Orchitis and epididymitis rarely occur as a result of a direct infection with the specific bacillus. They differ from the changes due to gonorrhea in that they are less painful and more rapid in their course to suppuration or recovery. They are usually unilateral and the testicle is first affected. Typhoidal cystitis due to the presence of the bacillus of Eberth rarely occurs. Respir.\tory Complic.a^tions. — The respiratory disorders met with in connection with the course of typhoid fever, aside from the bronchitis already mentioned, are quite numerous. In the later stages of the disease we may meet with severe laryngeal ulceration, which in turn may be complicated by perichondritis or edema of the glottis. Hoffman found 28 cases of ulcer of the larynx in 250 autopsies in this disease, and Griesinger in 26 per cent, of those dying of the malady, so that it is by no means rare. Keen collected 146 cases of severe laryngeal disease due to this cause, and found that necrosis of the laryngeal cartilages when it occurred was a very fatal complication, death occurring in 9.5 per cent, of the ca.ses. Intense hypostatic congestion is one of the most constant pulmonary changes seen at autopsy; in some cases the blood may inundate the air vesicles, causing solidification. How often this change is agonal cannot be tletermined with any degree of certainty, but as it depends on more or less prolonged maintenance of one position aided by an enfeebled circulation the danger can be greatly lessened, if not avoided, by frequent changes in posture. Pneumonia develops in typhoid fever in three forms and in different stages of the disease: (1) As an acute loliar pneumonia ushering in the attack of enteric fever, and due to the pneumococcus, or, it is thought by some, to the infection of the lung by the bacillus of Eberth, the so-called "pneumotyphoid." True rYPIIOID FEVER 39 croupous pneumonia in the later stages is very rare. (2) Bronchopneumonia, l)rolKit)ly arising from terminal infection or by hypostatic congestion iluc to the profound toxemia and cardiac degeneration and feebleness, is more common. (3) Acute tuberculous pneiunonia sometimes seizes the typhoid-fever patient when he seems about to begin his convalescence. It is not to be forgotten that infarction of the lung may occur as the result of cardiac or venous emboli. Such an infarction may mislead the physician into a diagnosis of lobar or lobular pneumonia by reason of the dulness on percussion, the rise of temperature, and blood-tinged sputum: An infarction may, if the patient survives, result in pulmonary abscess or gangrene. Pleurisy arises very rarely as a primary lesion. It is usually secondary to infarction, pneumonia, or gangrene. Cases of empyema due to the specific bacillus have, liowever, been recorded. Nervous Complications. — ^The nervous disturbances vary very greatly. In the average case there is in the early part of the onset no mental change save that of unfitness for mental occupation, with dreamful sleep which is apt to be restless. Later the patient continually dozes off, yet awakens easily, and for a moment may be a little confused between the mental impressions left on his brain by the dream and the conditions he finds about him on returning to consciousness. Still later, if the infection is severe, he becomes more apathetic when awake, less easily aroused when asleep, and often delirious in his sleep, his dreams being evidently vivid, so that he keeps muttering the conversation he thinks he is actually having, or calls out loudly, as his dream seems to lead him to a point where an imperative call or sudden action is needed. Sometimes the delusions in the delirium amount to imperative conceptions, and the patient belie\'es that he is away from home and must return there at once, or that he is being restrained by force, or, again, that some member of his family is in distress and needs his aid or is calling for him. Often this form of mental disturbance is painful to witness, difficult to overcome, and harassing to the patient. In these cases the hands may be moved continually in active motions, as if to illustrate the ideas of the patient. Such cases are apt to be grave if for no other reason than that they exliaust themselves if relief is not given. The more encouraging type of delirium is of the quiet, mutter- ing form, as if the patient was gently "speaking in his sleep" as in health, and this may be taken as the natural form of delirium in the disease. Later the stupid condition becomes more and more marked in some cases, and absolute mental stillness is reached, in which only rough shaking or loud calling will arouse the patient. In severe cases with marked toxemia we find at times a state of mental confusion, staring eyes, and semi-stupor, with persistent muttering — the so-called coma mgil. During convalescence viental aherration, depending usually upon exhaustion, may develop. The prognosis in such cases is usually good. Rarely in the course of typhoid fever symptoms of irritation or inflammation of the meninges of the brain develop, and it is important to remember that these symptoms may arise from several causes. The most common of these is congestion and engorgement of the meningeal vessels without any true inflammatory process; the next most common form is that due to the extension of an infection from abscess in the middle ear; the third form is that in which there is infection with the strepto- coccus or pneumococcus, and very rarely the meningitis is due to the bacillus of Eberth. Cole has recorded three instances in which the typhoid bacillus was obtained from the cerebrospinal fluid by lumbar puncture in typhoid fever. In one the meningitis was serous, in another purulent; the character of the other is not stated. The frequency of this complication in the different periods of the disease when due to true typhoid infection of the meninges is in direct ratio to the length of the malady, namely, in the third or fourth week. In the great majority 40 DISEASES DUE TO A SPECIFIC INFECTION of instances in which the complication lias appeared the patient was under thirty years, and usually between twenty and thirty years. That is the period in which typhoid fever is most commonly seen. In every case of true typhoid meningitis, so far recorded, death has occurred, but this is a statement which does not possess as great prognostic value as would appear at first glance, since an absolute diagnosis of true typhoid meningitis can- not be made during life, for the positive test is the bacteriological examination of the skull contents. Nevertheless, the presence of marked meningeal symptoms is of the gravest import in all' cases. Sometimes, because of degenerative changes in the vessels, a hemorrhagic effusion into the meninges of the brain takes place, but this does not commonly produce marked symptoms unless it is profuse. Conmihions, generalized or localized, with coma and delirium may arise from thrombosis of the cerebral sinuses or of the cerebral arteries, but they are very rare from any cause. Murchison met with them in only 6 cases out of 2960. If due to the lesions named, they indicate a fatal termination in the near future. In Osier's case death followed convulsions, produced by thrombosis of the branches of the left middle cerebral artery, in twelve hours. If they occur in neurotic children or females, the outlook is not so gloomy, as they probably do not depend upon an actual lesion in the brain. Sometimes acute otitis viedia produces violent headache and finally symptoms of meningitis, but its presence is often unrecognized as a cause imtil a disciiarge takes place from the ear. Neuritis, generalized or localized, is met with occasionally in the later stages, producing wrist-drop or toe-drop, and sometimes causing severe pain. When there is a multiple neuritis the sjinptoms may closely resemble locomotor ataxia or anterior poliomyelitis. Sometimes the skin of the toes or of the whole foot becomes exquisitely sensitive. When hemiplegia occurs, which is quite rare, it results from cerebral embolism or thrombosis or very rarely from actual hemorrhage. Complications in the Bones, Joints, and Muscles. — Secondary disease of the bones, consisting of post-ti/phoidal osteomyelitis due to the specific bacillus or to infection by associated microorganisms, may occur. The tibia and the ribs are the bones most commonly involved, and the changes are subacute or chronic rather than acute. So, too, arthritis maj' be due to pyogenic microorganisms or to the Eberth bacillus, and is usually of a subacute or chronic type. Spontaneous dislocation of the hip may occur in very rare instances. Many years ago V. P. Gibney, of New York, described, under the name of typhoid spine, a condition in which there develops, often some days after the patient is up and about, and often only after some very slight jar or trauma, great tenderness of the spine, with pain in the back, and in the legs when they are moved. It has been held that this condition is not dependent upon a spondylitis, neuritis, or Pott's disease, and is probably a neurosis closely allied to the neuroses seen in cases of severe trauma, but in most cases it is probably spondylitis. In most cases it is probably due to periostitis. Fraenkel has recently shown that in fatal cases of tN-phoid fever the bacillus may be obtained from the cancellous tissue of the bodies of the vertebrae and some of these cases of so-called typhoid spine may be instances of osteomyelitis involving these structures. Sometimes in the stage of con\'alescence a curious state is developed in which the muscles of the lower extremities become painful, somewhat brawny, and e\-en slight redness may appear in the skin covering them. Usually this is unilateral, but it may be bilateral. Most commonly it affects the calf of the leg, and pain is developed on pressure or on movement, acute or passive. This is due to a niyosili.s-. It should not be confused with phlegmasia dolcns due to thrombosis. TYPHOID FEVER 41 Typhoid Fevee Complicating Pregnancy. — In a very large number of cases of typhoid fever complicating pregnancy, abortion or premature labor comes on. Corbin collected 364 cases of typhoid fever occurring in pregnant women, and Fellner, of Vienna, has added 7 others to this number, making a total of .371 cases. Of these 371 cases 228, or 61 per cent., ended in premature births, and in 202 cases pregnancy terminated before the sixth month. Most of the full-term children were born dead, and those who were born alive were weak and did not long survive. The mortality in the mother under these circumstances is about 16 per cent. Diagnosis. — The diagnosis of typhoid fever is to be based on the characteristic ascent of the temperature, the general malaise of the patient, the peculiarly coated tongue with red edges, the tumid belly, and the development of the rash about the seventh to the ninth day. If to these symptoms are added an enlargement of the spleen and liver, the diagnosis becomes still more certain, and is confirmed if the laboratory tests mentioned on the following pages are positive. The laboratory aids to diagnosis are the Widal or agglutination test; the isolation of the bacillus from the blood, from the stools, from the urine, and from the rose spots, and the diazo-reaction. The objection to these tests is the difficulty as to technique for the general practitioner, and, more important still, the fact that some of them are obtainable in many instances so late in the course of the disease as only to confirm the clinical diagnosis already made. (See page 43.) Typhoid fever must be separated from a number of maladies which closely resemble it. Pure typhoid infection may result in the production of a fe\'er which closely follows the remittent or intermittent malarial types, and which is often asso- ciated with so much gastric disturbance and vomiting and so lacking in the more prominent typhoid symptoms usually seen that the picture of remittent malarial fever is clear, while the true picture of tj'phoid fever is clouded. Again, there can be no doubt that cases of true malarial infection occur in which the symptoms so closely resemble those of t^-phoid fever that a purely clinical diagnosis is almost impossible if an epidemic of typhoid fever is in full swing at the time. Finally, there can also be no doubt that it is possible for the patient to have a double infection with the bacillus of Eberth and the plasmodium of Laveran, in which case, however, the malarial manifestations are usually dwarfed by the typhoid poison, and are marked only at the onset of the enteric fever and at its termination. To this mixed infection the term typhomalarial fever may be correctly applied to indicate not a separate disease, but a double infection. Etymologicallj^, this term might also be used to define a condition of malarial fever in which, because of profound debilitj', the patient was in a typhoid state — that is, in a condition of which typhoid fever is a type. Practically, however, it should be discarded or limited in its use to the double infection just described. How far constant fever occurring day after day and associated with manifestations of general loss of strength and debility can be relied upon in the diagnosis of typhoid fever is hard to determine. Certain it is that if a physician makes a diagnosis of enteric fever upon these symptoms alone, without bearing in mind the fact that similar conditions are equally well developed under other forms of infection, he will find himself in error in not a few instances. Chief among these conditions may be mentioned tuberculosis of the lungs or peritoneum, that form of influenza in which the chief symptoms are abdominal, cases of ulcerative endocarditis, septicemia, and pyemia, and those of cholecystitis with ulceration, as from impacted gallstones. It must not be forgotten, too, that syphilitic fever may in very suscept- ible persons resemble typhoid infection. The febrile movement, rose rash (if it be scanty), malaise, and signs of general infection in this disease may readily mislead the physician. Again, in the more advanced, or tertiary, stages of syphilis a prolonged low, septic fever may be present. Any case of so-called typhoid fever which lasts more than four weeks without the attack being prolonged by a relapse 42 DISEASES DUE TO A SPECIFIC INFECTIOX is almost certainly suffering from another disease, often tiihereiilosis. It is not to be forjjotten that trichiniasis may resemhle typhoid fever, for in it we have fever, IJitins in tlie iiinhs and back, headache, stupor, and nausea, with i)ain in the belly and diarrliea. The differentiation of typhoid from other fevers is aided by a study of the following table : Typhoid Fever. Onset gi-adual. Face dull and apathetic. Delirium a late symptom. Coma a late symptom. Eruption very late. Eruption chiefly on trunk, well defined, and appears in several crops of small rose-red spots. Leukocytes decreased. Widal test positive. Bacilli of Eberth in blood. Typhoid Fever. Rash appears in crops. Profuse sweats rare. Temperature curves regular. Pulse rarely over 100. Bacillus of Eberth in blood. Widal test positive. No eye changes. Respirations slightly increased. Cyanosis rare. Typhus Fever. Onset abrupt. Face livid, anxious, swollen, conjunctiva red- dened. Pupils contracted. Delirium an early symptom. Coma an early symptom. Eruption early. Eruption over trunk and limbs and ill- defined. Does not appear in crops, and is dusky red or petechial in character. Leukocytes increased. Widal test negative. Bacilli absent. Acule Miliary Tuheradosis. Rash, if present, not in crops. Profuse sweats constant. Temperature cm-ves inegular. Pulse usually rapid. Absent from blood. Negative. Choroidal tubercles. Greatly increased. Cyanosis common. Typhoid Fever of the Cerebral Type. Regular temperature. Na marked blood change. Herpes very rare. Rose rash on trunk chiefly. Cerebrospinal fluid negative. Typhoid Fever. Onset gradual. Fever gi-adually rises. Chills rare in onset. Unaffected by quinine. Heavy facial expression. Herpes rare. Early delirium rare. Anamia moderate. Moderate reduction in leukocytes. Rose rash. Bacilli in blood. Typhoid Fever. Onset gradual. Enlarged spleen. Rose rash. Prostration gradual. Lasts several weeks. Typhoid Fever. Onset gradual. Nervous symptoms moderate. No leukocytosis. Widal tost positive. Bacilli in blood. Lasts weeks. Disease of youth. Cerebral Meningitis. In'cgular temperatiu'e. Increase in polynuclear white cells. Very common. Petechiae over whole surface. Positive for the specific bacillus. Estivo-axdumnal Fever. Onset acute. Fever rises iiTegularly. Severe chills common. Improved by quinine. Anxious facies with slightly icteroid conjunc- tiva. Herpes common. Early deluium common. Ansemia marked. Great reduction in leukocytes. No rash. Plasmodium in blood. Influenza. Onset sudden. No enlargement of silicon. No rash. Prostration rapid. Lasts a few days. Typhoid Pneumonia. Onset more rapid. Nervous symptoms severe. Some leukocytosis. ^^■idal test negative. None in blood. Lasts a sliorter time. Disease of old age. TYPHOID FEVER 43 Typhoid Fever. No cardiac murmurs. Regular temperature. Sweats rare. No leukocytosis. No cardiac dyspnocna. No petechiffi. No infarctions. No leukocytosis. Widal test positive. No retinal emboli. No chills. Bacilli in blood. Typhoid Fever. Rose rash. Face not swollen. Muscles normal. Eosinophiles decreased. A common disease. Ulcerative Endocardilis. Cardiac murmurs. Irrffriilnr pcpHc temperature. Sur,-,l rohlMM.Il. Ahiik.'.l l.iil.Mcytosis. Cardiac Uyipuu'a. Petechia;. Infarctions. Leukocytosis. Negative. Retinal emboli. Repeated chills. No bacilli in blood. Trichiniasis. No rash. Face swollen. Myositis. Eosinophiles numerous. A rare disease. For the diagnosis of paratyphoid fever from typhoid fe-\er, see the article on that disease. Tests. — The so-called Widal test depends upon the fact that if a small amount of blood, or blood-serum, or even the breast milk or tears from a patient having, or recently having had, typhoid fever, are brought in proper dilutions in contact with living typhoid bacilli, these organisms soon cease to move, that is, lose their motility, and gradually come together in clumps, or, in other words, agglutinate. The typhoid bacilli to be employed in the test are not such as have been recently isolated from a case of typhoid fever, but those which have been modified by repeated transplantation on artificial media. These bacilli are kept in sealed tubes of nutrient agar-agar in an ice-chest; from such a stock culture inoculations are made, and when the test is to be used are placed in broth-bouillon, incubated for twenty-four hours at a temperature of 37° C., and then employed for the test. It is essential that it be proved beforehand that this culture is composed of organisms reacting to known tjqjhoid serum and not to healthy serum. From this test culture a proper dilution is made by adding the bacilli to blood diluted with normal salt solution. A hanging drop is now placed under the microscope and examined with a magnifying power of about 800 diameters. The bacilli should appear as actively motile organisms which do not clump. The finger-tip or lobe of the ear is pricked, and by means of the "white pipette" of a blood-cell counting apparatus the blood is drawn up to the mark 0.5. Then the pipette is dipped in distilled water and the water is drawn up till the figure 11 is reached. This gives us a dilution of 1 : 20. One drop of the mixture of bacilli in salt solution and one drop of the diluted blood are then placed on a cover-glass, which is inverted over a hollow slide and the drop examined. A positive reaction consists in an absolute immobilization of all the bacilli and of a clumping of a majority of them. This reaction should occur in five minutes if the dilution of blood has been 1 : 20, and in thirty minutes if it has been 1 : 40, and in two hours if the dilution has been 1 : 60. A rapid clumping with a weak dilution is to be regarded as a very positive test. On the other hand, it is to be remembered that a dilution of blood in the porportion of 1 :10 may give a reaction even if normal blood is used. An exact estimate of the strength of the solution and of the time of reaction is therefore of importance. This test is an exceedingly accurate one, if properly employed. The chief difficulty about it is that the reaction is often absent until the seventh or even the twelfth day of the disease. Out of over 8000 cases reported by a number of observers, the test was positive in 94 per cent. A negative result is unimportant if 44 DISEASES DUE TO A SPECIFIC INFECTION it is obtained prior to the third week. But cases have been recorded in wliich bacilli were isolated from the blood during life and at autopsy the lesions were those of typhoid fever, yet at no time during the course of the disease did the blood yield the agglutinative reaction. Repeated tests should also he made before it is decided that the lilood does not give the reaction. \Yboii dried 1)I(i(m1 is u>fi\ Agglutomclcr for the iigsjlutinalicm test for typhoid ami paratyphoid fever. its volimic as near as may l)e should be restored by the adilition of distilled water, and from this the proper dilution is to be prepared and the resulting dilution used as already indicated. The fallacies of this test lie in the i)ossibility that the patient may have had typhoid fever at some previous time and so give the reaction, and in mistaking irregular and delayed clumping as true agglutination or as a partial reaction. The time of appearance of the Widal reaction has distinct prognostic TYPHOID FEVER 45 as well as diagnostic value. When it occurs in high dilution and early, that is in the first week of the illness, the course is usually mild, and when it occurs as late as the fourteenth or sixteenth day the illness is usually a severe one and lasts longer. This test has now been brought within the reach of everyone by the use of an agglutometer which has been placed on the market by a well-known house. (Sec Fig. 12.) This apparatus is designed to obviate the use of the microscope andthe fresh live culture of typhoid bacilli necessary in the Widal test when made in the old way. Laboratory experiments have showai it equal in delicacy to the former method. The limits of the reaction are more distinct than in the old process. One bottle of a sterile permanent suspension of typhoid bacilli is furnished, together with four test-tubes, one lancet and tube for collecting l)lood, one vial for diluting the serum, one small pipette for distributing the diluted serum, and one large pipette with two graduations (each corresponding to ten drops of the size delivered by the small pipette) for filling the tubes with suspension. The three tubes labelled 50, 100, and 200, are to be used for the test; the fourth is a control tube to which no serum should be added. Let blood flow into the blood-tube until the bottom is covered with a layer one-eighth to one-fourth inch thick. The blood will flow much more rapidly if the lobe of the ear is squeezed imtermittently between the thumb and index finger. Cork the tube and replace in an upright position. In a short time (an hour) the serum will have separated, or may be readily made to do so by carefully loosening the edges of the clot with the lancet. After the serum has separated, insert the pipette into the blood-tube, the point resting in the lateral depression, and incline both slightly, when the serum will readily enter the pipette. Add one drop of serum to ten drops of clear water in the diluting tube, and shake well. If the diluted serum is cloudy, let it clear by standing a few minutes before distributing to the tubes of suspension. By means of the large pipette put 20 drops (two graduations) of the suspension of typhoid bacilli in each of the four test-tubes. Add the serum dilution to the typhoid suspension by means of the small pipette, in the following amounts: four drops added to the tube marked 50 gives a dilution of 1:50; two drops added to the tube marked 100 gives a dilution of 1: 100; one drop added to the tube marked 200 gives a dilution of 1 : 200. No serum should be added to the control tube. After adding the serum dilution, cork the tubes and shake well. Put away in a warm place. Examine the tubes at the end of one and four hours, and again on the following day. The rapidity of the reaction depends both upon the agglutinating power of the blood-serum and the temperature at which the tubes are kept. The reaction may be seen with the greatest distinctness when one stands near the middle of the room facing a window. The tubes should be held on a level with the eye and inclined slightly away from the observer. When the reaction is positive, floccules appear in one or more of the tubes, depending upon the agglutinating power of the serum tested. These flakes are small at first and disseminated through the fluid. They gradually increase in size and settle to the bottom of the tube. In a complete reaction the supernatant fluid is perfectly clear. In a positive but incomplete reaction, floccules are seen in the still cloudy fluid. In a negative reaction the fluid in the tubes remains uniformly clouded, as in the control. All apparatus and corks should be thoroughly washed before using a second time. The diazo-reaction, sometimes called Ehrlich's reaction, depends upon the fact 46 DISEASES DUE TO A SPECIFIC INFECTION that in typhoid fever the urine of the patient contains a chromof;en which, when treated with diazo-benzine-sulphonic acid and ammonia, proihices a distinct red Inie in the urine, which may be as deep as garnet red. Other diseases give this reaction, such as tuberculosis and some cases of pneumonia, but it is of consider- able value in determining the presence of typhoid fever if taken in conjimction with other signs. It is usually present as early as the sixth day, and lasts initil about the eighteenth day. The test itself consists in using two solutions. One of these consists of a 5 per cent, solution of hydrochloric acid to which has l)eeii added sulphanilic acid in the proportion of 1 gram for each KJO c.c. The other is a 0.5 per cent, solution of sodium nitrate. When the test is to be made the two solutions are mixed in the porportion of 40:1. Equal parts of urine and this mixture are then shaken together and rendered alkaline by the addition of animoninm hydrate, which is allowed to flow down the side of the tube, forming the layer above the mixture just named. At the dividing line between the.se two fluids the reaction appears. If tj'phoid fever is present a garnet-red hue develops. If it is not present, only an orange tint is seen unless one of the other maladies which give this test is present. After the test tube containing these liquifls has stood for some time a green sediment forms, which Ehrlich considers very characteristic of a true reaction. Another method of reaching a positive diagnosis is the examination of tliu blood itself for the specific bacillus, which, as already stated, is present in this fluid in nearly all, if not all, cases of typhoid fever. While it is true that this examination is not possible for one who is not trained in its technique from the bacteriological stand-point, it is also a fact that this test is not open to the fallacies of the Widal test, and that the bacilli are often found as early as the fifth day, whereas the Widal test is frequently not positive till the ninth day, or even later. The urine and stools may be examined for the specific infecting microorganism, but they are rarely discoverable in these discharges early enough to aid the diagnosis. The Widal test and the discovery of the bacillus of Eberth in the blood enable us to difl'erentiate true typhoid fever from paratyphoid fever. Finally, it is to be remembered as a valuable diagnostic fact that the fever of the first stages of typhoid fever is more resistant to the cold bath than in any other malady, although it yields readily enough later on in the course of the nialad\- to this therapeutic measure. Prognosis. — The prognosis in typhoid fever depends upon several iiufjortant factors. One of these is the time at which the patient comes under medical care, not because active medication is of great advantage, but rather because patients that go to bed late in the onset of the disease usually become more seriously ill than those who conserve their vital forces by rest from the very beginning of the malady. Patients who travel long distances in the early stages of typhoid are wont to have severe attacks, and if, after the disease is well developed, travelling is resorted to the illness nearly always increases in violence. Another factor is the state of the patient at the beginning of the malady, as to his vital resistance and general health. Fat persons usually do not bear typhoid fever well. Children nearly always reco\er from typhoid fe^•er in its iuicom])licated forms, and aged persons, while rarely aft'ected, succumli when attacked in direct proi^ortion to their years. (See F'ig. 6.) A third factor is the degree of toxemia which di'velops in severe cases, particularly if they are not treated skilfully at first. Aside from these general con.siderations it is inii)ossible to make an accurate prognosis as to the severity of the attack or ])robai)le recovery of the patient in the first week of the disease, because the malady develops slowly and because a fatal termination is nearly always due to some intercurrent complication which cannot be foreseen. Even when the disease is ushered in with violence of all the TYPHOID FEVER 47 symptoms, particularly an exceedingly high temperature, it often happens that it follows a very short and fairly mild course, so that a severe onset indicates a speedy recovery in many instances. When, however, complicating conditions such as pulmonary, cerebral, or meningeal manifestations develop, the prognosis is of course correspondingly grave. Recovery in typhoid fever, under the modern and favorable methods of treat- ment, takes place in about 93 per cent, of cases in the best types of private practice and in hospitals in which the patients are received early and in fairly good condition. In private practice among the poor the mortality is much higher. In army practice the mortality may vary from 2 or 3 per cent, in time of peace to 50 per cent, in time of war, illustrating very well the fact, already stated, that early re.st in bed, perfect quiet of mind and body, and proper nursing are most favorable in their influence, whereas an absence of these aids to recovery is most harmful. Under the cold-bath treatment of typhoid fever, when it is instituted early, the mortality of about 7 per cent, is largely due to those unavoidable accidents, hemorrhage and perforation of the bowel. Much depends in all cases upon the severity of the infection. In some widespread epidemics the mortality is singularly low even when the care of the patients is not very skilful ; in others it is correspondingly high. In the United States army in the Spanish war it was only 7 per cent., a remarkably low rate for war time; whereas in the Boer war the English troops suffered from a death rate of nearly 21 per cent. Sudden death sometimes occurs in tj'phoid fever without the autopsy revealing any adequate cause, the real cause being in all probability an acute cardiac dilatation. Treatment. — The following is the plan pursued by the author in the treatment of this disease. As soon as the patient comes under observation, unless his bowels have already been moved by the aid of calomel,. he is given 1 to 2 grains of this drug in quarter-grain doses every hour. If his bowels are not moved in twelve hours, a movement is produced by the aid of a large rectal injection of soap and water, and if need be by the ingestion of a Seidlitz powder. Twehe hours later he receives 5 to 10 minims of dilute hydrochloric acid with a teaspoonful of essence of pepsin; this is repeated regularly every six hours throughout the disease after food. Hydrotherapy. — ^An order is gi^-en that if the temperature rises as high as 102.5° the patient is to be rubbed with tepid, cool, cold, or ice-water, or even with a piece of ice, according to the degree with which his temperatiu-e resists the bath and according to the degree of toxemia present. If toxemia is very great, it is often necessary to give a thorough, brief and brisk, rub-off with a small piece of ice, not so much to reduce the fever as to cause reaction and arouse the patient's vitality. With this application of cold, in different degrees according to the needs of the case, there must be employed by another nurse, or by the free hand of the nurse who uses the cold, active friction to the skin as the cold comes in contact with the integument, because friction increases the heat loss 50 per cent., aids in produc- ing those most essential conditions reaction and equalization of the capillary circulation, and prevents the patient from being chilled. It is a cardinal rule that if the patient has been ill so long that reaction does not occur under the bath, it is contraindicated and we must endeavor by gentle measures and the use of tepid or even of hot water to redevelop the power of the body to react. In other words, that temperature of water should be used which is necessary when combined with active friction to reduce the temperature at least 2° in fifteen to twenty minutes, provided reaction can be produced. Without reaction we simph- increase internal congestions by the use of cold water. It is interesting to note that Hirschfeld has treated over 1000 cases with tepid immersion baths of 80° to 90° and friction with a mortality of only 3.4 per cent. 48 DISEASES DUE TO A SPECIFIC INFECTION AVlieiiever cold is used, an ice-bag or cold cloth slioiild he apjilicd to tlic licad to l)rpvent cerebral congestion. Willie the method of bathing just described is that nearly always jjursued by the writer, it is proper to give definite information concerning the so-called Brand method of cold bathing, a plan which was introduced by Brand, of Stettin, many years ago, but which has only received its full share of credit during the past thirty- five years. This plan consists in immersing the patient, when his temperature reaches 102° or 102.5°, in a tub of water the temperature of which is 70°, and keeping him there with active friction for fifteen or twenty minutes, until the temperature is reduced to 100°. In order to combat chilling and aid the circulation it is custom- ary to give the patient one-half to one ounce of whiskey before, during, or after the bath. The bath is repeated whenever the temperature rises to 102°. Usually it is needed every two or three hours. In order that the patient's strength may be conserved he should be lifted into and out of the tub. This so-called plunge bath, or Brand bath, is a remedy of the greatest possible value, but is not needed in every case as a matter of routine. When used it is essential to produce reaction and to use friction, and to apply ice to the head. The indications for its use are identical with those just named. It is actually contra-indi- cated in the very young and very old, in whom it is often difficult to produce reaction, and if the case comes under treatment so late as the beginning of the third week, since reaction to cold is usually then lost. The presence of a complicating pneumonia also contra-indicates it. Its disadvantages are that the back cannot be rubbed, although the muscles in that part of the body contain much heat; this part of the skin is most prone to suffer from bed-sores, and the patient must be lifted or raise himself out of the tub. The temperature of the plunge bath when its use is deemed wise should not be placed at a tepid level and then reduced while the patient is in the water, as this does not administer a stimulating and awakening shock to the system, but simply chills the patient, thereby doing no good, for the object in using water in typhoid fever is to produce reaction, eliminate poisons, and reduce temperature, and the means by which this is best accomplished can be determined in each case by the physician. Personally the writer has never failed to successfully accomplish all these results by cold rubbing, with friction, if it is properly given, but many physicians prefer to follow the method of Brand as a routine pratice. An enormous array of statistics proA'c its value as a life-saving agent.' When cold is properly used it should, after the first week of the disease, produce changes in the temperature, as shown in the following chart (Fig. 13). Some form of bath at least once a day is absolutely necessary, even if the tempera- ture never exceeds normal, to establish cleanliness and equalize the circulation everywhere, and he who treats t.\'])hoi(i fc\-cr \^itliout resort to efficient hydrother- apy, if it can be used, is not doing all for his patient tliat can be done. The use of hydrotherapy greatly lowers the mortality, sa\-ing about 10 in everj' 100 cases, but it does not diminish the frequency of perforation or hemorrhage, and it apparently increases the frequency of relapse. This may be due to the fact that more are saved to run the chance of relapse, but also may depend upon the fact that mild cases are more prone to relapse than severe ones. Hydrotherapy does not shorten the duration of the fever, but it often shortens the length of the illness by preventing complications. Diet. — The diet consists of milk in the first week and often for most of the second week, about a quart to a quart and a half a day being given, so divided that the patient gets it every three or four hours. It is followed by the acid and pepsin already named, unless the stomach is irritable, when a little lime-water ' Sec article by the author in Therapeutic Gazette for March, 1898. TYPHOID FEVER 49 may be given as a substitute, or a little Celestins Vichy water may be used. When the digestion of milk is difficult it is well to add to it hot water or to dilute it with an alkaline or carbonated water. If the taste of the milk is unpleasant to the patient, it may be flavored by the afldition of vanilla, nutmeg, coffee, tea, or cocoa in small amounts. After the first week or ten days the patient is allowed from one to two soft-boiled eggs twice a day, so soft that they can better be taken as a drink than eaten with a spoon, and ifavored with a little salt. Well-boiled rice strained through a fine sieve, and even thin cornstarch or barley-gruel, if well cooked, may be given several times a day at this time with advantage, particularly if at the same time a little taka-diastase is used to aid their digestion. The author is firmly convinced that by this means terminal infections and general feebleness can be largely avoided and the patient brought to the stage of convalescence ready for speedy return to health and with greater vital force. Broths and other liquid animal soups are inadvisable, for they are good culture media, and often tend to increase tympanites and diarrhea. They are largely used by many physicians. Chart showing the falls in temperature and reactions following the use of cold spongings in a case of typhoid fever. The dotted lines show the fall. The broken, nearly horizontal line shows the morn- ing and evening range unaffected by sponging. Thirty-four baths were given in eight days. but never by the writer. When curds appear in the stools, the quantity of milk should be diminished or it should be peptonized, or its digestion aided by the use of pancreatin given after it is taken. The use of 5 to 10 grains of citrate of soda in the milk will also prevent the formation of curds. Medicines. — Drugs are not to be given if they can be avoided — that is, they are not to be used unless they are certainly needed to combat some definite condition which should be alleviated. In the great majority of cases, if not in all, the so-called antipyretic drugs are not only useless but harmful, and particularly harmful if their use is resorted to simultaneously with bathing. Their only justifiable use in a case which can be properly nursed and bathed is for the purpose of relieving headache and backache, when they may be given in small doses, such as 2 grains of acetanilid three or four times a day. Quinine is of little, if any, value except as a tonic in small doses. Stimulants are to be used when the pulse is actually weak and the cardiac first sound distant or feeble. The best of them is whiskey or brandy, diluted with 4 50 DISEASES DUE TO A SPECIFIC INFECTION milk or water, and given in doses of half an ounce every three to six hours as needed. Many cases do better without any stimulation, whereas others need much larger doses of alcohol than those just named. Digitalis is rarely of any service because it does not act well in the presence of fever, rarely supports the degenerated muscle fibers of the heart, and is apt to disorder the stomach. When the cardiac condition is desperate, Kofl'mann's anodyne in dram do.ses every two hours in cool water is very valuable. When profound adynamia develops and the patient is critically ill, nnich good may result from the injection hypodermically of 1 grain of camphor in .'iO drops of sterilized olive oil every eight hours for five or six doses. Another metliod of value wlien the vascular system is relaxed and the patient adynamic is the use of normal salt solution by hypodermoclysis. Strychnine may also be used, but it is a mistake to employ it for more than a few doses in the active stage of this disease. It is better to keep it in reserve for attacks of sudden circulatory failure. Antisepsis. — Absolute intestinal antisepsis cannot be produced by any known means, although it is possible to modify very materially the growth of micro- organisms in the bowel by the use of proper remedies. If the physician takes the ground that by the use of these substances he destroys the Bacillus typhosus and so benefits the patient, he is largely in error, and his use of them is not rational because the bacillus is widely distributed in every part of the body. If, on the other hand, these remedies are given to combat intestinal fermentation, as shown by foul-smelling stools and tympanites and other evidences of an excessive growth of the non-specific bacteria which throng the bowel during the progress of this disease, his use of them is rational in that by this means other toxic materials are prevented from being generated in excess. Often the Bulgarian lactic acid bacillus may be given with advantage in these cases. Another remedy is the sulphocarbo- late of zinc in the dose of 2 to 3 grains in pill form three or four times a day. Still another drug of far older use is turpentine in emulsion in the dose of 10 to 20 drops three or four times a day. The latter I prefer. In many of these cases also the use of a few small doses of calomel or salol is advantageous. AntitypJioid Vaccine. — The employment of antityphoid vaccine in the treatment of a patient suffering from typhoid fever is an entirely different proposition from its use to protect an individual by rendering him immune. In the patient who is ill the Bacillus typhosus has already more or less overwhelmed the patient, who is suff'ering from ha^■ing .set free in his body the poison of the invaders, for the poison of the bacillus of Eberth is endogenous and is not set free until the germ is destroyed. Given to a healthy man the vaccine puts him in such a condition that he is an unfavorable field for the growth of the infection, but given to one who is ill we only add to the number of dead bacilli and the poisons already present. It is conceivable that the use of vaccine may rouse dormant protective processes to active effort, but it is more conceivable that the do.se may be "the last straw that breaks the camel's back." The use of antityphoid vaccine after the disease is developed has been quite largely resorted to, but the results have not been very encouraging, probably for the reasons given, although there are some who advo- cate its use. Tkeatment oe Si'EciAi. Sy.mitoms. — Constipation is to be relieved, preferably by the use of enemata of soap and water, to which may be added in obstinate cases a tabiespoonful or two of glycerin. Many of these patients have no constipation in the sense that the ileum or colon is sluggish; but, on the other hand, the sigmoid flexure becomes packed with hardened feces, and mechanical obstruction occurs. The use of purgatives by the mouth is therefore useless unless very strong drugs arc used, which are dangerous. If it is thought that the bowels are really sluggish a little cascara sagrada (20 to 130 minims of the non-bitter extract) may lie given each evening. TYPHOID FEVER 51 Diarrhea, if excessive— that is, more tlian three or four stools a day — may be controlled by 5- to 10-drop doses of aromatic sulphuric acid in simple elixir several times a day or by adding to these two ingredients a half-dram of fluid- extract of hematoxylon. If much fermentation is present, an intestinal antisei)tic should be used, such as zinc sulphocarbolate. Vomiting is to be primarily prevented by regulating the diet as already referred to. If it persists, as little food and drink should be given as possible for a few hours to let the stomach rest; and if there be much nervous irritability, GO grains of sodium bromide in a little starch-water should be given by the rectum to quiet the vomiting centre. Counterirritation should be applied over the epigastrium in the form of a mustard plaster or turpentine stupe. If alcohol is being used as a stimulant its use must be stopped, or, if this is impossible, then a very old brandy or wine should be substituted for the whiskey and given often in very small quantities. For tym-panites a turpentine stupe is to be placed over the belly, if possible, before the gas accumulates in any amount, and if it persists a rectal injection of the emulsion of asafetida, with or without a dram or two of turpentine, should be given. The efficiency of this injection may be much increased in the way of expelling gas, and if marked adynamia is present, by adding half an ounce of Hoff- mann's anodyne to the injection. Turpentine in the dose of 10 drops, in emulsion or capsule, may also be given by the mouth for this condition. When the gas fails to come away, its passage may be aided by the introduction of a long rectal rubber tube. Hemorrhage from the bowel does not offer very much opportunity for direct rational treatment. In the majority of instances the best we can do in the way of real benefit to the patient is the maintenance of body heat by the application of hot bottles; and if the circulation becomes markedly feeble, the employment of normal salt solution by hypodermoclysis, a pint of it being given once, twice, or thrice in the succeeding twenty-four hours, according to the needs of the patient. Bandages may be applied to the limbs to limit the circulation to the vital parts, and th& foot of the bed be raised for a similar purpose. The large number of remedies which have been suggested for the direct control of the hemorrhage indicate how feeble they all are. There is no more reason for supposing that astringents given bj' the mouth can check hemorrhage from an ulcerated vessel in the bowel than that they can check a hemorrhage from a branch of the anterior tibial artery; and when they are given and hemorrhage ceases, the arrest is due more to coincidence than to the eft'ect of any drug. If any remedy of this type is of value, it is probably Monsel's salt (ferri subsulphas), which should be given in a hard pill or compressed tablet inclosed in a capsule, with the hope that it will escape from the stomach into the intestine without being dissolved, and thereby exert its styptic influence. Of course, if it is dissolved in the stomach, its chemical characteristics are altered. Many physicians apply a small ice-bag over the centre of the belly to influence the circulation in the small intestine, with the hope that in that way hemorrhage will be controlled. There is no objection to this plan of treatment, and the author often resorts to it; but it should be used with caution, if the hemorrhage is se\'ere, lest it aid in devitalizing the patient by abstracting heat. Simultaneously with the application of the ice-bag to the belly, hot bottles should be applied to the other parts of the body, for it is to be remembered that the loss of bodily heat is an important factor, not only because the vital processes cannot be well performed at a low temperature, but also because the sudden reduction of temperature caused by the hemorrhage deprives the heart and other organs of the stimidating effect of the fever which has been present for days. An- other popular method of treatment is the administration of a pill containing a grain of opium and a grain of acetate of lead; the opium being expected to diminish 52 DISEASES DUE TO A SPECIFIC INFECTIOX peristalsis and so aid clottiiij;, and the lead to act as a styptic. The opium is pr()l)at)l,v of value, hut it is doubtful if the lead e\er reaches the bleeding spot without becoming altered by the gastric and intestinal juices. When there seems to be continued oozing of blood from a large intestinal ulcer \vith ; 1 ■ ■ ■ ■18 , . __. . ' 1 1 IT ': 1 Jii 1 ' 1 1 ■1-j ' 1 -11 ; , . 1 ' 1 ' '' / ' i;i 1 1 , 1 ; 1 41 1 / J 1 10 3'J ' MM , ; 1 ! as ! i Mil T r 1 1 i , 1 a7 1 1 '1 1 1 1 30 ■ ! M ' ' "i 3J ! MM ' 31 ! ^ 'Si i 1 ",■1 [ 1 M 1" i i 1 ;{i ■ 1 :iu ■2'.' III I ■zn / 1 ' 1 i { / L'l; 7 :iO / 21 yl i 1 . V ^\ / 21 20 ! i;i 1 > 18 1 1 \ . IT 1 V 10 / 10 1 s.,^ II 1 It ^^ ^ i;; U. "^ vz i '^ N^ 11 \ :/ M ! 1 1 ^\ 10 1 1 v*: M ' 1 1 ■^ 'J ■ ; . 1 ; 1 1 i s ^\l 1 1 7 : ■'1 1 M^ I i ■ ! M 1 i ■■ ■::| 1 1 1 . 1 ! 1 M M < 1 M M 1 Showing the decreasing morbidity and increasing mortality percentage of typhus fever n-ith advancing years. Solid line represents morbidity from Murohison's statistics. Broken line, mortality percentage from the statistics of Murchison, Guttstadt, and CmBchmann. Relapsing fever is separated from tj-phus fever by the clear mental condition of the patient notwithstanding his high temperature, by the lack of petechise, and the absence, as a rule, of severe initial symptoms. Prognosis. — The prognosis in typhus fever varies greatly with the previous condition of the patient, and also to some degree with the severity of the epidemic. 60 DISEASES DUE TO A SPECIFIC' IXFECTIOX Usually the mortality rate varies from 10 to 20 per cent, in young afhilts, but in children it is often much less than this. In advanced years the mortality is very high. Curschmann has stated that "old age makes itself felt as early as the furtictli year and that after fifty almost 50 ])er cent, die." The accompanying chart. Fig. 14, made from the statistics of Murchison, Guttstadt, and Curschmann indi- cates the influence of age on the prognosis. Death in typhus fever rarely occurs before the second week. After the end of the .second week it seldom takes place except as the result of some untoward com])li- cation. Treatment. — The treatment of typhus fever is in many respects identical with that now recognized as useful in typhoid fever. The patient .should be isolated, of course, anrl provided with an abundance of light and air. As already stated, in no disease are these aids to health more es.sential for recovery. As the course of the malady is one toward profound asthenia, easily assimilated or predige.sted foods .should be given as freely as the patient can utilize them. Milk to which is added a little pancreatin and sodium bicarbonate, barley- and rice-gruel in which is placed some takadiastase, and copious draughts of water to flu.sh the kidneys and aid in the elimination of poisons are to be administered. The fever is to be treated by cool or cold bathing as the patient lies in bed, according to the directions given under typhoid fever, and cold is to be kept applied to the head continuously. The coal-tar antipyretics are not to be used if they can be avoided. When signs of cerebral and pulmonary hypostatic congestion manifest themselves the patient may be immersed in a bath of about 90°, and cold water at 60° poured over his head and shoulders as a douche, active friction of the body and limbs being performed by the nurse for several minutes before the sick man is returned to his bed. Should the circulation fail, alcohol in the form of whiskey or brandy, well diluted with water, is to be employed for the purpose of equalizing the circulation and cjuieting the nervous system. Camphor in 1-grain doses is useful for this purpose. If the nervous restlessness of the patient is sufficient to endanger life by the resulting exhaustion, a hypodermic injection of morphine may be given to prorlucc sleep or nervous quiet. The bowels should be kept open by the use of gentle laxatives, or be evacuated by a saline purge if obstinately confined. The activity of the kidneys must also be maintained by the u.se of alkaline diuretics and sweet spirit of nitre and by the free administration of a pure drinking-water. As retention of urine often occurs, the state of the bladder must be carefully watched. VARIOLA. Definition. — Variola, or smallpox, is an acute infections disease aiTecting the entire body, but manifesting itself chiefly by the (le\elo]jiuent upon the skin, more particularly that of the face and forearms, of an exanthem which is at first macular, then paj)ular, then vesicular, pustular, and finally umbilicated. History. — Smallpox is one of the ancient diseases, for records exist which show it to have occurred many centuries before the time of Christ. The first authentic medical record of the malady did not appear, however, before the tenth century, when Rhazes, of Bagdad, wrote his Treatise on Smallpox and Mea.slrs. It is generally considered that smallpox did not gain entrance to Europe till about .\.D. 710, when the Arabs conquered the Spaniards. It reached Germany about the tenth century, at which time it also appeared in England. At times since the tenth century it has swept away thousands of persons in a single epidemic, and very few escaped its ravages. Indeed, a large part of the population of London were at one time pock-marked. It was first introduced into Mexico in 1520, VARIOLA 61 destroying 3,500,000 persons, and into Massachusetts in 1633. I'ntil the introduc- tion of vaccination it was one of the most death-dealing maladies known to man. (For tlie influence of vaccination in diminishing smallpox see article on Vaccinia.) Distribution. — Smallpox has occurred in all parts of the civilized world, from the Arctic to the Tropics, and is of ecjual virulence in very cokl and in very warm climates. The disease affects persons who may be exposed to it at all ages, and re- markably few people who are unvaccinated are able to resist the infection, not more than from 1 to 5 per cent. The negro race is peculiarly susceptible, and in this race the rate of mortality from the disease is usually very high. Smallpox affects males more frequently than females. It is more common in the winter and spring than in the summer, perhaps because of the crowding in the homes of the poor during the cold months. Etiology. — Variola is believed by some to be due to a parasite named by Guar- nieri, in 1892, the Cytorydcs variolw, and carefully studied by Wasielewski in 1901. Its evolution has become more fully known by the labors of Councilman, ]\Iagrath, and Brinckerhoff in 1903, and Brinckerhoff and Tyzzer in 1905, the latter research being an extensive investigation of experimental variola and vaccine in Philippine monkeys. These in every respect confirm the previous findings in human beings. Basing his views upon previously accomplished work, but especially upon the study of Councilman and his students. Calkins has attempted to formulate the different stages in the life history of the parasite. A full review of these and previous inquiries into the nature of the organism of variola and vaccinia will be found in the Journal of Medical Research, February, 1904, vol. xi. No. 1, pp. 8-360 and January, 1906, vol. xiv, No. 2, pp. 209-359. (For the process of the development of this organism see Pathology and Morbid Anatomy.) Notwithstanding these studies many authors still regard the cause as unknown. The contagion of smallpox is spread in several ways — viz., directly, that is, by contact with the patient's body and his clothing; and indirectly, by the air. Stokes has recently published a paper indicating that the infection usually enters the body through the lungs. A nurse may convey the disease from a patient to a healthy individual, and rats, mice, and flies may do likewise. The patient ill of smallpox is capable of infecting a healthy person from the initial stage of the disease to the moment when, recovery having occurred, every particle of pustule or desqua- mating skin has been cast off. The most contagious periods are, howcA-er, those of vesication, pustulation, and exfoliation. The fact that the disease is spread by aerial convection is never to be forgotten, and it may be carried in this way from a few feet to several yards (Fig. 15). Much difference of opinion, however, exists among those who have studied the question of aerial convection. Power, of Fulham, and Barry, of Sheffield, England, found a noticeable influence exercised by the propinquity of a smallpox hospital, but Savill, from investigations carried on at Warrington, came to the conclusion that aerial currents influenced the spread of the disease but little. It must be remem- bered, moreover, that before we accept figures as to aerial convection we must be sure that the contagion was actually carried by the air and not by insects or animals. I know of one smallpox hospital from which flies, mice, rats, and cats passed freely, and surrounding which smallpox was almost constantly present. Bodies dead of smallpox can also spread the disease among those who handle them. The severity of the infection depends not so much upon the violence of the disease in the giver as in the susceptibility of the receiver of the malady. A mild case may therefore be provocative of most virulent epidemic. Incubation. — The period of incubation of smallpox varies from five to twenty days, but as a rule it is about twelve days. Cases occurring in less than five days after exposure are very rare. 62 DISEASES DUE TO A SPECIFIC INFECTION Prevention. — Tlierc is one measure above all others to be used in the pre\'eiitioii of smallpox, and that is vaceination, which by its beneficent influence has changed smallpox from a common and fearful scourge of mankind to a disease so rare that many jihysicians practise a lifetime without seeing a case. (See Frequency and Vaccinia and Vaccination.) 0.(12 piT esni. Diagram sliowiiig the percentage of aerial convection of smallijox. (iMoore.) It is very important to bear in mind the clinical fact that vaccination not only protects the patient who may be sulisequently exposed to smalli)ox, Init also that it protects the patient who, having been so exposed, is subsequently vaccinated. Even if the vaceination be performed so long after the exposure that smallpox nevertheless develops, the severity of the disease will be modified, the degree of modification being in direct ratio to the lengtJi of time between vaccination and the appearance of the variola. A most interesting illustration of this has been sent me most kindly by Dr. Allan Warner, of the Borough Isolation Hospital, Leicester, England. The history of the eases is as follows: A boy, aged fourteen years, unvaccinated, sickened with smallpox on April 14. He was removed to the hospital on April IS, where he had a severe confluent attack. The father consented to his wife and three children lieing vaccinated, stating that personally he would not be vaccinated, but would be a "test," to see if there was anything in it. Ten days later his daughter, aged three years, developed smallpox eruption; she had less than one hundred spots and never appeared ill. No other person in the house suffered from smallpox except the father, vaccinated in infancy, his eruption appearing fourteen days after the son had been removed to the hospital. A photograph of the father and daughter, taken on the twelfth day of the father's eruption, may be seen in Fig. IG, and requires no conmieut. VARIOLA 63 In cases of urgency it is generally held that humanized virus is more valuable than calf virus, but as humanized virus is often difficult to obtain it is better to vaccinate the patient in different places with glycerinated vaccine made by difl'erent manufacturers, since in this way there is httle doubt but that one will surely take. Father and child suffering from smallpox. The child was vaccinated in the incubation period. (Allan Warner's cases.) The second preventi\^e measiu-e of importance is the absolute isolation of the patient, and the third the complete disinfection or destruction of all garments and bedclothing which have been about the sick person, including those worn by his attendants. Finally, all individuals exposed to the contagion should be quarantined for a period of twenty-one days, in order that the physician may be sure that they are not going to be attacked and so spread the infection. 64 DISEASES DUE TO A SPECIFIC INFECTION Frequency. — Smallpox is so constantly present in the poorer part of large cities that it may be said to be almost endemic in all of them, but to a very moderate degree. Occasionally when a considerable number of unvaccinated persons have accumulated in a city or country district, the disease bursts out in a small epidemic, and sometimes, without any such apparent cause, certain districts seem to be affected, many unvaccinated persons being attacked. During the winter of 1901 and 1902 smallpox appeared almost all over the United States in .scattererl localities. It can, however, always be stamped out by house-to-house \'accination, and its spread depends upon imperfect quarantine and inefficient vaccination. As an illustration of the extraordinary effect of vaccination and sanitation upon this malady it is interesting to note that during the eighteenth century fully two- thirds of all children born in Europe were sooner or later attacked by smallpox, and an average of one-twelfth died of the disease. On the other hand, the death rate from smallpox in the latter part of the nineteenth century in London was 98.5 per cent, less than one hundred years before. To put it differently, the death rate from smallpox in 18.38 was 1064 per million, while in 1889 it was 1 per million, and in 1890 nil per million. During 1904 the disease was totally eradicated from New York and Pliiladei[)liia by \'acci nation and quarantine. Pathology and Morbid Anatomy. — The most noteworthy lesion produced by small- pox takes place in the skin. The dermal paillie become hypcremic, the cells of the rete Malpighii swell and so raise the epiderm, and under this epiderm serum exudes and pushes the stratum still farther upward. The cells of the rete are more or less elongated, pigmented, and form fibrils extending from the epiderm to the base of the inflamed zone in the derma, constituting the vacuolar focal degeneration described by Councilman, Magrath, and Brinckerhoff'. Into this reticulum still further serous exudation occurs, and so forms a vesicle which increases at its margin, where the exudation takes place very rapidly, while degenerative and necrotic changes progress in the epithelium of the area, involved. As a result the area under and around the vesicle becomes indurated and we have the characteristic hard pock of variola. The persistence of this free exudation at the margin of the pock and the greater densit\' of the centre lead to depression of the latter, giving rise to innbilication. Wright has shown that the central depression in the pock may be due to diptheroid degeneration. It may also be due to retraction by a hair or small gland. Councilman, Magrath, and Brinckerhoff' do not believe that the pock is always produced by the same cause, but that a number of factors enter into its formation. Following this stage, the serum in the pock is infiltrated with leukocytes, and these becoming great in number, the contents of the pock become opaque or turbid, and finally resemble pus. Sometimes if the inflammation in the adjoining pocks is very se\ere the deeper layers of the skin become involved, undergo necrosis, and so great local destruction of tissue takes jilace. After this stage epithelial regeneration progresses beneath the scab, which dries up and ultimately falls off, leaving a reil or pink depression in the skin, which (le])ends for its dejith upon tiie degree of pustulation or necrosis present during the acute stage. Not only do vesicles form on the skin, but upon the mucous membrane of the mouth, pharynx, tongue, and even tiie rectum, anus, vagina, penis, and conjunctiva in some cases. Myocardial degeneration is present in most cases, and a variolous myocarditis has been flescribed. In general the cardiovascular ciiangcs of smalliJox resemble similar alterations occurring in other infectious diseases. Proliferative changes occur in the hematoi)oictic organs (spleen, lymph nodes, and marrow), associated with the production of basophilic monoinielear cells which enter the circulation and also phagocytic endothelial elements. The basophilic VARIOLA (io mononuclear cells infiltrate the testicle and usnall.>- the kidney, liver, and adrenals. Cloudy swelling occurs in the glandular viscera and a diffuse toxic degeneration takes place in the liver, kidneys, adrenals, and testicles. The kidneys are more or less altered in all cases; in milder degrees this may amount to little more than intense cloudy changes, hut in other cases acute diffuse, glomerular, or, less commonly, suppurative nephritis occurs. Many of the lesions produced in the internal organs in smallpox are the result of a secondary infection from the skin and respiratory tract, and this usually' depends upon the presence of the Streptoroccvs pyogenes. When hemorrhagic smallpox takes place we have transudations of blood into the pocks and into the conjunctiva, the retina, the muscles, the subpleural tissues, into all the abdominal organs, and into the kidneys and the perirenal fat. Submu- cous extravasations also take place in all the organs of the body lined with mucous mem]:)rane. Such cases are nearly always fatal. Symptoms. — After an incubation period of about twelve days the symptoms develop. As in many acute infections, headache and backache are the predominant initial symptoms of smallpox, but they are peculiar in their severity in this disease, so that their very intensity possesses diagnostic significance. Sometimes the pain in the back extends down the posterior portions of the legs. Rigors also occur and pain in the epigastrium and vomiting may come on. Sometimes drowsiness and sleep with muscular twitching develops as a prominent initial sign in children. The urine is often scanty, loaded with urates, and usually contains some albumin. The temperature in smallpox is usually high from the onset, so that it may reach 104° as early as the latter part of the first day, and 105° or 106° by the end of the first forty-eight hours. It maintains this high degree with \ery slight remission until the eruption is developed. The jJuIse w rapicl, often as high as 120 per minute, in adults, and unless profound depression is very early manifested it is fairly strong. The abdominal organs present no signs of any importance, but constipation is more frequently present than is diarrhea. The true variolous eruption makes its appearance, in the majority of cases, on the third day, although many writers state that it appears most commonly on the fourth day, while others insist that it appears on the second. The facts are that the time of the appearance of the rash varies materially in different cases, for it is delayed in mild attacks and develops early in severe ones. Sydenliam said of the confluent form of this disease: "This kind usually comes out on the third day, sometimes earlier, but scarcely ever later; whereas the distinct (discrete) form appears on the fourth day or later, but rarely before." Boerhaave said: "The slower the small pocks 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 more favorable." Very rarely indeed the rash may be delayed till the fifth day, but this is an unfavorable sign. It must be borne in mind that the first signs of the eruption may be very scanty. But one or two papules may be present on the face, or hand, or forearm. In other iastances the papules are very numerous on the face, the extensor surfaces of the forearms, and then on the trunk, these being the parts which are particularly prone to present the first sign of the eruption. In still other cases the entire surface of the body is speedily covered and the mucous membrane of the mouth, pharynx, and vulva also are involved. The portion of the skin least affected in most cases is that of the anterior part of the thorax, the abdomen, and the flexor surfaces of the extremities. The eruption of smallpox proceeds through the following five stages of develop- ment with considerable rapidity : For the first few hours minute bright-red macules are present, which disappear on pressure. They soon become hard and ele^'ated — 5 66 DISEASES DUE TO A SPECIFIC IXFECTION that is, the macules become i)a|)ules. By the end of the first twenty-four hours of the eruption the papule begins to show at its apex a tiny vesicle, which rapidly develops so that by the fourth or fifth day of the rash the vesicular stage has reached its full development. This vesicle is, as a rule, less than a sixth of an inch in diam- eter, contains fairly pearly-looking fluid (lactescent), and is surrounded by a narrow areola of red. A peculiarity of the vesicle of smallpox is that though some serum may escape when it is pinched, it never empties itself or collapses, because of the fibrilla which are present in the cavity of the vesicle, as already described. ^Yith the advent of the fifth or sixth day the centre of the vesicle is seen to be slightly depressed, showing the beginning of the stage of iimbilication. Well-developed variola. The fluid in the vesicle now rapidly becomes cloudy and purulent, the surface of the pock gradually loses its umbilication, and by the seventh or eighth day of the eruption exists as a pustule, which by the tenth day is dome-like and surrounded by an areola. This pustule, when it is punctured and pressed upon, discharges pus and cloudy scrum. If the pustule is not meddled with it ruptures in about twenty-four to forty-eight hours and the pus escapes, dries, and forms a dirty-looking .scab, so that by the eleventh day of the eruption the primary macule has advanced through its stages of maturation to the ruptured pu.stule. These scabs produce a disgusting odor. Sometimes the pustule does not rupture, but simpl\- dries uji; when the scab falls off it leaves under its former site a red or pink depression in the skin, the future pockmark. This st^ge of desiccation or VARIOLA 07 drying, followed by exfoliation, may last in severe cases for several weeks, and it is followed by a period of desquamation of fine scales of epidermis, during which time the reddened pockmark gradually heals and cicatrizes. This desquamation rarely takes place earlier than the sixteenth and often about the eighteenth day. The eruption on the mucous membranes runs a much more rapid course than that on the skin, so that as early as the fifth day the pu.stule ruptures, leaving an ulcerated surface, which, if the eruption on the mucous membrane of the mouth has been confluent, may resemble the ragged, dirtj'-looking exudate of diphtheria. There are two additional facts of importance in connection with the eruption not yet named — viz., a peculiarity of the papule of smallpox is that when the finger is drawn over it, it feels indurated as if a shot were under or in the skin. The second point is, that the rash does not all appear at once, but different parts of the body are affected one after the other, so that one part may present vesicles while another is beginning to show pustules. Another point of interest from a diagnostic stand-point is the characteristic course of the fever. Primarily high until the eruption begins, it speedily falls to 99° in moderate cases, or to 100° in confluent ones, and remains low until pustulation begins, when the so-called secondary fever develops, which rises to 102° or even 104°. This fever, unlike the primary fever, has morning remissions of 1° to 2°, and grad- ually ends by lysis, so that about the twelfth day, which is the period at which the pustules rupture or become dry, the temperature reaches normal. As would be expected from the severity of the eruption, the skin during the active stage of the disease is deeply inflamed and so greatly swollen that the features of the patient may be unrecognizable. (See Fig. 17.) In many cases the mind is clear throughout the illness, but in others it is clouded, and active delirium, which may be violent, is met with in se^-ere cases. In the earliest stages of variola initial raphes may precede the true eruption and mislead the physician if he be not on his guard. In some instances an erythema, like that of early scarlet fever, is present, and in still others a rash appears which strongly resembles the early stages of the eruption of measles. These rashes may last from a few hours to a few days, and usually appear on the trunk and limbs and but slightly on the face. The scarlatiniform rash is to be separated from that of scarlet fever by the fact that it is not so punctate, nor so bright in hue, and is not associated with the presence of the sore throat of that disease. The rash which resembles measles is scarcely raised at all, as is the real rash of that disease; it develops much more rapidly, covering the entire body in a few hours, and dis- appears with a speed equal to that of its onset, rarely lasting over thirty-six hours. In some cases both the scarlatiniform and morbilliform rashes appear in very small patches on the wrists or about other joints. These initial rashes possess a considerable degree of prognostic importance, since they usually appear in mild cases. Still another initial skin lesion, of some importance because of its prognostic features, is an intensely red rash, which appears on the second day of the illness and spreads over the body so that the surface may after a few hours look as if it were affected by a generalized erysipelas in its early stages. Such a rash is said to indi- cate the future development of the hemorrhagic or malignant type of the disease. Petechial rashes also occur as initial or preliminary lesions. They usually involve the suprapubic or inguinal regions, but sometimes thej^ appear in the infraclavicular areas. The individual petechise may be bright red, or dull red, or purple in appearance. In still other cases an eruption which closely resembles that of true purpura develops. In very malignant cases death may occur before any typical eruption of smallpox appears. Something more must be said in regard to the variations which occur in the eruption of smallpox. In the first place, it is possible for smallpox to occur without 68 i)/si<:.\siis DC]': to a spkcific isfectiox ('riii)ti()n, altli()uj:;li, of course, sucli instaiifcs arc exceedingly rare. In all proljahility, careful examination of such patients will reveal one or two papules whicli otherwise niii^ht he o\erlookefl. Inileed, this type of smallpox may he considered as belonging to so-called varioloid, and to occur in those patients who liaxc been imperfectly l)r<)tected by early \accination. ^ ery rarely in the pustular stage, the epiderm at the base of a pustule may be displaced by the formation of a bulla, or blel), which contains a clear, straw-colored serum, and which holds in its centre the pustule. Councilman, ^NTagrath, and Brinckerhofi' describe secondar\- vesicles usually formed on the surface of the primary vesicle, but occasionally seen in the base. hIt^^ / -^ ^' ^^ > riola in a child with scant eniption. (Schainbirr.) Conjluent sniaUixj.v, as its name implies, may be localized or general; that is to say, the confluence of the various pocks may occur only in certain i)ortions of the body, while in other instances all portions of the body may be covered l)y a coalescence of the eruption. In these cases there is always an extensixe dermatitis. There is usually great restlessness, delirium, marked circulatory disturbance, and death very frecjuently occurs from the ninth to the ele\enth day. It is in this type of case, too, that the greatest degree of the edema of the subcutaneous tissues appears, and the temperature usually maintains a high degree. .Sometimes, how- ever, in confluent smallpox, the vesicles do not seem to reach as great a degree of fulness as in ordinary cases, and there is not the same degree of swelling of the subcutaneous tissues, although the skin is apt to be harsh and thickened. This form of confluent smallpox is considered by experts to be more frequently followed by death than that form in which the eruption seems to be more completely matured. 1 nder the name of hemorrJuKjic or black smallpox, which is by no means rare, and which takes place both in sjjoradic and epidemic cases, a form of the disease occurs in which the initial symjitoms are always very severe, and in which hemor- rhages into the skin occur early. Not only do the spots become puri)uric by extrava- sations of blood into the skin, ])articularly about the joints, but the hemorrhages also occur on the eyelids under the conjuncti\a, and even on the tongue, the palate, the fauces, and the \agina. Bleetling also frequently takes place from the gums. VARIOLA G9 and nosebleed, bloody vomit, and bloody stools may occur. Sometimes hematuria also develops. In these patients the temperature usually does not rise above 100°, and the mind remains clear and unclouded, but they are distinctly typjhoid in type, and death often occurs, sometimes as early as the third day, but more commonly between the third and sixth day, as the result of the profovmd toxemia and associated cardiac failure. Under the name variola jmstvhsa hemorrhagica, a form of the disease is dcscriljcd in which the eruption does not become hemorrhagic until the stage of pustulation is reached. This type is not so severe as that just described. Under the name of variola juhninans, an exceedingly fatal form, with a high temperature of 105°, delirium, coma, and collapse occur. In these cases death comes on within a few hours after the onset of the disease, and, while no hemorrhages are manifest in the skin, since the eruption is as yet scarcely developed, internal hemorrhages are, nevertheless, found at autopsy. It is much more apt to occur in unvaccinated than in vaccinated persons. Smallpox almost never occurs a second time in the same individual. In nearly every instance where a second attack is stated to occur, there has been an error in diagnosis, either at the time of the first or second illness. Varioloid. — While the symptoms detailed up to this point maj' be considered as those of ordinary smallpox which runs a natural course, it is not to be forgotten that a modified form of the disease quite frequently occurs, in which by reason of vaccination many years before, or natural immunity, or lack of virulence the mani- festations of the affection are quite markedly modified. To this type of the disease the term varioloid is applied. The whole of the eruption may appear within half a day after the first papule is developed. The vesicles which in an ordinary case reach their maturity by the fourth or fifth day, in these cases become fully developed in seventy-two hours, and they are often very small. Instead of the fluid in the pock becoming cloudy on the fifth day, this change develops as early as the third or fourth day, and many of the vesicles never become pustules, but dry up. Those that do develop into pustules reach this condition by the fifth or sixth day, instead of as late as the seventh or eighth in the unmodified form of the disease. It is evident, therefore, that, as most persons in all civilized coimtries have been vaccinated, physicians will often meet with a modified type of smallpox rather than the severe form. The temperature in these cases runs a very mild course, often remaining at the normal point as soon as the rash develops, and never partaking of a secondary rise. Indeed, the entire symptom-complex of the illness may be of the mildest possible type as to objective symptoms, suffering, or discomfort. The appetite is good, the patient sleeps well, no complications develop, and convalescence is rapid. The important fact to be remembered concerning these mild or modified cases is that they are quite as competent to spread the disease as are the more severe types of variola, and they require as strict quarantine as severe cases of the dis- ease. There is therefore every reason why a case of varioloid should be quaran- tined most strictly. Chapin points out that in 1896 such a mild type prevailed in the Southern United States, and rarely caused death, but gradually spread over a very wide area. Unrecognized it developed a host of ludicrous names such as: "Cuban itch," "elephant itch," "Spanish measles," "Japanese measles," "bumps," "impetigo," "Porto Rico scratches," "Manilla scab," "Porto Rico itch," "army itch," "African itch," "cedar itch," "Manila itch," "Bean itch," "Dhobie itch," "Filipino itch," "nigger itch," "Kangaroo itch," "Hungarian itch," "Italian itch," "bold hives," "eruptive itch," "bean-pox," "water-pox," and "swine-pox." P^ven in some cases of modified smallpox, coalescence or confluence takes place 70 DISEASES DUE TO A SPECIFIC INFECTION with associated edema. In these instances the confluence is not to be regarded as a very grave omen, since the pocks mature early, frequently do not rupture, and convalescence may begin as early as the eightli or ninth day of the illness. Variola sine eniptione is a well-recognized mild form of the disease occurring usually in hosj)ital attendants, about twelve days after exposure to a case of variola. There is general wretchedness, headache, backache, fever, and nausea. Often the patient is not ill enough to stop work. These symptoms last only two or three daj's. The initial rashes may appear but the pocks do not. This condition may be con- sidered as a modified form of mild smallpox or variola, but in the latter pocks appear and the disease differs from true variola only in its severity, ^'ariola sine eruptione is infectious but does not cause smallpox as does varioloid in the un- vaccinated. Ashburn, Vedder, and Gentry believe it is due to the fact tiiat vac- cination with cow-pox protects the individual from the eruptive pustular stage or form of variola but not from the whole infectious agent. (See Vaccinia). Complications and Sequelae. — When the severity of variola as an infectious disease is considered, it is remarkable that it has so few severe complications, and, aside from the state of the skin, so few serious sequelte. In some instances where the infection of the skin seems to be very severe, multiple abscesses may develop, varying in size from a small bean to a large .slough. They usually do not appear until after the eruption has passed on to the stage of desiccation, but they may persist for a long period of time and so prolong the illness. Moore speaks of a case in which a patient who suffered from this condition could not be discharged from the hospital until after a period of nine months and nine days, because he had forty-two large abscesses following confluent smallpox. The most common seat for these abscesses is upon the extremities and about the buttocks and shoulders, and occasionally on the scalp. Much more rarely abscesses which are more deeply situated form, as, for example, ischiorectal abscess. Such abscesses may produce marked systemic symptoms, but ordinarily evidences of septicemia are not severe. Occasionally erysipelas occurs as a late complication of the disease, either upon the face and scalp or on the scrotum. Under these circumstances it is a most serious malady, and frequently destroys the patient, since he has not the vital resistance to withstand the new infection. Bed-sores are rare if proper nursing has been carried out, but boils may occasion- ally occur, and are caused most frequently bj- the Staphyloeoccus pyogenes aitreiis. Gangrene of the skin complicating smallpox is almost unknown. But when it occurs it usually affects the scrotum. The eyelids sometimes become the seat of abscesses, or more rarely slough, as the result of the swelling and edema, but actual disease of the eyeball complicating smallpox is not common. The ears, on the other hand, are not rarely affected, and deafness occurs in a certain proportion of cases. When earache is complained of, the possibility of an extension of the suppurative process to the ma.stoid should be borne in mind, as this sometimes occurs with serious results. So far as the respiratory organs are concerned, it is important to note that small- pox sometimes produces laryngitis, \-arying in severity from a catarrhal to an ulcerative type. As in typhoid fever, the development of aphonia, due to ulcerative laryngitis, is an exceedingly serious complication, since the cartilages of the larynx may become eroded. Bronchitis and bronchopneumonia may develop, and occasion- ally pleurisy results from an extension of the infection from the lung or by direct involvement of the pleura by pyogenic organisms. The circulatory system does not suffer with anything like the degree of severity which we would expect. Pericarditis and endocarditis are exceedingly rare complications. Myocarditis, on the other hand, is more frequently met with as a result of the infection, as it is, indeed, in all of the acute infectious diseases. VARIOLA 71 The kidneys, aside from the ordinary albuminuria of ail acute infectious maladies, usually escape, as does also the nervous system. That there is irritation of the kidneys is evident from the fact that Arnaud, in 1S98, found alt)uniinuria in 95 per cent, of his cases. Septic arthritis occasionally occurs. The occurrence of smallpox in a pregnant woman very frequently results in abortion,- but if the mother goes to term, the child is to some extent protected from smallpox, although cases are on record in which children have ai)parently had smallpox in utero, and, extraordinary to relate, there are instances reported in which the child bore the eruption at birth, although the mother seemingly did not have smallpox. MacCombie even states that one case is recorded in which the mother contracted smallpox from her newborn infant. Diagnosis. — In the later stages of well-developed smallpox there is little difficulty in making a positive diagnosis; but in the early stages, when the initial skin lesions which have been named are present, the diagnosis may be for a time impo.ssible. Indeed, great difficulty may be experienced in expressing a positive opinion as to the presence of smallpox, even when the papular stage is in its early development. The unusually severe headache and backache, with chills, and pain in the epigas- trium, are strongly in favor of smallpox, particularly if there is a history of exposure to this disease within the incubation period already named. The absence of throat symptoms, of enlargement of the cervical and submaxillary glands, and of the peculiar coating of the tongue of scarlet fever may enable us to determine that the initial scarlatiniform rash sometimes seen is probably to be followed by smallpox, and, furthermore, as has already been pointed out, this scarlatiniform rash lacks the punctated appearance of true scarlet fever. On the other hand, it is to be borne in mind that in persons in whom the protective effect of an early vaccination is waning, it not rarely happens that true smallpox, or varioloid, develops in so mild a manner as to present but a few pocks and very mild systemic symptoms. A similar state may also be present in those who possess a natural immunity even if they have never been vaccinated. (See Sjinptoms.) "When the measles-like rash is present, the absence of the characteristic catarrhal symptoms of that disease, with its cough, running at the nose, and puffiness of the face, should cause the physician to hesitate in making a diagnosis until a suffi- cient time has elapsed for the eruption to be well developed. The papules which form in measles, while they are often confluent, do not possess the shot-like feeling so typical of the early papular stage of smallpox. Finally the measles-like rash preceding smallpox disappears in twelve to twenty-four hours, leaving no stain on the skin, while that of true measles pursues a course lasting several days. (See Measles.) Chicken-pox is one of the diseases which is most frequently confused with small- pox. In this disease, however, the initial sjTnptoms are always mild, and the tem- perature does not rise as rapidly as it does in variola. Then, too, in variola, the eruption occurs on the arms and face; whereas, in chicken-pox it is most abundant on the trunk, and sometimes on the scalp. It is always discrete, and it appears in successive groups. The vesicles of varicella, when punctured, collapse, since they are unilocular; while, as has already been pointed out, those of smallpox are multi- locular, and so do not completely discharge their contents when punctured. The vesicles in chicken-pox also reach their full development in twenty-four hours after the appearance of the papule; whereas, in smallpox they are not completely developed for five days. Next to varicella, syphilis may be considered as the disease which most frequently produces confu.sion in diagnosis, for variola must be separated from that form of pustular syphiloderm which is sometimes called variolaform syphilide. In most in.stances pustular syphiloderm is preceded by macular or papular syphilitic 72 DISEASES DCE TO A SPECIFIC IXFECTIOX eruptions, but in certain instiuicos a liistory f)f these previous ern])tions may not be present. Pustular syphiloderm is more Frecjnentiy met with in nejiroes tiian in tile wliite race, and occurs, as a rule, somewhere lictween the sixtii montli and the second year of the sy])hilitic infection. Important [joints in tlie dilVcrcntiation are tliat in ])ustidar syphiloderm, the ])iitient does not jjresent the wcil-marki'd prodromal symptoms of smali|)ox, such as intense backache, althouf^ii tiiere may be a moderate fever and some pain and achin<;. Afjain, in syphiloderm there is no marked remission of the temperature such as occurs when the erujjtion a])pears in small])ox, and syphilitic patients jiresenting such an eruption do not, as a rule, appear very ill or have to take to their beds. Further than this, the .syijhilitic eruption comes out in successive crops, is often profu.se upon the trunk, and the individual pustules never become so large and deep seated as do those of variola. Again, they are practically always non-confluent. Many cases of syphilitic eru])tion have associated with the vesicles coppcr-cf)lored papules, which shoidd render the diagnosis easy. Drug eruptions, which are sometimes ])apular and pustular, arc diltVrentiated by the alisence of fever and of constitutional symptoms. Prognosis. — The prognosis of smallpox differs greatly in ditt'erent e])idemics and in ditt'erent individuals. The greatest difference, of course, exists between those who are vaccinated and those who are not vaccinated. The mortality present in the unvaccinated may be said to amount to nearly 45 per cent., and in the vaccinated to about 8 per cent. If a patient has been vaccinated more than once, the mortality of the disea.se is wonderfully decreased. Thus, while among those who have been vaccinated once the mortality may be 8 per cent., those who have been vaccinated twice have a mortality of less than 4 per cent. If the mark of both vaccinations is a satisfactory one, the prognosis is exceedingly favorable, for death very rarely occurs unless the patient is already sutt'ering from some serious disease which has undermined his constitution and therefore aids materially in causing death. In most of the instances in which .smallpox has occurred after even a single vaccination, the vaccination mark has been so unsatisfactory that there has be£n grave doubt as to whether the patient has been protected at all. The age of the patient influences the prognosis materially. It is much more grave in early infancy and after thirty years of age, and best at about the end of the second decade of life. Chronic alcoholism and the presence of any antece- dent disease in the heart, lungs, or kidneys makes the prognosis more grave. Marked severity of onset is an evil prognostic sign, but a mild onset docs not necessarily promise recovery, for in many instances cases which seem mild afterward become severe and fatal. Petechial rashes are always of evil import, whereas early maturation of the eruption or an aborted maturation, so that it does not go on to pustulation, is a favorable omen. Confluent smallpox, if it has not been modified by previous vaccination, is more dangerous than the discrete form, and varies in its mortality with the age of the patient. Young children almost invariably die from it. Older children and adults often recover, and it may be said that prognosis is favorable in confluent cases in direct proportion to the age of the patient until after the third decade. • Great swelling of the hands and feet, associated with salivation and swelling of the face, in confluent smallpox has long been regarded by physicians, who have had a large ex])erience, as possessing considerable prognostic value, since if the eruption fails to appear the patient very frequently dies. The swelling is, of course, due to non-maturation of the pustules. Hemorrhagic smallpox, if well developed, always ends in death. When death takes place from smallpox, it most commonly occurs about the twelfth or sixteenth day, as the result of pneumonia, hypostatic congestiim nf the lungs, or from the profound exhaustion and septicemia. VARIOLA 73 Treatment. — As in most infectious diseases, the treatment of smallpox consists chiefly in good nursing and the maintenance of vitality by the use of proper nourish- ment and care. The air of the room should he fresh and cool, and frecjuently changed. Draughts should be avoided, and food should be given fretjueiitl.v in small quantities. Water should be given freely for the purpose of allaying thirst and flushing the kidneys, and there is no objection to the patient receiving a small quantity of ice to relieve the dry condition of the mouth. If the urine is scanty 5-grain doses of citrate of potassium or citrate of lithium should be given every six hours. Stimulants are not needed, unless there are evidences of circulatory feeble- ness, when alcohol is considered by most practitioners of experience to be valuable. Good brandy and whiskey are the best forms of alcohol to employ. For the relief of intense nervous irritation, opium or morphine may be administered in small doses, particularly if the condition of the skin seems to be the chief cause of the patient's suffering. These drugs are also, perhaps, the best for the purpose of allaying excessive delirium, since they do not irritate the kidneys as do some of the newer hypnotics. Where the deliriimi is active and threatens to exliaust the patient, a hypodermic injection of | to | grain of morphine will often produce several hours of restful sleep, with benefit. For the relief of the intense irritation of the skin all over the body, a very useful dressing is ordinary carron oil — that is, lime-water and olive oil mixed in equal parts. To this may be added 1 per cent, of carbolic acid for its local antiseptic and anesthetic properties, and where great pain is experienced, because of the occurrence of the eruption in the thick skin of the hands and feet, prolonged hand- baths and foot-baths of lukewarm water may be employed, or hot poultices used. An ointment of aristol of the strength of one drachm to the ounce may also be used. It seems to be generally considered that local applications to the eruption are of little value in the sense of modifying its severity, although certain parts of the skin which seem to suffer from an excessive degree of irritation may be relie\'ed by cool compress or by the application of antiseptic poultices. MacCombie states that the best dressing for the face is a mask with holes cut for the eyes, nose, and mouth. Upon this mask is smeared on its inner surface a small linseed poultice, over which is placed some vaselin which contains iodoform. This poultice should be changed every two hours. It aids materially in separating the crusts, and so leaves the skin free for the application of the dressings, which tend to prevent ulceration and the formation of scars. The local use of antiseptic drugs to the surface of the entire body has not met with favor. The mucous membrane of the mouth should be kept cleansed by mouth-washes of boric acid or chlorate of potassium and myrrh. When the mouth is exceedingly dry, flaxseed-tea, sweetened with a little white sugar and acidulated with lemon- juice, may be used. The primary fever of smallpox does not last long enough to require treatment, but the secondary fever may be sufficiently high to demand relief. Cold compresses may be applied to the head, and sponging the body with cool or tepid water may be emplo^yed, but the cold-bath treatment, so successfully employed in typhoid fever, has not apparently given good results in smallpox, and it is practically never employed. Should any irritation or inflammation of the eyes appear, thej^ should be carefully washed every few hours with boric acid solution, and, if necessary, cold-wet com- presses should be applied, great care being taken that the warmth of the body does not speedily change the cool compress into a hot poultice. During the suppurative stage, it is exceedingly important that the nutrition and vitality of the patient be preserved by the frequent administration of easily digested and predigested food. In considering the general condition of a patient who is sufl'ering from smallpox. 74 DISEASES DUE TO A SPECIFIC INFECTION it must be borne in mind that the disease is essentially one whicli is prone to produce profound toxemia, since it is incredible that such widespread infection can take place all over the body without simultaneously resulting in septic absorption on the one hand, or profound exliaustion on the other. For this reason the degree of suppuration should be controlled as far as possible, measures should be introduced to aid in the escape of pus, and the treatment should be stimulating and supporting. Finally, mention should be made of the so-called red-light treatment of smallpox, in which patients are kept in rooms to which no light is allowed to enter save through red glass, it being claimed by advocates of this method that the severity of the eruption, and so indirectly the severity of the disease, is greatly modified, and, further, that scarring of the skin is diminished. Suffice it to state, that while certain European clinicians have claimed to have obtained excellent results from this method, Welch and Schamberg in Philadelphia, and others, have found it entirely useless. When repeated attacks of boils occur in convalescence, staphj'- lococcus vaccine may be used. There are several points in the treatment of variola which should be carefully avoided. For the relief of the severe backache and headache, counter-irritation is sometimes employed in the early stages of the disease. Such treatment frequently results in severe ulceration or sloughing of the part to which the irritation is applied. Again, the application of powders, antiseptic or otherwise, is, as a rule, disadvan- tageous. The opening of individual pocks by means of a needle or the fine blade of a knife is not advisable. VACCINIA AND VACCINATION. History. — Little is known of the history of vaccinia, save that it has been recog- nized for many years as a disease which affects heifers and cows, and that it causes an eruption to appear on the teats and udder or neighboring parts. Although it was known, among those persons who milked these animals, or other- wise handled them, that the disease coidd be transmitted from the cow to the himian being, and although many of these persons also knew that this transmission protected the human being from smallpox, it was not until Jenner, on May 14, 1796, first inoculated a patient with the contents of a cow-pock that the preventi\'e Influence of vaccination was first tried in a scientific manner. Two years before this an English farmer, by the name of Benjamin Jesty, inoculated his wife and two children in a similar manner, but at the time no report of the procedure was made. From this small beginning so-called vaccination, or the inoculation of human beings with vaccine virus, has spread all over the world, and is a well-recognized procedure, by which millions of lives have been saved. There are a few persons, not medical men as a rule, who still express doubt as to Its efficacy, but they are not worthy of credence, and the statistics of every civilized land prove that vaccination Is one of the greatest blessings yet discovered for mankind. It Is only necessary here to state that vaccination Is now obligatory in most civilized lands, and that the frequency of smallpox is in direct ratio to the laxity with which vaccination laws are enforced. Immense statistics as to its protective value are to be fomid in all works on public health. In the Philippine Islands, about Manila, with a population of about 1,000,000, there had been for years an annual mortality from this disease of about 6000. From 1907 when the United States Government Instituted vaccination, until 1911, not one death from this disease occurred among vaccinated persons. Heiser also states that in May, 1904, the United States Army transport Liscitm left Manila with 26 cabin passengers, 170 steerage passengers, 16 officers, and SO members of crew, or a total of 292 souls on board. During the first week smallpox broke out aboard the vessel, in an unvaccinated child, in the steerage. An examination VACCINIA AND VACCINATION 75 of the personnel on board showed that 3 members had never been vaccinated. Within a period of two weeks these unvaccinated persons were stricken with tlic disease and not one of the 289 remaining persons contracted it. If the patient contracts smallpox many years after a vaccination, the severity of the disease is usually modified. Thus in 58,278 cases of variola collected from various sources, occurring in individuals who had been vaccinated, but in whom the "takes" were not known to be good, there were 4872 deaths, a percentage of 8.35; whereas in 23,360 cases of variola, occurring in individuals who had not been vaccinated, there were 8682 deaths, a percentage of 32.88. Vaccination, when properly performed, and when an active vaccine is used, may be said to be a sure preventive of smallpox for a very considerable space of time, if not for the lifetime of the individual; but it is safer to be vaccinated every few years, and every year if exposed during an epidemic. Not only does vaccination protect the individual for a long period of time, but it also modifies the severity of smallpox if the patient contracts this disease before the vaccinia can completely protect him. This has been proved by practical experience so often that it is a fact bej'ond all doubt, and it bears this important truth with it, namely, that when a person who has not been recently vaccinated is exposed to smallpox he should be revaccinated at once, since if the vaccine fails to confer complete immunity it will modify the disease if it develops. The degree of immunity, or the degree of modification, if smallpox develops, depends upon the space of time elapsing between exposure to the smallpox and the vaccination. The influence of a primary vaccination, which has been successful, upon the susceptibility of an individual to a second inoculation and indirectly as to his susceptibility to smallpox, is illus- trated by the results of Kitasato who analyzed 931 revaccinations. His results were as follows: After one year, 14 per cent.; after two years, 33 per cent.; after tliree years, 47 per cent.; after four years, 57 per cent.; after five years, 51 per cent.; after six years, 64 per cent.; after seven years, 73 per cent.; after eight years, SO per cent. ; after nine years, 85 per cent. ; after ten years, 89 per cent. Difference of opinion exists as to the scope of vaccine protection. Some hold that it protects against all the phases of smallpox; others that it protects against only one phase of the disease, that is the virus that produces the eruptive forms of the disease. One fact that supports this view is the development of variola sine eruptione in vaccinated persons. Ashburn, Vedder, and Gentry support this view but Ricketts and Bayles oppose it. It is well recognized that vaccinia is not a modified form of variola, since if the virus that causes all the sjTnptoms of malig- nant smallpox in man be passed through monkeys or cattle for several generations it loses all its virulence as to local lesions, although it causes systemic illness. Unlike certain infectious agents, small-pox vaccine never regains its lost power for evil even when it is passed through human beings which are favorable fields for the growth of smallpox virus for 100 years (Immermann). If the views of Ash- burn, Vedder, and Gentry are correct we would expect variola sine eruptione to be a fatal disease without eruption, instead of the mild one which it is. (See Variola.) Method of Vaccination. — The skin on the arm or calf of the leg, having been cleansed by washing it with soap and water, is scarified or scratched by a needle or knife-blade in such a manner as to remove the epiderm and expose the true skin over an area of about an eighth of an inch in all directions. Care should be taken that the spot is not so deeply scratched as \.o cause free bleeding. Upon this area is now deposited the vaccine, which is then gently rubbed into the part and allowed to dry before any clothing comes in contact with it. Several forms of vaccine are used, but that most commonly employed at present is known as " glycer- inated vaccine lymph," prepared from the contents of the vaccine vesicles as the.y have developed on the belly of a heifer. This glycerinated lymph is put up in 76 DISEASES DUE TO A SPECIFIC IXFECTJOX small glass tubes, which are hermetically sealed at the ends, so that it may not be contaminated before it is used. Schamberg and Koimer have shown that the apphcation of a solution, made up of picric acid 4 grams, iorline 1 gram, ak-oh(»l 100 c.c, forty-eight hours after vaccination ])revcnts secondary inflammation. Another plan which has the advantage of avoiding a scab is to make two or tlirce superficial incisions in tlic skin and to ml) the \'accinc into the cuts. Children should always be vaccinated during the first >ear of life, or inmicdiately after birth, if exposed to smallpox. Vaccination shoukl be re[)eatcd through life every five years, and oftener if smallpox is prevalent. If one inoculation fails it should be repeated at least three times, since sometimes primary failure is due to poor vaccine or to an error in technique. If after three attempts no "take" is ])rodnced the ])atient may be considered as immune, at least for a time. Primary Vaccinia in Man. — Three or four days after vaccination has been per- formed the infected area begins to be slightly reddened, and this reddening increases while at the same time a reddish papule develops which by the fifth day begins to look like a vesicle, particularly if the margin of the area inoculated be examined. This vesicle increases in size, becomes filled with thin, clear lymjjh, and b\- the eighth day reaches its greatest development. At this time the contained fluid begins to be more opaque and yellow and the top of the vesicle is seen to be slightly sunken — that is, the early stage of its umbilication has been reached. The skin surrounding the vesicle is now surrounded by a zone or areola of red which by the ninth or tenth day becomes very well developed, so that it extends for a consider- able distance in all directions; the spot inoculated is painful and the neighboring lymphatic glands may be swollen and tender. At this time, too — that is, about the tenth day — constitutional symptoms may come on and the patient suffer from mofl- erate chills, a slight rise of temperature, and malaise. Sometimes roseola {roseola mccinosa) may develop over the body. By the eleventh or twelfth day these sym]> toms are modified, the vesicle begins to desiccate, and by the end of the fifteenth day it is completely dried up, although the scab may not fall off till the twenty-first or twenty-fifth day. The crust or scab is dark red in color and thin at its centre and at its edges, but there is a thickened area, or ridge, between the centre and the periphery. After the crust falls oft' it leaves a pink spot which gradually fades and leaves, after some months, a foveated or pitted mark from which small scars may radiate. It is to be borne in mind that in some cases the constitutional symptoms are so mild as not to be worthy of note, while in others they ma\' be quite severe. To be a true "take," the full development of the pock by the stages named is essential, but it is possible for the "take" not to ensue for a month after inoculation. (See Plate II.) If the vaccinated area becomes very much inflamed and painful the part should be put at rest and dressed with lead water and laudanum. Secondary Vaccinia in Man. — ^^ery few persons who ha\-e once been successfully vaccinated i>rcscnt the conditions just described when inoculated a second time. The difference, however, is one of degree, not one of kind, and vesiculation and umbilication should iippear in all cases. The variations depend upon the degree of immunity induced and persisting from the first \accination. If immunity is complete there is no "take." If not complete the ])rimary papule may occur a day earlier than usual and a typical pustule may be reached as early as the end of the seventh day with the development of more or less severe systemic symp- toms as early as the fourth or sixth day. It is a point worthy of note that the so-called "raspberry excrescence" which sometimes follows vaccination on the fourth or fifth day, looking like a small nevus, is not a vaccine pock and confers upon the patient no immunity to smallpox — that is, it is not to be considered as a "take." Care must be taken, too, that the sore or mark |)roduced by the injury of the operation be not taken fur the sj)ccific k'sion of \-Mcci?iia. S I s I Q VARICELLA VARICELLA. Definition. — Varicella is often called chicken-pox. It is an acute infectious disease which usually occurs in children under ten years of age, and rarely attacks individuals after puberty. In adults it is still more uncommon, although Tyzzer reports 38 cases occurring in adult male Filipinos and states that at tiie time of the last observation .300 cases had been recorded. The men were prisoners, and this, together with race and climate, are considered possible factors in increasing suscep- tibility. In all probability one of the reasons for its rarity in those of mature years is that it affects so large a proportion of all children that most atlults are rendered immune by an attack in childhood. The most marked characteristic of the disease is the appearance within the first twenty-four or forty-eight hours of fever and malaise and of papules, followed by vesicles, upon the skin of the fore- head and face, or upon the chest and back. (See Fig. 19.) Chicken-pox. (Schambcrg.) Etiology. — Like all acute infectious diseases, chicken-pox is produced by a micro- organism, but as yet it has not been isolated. Tyzzer found specific nuclear and cytoplasmic inclusions in all the lesions, but obtained no evidence favoring the hypothesis that they are parasites. It also resembles the other acute infectious 78 DISEASES DUE TO A SPECIFIC INFECTION eruptive diseases in that it occurs in epidemics, althougli at times isolated cases take place that cannot be traced to any source of contagion. While the eruption in its peculiarities resembles to some extent that caused by smallpox, chicken-pox bears absolutely no relation to that malady and in no way protects a patient from developing a typical attack of variola. (See Variola.) Symptoms. — At a time varying from ten to fifteen days after exposure to varicella ihe child usually manifests some evidence of a beginning illness. If very young it may be unusually restless and fretful, there may be some disorder of the digestive apparatus, and vomiting may occur. Fever is an early symptom and it may be moderately high — that is, about 10.3° or even 104°. Often, however, it fails to reach such a height. If the child is old enough to describe its sensations, some aching in the back or in the limbs may be complained of. After about twenty-four hours the eruytion appears in the form of red papules, which speedily become vesicles containing clear or turbid serum. The vesicle is superficial, it is not surrounded by a zone of induration, as it is in smallpox, and it does not become umbilicated, although the top of the vesicle, when it is ripe, may be flattened. By the end of thirty-six to forty-eight hours the vesicle becomes a true pock, the previously clear serum becoming opacjue but not purulent unless it is denuded by scratching, and then infected. These pocks speedily shrivel and by the fourth day form crusts, which readily fall ofl" and rarely leaA'e a scar unless the skin be scratched by the child so that the deeper layers become infected. Many individuals bear scars of this sort upon the face, and they are particularly well marked in women with a fair skin. The eruption of chicken-pox develops in a series of crops, or, to speak more accu- rately, it continues to develop in new areas as those which were afl'ected first begin to pass into the stage of crusts. An examination of the patient on the third day may therefore reveal the eruption in all stages of development. It is a noteworthy fact that the eruption of varicella is always discrete and ne\'er confluent. It is never profuse as in smallpox. Rarely the vesicles appear on the mucous membranes. The severity of the fever and of the signs of general illness vary greatly in children affected by varicella. In some cases the disease runs so mild a course that the child is not kept in bed, in others it causes a considerable degree of illness; but in the majority of instances it is a very mild malady. In children who arc weakened by previous disease it sometimes develops into a dangerous malady, in that the associated digestive disturbance still further impairs vitality, or because the lesions of the skin become infected and sloughing or gangrene appears. Sometimes erysipelas is developed in this manner in poorly nourished children. Karely, if the child is exposed to cold, nephritis develops. Allaire reports peripheral neuritis of the left arm following an attack of varicella in a child aged eight years, the pocks having suppurated. Diagnosis. — The eruption of chicken-pox must be separated from that of modified (ir mild smallpox. The most important factors in this separation are the superficial character of the pock, the lack of the sense of induration when it is taken lictwcen the thuml) and finger, the early appearance of the rash on the chest rather than on the forearms, as in smallpox, and the mild character of the general symptoms, combined with the brief course of the disease and the speedy completion of the illness. Additional diagnostic factors are the presence of a good vaccination mark which largely excludes variola. Again, the onset of varicella is usually devoid of pro- dromes, whereas smallpox presents for some days backache, vertigo, fever, nausea, and chills. The mere fact that the eruption is scanty does not, however, exclude smallpox. The vesicles of varicella do not become umbilicated as do those of variola, but they rapidly dry up and make a dark-colored scab. The eruption SCARLET FEVER 79 of smallpox comes out in one crop, that of varicella in several crops; that of smallpox lasts from ten to twelve days in typical cases, never less than six days, whereas chicken-pox lasts but from two to four days. Prognosis. — The prognosis is always favorable unless the unfavorable preliminary states just noted are present. Treatment. — Medicinal treatment of varicella is usually unnecessary. Careful nursing that prevents exposure to cold and wet, regulation of the diet, and the \ je of a few drops of sweet spirit of nitre in a teaspoonful of liquor potai'sii citratis every four hours, to keep the kidneys active, are all that is needed in most cases. The fever runs so brief a course that antipyretic measures are not necessary. SCARLET FEVER. Definition. — Scarlet fever is an acute infectious disease which chiefly affects children under fifteen years of age. It is characterized by the development of an intensely scarlet, punctated rash on the second day of the illness, accompanied by a marked febrile movement. It is sometimes called "scarlatina," and it is to be clearly understood that this word is synonymous with scarlet fever and that it does not describe a modified or diminutive form of the malady, although the laity often employ the term in this manner. History. — Hirsch states that the oldest reference to an epidemic of scarlet fever dates from Sicily in 1543, but Sydenham, of London, first differentiated it from measles. Prior to his time it had been considered a form of measles. Distribution. — Like almost all of the acute infectious maladies, scarlet fever occurs in all parts of the world, although it seems to be much more prevalent in the temperate zone than elsewhere. In the United States it occurs less frequently in the Southern States than in the Northern States. It did not develop in the United States until 1735, nor in South America until 1830. In Australia and in Polynesia the disease first appeared in 1848, assimiing a mild type, but a severe epidemic occurred in Melbourne in 1876. It is said that only imported cases are met in India, and only one case has been reported in Greenland. It does not occur nearly so frequently as does measles, and very many persons reach adult life without having sufJered from it. This is in part due to the fact that it is not so readily transmitted as some of the other acute infectious fevers, and also because a large number of persons seem to be resistant to the disease. Johannessen states that of 185 children exposed only 28 per cent, developed scarlet fever, and out of 314 adults exposed only 5 suffered from the malady. If the same number of cases had been exposed to the infection of measles, very few of the children would have escaped. Scarlet fever is more apt to occur in the winter months than at any other time, but statistics differ as to the winter months' frequency. Thus, Whitelegge from his statistics based upon cases occurring in nine English towns, found in the first quarter 219 cases; second quarter, 194; third quarter, 327; fourth quarter, 460; and Reece has supported his conclusions by the accompanying chart. (See Fig. 20.) On the other hand, Seibert, of New York, gives a statistical table which shows that the last winter months are those of greatest frequency. (See Fig. 21.) August Hirsch gives the following statistics based on an analysis of 435 epidemics occurring in all parts of Europe and North America: 178 epidemics occurred in winter; 157 in spring; 173 in summer; 213 in autumn. The frequency and mortality of scarlet fever have greatly decreased in the last sixty years. (See Fig. 22.) Etiology. — Scarlet fever does not disseminate itself through the air as does measles; direct contact or near association with the infected person, being needful for the transmission of the disease. The desquamated skin has been recently denied 80 DISEASES DUE TO A SPECIFIC INFECTION Jim. Fell. ]lar. Apr. 3i«r tUM Jul, in?. Sf|.l. Ucl. .\.». llcr. ^ ^ / \ / \ / \ / ~\ / \ \ 7 ■ s / \ . r> ■^ / Ni ^. + 70 + 00 + 60 + 10 + 30 + 80 + 10 McanO - lU Showing seasonal mortality of scarlet fever in all ages and both sexes in England and Wales. (Reece.) JAN. n 'M. MAR, 1 APRIL 1 MA"i ! 1 JUNE { JULY AUG. SEPT. [ OCT. 1 NOV. 1 DEC. 200 '•■""■'-]■"' w»£::^::"^;i'- rc-:c S KlwtSS K«*S«ro««|m is w'*iS S;Sf?3:S "S5 «S s S 1 160 150 140- 130 — ■ 120 — - 110 100 90 SO 70 ,60 50 -f' ;- ! B 1 »B..aEiiiii[ 40 1 30' 1 20 - - 1 10! 1 ]_ ^ ^ 1 Frequency of scarlet fever, by weeks, throughout the year. A comparison of Charts 20 and 21 shows that although the greatest morbidity is in the first five months, the greatest mortality is in the last five months of the year. (Seibert.) Fig. 22 Showing the decreasing mortality of scarlet fever in England and Wales. Deaths per 100,000 population. (Modified from Wilson and Reece.) SCARLET FEVER 81 as a cause. The disease is usually transmitted by the nasal mucus as in sneezing, and by clothing, and other articles which have been in contact with the patient. Thus books, cards, letters, and pets, such as dogs and cats, and other means of conveyance may assist in spreading the infection. The clothing of the nurse and physician may convey the disease, and cases are very numerous in which physicians have so communicated scarlet fever to their own children after visiting patients ill with this malady. The persistence of the infection in articles of clothing is very remarkable. No other acute disease renders the surroundings of the patient a source of danger for so long a period. Instances in which clothing or upholstered goods have transmitted the disease to healthy children two years after recovery of the first patient are recorded. Articles of food may also convey the infection. Thus Ekholm has reported an instance in which six families who partook of milk from a dair\- in which there was a milkmaid who had a phlegmonous pharyngitis, suffered from scarlet fever. UNDER 1 YEAR BETWEEN 1 AND 2 BETWEEN 2 AND 3 BETWEEN 3 AND 4 BETWEEN 4 AND 5 BETWEEN 5 AND 5 BETWEEN 6 AND 7 BETWEEN 7 AND 3 BETWEEN 8 AND 9 BETWEEN 9 AND 10 1 1^ 1 ^ " t:::::::_:V: Vi - - - ' \ '- :::::;::::: \. ±— \ " "" 5 in ; - - i. 10 t- \ -p ' ::t::::: i „ t V ^ _ __^L ' ' ^i~~- 6 — ~J :::::::::::::::::::::::::::::s:::::: ' 1 s T__ / \ 5 / -V- T ~ ' 4_ 3 7 :""":::::: t - -r- - Showing age incidence of scarlet fever based on 7470 cases, and representing the combined statistics of Whitelegge, Ballard, and Keen. The breath of the patient and the air of the bed-room are probably incapable of transmitting the infection, unless the latter is laden with the dust containing the microorganism. It is noteworthy that nurslings are not as susceptible as children of from two to five years, at which period of life the disease most often occurs. The age incidence is well shown in Fig. 23. A patient who is a sufferer from the infection of scarlet fever is not capable of transmitting the disease until the rash develops. At the fourth or fifth day of the disease the infectiousness of the case is perhaps at its height, and the ability to transmit the malady exists as long as there is the slightest discharge from the G 82 DISEASES DUE TO A SPECIFIC INFECTION nose, which is often for as long a period as six weeks. It is important to remember that not only the nasal mucus but the discharge from a purulent otitis media or from a chronic consecutive scarlatinal pharyngitis are also active sources of infec- tion, and until all these parts arc entirely healtliy the danger of spreading the disease exists. Indeed, numerous instances are recorded in which children with such mild consecutive pharyngitis as to escape notice have conveyed the disease several weeks after apparent complete recovery from scarlet fever. Many investigators have endeavored to isolate the specific microorganism of scarlet fever, but without success. LoefHer, Fraenkel, and other German physicians first demonstrated the presence of streptococci in cultures prepared from secretion taken from the throats of scarlet fever patients, but their observations were limited to a small number of cases and are of interest from an historical rather than a practical stand-point. The same statement may be made concerning the researches of Klein in connection with an epidemic of scarlet fever (1SS5) caused by contaminated milk from a farm at Hendon, in England, for although Klein cultivated a microorganism from lesions on the udders and teats of cows on this farm, which apparently was identical with one he found in the blood of scarlet fever patients, and although this latter organism when injected into calves produced a lesion resembling the one with which the Hendon cows were affected, the inquiry instituted by the Medical Society of Edinburgh and the investigation of Dr. Crook- shank, of London, proved that the disease from which the cows suffered was a modified form of cow-pox, and, moreover, that the persons who milked the cows did not contract scarlet fever. A similar history as to cows and patients has more recently been recorded in Lincoln, England. In 1891 Kurth found in the throats of scarlet fever patients, in pus from the cervical abscesses and in the viscera of persons who had died from scarlet fever, a streptococcus which formed a twisted, gelatinous mass when grown in broth. This organism, called by Kurth Strepto- coccus conglomeratus, was subsequently studied by Mervyn Gordon, who found it present in the throats of twenty out of twenty-seven scarlet fever patients, in the internal organs of most patients who died from the disease, and in the fluid of a scarlatinal pleural effusion. Baginsky and Sommerfield, who published the results of their investigations at about the same time as Gordon, found a streptococcus, having virulent properties and generating a toxin, in all cases of scarlatinal angina, and in cultures made from the viscera, bone-marrow, and blood of one hundred and forty-two children in whom the disease terminated fatally. This streptococcus they considered to be the specific organism of scarlet fever. Of the work done by American bacteriologists that of Class, of Chicago, should be mentioned. In 1899 Class noticed the frequent presence of a diplococcus in cultures made from the throats of patients having different forms of angina, and upon further investigation he found that the organism in^•a^iably occurred in cases of scarlatinal angina. He then made cultures from the blood of scarlet fever patients and from desquamated epidermal scales, and found the same diplo- coccus. Gradwohl, of St. Louis, and Calvin Page, of Boston, have also found an organism identical with the one described by Class, but their observations were confined to a small number of cases. From this brief resume of the bacteriology of scarlet fever, it is apparent that streptococci are generally present in the throat of scarlet fever patients, and that they are often found in the blood and internal organs; but when wc come to consider that streptococci have been found in healthy throats, that cases of streptococci angina exist independent of scarlet fever, and tliat streptococci are found in the blood in other diseases, it is not justifiable to assume that any one of the forms thus far described is the specific organism of scarlet fever. Closely associated with the specific germ of scarlet fever, whatever it may be, we always find a variety of the streptococcus, and it has been claimed by some that this is the cause of the SCARLET FEVER 83 disease. There can be no doubt that it is responsit)ie for a large nuinlKT of tlie symptoms and comphcations of the disease. Prevention or Prophylaxis. — Every case of scarlet fever should be promptly isolated and every attendant of the patient should also be prevented from mingling freely with the inmates of the house. The food should if possible be placed in an outer room and from there oljtained by the nurse for the patient. If the nurse is to leave the room her clothes should be changed. Before she lea\-es the con- valescent patient to take care of other cases she should take a hot bath and have her hair shampooed. Her nasopharynx should be well cleansed by an antiseptic spray or douche. The clothing she has worn in the sick-room should be steril- ized by boiling. The physician should always change his clothes on entering and leaving the room, or at least wear over his street dress a long operating gown to protect him from the infection. If he is attending, or about to attend, a case of confinement he should refuse to take charge of a case of scarlet fever. The same rule holds true as to operative cases. All clothing and bedclothing should be immersed in boiling water, or in a disin- fectant solution, before they are taken -from the sick-room, and books and cards which have been in the patient's room should be burned. If possible it is better to burn the pillows and mattress than to attempt to disinfect them. If they are disinfected, steam under pressure should be used for this purpose. The hanging of sheets saturated with disinfectant fluids over doorways and the placing of pans of dis- infectants about the house are utterly useless except that their presence constantly reminds the inmates or visitors that an infectious disease is present and so aids in the maintenance of caution. An amount of disinfectant in the air sufficient to destroy the contagion will destroy the patient and nurse. After the illness is over and the patient has left the room, it should be carefully disinfected by an adequate formal- dehyde generator, the floors and walls being first moistened with water to aid in the efficiency of this gas. Afterward the floors and walls should be scrubbed with 1 to 2000 bichloride solution or one of chlorinated lime. No case should be isolated less than five weeks, and no case should be allowed to mingle with other persons as long as nasal, aural, or pharyngeal discharges exist even if they persist for months. There is no proof that infection is transmitted by scales. Before the patient is discharged he should receive at least three hot baths. Particular attention should be paid to the scalp and hair. Sleeping with other children is to be prohibited for several months. After exposure, a child should be placed in quarantine for at least a week to discover if the disease is to develop. When an epidemic is present all schools should be closed. Pathology and Morbid Anatomy. — A point of primary importance to be borne in mind in considering the pathology of scarlet fever is that the organs of the body suffer from a multiple, not a single infection. Whether a special form of strepto- coccus is the cause of the disease, or whether an entirely distinct organism is the cause, the fact is that the disease is accompanied by streptococcus infection in all cases and not rarely by other forms of infection as well. The organic changes produced in the body by an attack of scarlet fever are marked, but none of them can be said to be characteristic of the disease. Altera- tions in the skin and inflammation of the mucous membrane of the mouth and pharyixx are the most constant changes, but even these may escape notice. The skin is the seat of a very acute inflammatory process involving to a varying degree all its layers and terminating, even in mild cases, in exfoliation of the superficial cells, often in large flakes. The pharyngeal mucosa is inflamed, the inflammation varying in degree from a mild acute pharyngitis to extensive necrosis involving the deeper strata of the uvula and tonsils. This inflammation in a modified form extends at times all the way down the esophagus and by way of the Eustachian 84 DISEASES DUE TO A SI'ECIFIC IXFECTIO.X tiihe into the middle car, where it not infreqnentiy causes so destructive a change as to produce permanent deafness; or if the infection be severe and no vent for the pus is afforded the mastoid cells become involved and, finally, a secondary meningitis, or abscess of the brain, is produced. This is a rare sequel. In still other instances the inflammatory process extends into the nasal cavities and from them proceeds to an infection of the antrum of Ilighmore or even the frontal sinus. Extension of the pharyngeal lesions to the lymphatics of the submucosa may cause infection of the cervical and submaxillary lymph nodes, so that there is developed great swelling under the jaw, and in some instances sup])urati(iii, the so-called "collar of brawn." Equal in frequency with these changes, and of more importaiu'c, are tlmse wliich take place in the kidneys. These changes not only endanger the life of the |)aticnt during the illness, but occasionally leave him with kidneys structurally so impaired that complete restoration to health may never take place. The renal changes are primarily those of an acute diffuse nephritis involving the whole texture of the kidney, particularly- the cortex, and accompanied by marked albuminuria, inter- tubular cellular infiltration and necrosis, and desquamation of the epithelium lining the tubes. Areas of necrosis and infarction and even acute suppurative nephritis occur, although infrequently. When the infection with the streptococcus is particularly severe and the evidences of toxemia are profound the autopsy reveals degenerative changes in the heart muscle, areas of necrosis in the liver, and bronchopneumonia with swelling and softening of the brt)nchial nodes. I)egenerati\-e or necrotic changes in the myo- cardium and endocarditis, vegetative or ulcerative, may l)e present. Pericarditis may be marked. As in all septic infections arthritis may be found in numerous joints. Pleurisy, if present, often results in empyema. With the onset of scarlet fever there develops a hyperleukocytosis amounting, according to Tileston and Locke, to from 18,000, to 40,000. After the eighth day, if there are no complications of an inflammator>- nature, there is a gradual decline to the normal, somewhere about GOOO to 8000. The increase is chiefly in the polymorphonuclear cells. Schick and von Pirquet have advanced the \iew that the eru])tive stage of all the exanthematous fevers is a manifestation of anai)hylaxis, the time between infection and the appearance of the rash being that required for anajjliylactie bodies or ergins to de\'elop. This view is not unix'ersally accepted, i)Ut both Schick and Cederberg liave i)retty clearly shown that the late symptoms or sequela% particularly po.st.scarlatinal nephritis are due to this cause, at least in part, in that a state of hypersensitiveness is developed as the result of the jjresence of reaction or anaphylactic bodies which, if the system has not succeeded in eliminating or destroying all the germs, sensitize it to the toxic substance which the germs develop. As the kidneys are the organs actively engaged in excreting germs and toxins, these germs or poisons are present in the renal tissues in great abundance and this, perhaps, explains the frequency with which postscarlatinal nephritis develops. In those cases which escape such complications, the germs are elimi- nated or destroyed before the reaction bodies de\elo]). The i)rimary rasii is toxic while the secondary rashes and comi)lications are probably ana])hyla(tic. Incubation. — The period of incubation of scarlet fever is about two to six days, but cases are recorded in which it has been as l)rief as twenty-four hours and as long as twenty-one days. Reimer gives the following figures: 1 day, 379 cases; 2 days, 928 cases; 3 days, 751 eases. The perioil of incubation is, therefore, the siiortcst of all the acute exanthematous fevers. Symptoms. — The symptoms of an ordinary case of scarlet fever consi.st chiefly in soir throat, a modrnitrli/ hiqh fever, a scarlet rash first aj^jjearing on the chest, albumhiiiria of moderate degree, and a tendency to middle-car iujlaminatiun. SCARLET FEVER 85 The onset of the symptoms in scarlet fever is usually abrupt and the se\x'rity and abruptness of these symptoms is often indicative of the severity of the attack which is to follow. A child api)arently in good health in the evenin}< i)asses a restless night, and in the morning suddenly, without apparent cause and perhaps without preliminary nausea, vomits actively as soon as its breakfast is swalUnved. Often this vomiting is almost malignant in its severity. If the iemperuture is taken, it will usually be found to be 101° or \0'.'°, the skin feels hot aiifl dry, the pulse is quick, the eyes bright, the expression listless, and the tongue and mucous membrane of the mouth distinctly reddened. Sometimes the first complaint on the part of the patient is one of sore throat, in other cases no such discomfort is mentioned; but if the mouth he opened the ])haryngeal mucous meml)rane is seen to be angry and inflamed, and perhaps unduly dry. The child is manifestly ailing, is peevish, and is anxious to lie down. In from twelve to twenty-four hours from the manifestation of the preliminary symptoms just detailed, and in some cases in even less time than this, the eruption, or rash, develops, beginning on the neck and upper part of the chest, as a rule. No one of the eruptive diseases is so characteristic in its appearance as is scarlet fever, the skin of the patient being, as the name of the disease indicates, actually scarlet or as bright a red as is the shell of a boiled lobster. Again, in no other one of the eruptive diseases does the rash appear over so wide a surface in the first hours of its appearance as in scarlet fever. Not rarely the entire body and extremities are involved in four or five hours. There are four peculiarities about this rash which are worthy of note: first, it is punctate — that is, about each hair follicle in the skin the color is slightly deeper than elsewhere; second, the rash is often most marked in the folds of the joints, as about the groins; third, the skin of the face about the moutli or in the nasolabial line is pallid, forming a marked contrast to the scarlet hue elsewhere; and fourth, the rash on the upper part of the thorax is often very profuse. When the rash is developed, the sense of heat conveyed to the hand and com- plained of by the child is notable. The eruption persists from three to seven days in the majority of cases. Desquamation of the epiderm, which comes away in large flakes, rather than in fine bran-like scales, begins at the twelfth day but sometimes not until the twentieth day. The skin may literally peel off the hands and feet. In rare instances it may be shed from the hand in the shape of an old glove. This desquamation lasts from a week to three weeks, beginning about the neck and continuing longest on the palmar and plantar surfaces, where the skin is thick. Indeed, I have seen it continue- between the toes for six or eight weeks. The period of desquamation is, however, greatly shortened, as a rule, if during the illness the child has been anointed by some oily substance to allay dermal irritation, or if during convalescence it is frequently bathed. The stage of invasion, already described, varies in certain cases to a considerable degree. It may be so mild as to lead to a belief that the rash is due to indigestion, and it may be so severe that the patient is first convulsed, and then speedily over- whelmed by toxemia. The eruption may not be widely diffused, but appear for a short time on the chest and abdomen, in the groin, or about the buttocks before it spreads elsewhere. It may not spread farther than these areas, and may last only one day. Such cases are often given the unfortunate name of "scarlet rash." They are just as capable of giving scarlet fever to another child as a more severe attack. In other cases, of a malignant type, the rash seems to be suppressed, the skin is mottled, but the true rash fails to appear, or it may appear in blotches, which may seem to be macular, as in measles. When doubt exists in such cases, the patient will be benefited and the diagnosis cleared by a warm bath or warm pack to stimulate the peripheral circulation and bring out the rash. The temperature in scarlet fever runs its course side by side with the severity 86 DISEASES DUE TO A SPECIFIC INFECTION of tlio disease. It reaches its acme within a few hours from tlie onset, and is often as high as 105° within twelve hours. As a rule, this height is not maintained, but after twenty-four hours to three days it falls gradually to alwut 10.3°, and then gradually decreases daily by lysis, reaching normal, as desquamation l)egins, about the eighth or ninth day (Fig. 24). If it remains high or if a recrudescence occurs, some secondary trouble, such as middle-ear disease or bronchopneumonia, is to be sought for. Fig. 24 Slhf^ . 2 9 4 .-, (1 8 » 10 11 12 I!! 14 1.-. los' 104'- 103' 102' loi' 99" M E ME ME M E ME ME M E ME ME M E ME M E M E M E ME f\ A 1 J 1/ A / ^ 1 * / V / / / / / / /^ A 11 \b ib \b \L b Chart of scarlet fever. In the stage in which the disease is fully developed the clinical picture presents very great variations in different cases. In some children with a well-developed rash, the systemic symptoms are so mild that it is difficult to keep the patient in bed, and all the manifestations seem of little moment. In others the general symptoms are sufficient to show that the child is seriously ill, and in still others of a severe type the systemic state may be one of deep toxemia, so that the child seems overwhelmed by the infection. The cases in which toxemia is marked are not necessarily those in which great glandular involvement is present, although both sets of symptoms may occur simultaneously. Sometimes the throat symptoms by their severity mask all others. Not only may the pharyngeal and tonsillar surfaces be ulcerated, but they may be covered by a false membrane, which, in some cases, is due to a concurrent diphtheria, but which may also be due to the streptococcus, and is always polymicrobic in nature. Such cases often present a horrid type of the disease, for the lips and teeth are covered with sordes, the tissues of the neck are infiltrated and swollen, and the head thrown far back to diminish pressure on the air-passages prodnccil by the swelling. In such cases the general infection extends rapidly into the chest, and bronchial or pulmonary symptoms develop with great rapidity, thereby causing a fatal issue, although even with these grave complications recoverj- sometimes takes place. (See Complications.) If to these malignant manifestations are added a tendency to suppression of urine, because of the intense nephritis which has been produced, the signs of toxemia deepen into stupor and death ensues. Cases of this type rarely die before the sixth day, since this time is required to develop the contlition described. There is, however, a fulminant form of the disease in which the malady, after being ushered in by severe convulsions, speedily develops into deep stupor, with hypcrinrexia and death. In some of these cases, however, the infection is so profound that a high temperature does not occur, the temperature never rising above 101°. These cases are very rare and are described more frequently by French clinicians than they are seen by Anglo-Saxon practitioners. A few cases are on record in which no fever has developed, and others in which no rash has been seen. Under the name "surgical scarlet fever" is described a febrile affection which attacks persons, usually children, after surgical operations or injuries. The term SCARLET FEVER 87 is an unfortunate one, for no such malady exists as a distinct disease. The con- dition is an erythema due to sepsis or else it is an attack of scarlet fever coming on during convalescence from the operation. Complications and Sequelae. — Scarlet fever depends very largely for its gravity upon its complications and sequeliK, which are not rarely met with. The most constant of these is a certain degree of renal irritation or inflammation. The con- dition of the kidneys from a time very early in the attack is such that slight albumin- uria may be considered a fairly constant symptom. In some instances this febrile albuminuria is the only evidence that the kidneys are aft'ected, but in others the character of the urine and the general systemic condition render it very plain that a true nephritis is present. Not only does the urine of such patients show consider- able quantities of albumin and casts, but there is distinct puffiness of the eyelids and edema of the ankles, or even a generalized anasarca. In such patients, if this state persists, transudation may take place into the serous cavities of the body, and the patient suffers from the pressure produced by the fluid upon the heart and lungs. He may develop uremic symptoms, and these in turn may cause death. In manj^ of these cases, however, the acute nephritis, responsible for these manifestations, speedily diminishes with the subsidence of the disease itself, and recovery follows with a rapidity which is extraordinary. I have seen recovery take place, even after the anasarca was so marked as to almost close the eyes and after repeated severe uremic convulsions. There is still another type of renal disorder met with in a few cases of scarlet fever in which the infection seems so intense that the kidneys are completelj' sup- pressed in their functional power very early in the attack, and in which we find great diminution of urinary flow, hematuria, and copious amounts of albumin and casts. In these cases the toxemia of the disease and that resulting from the renal lesions produces death in a very short time. Suppression of urine may be the first symptom. The renal changes of scarlet fever are, therefore, to be carefully watched, and the greatest care must be taken that the kidneys are not permitted to be additionally congested by the patient being chilled. Exposure during and soon after scarlet fever may change a mild renal state into a most desperate condition. A very considerable number of cases of scarlet fever give positive cultures of the Bacillus diphtherias during convalescence as well as during the attack. Higgins states he found this organism in the nose and pharynx of no less than 25 per cent, of the children sent home as cured of scarlet fever. As long ago as 1898 Todd reported such a result in five cases out of 365 patients suffering from this disease. This is far in excess of the percentage of positive cultures in supposedly healthy persons. Thus in 3096 persons in communities in Massachusetts, practically free of the disease, the bacillus was found in only 1.4 per cent. As a sequel, rather than a complication of scarlet fever, inflammations of the joints sometimes occur. This is not acute rheumatism, but of the nature of a sejjtic arthritis. Rarely the joint suppurates. The swelling does not persist, as a rule, if the effusion be simply serous. Another very rare sequel of scarlet fever is dislocation of the hip-joint. In 1804 J. Franck reported a case of dislocation of the hip occurring in an attack of scarlet fever. In 1894 Champenois published an account of three other cases, which were all he could collect from the literature. Since 1894 H. Stanfield Collier has reported two cases. Robert Jones, of Liverpool, states that one such case has come under his observation. Much more common that arthritic changes during or after scarlet fever are those which are met with in the ears, due to an extension of the septic inflammation from the throat through the Eustachian tube to the middle ear. These have already been referred to when considering the pathology of the disease. The physician should always be on his guard for aural inflammation in the course of 88 DISEASES- DUE TO A SPECIFIC IXFECTIOX tliis malady and after it has run its course. I'ermanent deafiii's.s not rarely results from the otitis media due to this cause. Parotitis sometimes occurs as a complication. Next to acute articular rheumatism, scarlet fever stands as the most common of all the acute infections in producing vnlviilnr disease of the heart. Tliese changes are in the endocardium and myocardium, and may be acute and transient or become permanent. Very rarely does the endocarditis become severe enough to be called ulcerative. Great responsibility rests upon the physician in regard to the cardiac changes in this disease, because, while it is true that lie cannot ]jrevent them, lie can often, by insisting on rest during the attack and during convalescence, to a large extent, limit their severity, both as to their temporary and permanent character. This is the more important, since, as in all acute infections, the heart is often the seat of a myocardial change. Bronchopnemnonia develops in a small proportion of cases. EDipi/enin ma\' be a secpiel to scarlet fever, and is usually insidious in onset. The induration of the cervical (/lands, which may suppurate, has already been referred to. Nervous complications of scarlet fever, aside from delirium and convulsions due to the toxemia, are rare. As a sequel, chorea may develop, or hemiplegia arise, caused by an embolus lodging in a cerebral vessel, ^'ery rarel\- an acute ascending paralysis, which is the result of neuritis, may develop in the lower limbs. An exceedingly rare complication of scarlet fever is perito7iitis, due in all proba- bility to a streptococcus infection of the peritoneum. McColIom and Blake, of Boston, have reported two such cases in the Boston City Hospital Reports. Diagnosis. — While scarlet fever in its typical development is not difficult of diagnosis, it not infrequently happens that mild attacks render a decision as to the exact nature of the illness most difficult to determine. The chief reason for this is that children very commonly, and adults more rarely, develop a roseola or rose rash as a result of many different causes, and if the manifestation of scarlet fever be mild, or the rose rash be severe, the skin lesions may not only not aid in diagnosis, but greatly impede the physician in reaching a decision. The most common of these rose rashes is that produced by certain types of indigestion, and particularly that which follows eating fish, shell-fish seeming especially prone to cause it. As active vomiting and diarrhea and even fever may be present in such cases, the patient at first sight quite markedly resembles one suffering from scarlet fever; but the absence of sore throat, of enlarged tonsils, of enlarged cervical glands, and a history of no exposure to the specific fever, all aid in excluding scarlatina, particularly if it can be discovered that indigestible food has been ingested. Then, too, the rose rash of indigestion does not, as a rule, appear first on the chest. In some persons, with a very sensitive skin, contact with nettles or other irritants may cause a roseola. In all such cases the physician should not be hasty in making a diagnosis, but insist that enough time be given to permit him to make a careful study of the case for several Hays before expressing an opinion. In such instances the patient should be isolated until the diagnosis is decided. The rose rash sometimes met with in German measles is never as scarlet as it is in true scarlet fever and is distinctly maculated. Further, it appears on the face before it is seen on the chest, the punctation of the rash of scarlet fever is absent, the fever is slight and lasts but two or three days, and flaky desquamation does not occur. Roseola due to vaccination and that due to the use of diphtheria antitoxin are easily diagnosticated by the history of the patient. Should a rose rash with fever develop in an adult there is much more likelihood of its being due to early secondary syi)hilis than to scarlet fever. The rose rash SCARLET FEVER ■ 89 of syphilis is not, however, so bright a red as that of scarlatina. Such a rash, when due to syphihs, disappears and reappears, becomes dusky, and, finally, it is apt to be circinate. Sometimes in acute and chronic nephritis nanptom which becomes manifest. The patient's face looks lluslicd and, it may be slightly swollen about the eyes and nose, and the eonjunctivie are injected, the general expression of the face being tearful. At this time, and later, in the disease photophobia may be marked. Sneezing may be noticeably frequent, and an examination of the phar.ynx will reveal the fact that its mucous membrane is reddened and the hard palate dotted with a measles- like rash, which often appears here before it develops on the skin. Some cough may be present in the stage of onset as the result of the pharyngeal and laryngeal irritation, and headache may be complained of. Showing initial fever with the subsequent fall and then a rise when the rash is well developed in a case of measles. Also shows an ending of the fever by crisis. There are present in many cases upon the buccal mucous membrane before the rash develops a nvmiber of small, white-tipped, reddish spots first described by Filaton, but more commonly called "Koplik's spots." (See Plate III.) When present they are pathognomonic of measles, but their absence does not negative the diagnosis of the presence of this disease. The fever usually begins to rise with the onset of the catarrhal symptoms, increas- ing day by day till it reaches its acme of 103° to 105° on the fourth or fifth day from invasion, and remains fairly constant at about this level until the rash begins to fade, on the fifth to the seventh day, when the fever ceases abruptly or by lysis, reaching normal in a few hours or by the end of two or three days (Fig. 2H). The eruption of measles develops on the third or fourth day of the disease, and at first is most marked back of the ears and about the roots of the hair or on the forehead. The individual spots look like a fiea-bite and are rather dusky red in appearance. By the end of twenty-four hours or at the expiration of the fifth day this rash is usually pretty well diffused all over the body, and the macular appearance of the eruption begins to become papular, so that it can be distinctly felt by the finger-tip of the phj'sician. This rash varies greatly in its degree. Sometimes it is so profuse that every part of the body is covered; in other instances very considerable spaces of unafl'eeted skin can be found between the groups of papules. It has been generally stated that the erescentic arrangement or grouping PLATE III Fiy. 2 Fig. Fig. 8 The Pathognomonic Sign of Measles (KopUk's Spots). Fig. 1.— The discrete measles spots on the buccal or labial mucous membrane, showing the isolated rose-red spot, with the minute bluish-white centre, on the normally colored mucous membrane. Pig. 2.— Shows the partially diffuse eruption on the mucous membrane of the cheeks and Ups; patches of pale pink interspersed among rose-red patches, the latter showing numerous pale bluish-white spots. Fig. 3.— The appearance of the buccal or labial mucous membrane when the measles spots completely coalesce and give a diffuse redness, with the mjTiads of bluish-white specks. The exanthema on the skin is at this time generally fuUy developed. F'°- 4.— Aphthous stomatitis apt to be mistaken for measles spots. Mucous membrane normal m hue. Minute yellow points are surrounded by a red area. Always discrete. MEASLES 95 of the rash is diagnostic of measles. That this is erroneous the author is conviiiecd, as he has frequently seen it occur in other morbilliform eruptions. ^Vhen the disease is in its fully developed stage the skin of the face may be quite swollen and that of the neck and chest well covered by the eruption; but as the lower part of the trunk and the lower limbs become involved the rash on the face usually begins to diminish and slowly fades/leaving for several days after it has entirely disappeared, a faint mottling of the skin with the desquamation of branny scales, which is scanty in some cases, but profuse in those who have had an intense eruption. The entire duration of the rash is from five days to one week, and the period of desquamation lasts for about the same length of time. Occasionally the patient suffers from prodromal rashes such as a punctate erythema which begins on the trunk instead of the face. Sometimes it develops on the limbs. Sucii a rash may at first be thought due to scarlet fever. In other cases a papular erj'thema may be present. Hecker and others have proved that during the last few days of incubation and dm-ing the course of the eruption in measles there is constantly present a distinct leukopenia. It is so constant that he proposes to use it as a diagnostic aid, asserting that the leukopenia is present four and a half days before the outbreak, and three and a half days before the appearance of Koplik's spots. Two or three days before the eruption there may be a temporary increase ia leukoc\-tes. The decrease is almost solely in lymphocytes, the neutrophiles being relatively in excess. Indeed a diminution of l\Tnphoc}i;es may be present six days before the eruption. Diu-ing the well-developed stage of the disease the patient nearly always presents some symptoms of hronchitis. These may be so mild as to be undemonstrable, or so severe as to threaten life. The thorax should be frequently examined, in order that the development of this complication may be recognized and its severe effects, as far as possible, avoided. Variations. — It must not be thought, however, that measles always follows the course just described. All the acute infections present widely different sjTnptoms in different epidemics and in different persons, and measles is no exception to this rule, for in some cases the systemic or constitutional distiu-bance is so slight as to be of no importance, whereas in others it is exceedingly severe. In strong, hearty children the course of measles is rarely grave if they are protected from cold and exposure, whereas in puny, badly nourished infants it is one of the most fatal maladies. The following variations from the ordinary course of measles are met with: A mild type, with a scanty rash and almost no constitutional disturbance, which runs its course without complications if ordinary care is exercised. A severe t\-pe, in which nervous and constitutional sjTnptoms predominate, in which the eruption may be exceedingly profuse, but is more commonly indistinct or poorly developed, perhaps because of poor circulation in the skin by reason of toxemia. Another severe tj'pe is known as hemorrhagic or "black" measles, because of the tendency to the occurrence of hemorrhages in the skin. Still another form is a respiratory tj-pe, in which the patient may suffer from great laryngeal and tracheal distress or from a serious bronchopneumonia. It is often said of these cases by the laitj' that the rash has been driven in by exposiu-e to cold and is exerting its deleterious influence on the lungs. This is not exactly true, but it is, neverthe- less, a fact that when we can, by means of a hot pack, restore the peripheral circula- tion and so indirectly cause the rash to be manifest, the sjTnptoms of toxemia and respiratory disorder often become decidedly less. Rare cases are met with in which, after vomiting, purging, convulsions, and coma, death speedily occurs, even before the rash has had time to become well marked. 96 DISEASES DUE TO A SPECIFIC INFECTION Complications and Sequelae. — It has already been intimated that measles in itself is a disease which, in most indi\'idiials, with ordinary care, pursues a safe course and ends in recovery. While this is undoubtedly true, it is also a fact that it takes high rank among the acute infectious diseases which produce death, by reason of the complications which are prone to occur. Of all these by far the most frequent and deadly is bronchoptieiimonia, a complica- tion which is often severe in its course and which causes a great number of deaths when measles attacks young infants. The physical signs and symptoms are describcfl in full in the article on that disease, but it is important to remember that in measles the disease is insidious and speedy in its onset, so that a pneumonia may be developed before the physician discovers it, unless he be on his guard and resorts to frequent examinations of the chest. Bronchopneumonia during an attack of measles in a child under one year of age is an exceedingly common and very grave complication of the disease. In children of five years or more this complication usually does not occur if the primary state of the health is fairly good and if careful nursing prevents exposure to "catching cold." A second complication of far less importance than bronchopneumonia, both as to frequency and results, is diarrhea and vomitinq due to a catarrhal state of the bowels and stomach. It also is a complication which is due in a considerable proportion of cases to bad nursing and can generally be avoided by proper feeding and the avoidance of draughts. It not infrequently hajjpens that these digestive disturbances are mild during the acute illness, while the patient is required to be prudent and quiet, and become pronounced when the acute illness is past and the attendants become careless as to exposure and feeding. This gastro-intestinal disorder varies from a mild catarrh to a severe enterocolitis. Another complication seen in many cases is a mild degree of xtomatUis, which in poorly nourished children may become ulcerative. Even so severe aufl fatal a lesion as noma may develop in cases with very low vitality, ^"ery rarely gangren- ous nlceration of the ear, the labije, or the prepuce takes place. So far as the nervous system is concerned, it may be said that it is rarely affected. In the stage of onset in very young children with poor resistance and an unstable nervous system there may be con\'ulsions, but they are exceedingly rare. Meningi- tis as a sequel to measles is also very rare. Even meningitis due to middle-ear disease is rarely met with, for the otitis of measles, while not macommon, is usually mild and rarely causes secondary lesions. The eyes are usually inflamed and there may be a mucopurvlent conjunctivitis, or, if the general health be i)oor, keratitis may prove troublesome. So rarely are the heart and kidneys affected to any serious degree that these organs may be considered almost immune. A feebleness of the heart due to the infection and fever may be present for a time, and a transient albuminuria is often manifested, but both of these symptoms usually rapidly disappear if the patient is kept at rest. Measles is an infection which is not rarely complicated by other acute infections. Diphtheria may develop during its course, and whooping-cough is so exceedingly frequent that some relation between the two diseases has been thought to exist. When whooj^ing-cough does occur as a complication the danger of hrochopneu- monia is greatly increased. Still another sequel of measles is tuberculosis, probably because the catarrhal state of the mucous membranes offers a path for infection by the tubercle bacillus or because the devitalizing influence of measles -permits an old focus of tuberculous infection to become active. The persistence of a felirile movement in a case of measles after seven days should always arouse the suspicion of some inflammatory complication which should be most carefully searched for. Neumark calls attention to the value of leukocytosis as indicating a complication, the leukocytes being about in number normal in uncomplicated measles. MEASLES 97 Diagnosis. — Measles must be carefully separated from a large number of cou- ditious which somewhat resemble it. Many kinds of food, particularly shell-fish, produce a rash which looks remarkably like measles, but which usually lasts only a few hours, but the watering and hypercmic eyes and swollen visage of measles are not present. Antipyretic or other coal-tar products do likewise in some persons, and the physician should always inquire as to the use cjf these foods or drugs before stating that measles is present. Sometimes a morbilliform rash follows vaccination or precedes smallpox. The use of antidiphtheritic serum may also cause such an eruption. The contact of a cater- pillar with the skin in some persons may cause ^^^- 27 a measles-like eruption which lasts only a few hours. None of these states, however, are ac- companied by the appearance of Koplik's spots, hy marked coryza, nor by the appearance of the rash on the mucous membrane of the soft palate. Fever, too, is usually absent. (For the diagnosis from Rotheln, see Rubella.) Prognosis. — From what has already been said it is evident that the prognosis in a case of measles is dependent not on the fact that measles has developed, but rather upon the age of the patient, the vital resistance or the general condition of the system, and the sur- roundings as to sanitation and nursing. Given a poorly nourished infant in bad surroundings and with inefficient care, measles becomes one of the most fatal diseases to be met with, whereas in a case where these conditions are good the prognosis is fairly favorable. AVe find, too, that the danger of the disease de- creases greatly with each year of life; so that children near puberty rarely die from this malady unless poorly nourished or badly ne- glected (Fig. 27). If bronchopneumonia de- velops, the prognosis must be guarded in direct proportion to the youth of the child. Thus, out of a series of 408 cases of measles complica- ted in this manner, 290, or 71 per cent., died. This, however, is an exceedingly high figure and by no means represents the death rate in a general run of cases in which all ages and conditions of patients are considered. Under these conditions the death rate for all cases is probably about 35 per cent. Thus, Holt speaks of an epidemic in the Nursery and Child's Hospital in New York in 1892, in which the mortality was .3.5 per cent., and in 9239 cases of measles occurring in France, principally in hospitals of Paris, there were 3096 deaths, or a mortality of 33.5 per cent. It is, moreover, to be carefully borne in mind that hospital or asylum statistics are utterly worthless in determining the death rate for ordinary private practice, because most of these hospital cases are primarily in bad health or are brought to the hospital desperately ill from neglect. Including all cases in private practice the mortality should not be over 5 to 10 per cent., and in many epi- demics it is much lower, even in institutions and where good nursing is not to be PERCENTAGE UNDER 1 YEAR BETWEEN I AND 2 BETWEEN 2 AND 3 BETWEEN 3 AND 4 BETWEEN 4 AND 5 40 1 _M_ Mil 39 1 jy 1 III 38 1 j\ i ; : 1 3T 1 / \ 1 ' ! 1 30 1 ! ;/; \ i i a5 1 1 i ! 7i \ 34 1 / : \ *J jT T 1 33 Ir 1 31 fl (ill 30 I M i ill _L •' 1 1 ii9 Ml il ' i 1 ( i as i J i V I i ar ./ \ as 1 _J MJ i\ i ■^.^JLITT j\i_ ■24 /; i; ; \ ^-_X 1 \- ~i~ j i\ ( } 21 1 1 1\ 20 ! 1 1 \ i 19. J , 1 l\ ; , I 18 "7t\" " _n± IT 1 ' 11 16 \ L , [ ,1 IS \ 14 — { 13 -y-T— 12 L 11 ^ 10 ^ ::::"" \ 9 j^ \ii S \m T \ 6 5 4 1 3 1 Showing the mortality of measles according to age, based on 29,464 cases collected by H. Courtenay Fox. 98 DISEASES DUE TO A SPECIFIC INFECTION had. Thus, in an epidemic in the Faroe Islands only S cases out of 1123 cases died, and at the Boston City Hospital only 5 were fatal out of 3GG. Treatment. — When measles runs a natural course, little or no medication is required; for, as it is a self-limited disease, it cannot be jugulated. The therapeutics of an attack of measles, therefore, consists in the prevention of comjilications and the relief of symptoms which are so prominent as to be distressing or |)crhaps even dangerous. In order to avoid irritation of the eyes and to lessen the suffering due to photophobia the sick-room should be kept dark. Light bed-covering should be employed, and heavy cjuilts which cause the child to perspire unnecessarily are to be tabooed. As a mild gastro-intestinal catarrh is often present with the fever, food should be light, given at frequent intervals, and should consist chiefly of nutritious fluids, such as the various broths, milk, an egg boiled only one minute, and similar substances. If the irritation of the conjunctivae is marked, eye drops, composed of 4 grains of common salt and 4 grains of boric acid to an ounce of water, may be used several times a day; and if the cough is sufficiently constant to prevent sleep, it may be controlled by small doses of codeine, .rV of a grain once, twice, or thrice in twenty- four hours, to a child of two years, or heroin may be used. Should the fever reach 105° there is usually no necessity of reducing it owing to its short duration, but the child's comfort can be much increased by sponging it with tepid water and alcohol, or even with water at 70°, using active friction at the same time. These cases do not need an immersion bath and it is not wise to give it to them. If the circulation has a tendency to fail, carbonate of ammonium in the dose of 2 grains four or five times a day may be given in syrup of acacia. For the relief of headache a small ice-bag may be applied to the head, provided that a nurse is at hand to prevent it from slipping down upon the neck, or about the ears, and also to prevent it from wetting the pillow. It should usually be wrapped in a towel to prevent the accumulation of moisture, and also to protect the head from too great cold. In cases in which the rash is not well developed and the skin is dusky in hue, the brief use of a hot pack is very useful. Should diphtheria arise as a complication antitoxin should be given. After the disease has run its course, convalescence should be aided by the use of simple bitter tonics, the hypophosphites, iron, and arsenic, and, if malnutrition is present, cod-liver oil proves itself an exceedingly valuable remedy, since it im- proves the nutrition of the patient and exercises a most beneficial efl'ect upon the mucous membranes. If the bronchitis is persistent and a considerable quantity of mucus is in the bronchial tubes, 3 grains of chloride of ammonium may be given in a teaspoonful of fluid extract of liquorice and a teaspoonful of water three or four times a day, and gentle counter-irritation in the form of chloroform liniment or ammonia liniment may be applied to the chest. After the eruption has dis- appeared and desquamation has begun, the child should be bathed daily in order that the skin may be thoroughly rid of dead epithelium; and before the patient plays with other children the scalp should be shampooed several times, since not infrequently desquamation continues upon the head long after it has ceased upon the trunk. For a long time after the rash of measles has disappeared the greatest care should be exercised that the patient is protected from exposure, as acute and chronic catarrhs of any or all the mucous membranes are very prone to develop under very slight provocation. RUBELLA. Defiiiition. — Rubella is sometimes caWed" Rothcln" or "German measles," " R2ibeola 7uiiha," "Epidemic Roseola," and "Hybrid Scarlet Fever." It is a disease distinct from measles and scarlet fever, and is one of the mild acute infectious eruptive MUMPS 99 diseases of childhood. It rarely affects adults. Johann Seitz studied an epidemic involving 21 families and comprising 111 cases, and found that 4 per cent, of all adults were attacked. The ratio for children was much higher, being 04 per cent. Rubella occurs as a rule in epidemics, but sporadic cases are met with. Etiology. — The microorganism of this affection has not been isolated, but the disease is distinctly infectious and is contracted by one patient from another, not only by contact, but also by clothing and through the air. Symptoms. — After a period of ijinbation lasting from ten to twelve days the stage of onset manifests itself by chilliness, general malaise, some running of the eyes and nose, but there is not marked reddening of the conjunctiva. As early as the first day of the illness the rash appears as a macular eruption which is red in hue, but is not scarlet. This is a so-called "rose rash." In some cases, however, this rash does not develop till the third day. The rash shows itself first on the face, then on the anterior surface of the thorax, and speedily covers the entire body. It is not as scarlet as in scarlet fever nor so dusky as in measles. It can often be seen on the soft palate before it appears on the skin, in the form of bright rosy-red spots (ForcWieimer's spots). The individual macules may remain separate; or coalesce. In some instances, however, the skin has a diffuse redness like that of scarlet fever, but it is less scarlet. The macules last about tliree days and then fade gradually, being usually, but not always, followed by slight scaly desquamation. As a rule the rash on the face fades at about the time it becomes well developed on the lower part of the trunk. The skin is rarely as much stained after the rash disappears as it is after measles. A noteworthy sign to be sought for is the enlargement of the lymph nodes. They feel like a string of beads below the ears, in the lateral cervical region, and at the back of the neck. Sometimes the inguinal glands are also affected. The febrile movement is usually \ery moderate, the temperature often not rising above 100°. The general symptoms may be so mild that the attention of the nurse is first called to the illness by the rash. If the child is carefully nursed and clothed and properly fed, the malady pursues a rapid course of recovery. If, on the other hand, the child be feeble and exliausted, this disease may be severe in its manifestation and be accompanied by otitis media, catarrhal pneumonia, or even albuminuria and jaundice. Isolation should be kept up for ten days. Diagnosis. — Rubella is to be separated from true measles by the moderate character of the coryza, by the absence of Koplik's spots, the early swelling of the glands in the neck, and by the absence of bronchial irritation. From scarlet fever it is separated by the absence of high fever and of the well-diffused scarlet rash, which is not macular, and by the absence of the sore tliroat of that affection. Vomiting in onset is rare in rubella but very common in scarlet fever. While these differential points are of value in many cases, it is a fact that in some instances a diagnosis is most difficult until the case has been studied for some days, when the mildness of the symptoms and the brevity of the attack aid in deciding that neither measles nor scarlatina are present. For this reason careful isolation should be practised. If the rash lasts more than three days it is probably not German measles. The presence of albuminuria and nephritis points to scarlet fever. Treatment. — The treatment of rotheln consists in rest in bed and the use of spirit of nitrous ether and citrate of potash as diuretics, and in attention to the bowels and kidneys. Exposure to cold should, of course, be avoided. MUMPS. Definition. — Mumps, or epidemic parotitis, is an acute infectious disease affecting the parotid gland and accompanied by mild systemic symptoms which may not 100 DISICASI'JS Dl'H TO .1 SPECIFIC ISFECTION l)c severe enough to demand notice. It oecurs in the great majority of instances during childhood, lietween the fourth year and puberty, and one attack protects the ])atient from a second. Etiology. — Mumps is usually conveyed hy contact from one patient to another, hut it may be carried by a third person or by garments to a susceptible indixidual. It is contagious from the Ijcginning to the end of the attack, and it is probable that ])crsons\vho have so far recovered as toha\-e no \'isil)le swelling of the ])arotids can still transmit the disease. For this rciison the jjatient should be kcjit sei)arate from other children for a period of three weeks after the swelling disappears. It is, however, a noteworthy fact that mumps is by no means so infectious as are the eruptive fevers, and many children escape the disease even when thoroughly exposed to it. The period of incubation is uncertain. Sometimes it is brief, in other cases surprisingly prolonged. Holt, in 42 cases collected from literature, found it varied from three to twenty-five days. In all probability it is about fifteen days in the average case. Pathology. — The chief change in mumps, and, indeed, the only one which is characteristic, is the swelling of one or both parotid glands. The swelling is d"ue to a i)rimary parenchymatous inflammation, followed by involvement of the connective tissue of the gland as well. Rarely the other salivary glands become swollen, and still more rarely the parotids suppurate. This result occurs only in children who are impoverished by other diseases, and is due to an invasion of the gland, through the duct of Steno, by pyogenic organisms. Symptoms. — The chief symptoms of mumps, aside from the swcHiiki nf llir gldiids, is pain in the parotid region, which is greatly increased by moving the jaw or by taking any sour material into the mouth. In susceptible persons there may be some feeling of malaise or wretchedness and the fever may reach 103° or 104° on the first day, although a temperature of 102° is more commonly met with. The swelling of the gland is usually at its height by the third da\- and remains at this stage for two or three days more, when it begins to decrease and then grad- ually disappears. In some cases the degree of swelling is so marked that the tissues of tiie face and neck share in it to such an extent that the patient is unrecognizable. The swelling is bilateral in the vast majority of instances, but it often begins in a single gland. Complications and Sequelae. — While mumps is a very mild disease in many cases, it at times becomes severe, chiefly because of the complications which arise. These are more frequently met with in adults than in children. The most common of them is orchitis, which may be bilateral and severe enough to cause the patient intense suffering and- force him to remain in bed. Before the age of puberty the testicles are rarely involved, but after puberty orchitis is a frecpient complication. Bich collected statistics on .S62 cases of mumps occurring in young men between the ages of eighteen and twenty-five years, and founfl that 29 per cent, of the number were affected with orchitis. Granvier's record of cases occurring in the French army gives a percentage of 23. Usually only one testicle is involved. Thus, of 159 cases collected from various sources 152 were unilateral. The combined statistics of Granvier and Bich, based on 309 cases of orchitis, showed that atrophy of the testicle resulted in 17() cases, or 57 per cent. Active exercise seems to predispose to this complication, and it is much more frecpient in some epidemics than in others. Some years ago mumps ai)peared in an epidemic among the students of the Jefl'erson Medical College, and a \-ery large proportion of those attacked developed metastasis to a testicle. The development of the orchitis is usually associated with a second rise of tem])erature and a general .sense of illness which is in excess of that present at the onset of the primary illness. The swelling of the testicle lasts about a WHOOPING-COUGH 101 week, and after the acute iiifliiininiition has passed the f^hmd may be enlarged for a long period of time. Cases have been recorded in vvliich coiiotilsiDns, inetiiiKjUls, and nrllinlis liave developed as compHcations of mumps. In young girls who have mumps, secondary swelling of the mammary gUmds, of the ovaries, or of the labite may develop, but secondary changes are far more rare among females than are those detailed as occurring in males. Simonin, a French surgeon, has reported 10 cases of pancreatitis which occurred among 652 cases of mumps. The symptoms of pancreatitis appeared from the first to the twelfth day of the disease, but usually from the third to the sixth day, and lasted from two to seven days. The chief symptoms were ejjigastric pain and vomiting, but no glycosuria. Cuche has stated that he found epigastric tenderness present in 20 out of 26 cases of mumps. Treatment. — The treatment of mumps consists in the use of mild alkaline diuretics and rest, for if the patient can be persuaded to avoid exercise and to use a light diet active medication is never needed. Sour foods and acid drinks are to be avoided, for when they are taken into the mouth they cause severe pain. If the febrile movement is marked and the pulse is quick 3 minims of tincture of aconite every two hours is useful for the first twenty-four hours of the malady. By decreas- ing the congestion in the gland the aconite not only moderates the inflammation, but also diminishes the pain. Local applications to the swollen parotids are usually not needful, but if any are employed they should be hot rather than cold. Should metastasis to the testicle occur, rest in bed is imperative, since taking exercise at such a time causes great increase in the swelling and pain. The scrotum should be supported by a bandage. Aconite in full doses and citrate of potassium are useful remedies when the swelling of the scrotal contents is severe. WHOOPING COUGH. Definition. — Whooping-cough is sometimes called Pertussis, and is an infectious disease chiefly met with in childhood. It consists, as its name implies, in a respira- tory disorder which is peculiar in two particulars. The patient in the well-de^'eloped stage of the disease is seized at varying intervals by a paroxysm of coughing which is so constant and violent that in a few seconds the quantity of residual air in the thorax is greatly decreased below the normal amount, producing in this way a sense of suffocation and flushing of the face or cyanosis. Immediately after the cough ceases the patient endeavors to take a deep inspiration to compensate for the excessive expiratory effort, when there is developed a narrowing of the glottic opening so that it is very difficult for the air to enter the larynx. This violent effort to draw air through a narrow opening produces a peculiar "whoop," which gives the disease its name. The name "whooping-cough" does not signify that the cough is whooping in character, but that there is a cough followed by a whooping sovmd. History. — The first recorded epidemic of whooping-cough appeared in Paris in 1573. Distribution and Frequency. — Whooping-cough is a disease which is found in all parts of the world, and is apt to occur in epidemic form, particularly during the months of March and April. It is least prevalent in September and October. It is rare and mild in the Tropics, severe in colder climates. Ceylon has 17 cases per 1000, England 347 per 1000 population. As already stated, it is particularly prone to attack children; so that few persons reach adult years without suffering from an attack. If they do escape during childhood, they may suffer from it even in advanced old age. Even sucklings are attacked by it, and in this class 102 DISEASES DUE TO A SPECIFIC INFECTION of cases it is an exceedingly fatal malady. Two-thirds of its deaths occur in patients under one year of age. It is also a grave disease in old age. Whooping-cough attacks both sexes with about equal frequency. Rosen col- lected 43,393 cases, of which 21,850 occurred in boys and 21,543 in girls. If the statistics of Goodhart, Comly, and Rilliet and Barthez are combined, it is found that in 4157 cases 1868 occurred in boys and 2289 in girls. Etiology. — The baccillus of pertussis was discovered by Bordet and Gengou in 1900 and obtained in pure culture in 1906. It is a minute ovoid Gram-negative cocco-bacillus about the size of the influenza bacillus. Whooping-cough so often occurs in close connection with an attack of measles that the two diseases must be regarded as nearly related. The exact period of incubation is unknown. It proliably varies greatly in different persons and in different epidemics. Sometimes it seems to be as short as two days; in others it apparently takes ten days, or even longer than this. The infection is perhaps conveyed by the air and certainly is transmitted by the sputum, either by the direct expulsion of particles of it into the face and air-passages of the child not as yet affected, or upon clothing or the food, so that it gains access to the respiratory tract. The infection is most marked during the acme of the malady, but is active at all times during the attack, and probably for a week or more after the cough has lost all characteristics of the disease. Children who have suffered from this disease should not come in contact with those who have not had it, for three or four weeks after the last whoop is heard. Pathology and Morbid Anatomy. — Mallory, of Boston, has shown that in pertussis the bacillus pertussis is found packed in large numbers about the cilia of the epithe- lial cells lining the trachea and bronchi. The organisms interfere mechanically with the movements of the cilia. This condition is peculiar to this malady. Pri- marily the only noteworthy change present in the thoracic organs during whooping- cough is a mild catarrhal state of the mucous membranes of the \vhole respiratory tract. Secondarily, the pathological results are far more serious in that the bron- chitis and the great strain thrown ujjon the heart by asphyxia result in conditions which may destroy the patient, death usually ensuing in fatal cases from exhaustion due to excessive cough, lack of food, and lack of rest combined with bronchopneu- monia, which in turn is also due to several causes, of which lowered ^utal resistance and a feeble heart are important factors. Then, too, in the violent inspiratory efforts of the patient small particles of food or infected mucus may be drawn into the smaller bronchi and so produce local infection. As stated in the article on Bronchiectasis, this condition in its cylindrical form may be caused by pertussis. (For further pathological changes see Complications.) Symptoms. — The symptoms of whooping-cough have already been described to some extent. Usually the patient develops what is apparently a slight cold in the head and thorax, followed by a cough, which may be described as nervous or spasmodic. Perhaps the word "sudden" can best be applied to it in the sense that each coughing spell is sudden in onset. At first there may be only one or two coughs, but soon they come in series, which day by day increase in frequency and violence. Sometimes the ^cJioop, which occurs at the end of the series of short, sharp coughs, does not appear for several days. It may never appear in the mild type of case, the patient sufl'ering only from the paroxysms of cough which exhaust the chest of air to a considerable degree. When the whoop does come on it appears at the end of the repeated coughs, and is caused by the attempt to inspire air suddenly and forcibly through the narrowed glottis. The whole paro.xysm, there- fore, consists, first, of a series of coughs which increase in rapidity as one would count 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12 with increasing speed, and, secondly, in the long-drawn inspiratory whoop. Owing to the violence of the cough the face becomes suH'used, the tears run, and the patient may even seem more or less con- WHOOPING-COUGH 103 vulsed. The frequency of the paroxysms varies very greatly in different cases and at different times in the twenty-four hours. Some patients cough but once or twice a day, while others are seized every few minutes. Usually the child is greatly frightened if the attack is severe, and often it soon learns to recognize the early signs of an approaching seizure and runs to its mother or nurse for help. The attacks are provoked by crying, laughing, eating or drinking, and by inhalation of dust-laden air. Between the paroxysms perfect quiet and respiratory comfort may be present unless complications arise. In the severe cases nose-bleed and ecchymoses of the conjunctiva may occur and blood may come from the ears and mouth. The convulsive efforts during the cough very frequently cause vomiting, and at times the urine or feces may be forcibly expelled, or they escape after an attack because of profound exhaustion and the relaxation produced by the asphyxia. A nodular infiltration, or an ulcer, at the frenum of the tongue is often produced by irritation of the projecting organ upon the lower incisor teeth. The circulation is usually not much affected save during the paroxysm, when it is labored, owing to the asphyxia. Between the paroxysms it may be rapid and feeble if the attacks are frequent and severe enough to strain and dilate the heart. Some clinicians assert that permanent cardiac feebleness and dilatation may result from this disease. In severe cases in young children and in feeble individuals great asthenia may be produced by the violence of the spasm, the loss of sleep, and the loss of food from vomiting, which may occur at every paroxysm. Inspection of the bared chest during the inspiratory part of each attack reveals in the stage of inspiration deep retraction of the intercostal spaces, of the episternal notch, and of the epiclavicular areas. The epigastrium is also retracted, for all the auxiliary muscles of respiration endeavor to aid in the drawing in of air. Auscul- tation of the chest, particularly over the posterior surface, almost always reveals bronchial rales, due to the bronchitis which is present in all cases, even if they be mild. Care should always be exercised that this bronchitis is not increased by exposure to cold and dampness, since it is exceedingly prone to develop into broncho- pneumonia, particularly in young children and old persons. Indeed, it may be said that the high mortality of the disease is due almost entirely to this complication. A number of clinicians, particularly Cima and Meunier, have shown that even in the very early stages of pertussis there is present a very extraordinary leukocy- tosis. This is accompanied by an increase in the percentage of large and small lymphocytes, both increasing until the height of the disease is reached. Eosinophiles are found during convalescence. The lymphocytosis is of distinct diagnostic value in uncomplicated cases, Kolmer diagnosing 81 per cent, of a series of cases by the blood examination alone. As in most infectious diseases, a small amount of albumin is found in the urine in the majority of cases. The duration of whooping-cough varies from sLx to eight weeks, more commonly the latter than the former. Complications. — The complications of whooping-cough are chiefly connected with the respiratory tract. Bronchopneumonia, as just stated, is very common, and follows the bronchitis which usually is developed in the earlier stages of the disease. It is particularly apt to attack young children and to occur in the winter months. Somtimes a true lobar pneumonia develops. In nearly all cases of whooping-cough a moderate degree of compensatory emphy- sema comes on because of the violent respiratory efforts of the patient, and rarelj^ this strain on the tissues of the lungs results in the rupture of an air vesicle and the development of interstitial or interlobular emphysema. In other instances the quantity of air which escapes in this way is very large and infiltrates the tissues of the mediastinum, the subcutaneous tissues of the chest, and in extreme cases those of the entire body. Instances of thig condition have been reported by Gelmo, Ferreil, and Bierbaum, and have usually proved fatal. Cases are also recorded in 104 DISEASES DVK TO A SPECIFIC l.XFECTIOX wliich pneumothorax has been produced. Another complication of iini)ort:iiice, although it has been descril)ed as a sym])tom, is voinitinfi, wliicli if it Ix'conies constant is a. serious condition, ])articuiarly in infants, since it may cause death from asthenia. The bronchial glands are nearly ahvays enlarged and may be so much increased in size as to cause dulness on percussion over the sternum. The area of cardiac dulness is increased by reason of the dilatation of the heart due to the strain tlirown upon it in the attack of coughing. Brick found clianges in tiic hearts of all of 14 cases coming to autopsy. There was in most instances an excentric hyp(Ttroi)hy of the right ventricle, less often sim])le hypertrophy or dilatation. Tiic heart muscle was often fatty, particularly on the right side. Measles and whooping-cough are, as already stated, very commonly associated, but the whooping-cough complicates the measles more frecpiently than the measles complicates the pertussis. Sometimes in very young children the disease becomes so severe that the spasm of the cough seems to spread to all the muscles of the body and produce general convulsions. These cases are nearly always fatal. Paralysis complicating whooping-cough is not common. It is nsuall\ in the form of a hemijjiegia, and occurs either during the acute period of the disease or as a sequel. When it takes place during the paroxysmal period it is due in the majority of instances to meningeal or cerebral hemorrhage in all probal)ility, although statistics as to this question are scanty. Twelve cases of cerebral hemor- rhage due to whooping-cough have been collected by Townsend, of which se\en recovered, and Brown has reported a case in which he operated for the relief of cerebral compression due to this cause, with excellent results to the patient. The literature of this subject has recently been analyzed by W. G. A. Robertson. Some- times paraplegia or monoplegia has occurred during the stage of convalescence. The prognosis seems to be fairly favorable, indicating that the lesion producing these conditions cannot be permanent. Small conjunciiral hemorrhacjc.i are not infrequent, and more rarely large extravasations of blood into the conjnncti\al tissues take place, amounting to ecchymoses. Still more rarely temporary anilili/opia develops as a result of disordered circulation in the retina or possibly of an actual retinal hemorrhage. Diagnosis. — The important points in the diagnosis of whooping-cough are the repeated and rai)id coughs in series until the chest is almost emptied of air, followed l\y a sudden inspiration through the narrowed glottic opening. Some cases develop only the series of short coughs, and present no whoop afterward. The only cough resembling it is one due to enlarged bronchial lymph nodes, and in adults that due to a laryngeal crisis in ataxia. Prognosis and Mortality. — The prognosis in whooping-cough, as in most infectious diseases, depends ui)on the age of the child, its general nutrition and \-ital resistance, and upon the care the child can receive. In general terms it may also be stated that the prognosis is not so good in winter as in summer, as fresh air is not so readily obtained and there is greater danger of exposure to cold in the winter months. In itself wlioo])ing-cough is not a fatal disease. Death is due to the comjilications which ensue, and if these can be ])revente(l the ])atient always gets well. In very young children, however, it is almost imjjossible to ])revent the development of bronchopneumonia, and this is a dangerous condition in projiortion to the youth of the child. In London whooping-cough stands second as a cause of death from the infectious diseases in children under two years of age. Ilagenbach, of Basle, gives the following mortality statistics, which are based on the cases that came under his observation during a period of eleven years: Under one year, 26.8 per cent.; between one and two years, 13.8 per cent.; between two and five years, 3 per cent.; between five and fifteen years, 1 .S per cent. Holt states that the mortality for children under one year of age is 25 ])cr cent. WHOOPING-COUGH 105 Treatment. — It is vitally important that children who have whooijing-cough should he put under the most favorable hygienic conditions as to sunlight, fresh air, and equable temperature. In the summer they do best out-of-doors when the weather is not too cool, if they are prevented from acting imprudentls-, as, for example, getting the feet wet. In winter they should be kept in a warm room, the temperature of which should be 70° night and day. The air of tiiis room should also be moistened by liberating in it small ciuantities of steam obtained from a kettle of .boiling water, from a croup kettle, or by dropping pieces of unslaked lime in a bucket of water. This is an exceedingly important measure if the room is heated by a furnace, since the air from the ordinary furnace is exceptionally dry and often laden with dust, and these two causes act as an irritant to the already irritated respiratory tract. When it is not possible to confine the child to a rooni which is heated evenly, a most excellent method of treatment, particularly in those cases where the paroxysms are frequent at night, is to place the child in a bronchitis tent. A bronchitis tent consists in throwing over a bed a large sheet which is supported several feet above the head of the child by means of broom- sticks or poles, which are tied at each corner of the bed. This tent can be made quite attractive for children by decorating it. Into this tent, at the foot of the bed, may be discharged a small quantity of steam such as is given off from an ordinary kettle of water when it is kept constantly boiling. In this way the child's mucous membranes are not irritated by dry or cold air, but on the contrary are greatly soothed, and I have frequently diminished the number of paroxysms per day at least one-half by the institution of this plan of treatment, which has the additional advantage that it is prophylactic, and prevents the development of those serious complications like vomiting and bronchopneumonia, which are much aided in their development by repeated and violent paroxysms of cough. With a little attention a child may be kept in such a bronchitis tent night and day through the entire attack. In the way of drugs there is no remedy so efficacious in diminishing the severity of the attack as small doses of antipyrin; that is to say, 4 to 1 grain of antipyrin every three or four hours to a child of one or two years, or 2 grains every three or four hours to a child of five or six years, care being taken that the drug does not too greatly relax the skin or depress the circulation. There is a widespread belief among the laity that quinine in small doses is not only a prophylactic against whooping-cough for other children in the family who have not as yet contracted the disease, but that it is also of curative value. Some physicians have used a spray of a weak solution of quinine in the throat with asserted advantageous results, but its value is doubtful, and its bitter taste makes its use impossible in a large proportion of cases. Vaccine treatment using 50,000,000 of the Bacillus pertussis has given excellent results, the dose being repeated about every five days. The development of complications, such as bronchopneumonia, necessitates the institution of those lines of treatment which will be found suggested for that disease. For the relief of the individual paroxysms of cough several remedies may be employed, of which the best is probably chloroform. It is needless to say that this drug should be used with great caution, and the patient's parents and the nurse should be instructed never to use it on a cloth, but, when the paroxysm is threatened, to pour the remedy over the back of the hand and place the hand under the child's nose. Under these circumstances a sufficient quantity of the chloroform is often inhaled to relax the spasm, without producing any of the marked physiological effects which would certainly be obtained to an undesirable degree if the drug were poured on to a napkin. This method also prevents an overdose of chloroform being given, since the excess of the drug rapidly runs off the hand or evaporates. As the hurry of an approaching paroxysm often makes the attendant careless as to the quantity which is poured out of the bottle, the physician should insist that 106 DISEASES DUE TO A SPECIFIC INFECTION the chloroform be used in no other way than that which has just been described. If the parosysms are too severe to be controlled in this way, nitrite of amyl may be occasionally employed. An innumerable array of drugs have been recommended for the palliation and cure of whooping-cough. Suffice it to say that most of them are entirely useless. Even such powerful nervous sedatives as the bromides cannot act advantageously in many of these cases, and the use of more powerful ones such as chloral and opium are contra-indicated for evident reasons. The physician should always remember that whooping-cough is a disease which is bound to run its course, uninfluenced in its duration by any treatment which he can employ. The most that the physician can do is to prevent complications, treat them if they arise, and endeavor to modify the frequency and severity of the individual parosysms, being careful in so doing that the remedy is not worse than the disease, in the sense that it produces digestive or circulatory disorders which are distinctly disadvantageous. INFLUENZA. Definition. — Influenza is sometimes called la Grippe. It is a pandemic disease; that is, one which appears in widely separated parts of the world simultaneously. It is also highly infectious, and the infection is produced by the bacillus of Pfeiffer. Influenza of this type is to be separated, theoretically at least, from that condition sometimes called "common cold" or "coryza," which often causes somewhat similar symptoms in a milder form, although during the presence of an epidemic of la Grippe the difi'erential diagnosis may be impossible. At the present time the term "influenza" is often employed when the physician is unable to reach a diagnosis, and as a consequence is greatly abused, particularly in the early stages of typhoid fever and tuberculosis. Leichtenstern has divided the disease into two varieties, namely, true epideujic influenza {influenza vera) due to the bacillus of Pfeift'er, and endemic influenza due to the same cause and occurring for some years after an epidemic has been present. Both of these forms are to be separated from ordinary pseudo-epidemic influenza or an attack of ordinary cold in the head. A peculiarity- of true influenza in its epidemic form is the large percentage of persons which it attacks within a short space of time, more than any other epidemic disease except dengue. History. — At various times in the past great epidemics ha\'e broken out and raged over the entire world, and have been followed by long periods of immunity. Thus, when the great epidemic of 1889 occurred, only a few ph>sicians, and they of advanced years, had ever seen a case, for the previous epidemic had occurred in 1847 and 1848. Pandemics have occurred during the last century in 1830-33, 1836-37, 1847-48, and 1889-90. In 1889 the disease began in remote parts of Russia in October, reached Moscow in November, ten weeks later it got to Berlin, a month later to London, and soon after to New York and Philadelphia, and thence it spread all over the continent of North America. Within t\\e next few months nearly the whole civilized world was affected by it. Since the last outbreak the disease has been endemic, but it is an attenuated form of the infection. An individual locality is rarely subject to an epidemic for more than two months, but sporadic outbreaks occur for a long period afterward. Etiology. — It is interesting to note that the word influenza is derived from the Latin sentence ah cocli occultes quadam influentia — from some hidden influence in the sky. Influenza, if entirely dependent upon a microorganism for its infectious character, must also be dependent upon certain telluric influences, at present unknown, which render the human race more susceptible to the ett'ects of the germ INFLUENZA 107 at certain times or which render the germ more capable of producing infection at certain periods. There are two chief factors involved in the production of an attack of influenza, namely, the presence of the bacillus, usually received directly from another patient by contact, or through the air; and, second, atmospheric states which are favorable to the growth of the germ or to the production of individual susceptibility. A third factor, always of importance in connection with infectious diseases, is the presence of preexisting disease which decreases the general vital resistance of the patient. The bacillus of Pfeiffer was first isolated by that investigator in 1892. The organism is small and non-motile, and can be well stained by Loeffler's methylene blue or by well-diluted watery solutions of carbol-fuchsin. It develops in myriads on the nasal and bronchial mucous membranes and in the secretions of those parts. A number of observers, and more particularly Ricciardi, have shown that the bacillus is readily distributed and spreads most actively by droplets of mucus. Even after the patient has recovered from an attack his nasal secretions may reinfect himself or other persons for a period of weeks, and therefore all handker- chiefs, towels, and pillowcases used by him should be boiled before being used by others. The room occupied by the patient should be fumigated with formaldehyde after his recovery occurs and before anyone else occupies it. It is a noteworthy fact that during an epidemic of influenza other infectious diseases seem to be less common. This is particularly true of malarial fevers, if the statistics collected by Anders, of Philadelphia, are correctly interpreted. On the other hand it is very common, and indeed it is almost constantly the case, to find that the illness is due quite as much to associated infection with the pneu- mococcus and pyogenic cocci as to the influenza bacillus. That is to say the infection is usually compound or complex and not single. Thursfield reports two cases of influenzal septicemia, with recovery of both. He believes that the organisms described as the B. infliienzw are not identical but form a group, like the typhoid-colon family, with different pathogenic powers. Lesions produced by the various members of the group include influenza, endocarditis, a septicemic form of cerebrospinal meningitis, septicemia, pertussis, and suppuration in the middle ear and nasal sinuses. Incubation. — ^The period of incubation is probably from twenty-four to seventy- two hours, but in some cases it seems to be longer than this. Symptoms. — The onset of symptoms of epidemic influenza is nearly always sudden. A person feeling perfectly well may suddenly be seized by a sense of chilliness or a severe rigor, followed by severe aching pains in the back and in the legs. There is usually congestion of the nasal mucous membrane, so that the patient seems to have a severe cold in the head. The chill is quickly followed by fever which may rapidly rise to a point as high as 105°, although as a rule 103° is the more common acme. Associated, with these early symptoms there is usually a sense of severe illness and a feeling of great wretchedness, so that the patient not only expresses himself as feeling very ill, but seems so to the physician. About this time the symptoms are wont to be associated with additional ones indicating involvement of certain viscera. Most frequently the respiratory system is affected, and, in addition to more or less intense congestion of the nasal mucous membrane, an acute bronchitis develops; the physical signs in the chest being typically those of acute bronchitis with excessive, unproductive cough and a sense of thoracic soreness. When the nasal mucus is examined it is seen to be unusually thin, excoriating to the nose and upper lip, and if any bronchial mucus is expelled it is also of this character. As the disease progresses the sputum becomes greenish-yellow and thick. The general state of the patient at this time is often one of profoimd depression, 108 DISEASES DUE TO A SPECIFIC I.XFECTIOX far in excess of that which usually accompanies sudi sifjns of hronciiitis. Tiie action of the heart may he frchic and tin- skin is relaxed and clannn.v, or it tna\- he very hot and dry. If convalescence is not soon estahlishcd tlic disease often de\elo|).s into a peenliar form of piilinonari/ conyestidn or pneiiiiionni, in wliich tiie sputum may he hlood- tinged ami frothy or in which no sputum may appear. A peculiarity of this pul- monary invohement, in one of its forms, is the fact that it moves from ])lace to place with remarkahle rajjidity. An area of imijaired resonance which existe(i yesterday is clear today, and still another area of congestion develops elscwhen — a form of wandering congestion. When true pneumonia fle\elops it may he croupous in type and be due to mixed infection hy the bacillus of I'feiH'cT and 1)\- that of true pneumonia, or it may be in the form of bronchopneumonia. The latter type is the more common, but both forms are apt to be .serious and j)articularly so in the feeble, the aged, the very young, and in alcoholic or renal cases. Pneu- monia and heart-failure due to an action of the toxin of the disease on the heart muscle are the chief causes of death in all epidemics. Pleurisy followed by empyema is not \-ery rare. In studying a case of influenza accompanied by pulmonary signs the physician must always bear in mind the possibility of the presence of associated tuberculous infection, because an attack of influenza not onl,\' often predisposes to this disease, but in addition permits unrecognized foci of early tuberculous infection to become active. In some cases of influenza the Jwart seems to bear the chief brunt of the attack so that repeated attacks of syncope ensue. These instances arc met with chiefly among patients who have persisted in remaining at work during the early stages of the disease, or who have had, previous to the attack, an impaired heart muscle. Thus, a heart dilated as the result of excessive exercise may succumb readily, or one in which early but hitherto unrecognized degenerative changes were dtveloi)ing may suddenly fail. Often the symptoms of influenza are chiefly gastro-intcstiiial or nervous. The gasiro-iniedinal form of the disease may have its onset in severe diarrhea and vomiting, with collapse and violent abdominal pain. In some cases the pain is entirely absent, and profuse watery stools are present. Jaundice may be present, due to an extension of the gastro-intestinal eatarrh to the common biliary duct. In the nervous form the symptoms consist of profound 7iervoiis and mental depression, or in severe neuralgic pain which may or may not be due to neuritis. Mental disturbances in the course of an attack of influenza are by no means rare. Indeed, it may be said that no other acute infectious disease is so commonly com- plicated, or followed, by such a condition. Leichtenstern states that he met with fewer p.sychoses among 2()()() cases of typhoid fever and .']()00 cases of pneumonia than he found among 439 cases of influenza. The.se psychoses may be of the exhaustion t\pe, but usually are due to a toxic state induced by the malady. The mental disturbance may develop during the stage of onset, the febrile stage, or the stage of decline or convalescence. The latter cases are usually of the exhaustion ty])e. The prognosis in these cases as to the state of the mind is usually good unless there is a bad history as to heredity. Very rarely men'nujitis develops, and still more rarely true cncciilialitis. The meningitis is primarily due to the influenza bacillus but other secondary organisms are nearly always found at autopsy. It usually occurs in children under one year of age and the mortality is ninety per cent. Lumbar puncture reveals a turbid fluid under high pressure with many leukocytes and an excess of polynuclear cells. In some instances, however, although the meningeal symptoms are most marked during life no definite lesions can be fovmd at autopsy. Particularly is this INFLUENZA 109 true in young children. In other cases extensive hemorrhages into the pia mater may be produced or a sharp perivascularitis in the vessels of the brain may develop. In still others there may develop a chronic perivascularitis which induces permanent palsies. It is usually met with in infants. Cases of cerebral abscess have also l)een ascribed to this disease. In rare cases toxic neuritli develops, and this may be single or multiple. Even paraplegia due to this cause may arise. Not only may this type of influenza affect the nerves of sensation and motion, but specialized nerves such as the vagus, thereby causing disturbances of the circulation such as paroxysms of tachycardia and bradycardia. In an analysis of 29,0(10 cases Lee found that 7000 were of the nervous type. In some instances the disturbance of circulation is due more to an influence exercised upon the vasomotor nervous system than to any direct aft'ect upon the nerve supply of the heart, so that attacks of syncope come on from acute vascular relaxation. Complications and Sequelae. — It is difficult to separate the complications of in- fluenza from the ordinary symptoms of the disease because its natural course presents such diverse manifestations in different organs. Without doubt pulmonary, cardiac, and renal disorders are the most common complications. In many cases death is due to an attack of pneumonia, which rapidly carries off the patient whose vitality is already sajjped by the onset of ki Grippe. In other instances the kidneys, which have been impaired before the attack, suffer from an acute congestion or true nephritis superimposed upon a subacute or chronic state, and so uremia speedily comes on, with its helpmate, pulmonary edema. Patients with influenza develop cardiac complications in three chief classes: either they already have mild cardiovascular degeneration which enables the influenzal toxin to work havoc with the cardiac muscle, or they ha\-e dilated feeble hearts, or, again, as already stated, they persist in remaining at work after the attack begins and refuse to go to bed. These patients not only haxe serious cardiac difficulty during the attack, but very frequently suft'er from cardiac weak- ness and distress for many weeks after convalescence should be well established. The man who persists in remaining out of bed when attacked by this disease, even if mildly ill, literally "takes his life in his hand." In children, as well as adults, severe middle ear inflammation is a very common complication even in mild cases. The German collective investigation of the epidemic of 1889-90, based on an analysis of 3185 cases, gave the following results as to the relative frequency of complications, which results, however, differ materially from clinical experience in America so far as the cardiac complications are concerned: 1. Diseases of the respiratory organs, exclusive of pneumonia, 48.76 per cent. Of these complications pleurisy was the most frequent, being present in 27 per cent, of the entire number of cases. Pneumonia was present in from 6 to 8 per cent, of all cases. 2. Diseases of the nervous system, 45.77 per cent. 3. Diseases of the ear, 37.95 per cent. 4. Hemorrhages, 25.33 per cent. 5. Diseases of the heart and vascular system, 14.09 per cent. 6. Diseases of the digestive organs, 10.36 per cent. 7. Polyarthritis, 7.28 per cent. 8. Diseases of the eye, 7.03 per cent. 9. Albuminuria and nephritis, 4.52 per cent. Diagnosis. — It is so easy to make a diagnosis of influenza during the presence of an e]jiflemic that physicians are wont to be careless in examining the patient thoroughly, and so may overlook complications of importance or decide that the case is one of influenza when in reality the chills, the fever, the aching, and the 110 DISEASES DUE TO A SPECIFIC INFECTION prostration are due to an oncoming typhoid fever or an acute tuberculosis or malaria. All of these diseases, and also ulcerative endocarditis and sepsis, should be carefully excluded before a diagnosis of influenza is made. Treatment. — Above all other things in the treatment of influenza is rest in bed. This is as true of mild as of severe eases and of the patient who is stalwart as of the patient who is feeble. A robust man who fails to rest almost always suffers from a severe attack or from sequelte, such as cardiac disorder and giddiness, which may invalid him for weeks. Aside from rest in bed little medicine is needed except for the purpose of relieving symptoms which are troublesome. For the relief of the excessive pain in the back and limbs the coal-tar antipyretics have been employed by the ton. Although they give ease they are harmful if the doses are large, and often fail if they are used in moderate amounts. They tend to increase nervous and circulatory depression, and to decrease the ability of the patient to resist the infection from which he is suffering and the possible secondary infections which may occur. If the patient will rest they may be used moderately; if he will not rest they should not be used, for they not only do harm directly, but by diminishing discomfort they also enable and encourage him to remain out of bed. A very useful drug for the relief of the aching and pains in the back and limbs is salicin in 5 grain doses every five hours in capsules. Many practitioners believe that this drug alone, or when combined with .3 grains of cinchonidine, acts as a specific in the cure of the affection. Should the pain in the back be intense it may be relieved by the application of hot stupes or compresses, or by rubbing with soothing liniments. A more ancient but nevertheless very useful remedy for this condition, jiarticularly in the early stage of the malady, is Dover's powder in the dose of from 2 to 10 grains once or twice a day. At one time used as a matter of routine in all infections, it has fallen into an undeserved disuse. Headache, if it be due to congestion, may be modified by the use of an ice-bag, or by the administration of 1 to 2 grains of caffeine with 10 grains of bromide of sodium or potassium every few hours. This formula can be given in the form of an effer-\-escent granular salt without the use of the coal-tar products often added by manufacturers of headache cures. Hot foot-baths also decrease headache. Menthol pencils may be used locally for neuralgia or a spray of chloride of ethyl may be used for the same purpose. As in all infectious maladies, it is of the greatest importance that the organs of elimination be kept active. The bowels may be first moved by a grain or two of calomel, followed in twelve hours by a Seidlitz powder, or, if constipation has been marked, they may be opened at once by citrate of magnesium. For the purpose of keeping the kidneys active 5 grains of citrate of potassium or of bicarbonate of potassium may be given every four hours in copious draughts of water if the urine is acid, or the same amount of benzoate of ammonium if the urine is alkaline. The latter drug is best given in konseals, and possesses the additional advantage of acting favorably upon the respiratory mucous membrane and upon the muscular pains. A hot compress or poultice applied over the loins will often establish renal secretion when it seems scanty. Dryness and soreness of the mucous membrane of the respiratory tract, in the stage of onset, may be much relieved by telling the patient to inhale steam which may be medicated by the addition to the water from which it arises of a few grains of menthol or of equal parts of menthol, oil of eucalyptus, and oil of pine. In other instances the patient may add to the boiling water a tablcspoonful of com- pound tincture of benzoin. The medicated steam may be taken directly from an inlialer or the vapor may be set free in the air of the room by the use of a bronchitis kettle. When the nasal mucous membrane is so congested and occluded that breathing is difficult and oppression is marked, adrenalin chloride, 1 : 5000, with chloretone may be sprayed into the nostrils or applied on pledgets of cotton. It ACUTE POLIOMYELOENCEPHALITIS 111 loses its effect if applied too often, but it does not do so as rapidly as does cocaine, nor is it dangerous in its systemic efl'ects. For the relief of the congestion of the respiratory mucous membrane, when the illness has lasted for several days and the secretion is thick and tenacious, chloride of ammonium in 5 grain doses four times a day may be administered combined witii codeine or heroin to relieve cough, or terpin hydrate may be used with the same sedatives in the form of the well-known elixir of terpin hydrate with heroin. For the persistent cough of convalescence, oil of sandal-wood in 5 minim doses four times a day is very useful. Circulatory and nervous stimulants are not to be used unless there is distinct evidence of their need. Alcoholic drinks are as a rule to be excluded, unless the patient uses them habitually when well, when they have to be given, preferably in the form of an old brandy or good whiskey. Great care must be taken that the patient does not overuse them in his endeavor to make himself feel stronger. For acute circulatory failure aromatic spirit of ammonia or Hoffmann's anodyne are the remedies of choice. When the failure of the cirulation is associated with nervous depression the use of strychnine is indicated, but it is greatly abused and should not be given day after day except as a tonic in convalescence, as it loses its power, is not a true stimulant but a nervous irritant, and often causes great irritability if not employed skilfully. As influenza is a disease which produces great prostration, a diet which is easily digested and nutritious is essential for the maintenance of strength, particularly in the very young, very feeble, and very old. Animal broths, oysters, and predi- gested foods are useful, and they may be fortified with advantage by barley-gruel, the digestion of which may be aided by the use of taka-diastase. Indeed, the various vegetable gruels with taka-diastase are in many cases better than the animal broths. Arrowroot and milk-toast and eggs are also useful. Prophylaxis. — ^There can be no doubt that much can be done to prevent the spread of la grippe from one person to another by isolating the ill and by forbidding healthy persons to occupy the sick-room after it is vacated, until it is thoroughly disinfected. This is particularly advisable when the old and feeble are about the house and when persons who are still weak from one attack are exposed. Every effort should be made to keep the malady out of the non-medical wards of hospitals, insane asylums, and almshouses. Patients in these institutions when taken ill should be isolated, and the bedding, napkins and handkerchiefs be promptly disin- fected. The sputum should be expelled upon pieces of rag and then burned. All rooms, clothes, and books used by patients suffering from influenza should be disinfected as carefully as if the patient had suffered from some more fatal malady. ACUTE POLIOMYELOENCEPHALITIS. Definition. — This infectious disease is sometimes called infantile spinal paralysis, because it most commonly presents spinal symptoms. It is also called acute infantile palsy, and acute atrophic paralysis. In its spinal form it is characterized by fever and sudden loss of power in one or more of the limbs, most commonly the lower extremities. As a rule, the loss of power is complete, but occasionally it is local- ized in certain groups of muscles. Immediately after the development of the paralysis, wasting of the muscles begins to take place and may be extreme. There is no disturbance of sensation. Etiology. — Within recent years it has become more and more evident that acute anterior poliomyelitis is due to an infection. That the disease at times occurs in epidemic form was noted by Colmar more than sixty years ago. Since 1907 out- breaks have occurred in many widely separated States of the Union, in Canada, 112 DJSI'JASl'JS DUE TO A SPECIFIC ISFECTKiS Fia. 28 aooo 8000 roco cooos; o jOOOu. o 4000 01 s :j(iOoi 21)00 11)00 ^ 1SS1-1S93- -isoi-iaoi-*" 02 "Oi '00 'OS "10 RuUitivu prevalence of infantile paralysis in the United States and Europe and Australia, ISSl -I'JIO. The solid black line refers to the United States; the dotted line to the following countries: Itiily, Sweden, Norway, Germany, Austria, France, England, and Australia. Part of this increase is due to better recognition. (Lovett.) Fig. 29 B . — .^ \\Vz\\':-:-^W- z- - x^. h----^P ::::::::+:.. ^ :-^ :^5i , ^ T.-T i "■^^■' ■■ 1 :jxr ■fl iiiitB"ftii"i^"'*^ ,_■■■ III PfWPPNri I i i: : : ^. ^ .; i; ^ || ^ '^'t i' '■' : :■' ' M ''Uh'.r ving graphically, age incidence of 1076 cases of poliomyelitis recorded in 1910. (Department of Health of Pennsylvania.) ACUTE POLIOMYELOENCEPHALiriS 113 Cuba, Austria, Germany, and Melanesia. In the last decade its occurrence has greatly increased in ail parts of the world. Flexner and Noguchi have grown the virus outside the body anaerobically. It developed in minute colonies of globoid bodies (0.15 to 0.3 microns in size). These cultures are capable of causing the typical disease in monkeys. It is killed by 1 to 500 of potassium permanganate or 1 per cent, of menthol in oil. The biting stable-fly (Siomoxys calcitrans) has been accused of transmitting the disease but this has been denied. House flies undoubtedly carry the infectious agent on their bodies. The disease is distinctly one of early child life, the greatest number of cases developing in the first three years of life, it being comparatively rare after the tenth year (Fig. 29). It is far more apt to develop in the summer than in winter, and has its greatest incidence in July and August. After this season it is most frequent in September and in June. The period of incubation may vary from two days to tliree weeks. One attack protects to some extent from another. The infection probably is spread by the nasal secretions of those who are convalescent or who act as "carriers." a. spin, post a. spill, post Dots show chief areas of disease in acute poliomyelitis. Prevention. — Patients in the acute stages should be isolated and their nasal discharges destroyed. They should be protected from flies which may carry the disease for at least two weeks. Kling found the virus in the nasal discharges, how- ever, six months after the illness. Dust should be avoided and the tliroat gargled with a 1 or 2 per cent, solution of hydrogen peroxide or treated by a spray of menthol in oil, 5 grains to the ounce. This may also be used in the nose. Urotropin may be given in 5-grain doses, i. e., as a prophylactic. Patients suffering from the disease should be quarantined for three weeks after the acute symptoms cease. Pathology and Morbid Anatomy. — As Flexner and his colaborers have well put it, epidemic poliomyelitis is a general disease of the nervous system, although the most prominent and important symptoms are those following injury to the motor neurones of the spinal cord and brain. The essential lesion of this disease is an acute inflammatory process in the anterior cornua of the spinal cord, with 114 I)/SKASr':S DUE TO A HI'Kcnnc INFECTION associiitwl liNpiTfiiiiu of tlie inenihraiK's cox criii}; tJio anterior .surface of the cord. Tlie branches of the anterior si)in:il artery (Ki}?. 130) hear the brunt of the attack and are intensely engorfjed. Their finer brandies are ruptured so tliat extrava- sations of blo(Kl take place into the gray matter. As a result of these changes the typical jjicture of tissues suffering from an acute inflammatory process is presented, for serum, leukocytes, and red cells crowd the nervous protoplasm. The ganglion cells of the gray matter in the anterior horns undergo marked degen- erative changes. They undergo cloudy swelling and the nuclei become granular, or if the change is still more severe the nuclei disappear and the neurones lose their dendrites and become \-acuolated. As a final stage the cell undergoes shrinkage, becomes a small, granular mass, and finally disappears. The damaged areas, in old cases, are occupied by connective tissue and are much shrunken, so that the affected gray horn is much smaller than its fellow. The anterior nerve fibres, which have their origin in this part of the cord, also atrophy. Associated with these changes in the anterior cornua of the cord there is often some involvement of fibres in the anterolateral tracts, because, it will be recalled, some of the fibres, or axones, which leave the anterior horns pass upward and downward in these columns to enter the anterior horns above and below to associate their function, and it is also due to the inflammatory process extending into the white columns. The degree of the inflammatory process in the gray matter ^•aries very greatly in difl'erent cases and may involve the cells supplying but a few muscles. It may affect chiefly that part of the gray matter which is most anterior or that nearer the commissure. In rare cases it would seem probable that no true inflammatory process develops in the cord, but that simple degenerative changes occur in the neurones in the anterior horns. Symptoms. — The symptoms of acute poliomyelitis of the mild form usually take the following course: A child in good health has a restless und fere r is It nKjhi, and seems on the next day to be somewhat out-of-sorts. In the course of twent\'- four or forty-eight hours it not infrequently happens that the parents consider the child recovered from its acute illness, and it may be some days or weeks before the mother notices that one or both of the lower limbs are lacking in power. Xot rarely it is found, as the child sits in its mother's lap, that one leg moves while the other hangs like a flail, or the mother notices that the child is unable to push its leg into its clothing as efficiently as it could do before it was taken ill. These may be considered as the symptoms of a comparatively moderate case. There is usually marked leukocytosis chiefly of the lympliocytes. Spinal jjuncture gives a fluid containing an excess of cells nearly all of which are lymphocytes. In the earlier stages the mononuclear cells may be in excess. In instances in which the onset and course of the malady is more severe, we find that fever is cjuite marked, often rising as high as 102.5°, and continuing at this point for several days. Occasionally, at onset, it may reach as high as 103°, and with this febrile movement there may be headache, loss of appefite, and romitiini. Sometimes diarrhea occurs. In these instances the manifestatioii of loss of power is usually so marked that its presence is recognized within a few hours of its onset. Even in these cases, however, it not infrequently happens that the child is supposed to ha^•e suffered from an attack of acute gastric catarrh or indigestion until its inability to make certain movements calls attention to the palsy. Occasionally pain is a symptom of some importance, if, as already pointed out, the lesions in the anterior horns extend sufficiently backward to involve some of the sensory fibres beyond the commissures. These pains are usually felt about the joints. In some cases they come on not as a symptom of onset, but as a sequel, and seem to be due to an associated neuritis. At times a fine fibrillating tlirill is seen in the muscles about to be chiefly affected. The degree of the parlilysig varies greatly in different cases. In some instances ACUTE POLIOM YELOENCEPHA LITIS 1 1 5 only one or two muscles seem to he affected. In others, the whole linih may be paralyzed, or both lower limbs and one upper limb may manifest loss of power. Even when the paralysis is quite widespread, it is rare for the cranial ner\-es to be affected, and equally rare for the sphincter muscles to lose power. There is still a third type of case in which crmindsions appear at the time of onset. This type is described as polioencephalitis. These convulsions may be cerebral or epileptiform in character, and may be followed by deep coma lasting for many hours. A fourth type presents a very typical picture of cerebrospinal men- ingitis arising from the diplococcus of Weichselman. Paralysis may not be present, but there is marked headache, \omiting, pains in the back, rigidity, and Kernig's sign. Later, if life persists the paralysis becomes noticeable. In other instances a child in preA'iously good health develops fever more or less severe. There may be headache and ^'omiting without the onset of convulsions. In some cases it passes into stupor. In other instances it is delirious and exceed- ingly irritable with excessive hyperesthesia. Kernig's sign is marked. Ocular palsies may be present, even with or without facial palsy, unilateral or bilateral. If the patient recovers consciousness returns, the signs become normal, but on attempting to let the child stand up he suffers from vertigo and ataxia. In some instances marked symptoms of hydrocephalus develop. Not infrequently in these cases, after recovery from the acute illness is established, there remains strabismus and sometimes tliere is dimness of vision which may progress to com- plete blindness. Very remarkable recovery from this blindness, howe\-er, some- times ensues. In those cases of the cerebral type which closely resemble tuber- culous meningitis, facial and ocular palsy, without Kernig's sign, accompanied by complete muscular relaxation and Cheyne-Stokes respiration, occur, ^^hile death frequently takes place in these cases a surprising number survive. In some instances the disease seems to be progressive in its type, the full degree of paralysis not developing at once, but beginning in one part and then spreading to adjacent parts. Rarely one attack speedily follows another, involving a dift'- erent set of muscles. In ^•e^y rare instances the paralysis ma>' de^'elop without any history of the symptoms of onset already described. Cases are on record in which the paralysis has been almost universal, but it is a noteworthy fact, in regard to the paralysis of acute poliomj'elitis, that it is far more widespread in its early stages than later on, this being due to the fact that as the inflammation subsides certain cells which have not been irreparably damaged regain part or all of their functions, and so adequately supply the muscles under their control, or collateral muscles supply the power needed. Occasionally the onset of the symptoms may resemble Landry's paralysis, since the paralysis starting in the lower extremities speedily travels upward and may produce grave respiratory difHculty through interference with the diaphragm. The bulbar type may cause rapid death and paralysis of the cranial ner\-es. Rarely the symptoms are those of a polyneuritis. Wickham has classified the type as follows: 1. Ordinary spinal paralysis, anterior poliomyelitis. 2. Progressive paralysis, usually ascending, less often descending; Landry's paralysis. 3. Bulbar paralysis; polioencephalitis of pons. 4. Acute encephalitis, causing spastic mono- or hemiplegia. 5. Ataxic form. 6. Polyneuritic form. 7. Meningitis form. 8. Abortive form. The period of recovery usually extends from one to three months. The muscles 116 DISEASES DUE TO A SPECIFIC INFECTION wliicli I'ail to recover soon lose their contractility to faradism and tlien to galvanic electricity. Tlie loss of faradic responses may be present as early as the eighth or ninth day, but in other instances some response is maintained, for a number of weeks. At the end of a few weeks the reactions of degeneration are observed. As would be expected from the lesions already mentioned and described when discussing the pathology of the aft'ection, sensation is usually unimpaired. Keflex activity is, of course, diminished or lost because of the spinal lesions and the atrophy of the muscles. As secondary lesions to the paralysis we find shortening of the muscles with consequent contractures and deformities. The legs are affected more frequently than the arms in the proportion of '.] to 1 . The muscles below the knee suffer more frequently than those above the knee, and the tibial and peroneal muscles suffer more frequently than those of the calf. Lovett and Richardson found the proportion to be one leg, 27.97 per cent.; both legs, 2.3.48 per cent.; back, 23.29 per cent.; both arms and both legs, 11.13 per cent.; one arm only, 7.25 per cent. In the forearms the supinators usually escape, but the deltoids suffer more frequently than any other muscles in the upi)er extremity. Diagnosis. — ^The acute poliomyelitis of childhood is usually readily diagnosed. Care must be taken that the muscular pains when they occur are not thought to be due to rheumatism. None of the other spinal lesions of childhood have such a characteristic onset, but postdiphtheritic paralysis and multiple neuritis due to lead or arsenic may produce similar symptoms although their onset is not so sudden and there is no fever. The meningeal type must be separated from cerebrospinal meningitis by an examination of the cerebrospinal fluid which in the latter disease is turbid and contains the diplococcus and an excess of polynuclear cells. From tuberculous meningitis it is differentiated by the aid of the von Pirquct and Moro tests, by the finding, very rarely, of the tubercle bacillus in the fluid and by the possible disco\-ery that the child has been exposed to tuberculous persons. Pueu- mococcic meningitis must also be considered. Prognosis. — This is usually good so far as life is concerned, although if the at- tack has been severe, vital resistance may be so diminished that other affections may readily cause the death of the child. The degree of ultimate paralysis can be determined only after two or three weeks of careful observation, when some idea as to the number of muscles which may recover can be obtained, particularly if electricity is used to determine the electrical contractility of the aft'ected muscles. The percentage of complete recovery after the attack is usually reckoned at about 2.5 per cent. Treatment. — In the treatment of acute poliomyelitis little can be done in the way of directly combating the disease. The ciiild should l)e put at absolute rest in a quiet and darkened room. Sweet s])irit of nitre and citrate of potassium should be given in small and frequent doses to diminish fever and to cause mild perspiration. The use of as large doses of hexamethylcnamine as the stomach and kidneys will stand (10 to 30 grains a day) inhibits the growth of the infection in the nose and tends to protect others, but can do little good to the patient already stricken. Hot applications have been recommended to be appliecl to the back. It is diflficult to understand how they can be of much \aluc. Some mild counter-irritant over the spine, such as a spice plaster, or a ])epper plaster, may be advantageous. The whole object of the physician must be to iiroduce nervous quiet and aid in diminishing the inflammatory process in the cunl by avoiding excitement of the nervous system. After the acute stage of onset is past, and the paralysis is present, that is to say, after sufficient time has elapsed for the acute stage of the inflammation to have passed by, or, in other words, in three or four weeks after onset, moderately large doses of strychnine may be given, but care must be taken that the doses are not so DENGUE 117 large as to produce twitching or great nervous irritability. At this time, too, tlie slowly interrupted faradic current may he applied to the paralyzed muscles, and particularly to those whicli are semiparalyzed, in the hope that in this way their nutrition may be maintained. It must not be forgotten, however, that the greatest care must be exercised that the muscles are not overfatigued, since if they are exhausted they will more rapidly atrophy than if no electricity was employed. If electricity is used before the spinal cord has recovered from the acute stage of the inflammation, it will make the condition worse. In many instances it is advis- able to use electricity on one day and careful, gentle massage on the next. The" electrical current should never be employed in such strength as to give the child pain or distress. As general tonics for the nervous system the hypophosphites, glycerophospjiates, cod-liver oil, and iron may be used. Should any tendency to deformity take place, this must be treated by the methods commonly resorted to by orthopedic surgeons. Rapid recovery should not be expected in these cases. Careful treatment for months is necessary to get the best results. DENGUE. Definition. — Dengue is an acute infectious, but non-contagious, usually epidemic fever, which is probably dependent for its development upon the presence of some specific organism the exact nature of which is still obscure, although INIcLaughlin and Graham believe that they have succeeded in isolating it. The disease is characterized by two febrile attacks with severe pains in the muscles and joints. Because of these latter symptoms it is often called "breakbone fever," and from the peculiar gait caused by this condition "dandy fever." A large number of other popular names have been given it, such as "three-day fever," "bouquet fever," or sometimes, as a corruption of the last name, "bucket fever." History and Distribution. — The earliest accurate description of dengue that we possess is that of Brylon, who described the outbreak of 1779; later the celebrated epidemic in Philadelphia, in 1780, was described by Rush. Since then it has occurred in a considerable number of epidemics in various subtropical parts of the world such as Batavia, Spain, India, Bermuda, Brazil, the West Indies, and in various parts of the Southern United States. Within twenty years it has also visited Turkey, Greece, Fiji, and Tripoli. It is distinctly a disease of warm climates, and, so far as I know, has never been met with north of Philadelphia. The disease spreads from point to point along lines of travel, being carried by infected individuals and perhaps by clothing. A peculiarity of dengue is the rapidity of its spread and the few people in a com- munity who escape its attack. In this respect it surpasses epidemic influenza. No age, sex, or race escapes, and in an incredibly short time after the first case is seen a multitude may be down with it. As Manson well says, it "bursts" upon a place. The spread of an epidemic is always arrested by the appearance of cold weather. High altitudes are also unfavorable to its spread. Etiology. — As the result of valuable researches carried out by Ashburn and Craig and by Vedder of the United States Army in the Philippines, in which they observed over six hundred cases, they conclude that the disease is not contagious. They also assert that no organism, either bacterium or protozoon, can be demon- strated in either fresh or stained specimens of blood with the microscope. The red blood count in dengue is normal. There occur no characteristic morphological changes in the red or white cor- puscles in this disease. Dengue is characterized by a well-marked leukopenia, the polymorphonuclear 118 DISEASES DUE TO A SPECIFIC INFECTION leukocytes heiiij^ flecrcased, as a rule, while tliere is a inarkcii increase in the small lynipliocytes. The intravenous inf)culati(jn of unfiltercd (lenj;iie Mood into healtiiy men is followed by a typical attack of den<];ue. Graham, of Beyrouth, believes that tiie infection is conveyed by the moseiuito, the Ciller fasliiiaii.i. In several instances (iraham ])laccd persons sufl'erincc from dengue in apartments in which all mosquitoes liad been destroyed by chlorine gas, and allowed healthy individuals to associate with the sick. In no case of this kind 'was the disease contracted. In addition to this negative evidence Graham offers positive evidence, which he obtained by allowing mosquitoes which had bitten affected persons to bite two healthy individuals who resided in a district where no cases of dengue were present. Both of these men developed the disease, one on the fourth and the other on the fifth da>' after they were bitten. They were kept under mosquito nettings until they had completely recovered and the infected mosquitoes were all killed. No other cases of dengue occurred in the village where these experiments were made. That mosquitoes convey the disease is belie\'ed by Ashburn and Craig from their reseraches in the Philippines. Symptoms. — Dengue is characterized by a train of symptoms which is quite remarkable. In the first place, the suddenness of its onset is noteworthy. A patient may be in perfect health at one hour and sick in bed with well-de\-eloped symptoms the next. In any event the onset is sudden, and sometimes it is ushered in by a chill or by pains in the limbs. Fever rapidly develops and may reach as high as 106° or 107°, but usually the acme is 103° to 105°. There is intense headache and the pains in the limbs are so excruciating that the term "breakbone fever" is well applied. The discomfort of the patient is increased by the pain caused by moving the body. The tongue is usually heavily coated, and nausea and vomiting may be distressing symptoms. With the onset of the fever there develops a rash which is of the nature of erythema. In from one to three days, usually two days, the fever suddenly ends by crisis and simultaneously the patient not only sweats freely, but also has free diuresis, diarrhea, and nosebleed. This nosebleed, by relie\ing the cerebral congestion, greatly decreases the headache, and the rash rapidly fades. In other instances the fever gradually falls by lysis, but this is less common than crisis. The fever having fallen to normal the patient, still feeling weak, is able to be about, although he suffers from twinges of pain in the joints and muscles, w'hich impress upon his mind the fact that he is as yet ill. After a remission of several days, usually from two to four, the fever returns with some violence, but it is rarely as severe as in the primary paroxysm, and it usually lasts only a few hours. With the appearance of this secondary fever a roseolous rash develops, and with its development the patient may have a return of his bone and joint pains to a very severe degree. Although the fever soon disappears the rash lasts for several days and may end in a slight desciuamation. Taking it all in all, the secondary attack is usually much milder than the first. The rash of the second attack is roseolous, and is peculiar in that it is usually first seen on the hands, both in palmar and extensor surfaces, and thence rapidly spreads to the entire body. The spots are as large as a pea, circular in appearance, dusky red, and ])erhaps elevated. As the disease progresses they may coalesce, leaving patches of healthy skin between. This rash is more apt to be profuse and to coalesce around the joints than elsewhere. The roseola fades as it begins, first on the hands, then on the arms and body, and lastly on the legs. The desquamation may last for weeks, but it is so fine that it may be overlooked. The skin never peels as after scarlet fever. In some instances the patient passes on to rapid convalescence after the terminal or roseolous rash fades, but in others he remains DENGUE 119 miserable for a long time from wandering pains in his joints or in the soles of his feet. The muscles are sore on pressure and stiff on moving after a long rest, and (]el)ility may be persistent. In some instances insomnia or furunfiilnsis delays complete recovery. In certain epidemics there is sufficient degree of swelling and redness about the joints to suggest the presence of acute rheumatism. Relapses of dengue occur not infrequently. Diagnosis. — Dengue may be separated from rotheln, which it resembles during the period of its secondary rash by the lymphatic swellings of the latter disease. The differentiation is also accomplished by the sudden severe onset and the pain in the joints. It is distinguished from scarlet fever by the lack of sore throat and })y the peculiar scarlet hue of that disease, and from syphilitic ro.seola by the absence of a history of venereal infection, and the fact that associated symptoms of the early secondary stage of syphilis are absent. On the other hand, it is to be recalled that many syphilitics, with the onset of the roseola of that disease, suffer from a chill and general wretchedness, with pains in the bones. Influenza is sepa- rated by the absence of catarrhal symptoms and by the presence of the rash in dengue. Acute articular rheumatism and malarial infection are two other diseases which must be borne in mind when the diagnosis of an individual case is in question. Prognosis. — The prognosis in a case of dengue is always favorable if the patient, prior to the attack, is in good health, and not debilitated by some other malady or old age. Death may be said not to be known as a result of this malady in ordinarily healthy persons. Convalescence, after a se^-ere attack, is, howe\-er, very often quite slow, and if the patient is living in a hot climate reco\'ery may not be complete until a change of residence is made. When dengue attacks the aged and feeble, or very young children, it sometimes indirectly causes se^-ere illness and death by predisposing the patient to other infections so that there develops a severe bronchitis or bronchopneumonia, or some other cA-idence of another acute infection. In such cases the prognosis depends chiefly upon the character of the secondary ailment. Treatment. — In discussing the treatment of this disease it is to be recalled that it presents very different degrees of severity in different cases. In many persons the symptoms are so mild that the patient seems scarcely at all ill, and in others the manifestations are so severe that convulsions and unconsciousness may be present. In the mild cases no drugs are needed, but in the severe cases active treatment may be essential. In general terms it may be stated that the treatment of the patient suffering from dengue consists in absolute rest in bed from the earliest stage of onset till the conclusion of the second stage of fever. Indeed, the longer he will consent to rest in bed after the fever develops, the more rapidly will complete convalescence be established. So far as drugs are concerned, there are no specifics for this disease, which, if permitted, will usually run its own self-limited course to recovery. When the pains are intolerable they may be controlled by moderate doses of morphine given hypodermically or by the use of acetanilid or phenacetin. A gentle antipyretic and sedative mixture, containing 5 grains of potassium citrate and 30 minims of sweet spirit of nitre in a dessertspoonful of water, is useful to keep the kidneys active. An ice-bag may be applied to the head to relieve the cephalalgia, and if the face is very much flushed, and the head throbs a hot foot-bath is advisable. Some- times a hot bath is useful to develop the rash and relieve the pains in the body and limbs. In these cases the salicylates may also be used for the same purposes, 10 grains of sodium or strontium salicylate, or of aspirin, being given every three or four hours. When the circulation is strong and full McLaughlin asserts that large doses of tincture of gelsemium serve to quiet the excited pulse and to relieve the neuro- 120 DISEA.SES DUE TO A SPECIFIC INFECTION muscular pains. The dose he recommends, namely, 20 to 30 minims every three or four hours, seems to the writer much too hirgc and capable of causing serious depression; but as McLaugliHn lias had large experience with the disease, his views demand respectful attention. The fc\er is rarely sufficiently liigh or pro- longed to require treatment. Should it require attention tejjid spongings are usually sufficient to control it within safe limits; but should it reach as high as 105° or more, then it must be reduced by cold spongings, or even by the use of the cold bath, with active frictions. Should nervous symptoms be very manifest and convulsions be threatened, chloral should be given in the dose of 5 grains by the mouth, or 10 grains by the rectum, if the patient is a child, and bromide of sodium added to aid it in its sedative action. The patient should be urged to drink water freely, if his stomach will retain liquids, in order to keep his kidneys active in eliminating the poisons of the di.sease. When the stomach is not retentive a pint of cold water may be gi\'en by the rectum every eight hours. Should diarrhea be troublesome it can be best controlled by giving castor oil to cleanse the bowels, following it by opium. MENINGOCOCCIC MENINGITIS. Definition. — Meningococcic meningitis, cerebrospinal fever, sometimes called "cerebrospinal meningitis," "spotted fever," or "petechial fever," is an acute, often malignant, infectious, but rarely contagious disease, due to the diplococcus of Weichselbaum, which is sometimes called the meningococcus or the Dipling-cough. This is an excess of 382 pneumonia deaths o\er the deaths from all the other preventable diseases— 1570, or 118.8 per cent., more than the deaths from consumption, and 1G53 or 133.5 per cent., more than those from the other specified diseases. 6400 5200 ,5000 4800 4000 4400 4200 I ; 4000 \ / asofl 1 1 .SfiOO k / 3400 \ / .. in addition to tlie changes already described, lenkoeytes hecome ahvnidant, l)a > ^ \ - \ \ - "- ; • I \ \ \\ I -i:-3:EEr-±^^±^^EE^± zt ''''W-^^±: 1- -~-o^--H- — '-- ' -■ '■ -* --'- - - -'- -' i-i--" 1 ■ i « '. . i ' ., , ■ ■..■.,'., , , ■ ^ Y -•-;- * „ 1 "■' ^s.A;._... 5- . - - . s-S- «~3--S 1 "■ ' '— ' \ ■ : ■ ., 1 !- -+- ■' iTi^i- ?-'- ---T- -5'! s^^n ' ^ -.' -1 ..::;.. *^y\ :.',■,.:,:= ,i :, i= . j:;.^! ::ii^ij:s:ji:i.!^ =t:± o ^- ^. • A ■ - .. • ■-■ A'A'/ ^\^A^-\--^2-- ^-^ ^- — ' — ' — ' °' '' \'^\K\TltT\\ '^"^^'^ ^ " 0"° V V V - ^ ■ y = V ' I ?■ ^. I -- *■ 2 -, ^ , » = _ ^ 1 _ L_ S: Vi 1 j 1 j i" \ -1 . S- S- S ;,i-i! ; '. ■:. -t-S—^ Si i 1 S, 1 \- = = ' A ' ^ -' ""^ 1 V.' '^ *^ \ 1- ^Fi 1 M ' N 1 ' fl o!sEA°se " -^ ■= = t- » PULSE s*$ •?:(.> f^ -J-"^). f^ -»\^; vtjC s*ic. -S?-^ «-V s*j.J N-O^vS ". In some instances the ixtralysi.'i i.s vumopJcqic, and this is well illustrated by a case descrilied by Boulloche in a patient thirty-two years of age, who from the onset of the disease, was delirious and who presented a typical right-sided croup- ous pneumonia. Paralysis of the right arm and right side of the face was dis- covered upon the sixth day of the disease. IMovements of the right leg were entirely retained. There was aphasia, but no loss of consciousness, neither was there any disturbance of sensibility; twelve days later the fever had subsided, the aphasia had diminished considerably, and the muscles of the face were less drawn. Sensation in the pharynx returned and a day later the aphasia disapjDeared. The facial paralysis passed ofi'; the relative strength of the two arms showed only a decrease of 10 degrees in the affected side, and at the expiration of twenty days the monoplegia had entirely disappeared. Tran.iiinrij aphasia is a comiiliciition reported by Chantemesse. This observer has found that aphasia usually occurs about the second or third day of the disease, , that it is ordinarily preceded by headache and giddiness, e\en to the verge of syn- cope; in some cases numbness or a sensation of pricking in the right side of the face and right arm is experienced; in other cases it may set in abruptly without loss of consciousness or become manifest after a typical apoplectiform seizure. The CROUPOUS PNEUMONIA 143 characteristics of the speech impairment do not (litter from those (Jepen- increase the tone of the vessels. This treatment, however, is rarely instituted before the fifth or sixth day, or at the ai)i3roach of crisis. If cardiac failure is the result of cardiac dilatation due to the obstruction of the flow of blood through the lung, digitalis may be ad^"antageous, but when CROUPOUS PNEUMONIA 149 the cardiac weakness is due to toxemia it is probahly of little value, and ii a clot has formed in a cardiac cavity it is manifestly useless. Sometimes when the fever is high and digitalis fails to act, it is well to aid its effect by c|nieting the heart through the application of an ice-bag placed upon the precordium. I have also known the reduction of temperature by the local ajjj)lication of the ice-bag and by cool sponging of tiie body, with friction, to be followed b\- the manifestation of a distinct digitalis influence. If moderate doses of 5 to 10 minims of a physiologic- ally tested tincture, three or four times a day, fail to produce good effects under these circumstances, I feel quite confident that larger ones will not be of any value. Should sudden collapse come on, a hypodermic injection of strychnine and atropine should be given, and it may be wise to introduce under the skin, by hypodermoclysis, a pint of normal saline solution. The normal saline solution, under these circumstances, cannot do much good directly because the relaxation of the bloodvessels is so great that even if it is absorbed its influence will not be felt, but it forms a reservoir from wdiich it will be slowly absorbed and so flush the kidneys. The value of saline infusion also depends upon the degree of toxemia which is present and upon the activity of the kidneys. If, in a given case, the urinary secretion is scanty and toxic symptoms develop, a pint of normal salt solution may be given by hypodermoclysis every six or eight hours for twenty-four hours with advantage. If, on the other hand, the pneumonia complicates renal disease, and there is any tendency to edema of the subcutaneous tissues, this method of treat- ment may be disadvantageous, in that it tends to increase the dropsy, and perhaps increase the tendency to pulmonary edema. As marked toxemia is usually asso- ciated with renal inactivity, this method of treatment should be borne in mind. Direct infusion of a saline solution into a vein is probably not advisable in the majority of cases, since it is usually absorbed with sufficient rapidity from the subcutaneous tissues. When the skin becomes relaxed and bedewed with sweat, atropine is often a life-saving drug. In cases in which the heart is laboring, where there is evidence of dilatation of its right cavity with pulsating jugulars and other evidences of venous stasis, free venesection may be practised with advantage, and sometimes gives wonderful relief; but in cardiac failure without these signs of venous obstruction, venesection is practically of no value whatever. The value of inhalations of oxygen gas is problematical. I always employ them because they seem to give comfort both to the patient and his friends. The oxy- gen should not be given through an inhaler, but be allowed to escape, through the opening of the rubber tube or glass nozzle, about the lips or nose of the patient, for the ordinary individual who is suft'ering from dyspnea in this disease will not permit one of his nostrils to be blocked or his mouth closed by such an inhaler, as his desire for ordinary air is too great. If the dyspnea is due to toxemia the oxygen is probably useless. If it is due to a large area of the lung being inca- paciated by consolidation, it is conceivable that oxygen can do great good. The treatment of the fever during the course of croupous pneumonia is not of as great importance as it is during the course of a more prolonged malady, like typhoid fever. Indeed, there is some evidence to show that fever within moderate bounds may be an efl:ort on the part of the organism to protect itself from the infecting germs. If the temperature does not exceed 102.5° to 103°, antipyretic measures need not be instituted, although sponging the patient with tepid or cool water three or four times a day will control the temperature somewhat, allay peripheral nervous irritation, keep the skin clean, and often produce sleep. These spongings are, therefore, useful in the ordinary case of pneumonia with a tem- perature of 103° or more, but they are not to be carried out with the same vigor, 150 DISEASES DUE TO A SPECIFIC INFECTION cither as to the activity of the rubbing or degree of cold, as is employed in typhoid fever, for the temperature, as a rule, does not resist the cold, and if it is ajjplied too freely the patient may be thrown into collapse by a sudden fall of fever. Nearly every case of acute pneumonia will be benefited if an ice-bag is kejit a])plied to the head, and if the action of the heart is very rapid when the fever is high an ice- bag over the prccordium, is often advantageous. The administration of antipyretic drugs to patients suffering from ])neinnonia is alisi)lutely inexcusable. In the first place, antii^yresis by drugs is rarely if ever needed. In the second place, there is overwhelming clinical and cx]jcrimciital evidence to show that the use of these drugs materially diminishes the vital resist- ance of the patient, decreases the ability of his blood to convey oxygen to his tissues, reduces its ability to destroy infecting micro-organisms, lowers vascular tone, depresses the heart, and is altogether evil in its influence, probably also diminishing the elimination of toxic materials by the kidneys, and certainly giv- ing these organs the additional labor of eliminating the antipyretic drug, which, ])erchance, may be irritating to them. Quinine is employed by some practitioners with the idea that it possesses specific as well as antipyretic power, and there is no objection to its use in small doses; large doses, which produce cinchonism or irritation of the stomach, are value- less, and may do harm by irritating the stomach, producing cerebral congestion and meningeal irritation, or irritating the kidneys. When croupous pneumonia is of the typhoid type and asthenia is marked, valuable results can be obtained very frequently by the hypodermic injection of 1 grain of camphor, dissolved in sterilized olive oil. This injection may be given once, twice, or thrice in twenty-four hours for one or two daj's, but ought not to be continued too long; first, because it rapidly loses its effects if used too frequently, and, second, because in these doses there may be some danger of camphor poisoning. Camphor is to be regarded as a remedy for an emergency, and is to be reserved for critical periods. Recently very large doses of camphor, as much as 30 grains a day, given hypo- dermically, have been advocated as a specific treatment of croupous pneumonia. I have proved these doses not to be poisonous, but have not used this method in a sufficient number of cases to assert its usefulness. If great mental and nervous excitement is present and persistent, life can often be saved by the administration hypodermically of ^, ^, or \ grain of morphine. This will often produce several hours of desired sleep, from which the patient awakens much refreshed and perhaps free of the delirium which before the admin- istration of the morphine was an annoying symptom, in that it produced jDliysical exliaustion through the constant activity of his body and mind. The employment of nitroglycerin in the treatment of pneumonia is limited to those cases which have a very high arterial tension before the acute illness. The drug, under these circumstances, is of great value in that it diminishes the work of the heart by removing the vis a fronte. If, on the other hand, vascular spasm does not exist, the drug is useless, for it is not, as some have thought, in any sense a direct cardiac stimulant. A blood-pressure, theoretically high, is often induced by nature to aid in maintaining the circulation through fibroid vessels, and it is usually better to leave it alone. The question of the employment of circulatory sedatives in the early stages of acute croupous pneumonia is one wliich has been widely debated, particularly in this country. There are many excellent practitioners who consider that full doses of veratrum viride or aconite in the earlier stages of croupous pneumonia are advantageous. Statistics, or, to speak more correctly, wide personal expe- rience on the part of many physicians, seeius to justify the use of this drug in some cases, namely, in those instances in which the physician sees the patient during DIPHTHERIA 151 the first hours of the attack, and if the patient is a strong, sthenic individual, with a full, bounding pulse, and great flushing of the face. Under these circumstances the relaxation of the general vascular system produced by the veratnun viride and the quieting of the excited heart seems distinctly advantageous. Whether such treatment in any way aborts, or jugulates, or diminishes the violence of the subsequent attack is difficult to determine. In a few instances of acute croupous pneumonia and acute pleurisy, seen in the very early stages, I have noted good results from such treatment. But in the vast majority of instances the physician does not see the patient for nearly twenty-four hours, by this time the disease is well started on its way, and the symptoms of great circulatory excitement have usually passed by, so that circulatory sedatives are distinctly contra-indicated. The use of chloral as a nervous sedative in the course of croupous pneumonia is usually inadvisable. The diet should be liquid and consist of milk, with a little pancreatin and bicar- bonate of soda, to aid in digestion, and of animal broths and gruels made of wheaten grits, oatmeal, rice, or barley; the digestion of these starchy foods being aided by the administration of taka-diastase or pancreatin. I am quite convinced that we too infrequently resort to these cereal fluids in the treatment of diseases of this nature, since they possess much nutritional value and, if their digestion is aided, agree with the vast majority of patients, and enable us to change the diet so that the patient does not become tired of any one particular kind of food, which is a great advantage. Care should be taken in cases of croupous pneumonia that the patient receives an adequate amount of water to drink, so that the kidneys may be well flushed with fluid in each twenty-four hours; but it is important that only small amounts of fluid be taken at a time, as distention of the stomach may cause fatal cardiac embarrassment. The bow^els should also be moved each day in the early stages of the attack by full doses of calomel, and in the later stages by salines, or, if the patient is too weak for the use of these purgatives, by a rectal injection of water or of glycerin and water. The administration of expectorants in croupous pneumonia is useless until the stage of resolution is reached. Even then they are probably of little value in clearing up the exudate in the vesicular portions of the lung. But the chloride of ammonium, the oil of sandal-wood, guaiacol, and terpin hydrate often prove useful at this time in aiding in removing the symptoms of chronic bronchitis which exist, a state which results in the formation of a good deal of thick, tenacious bronchial mucus, which the patient may have difficulty in expectorating. Excessive cough in all stages of croupous pneumonia is best controlled by the administration of Dover's powder, codeine, paregoric, or the newer drug, heroin. In the stage of resolution cough sedatives should not be administered unless the physician is certain that the cough is in excess of the needs of the patient in getting rid of the materials in his chest which should be gotten rid of in this way. Meningeal symptoms are to be treated by the application of cold to the head, and sometimes it is wise to apply a blister to the nape of the neck. DIPHTHERIA. Defiiutioii. — Diphtheria is an acute infectious disease, which chiefly affects children under puberty. It is due to the Klebs-Loeffler bacillus, and is char- acterized primarily by an acute local inflammatory process which affects, as a rule, the pharynx, larynx, or nasal mucous membrane, and which is peculiar in that it is associated with the development of a false membrane due to a fibrinous exudate. From the spot upon which this condition develops the general system becomes affected, not by the micro-organism of the disease, but by the poisons or 152 DISEASES DUE TO A SPECIFIC IXFECTIOX toxins ])ri)(lnc('(I by the specific organism ;it tlic site of iirimary infcctinii. Other infections may occasionally cause the ])n)(lncti()n ol' a false memhraiic, Imt the discovery of the presence of the Klehs-Loeffier l)aei!his determines tliat tiie affection is diphtheria. All cases in which a false inemhrane develops on a \isihle mucous rriembrane should he considered to he cases of (ii])htlKTia and treateii as such until proved to he non-diphtlieritic, because in this way the spread of the disease is prevented and the use of the specific remedy, antitoxin, will sa\-e life if the disease is present and do no harm if it is not. In the great majority of ca.ses the disease primarily afl'ccts the pharyngeal mucous membrane, or the mucous membranes immediately adjacent thereto, and from this area spreads to the nose or larynx, where the results of its dcNclop- ment are very fatal. The sijecific inflammation and false membrane may, ho\ve\er develop on any exposed mucous membrane, and even upon the true skin if the epiderm be remo\-e