TfC^G (.OLIMBIA I NIVERSIT\ HDWARO G. JANEWAV MEMORIAL LIBRARV I Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/textbookofmedici1895str TEXT-BOOK OF MEDICINE FOR STUDENTS AXD PRACTITIOXERS Dr. ADOLF STRUMPELL PROFESSOR AND DIRECTOR OF THE MEDICAL CLINIQUE A1 Scconb "l^mcrican (Ebilion TRANSLATED BT PERMISSION FROM THE SECOND AND THIRD., AND THOROUGHLY REVISED FROM THE SIXTH GERMAN EDITION, BY HERMAN F. VICKERT, A. B., M.D. AXD PHILIP COOMBS KNAPP, A.M., M.D. CLIXICAL INSTRUCTOR IX DISEASES OF THE NERVOUS SYSTEM, HARVARD UNIVERSITr ; PnYSICIAN TO OUT-PATIENTS WITH DISEASES OF THE NERVOUS SYSTEM, BOSTON CITY HOSPITAL ; MEMBER OF THE AMERICAN NEUROLOGICAL ASSOCIATION; FELLOW OF THE IIASSACHUSETTS MEDICAL SOCIETY, ETC. WITH EDITORIAL NOTES BY FREDERICK C. SHATTUCK, A.M., M.D. jackson professor of clinical medicine, harvard university ; visiting physician to the massachusetts general hospital ; member of the association op physici.\:ns ; fellow of the m.\ssachusetts medical society, etc. WITH ONE HUNDRED AND NINETEEN ILLUSTRATIONS NEW YOEK APPLETON AND COMPANY 1895 CoPYKionr, 1886, 18(>3, Bv D. APPLETOS AND COMPAXY. All liylils reserved. El.F. the temperature in typhoid is so abso- I .= lutely essential for the estimation of I each individual case that no scientific I physician ought to treat a case without i regular measurement of the tempera- 1 ; ture. The measurements should be -c. 7 taken, if possible, in the rectum. Their i " frequency must of coui-se be modified I H 2, r- If by circumstiinces, but it will probably be possible to have three or four meas- urements daily. At night, especially if the patients are asleep, it is generally not requisite to take the temperature. A geueral idea of the course of the fever ■lEiiniHHIHHIIIIII ■■■iiisiiiiHiiiiuiui ■■■■■sss!iiiniiinini ■■■■■iiuiifiE^ninui ■iiiiiiiiiiissii ■■■■■■■ISSSliHll EiiBSSHIIHIIinilllll ■■ilSBBDSSHIIIIIliiyi ■isa^iiiHiHHiinim ■iilassiuiuHiiiiini ■iiffiaiiiHiniiiiiiii iiiniiisanmnni ■iiisssEssaiiiiiiii ■■ii3iSBB»i»niiniiii ■igaassinniniiiiiiii ■■ieiiiiiiuiHUHiiii ■EsniiiniiiniiHini ■■IfBPIinillHIIIIIUI ■■iS^iiiHniHiiniiii ■laiiiiiniHHiiinii! ■■■ii2«iHHiniiinni ■■■■■■■■■ii;;uiiiinin ■■■■■■■■■■■■■iSSUIlil ■■■■■■■■■■■■■■■IwesBi TYPHOID FEVER. 7 can be gained only by representing the separate measurements graphically in a continuous "temperature curve." The typical curve of typhoid fever (see Fig. 2) falls naturally into three or four divisions. The first division is the initial period, or the pyrogenetic stage, and is seldom observed, since at this time the patients are generally not yet under the doctor's care. The initial period of the fever lasts, a.s a rule, some three or four days, seldom longer; and during this time the temperature rises, generally by gradual steps, so that the morning as well as the evening temperature is each day 2° or 3° (l^-l'S" C) higher than on the day before. A sudden and considerable rise of tempei'ature, such as occui-s in many other diseases, is very rarely seen in the beginning of typhoid fever. The second division of the curve represents the so-called fastigium, and cor- responds to the height of the disease. During this time the fever presents, in most of the severer cases, the general character of "febris continua " — i. e., the spon- taneous remissions of the fever seldom exceed 2° (1° C). Almost always the lower temperatui'es come in the morning hours and the higher in the evening. In cases of average severity the morning remissions touch 102°-103° (39°-39-5° C), and the evening exacerbations 104°-105° (■10°-40'5° C.j. Temperatures which reach o;- exceed 106° (41° C.) are seen only in very severe cases. Considerable morning remissions are always a favorable symptom, while morning temperatures of 10-4° (40° C.) or higher generally show the case to be severe. The duration of the fas- tigium varies with the severity and obstinacy of the case. It may last only a few days or one and a half to two weeks ; in violent cases still longer. In many cases of slight or average severity the period of decline follows directly on the fastigium ; but in severe cases there frequently intervenes another stage, which Wunderlich has graphically named the " ambiguous " period. The temper- atiu"e curve becomes irregular and more variable. The morning remissions may be great, even reaching the normal, while the evening temperatures ai'e often still very high. This stage has accordingly been termed the "period of the steep cm'ves." It may be said that in general the longer a case of typhoid lasts the more irregular will be the course of the fever. The last stage — i. e., in cases of slight or average severity the third stage, and in severe eases commonly the fourth — is the period of defervescence or recovery. The peculiarity of this period in tj'phoid fever is that the fall of the fever is never by crisis, but always gradually, by lysis. Commonly the temperature descends by degrees, so that on each new day the morning remissions as well as the evening exacerbations are 1° to 2° (0'5°-l° C.) lower. The zigzag form of curve, in which there are of course very frequently slight irregularities, must be taken as the rule. The duration of the defervescence generally exceeds that of the initial period. It lasts five to eight days, often longer. It is not very seldom that in defervescence the morning remissions become from the first very marked, even reaching the normal temperature, while the evening exacerbations become daily less and less, until they too are not above the normal. A third form of decline is much less frequent, in which the morning remissions become every day greater, while the evening temperature persists for some days at about the same height. Several times we have seen the fever take on a tertian type during recovery. To this outline must be added a number of observations of practical importance. The initial period does not exhibit especial variations from the course we have stated. Its entire duration is bounded by certain relatively narrow limits. The fastigium presents, as already mentioned, the greatest varieties in its dura- tion. In light cases it is wholly wanting, so that these consist onlj' of a period of gradually rising fever, and of a gradual defervescence almost immediately con- secutive to the rise. The entire duration of such light cases is only one and a half 8 ACUTE GENEEAL INFECTIOUS DISEASES. to two weeks. In other and tolerably frequent cases, which are often tedious, but still for the most part are lif^ht, the fever is not continuou.s, but remittent. We have seen in Leipsic, notably in the autumn epidemic of 1878, a number of cases where the fever was even perfectly intermittent during almost the entire illness, and where for two to three weeks afternoon elevations reaching 104° (-10° C.) or more daily succeeded normal morning temperatures. These cases had the general course of light attacks. Various influences, not to speak of therapeutic interference, may produce a considerable temporary remission of temperature in the course of the fastigium. Such a remission sometimes occurs spontaneously from the seventh to tenth day of the disease. If a marked intestinal haMuorrhage occurs (vide infra), the temjjera- ture generally falls several degrees centigrade, and the less frequent instances of severe epistaxis have the same effect. If, in female patients, abortion or prema- ture delivery occurs, we often observe a similar considerable fall of temperature, even without severe attendant lucmorrhage. Perforation of the intestine often causes the temperature to fall rapidly. At times the occui-rence of mental dis- tui'bances effects a moderate though noticeable lowering of temperature. TlK)se great and sudden depressions of temperature remain to be mentioned which are accompanied by a very small but exceedingly rapid pulse and general prostration. Every such collapse, if severe, is a most dangerous event, and demands prompt and energetic medical treatment (vide infra). The occurrence of local complications, such as pneumonia or inflammation of the parotid gland, is generally accompanied by a considerable rise of temperature. The fever in such cases often becomes more irregular. The period of defervescence departs most frequently from its tj-pical behavior by being lengthened out into a "stage of retardation." The morning temperature is then generallj' normal, while in the evening slight or raodera'e elevations con- tinue. The reason for this long continuance of the fever may frequently be found in some not yet completely healed local complication, but often no such lesion can be demonstrated. Then we are connnonly inclined to surmise sluggish intes- tinal ulcers which will not heal, or trouble in the mesenteric glands, etc. This sluggish fever may continue for weeks. It is prone to follow severe cases, but lighter attucks, especially in elderly or feeble patients, may also take ou this slug- gish character at a relatively early period. Entrance into comiilote convalescence is sho\vn with far greater certainty by the absence of elevations of temperature than by any other single symptom. There sometimes come, however, temporary elevations of temperature during con- valescence, follovring some error in diet, long-continued constipation, or incntal excitement. In other cases the new fever depends on some local sequela, e. g., a boil or a glandular abscess. Often, however, the most accurate investigiition fails to demonstrate a cause. Especially in the beginning of convalescence there some- times conies a high fever, or even a rigor, which may i-ecur several times, but soon gives ])lace to a normal tomperattn-e. Generally no certain cause for these brief but decided elevations of temperature can be pointed out. Perhaiis we might consider the possibility of some affection of the mesenteric lymph-glands. These sudden and great elevations have seldom any grave significance. This new fever which we have just described is best termed recurreiit fever- attack, in contrast with the proper tyjjhoid relapse. Tliat is. after tyj)hoid fever has ended, the whole process may be repeated ; and this occurrence is called a relap.se. Particulars as to the behavior of the fever in such cases will be consid- ered below, in connection with all the other peculiarities of typhoid relapses. TYPHOID FEVER. Phenomena and Complications relating to the Separate Organs.* 1. Digestive Organs, — We think it best to begin our consideration of the more special symptoms with the phenomena referable to the intestinal canal, for tlie reason that the anatomical changes in the intestine are pathognomonic. Indeed, these alterations may sometimes become of surpassing import in a clinical point of view, although in the majority of cases the intestinal symptoms are clinically not nearly so prominent as the general symptoms that result from the infection of the system as a whole. The characteristic typhoid lesion of the intestine consists of an affection of Peyer's patches, most marked in the lower part of the ileum. In the firet week the patches swell gradually (stage of medullary infiltration). The rest of the mucous membrane exhibits at the same time more or less marked symptoms of simple catarrhal inflammation. In the second week, necrotic crusts form on the surface of the patches, which are cast off in the third week, leaving behind the typhoid ulcers. Towai'd the end of the third week the ulcers clean up, and then in the fourth week, if the case takes a favorable course, the ulcers heal. Smooth scars are formed, often diffusely pigmented. Experience shows that these scarcely ever lead to stricture of the intestine. The same process also g'oes on in a greater or less number of the solitary follicles as well as in the Peyer's patches themselves. We may add that probably in lighter cases of typhoid (vide infra) there is often no actual ulceration. The swelling of the lymphatic tissue subsides in this case before sloughing occurs. We have already mentioned the occurrence of typhoid bacUli in Peyer's patches and the intestinal follicles. The number and extent of the ulcers formed have no direct relation whatever to the severity of the case. Although very extensive lesions in the intestine are often found in cases that end fatally, yet, on the other hand, we observe fatal cases in which only a few vilcers are found in the intestine. In eases with exten- sive intestinal lesions we often see follicular ulcers in the colon as well as in the small intestine (colo-typhoid). The clinical symptoms referable to the intestinal canal are, as we have said, prominent only in exceptional cases. In the beginning of typhoid fever there is usually constipation. This may last throughout the illness, so that the patients have but one dejection in every two or three days, or often none at all unless an enema be given. As a rule, a moderate diarrhoea begins during the second week. There are two to four stools, or sometimes more, each day. They usually have a characteristic bright-yellow color. On standing, they divide into an upper, cloudy, and quite liquid layer, and a lower layer composed of yellow, crumliy masses. They have generally an alkaline reaction, and upon microscopic exami- nation they are found to contam, besides remnants of the ingesta and granular detritus, a few epithelial cells, round cells, many crystals of triple phosphate, and numberless bacteria. Pfeiffer and other investigatoi-s have been able frequently, although not invariably, to demonstrate the true typhoid bacUli in the dejecta by means of special methods of cultivation. Severe diarrhoea (ten to twenty stools daily) is relatively infrequent. In some severe cases we have seen the stools take on a dysenteric character. The autopsy showed in these cases unusually severe lesions of the colon and a diphtheritic inflammation of its niucous membrane. Gaseous distention affecting the intestine, and especially the colon, is very frequent, but in most cases it is not excessive. Indeed, severe cases of typhoid are * To avoid repetition, we have in what follows united a description of the anatomical changes with the presentation of the clinical .symptoms. 10 ACUTE GENERAL INFECTIOUS DISEASES. observed in which tlic abdomen alwaj's remains concave. Marked tj-mpanitcs is always an unpleasant complication. We saw one case, which ended fatally, with very great tympanites, in which the lesions were almost exclusively in the colon, and it was the enormous distention of its entire length which had so swollen the abdomen. The noise that can often be produced by pressure in the ileo-caecal region (gurgling) used to be regarded, but probably erroneously, as especially characteristic of ty])hoid fever. Abdominal jiain is often entii'ely absent. Some patients, however, complain of abdominal pain during almost the entire illness. On pressure, the belly is generally somewhat sensitive, but the tendei-ness is sel- dom extreme. It is more apt to be marked when there is constipation. Often such tenderness is due to a participation of the peritoneum in the disease, even when there Ls no perforation {cide infra). There still remain two symptoms of the greatest practical importance, both of which have a direct connection with the intestinal lesions : they are intestinal haemorrhage and perforation. Intestinal haemorrhages in the course of typhoid are almost always due to the erosion of tlie walls of blood-vessels in connection with the formation and throw- ing off of the crusts of the ulcers. The hemorrhages occur, therefore, most fre- quently toward the end of the second and during the third week. The blood pours out into the intestine, and is passed with the stools. Its amount may be small, or it may reach to one or two pints, or even more. Its color is generally rather dark. The later discharges are generally taiTy. Liebermeister states that he has observed intestinal hcemorrhages in 7'3 per cent, of typhoid patients, and Griesinger in 5:5 per cent. We have ourselves seen, in the medical clinique at Leipsic, 45 intes- tinal hajmorrhages in 472 cases, i. e., in 9'5 per cent. In individual epidemics the frequency varies greatly. It rose in 1880 to eighteen per cent. Intestinal haemorrhage is alwaj's a gi-ave symptom. Even slight hajmori-hagcs deserve consideration, for they may be the precui-sors of severer ones. And yet intestinal hasmon-hage, even if profuse, is not necessarily fatal. Of the above forty-five cases of typhoid with hasmorrhage, twenty -six ended in complete recov- ery. In eight ca.ses, death occurred as the immediate result of the loss of blood. Eleven ended fatally after a time. After every considei-able intestinal hirmorrhage, the symptoms of general anaemia, often even of collapse, appear. The fall of the bodily temperature has been already mentioned. The haemorrhage has sometimes a favorable influence on severe cerebral symptoms, for consciousness succeeds to the pi-evious stupor or delirium. Often the hasmorrhage is directly followed by recovery fi'om the disease. Much more ominous than the intestinal haemorrhage is the occurrence of per- fo7'ation, as a result of the breaking through of a typhoid ulcer into the abdominal cavity, because, almost without exception, this is followed by a purulent or even ichorous peritonitis. The occurrcTicc of perforation is sometimes marked by a vio- lent pain suddenly felt by the patient; but it may also, even in severe cases, take place insidiously. The abdomen is generally (not always) greatly distended and very tender on pressure, so that even in stupor jiatients groan while being exam- ined. If gas has entered tbrougli the opening into the peritoneal cavity, we often observe absence of the ordinary dullness over the liver; but this symptom is to be enii)loycd cautiously as a factor in diagnosis, for absence of hepatic dullness may also result from distended intestines IjHng in front of the liver. When per- foration has occurred, the jiationt soon looks collapsed, with cheeks fallen in and sharp, cool nose. Frequent eructations and vomiting often follow. The pulse becomes small and very frequent. The temperature generally falls as the peri- tonitis begins, and later it usually undergoes great variations. TYPHOID FEVER. 11 Perforation of the intestine occurs most frequently in the third or fourth week of the disease. In sluggish cases, however, we can not be without apjjrehensions of it till a late period. The pei-foration generally takes place in a coil of the lower part of the small intestine, and with marked relative frequency in the right side of the pelvis — seldom in the vermiform appendix or in the colon. Willi few exceptions, death comes quickly, after a few days at latest. Out of fifty-six fatal typhoid cases in the Leipsic medical clinique we lost five, or nine per cent., from peritonitis following perforation. Here and there a case of recovery has been reported, probably resulting from a limitation of the peritonitis through speedy adhesion of the intestines. It should be mentioned here that sometimes in typhoid fever a local or general peritonitis may occur through direct extension of the process to the serous mem- brane without actual perforation. We have seen in one case, as a result of the peritonitic bands and false membranes, complete occlusion of the intestine (ileus), and death. Swelling of the mesenteric lymph-glands (less often of the reti'o-peritoneal glands as well) is found in typhoid almost as constantly as the anatomical changes in the intestine. Sometimes they break down, i. e., suppurate. In cases that have passed through the disease we often find considerable deposits of lime in the glands. These changes have a certain clinical importance ; for, as already men- tioned, we may often venture to refer a more or less tedious recurrent febrile state which has no other demonstrable cause to this lesion of the mesenteric glands. In some rare cases a general peritonitis has been observed as a result of the burst- ing of a suppurating gland. The swelling of the spleen (acute splenic tumor) is, in typhoid fever as well as in many other acute infectious diseases, one of the most constant symptoms. The enlargement of the spleen can often be demonstrated as early as the end of the first week, and is therefore of considerable diagnostic importance ; but percussion of the spleen is sometimes decidedly difficult and deceptive in this disease because of the existence of tympanites. The surest demonstration of splenic enlargement is therefore always by means of palpation, which, after a httle practice, gives a positive result in the majority of cases. Absence of splenic tumor is most fre- quently observed in elderly typhoid patients. The spleen may also diminish con- siderably in size after severe intestinal hsemorrhage. Pain in the splenic region, resulting from tearing of the distended capsule, is comparatively rare. The splenic infarctions which sometimes occur may, in exceptional cases, prove the starting- point of a peritonitis. Hepatic symptoms are seldom seen in typhoid fever, except that there may be a moderate swelling of the organ. The anatomical changes of "parenchymatous degeneration," and the frequent formation in the liver of the small lymphomata which Wagner discovered, have no clinical significance. The bile secreted is gen- erally pale and scanty. This is a partial explanation of the light color of the stools. A very rare complication, which we ourselves observed in one case, is acute yellow atrophy of the liver. The stomach presents no especial anatomical changes in typhoid. Anorexia is an almost invariable symptom in the beginning and during the course of all severer cases. There is seldom any desire for food till recovery begins ; but then, if convalescence is undisturbed, the appetite soon attains an enviable keen- ness. Vomiting in the beginning or course of the disease is an exception, unless after some error in diet. We have already mentioned it as a symptom of perito- nitis. The changes in the mouth and throat of typhoid patients deserve the careful attention of the physician. The lips and tongue are in severe cases dry and fls- 12 ACUTE GENERAL INFECTIOUS DISEASES sured. Tlie lips are often covered with dry, black crusts, sometimes described as a "fuliginous coating." Tlie tongue is apt to be thickly coated at fii-st, but later cleans off from tlie edges and tip. In severe ca.ses, especially if tlie moutli i.s not properly cleansed, a rather severe stomatitis may occur and produce superficial ulceration of the buccal mucous membrane and of tlie edges of the tongue. The gums sometimes become spongy, and are apt to bleed, a-s if scorbutic. Actual sore throat, at least, according to our experience in Leipsic, occurs but seldom at the beginning of typhoid fever. Tlie difficulty in swallowing, often complained of by patients, is generally due to dryness of the jiharynx. In certain epidemics, liowever, the occurrence of sore tbi'oat at the beginning of tlie illness has been frequently observed. It may even happen that this early sore throat is accompanied by an erytliema diffused over the body, so that at first suspicions of scarlet fever arise. In rare cases (so-called tonsillo-tyjihoid or pharyngo-typhoid) there are seen upon the tonsils peculiar whitish elevations, which later ulcerate. These are probably to be regarded as a specific typhoid lesiou of the tonsils. It should also be mentioned that in severe cases there is often an extensive gi'owth of thrush in the mouth and throat, and this may spread quite a distance down the ossophagus. The changes in the mouth and throat are of especial interest, for the reason that they may be directly propagated to important ueighboring organs. Starting from the pharyngeal cavity, the pathogenic agent, probably in most ca.ses the staphylococcus, may penetrate through the Eustachian tube into the middle ear. Thus arise those inflammations of the middle ear which are not very rare in severe cases of tyjihoid, and which lead to perforation of the membrana tjinpani and to purulent discharges from the ear. The not infrequent inflammation of the parotid gland is also, as we believe, occasioned in a similar way, the inflammatory agent reaching the parotid gland from the mouth by way of Steno's duct We do not regard the otitis and parotitis as especial localizations of the typhoid poison, but as genuine complications (secondary disease), for the occurrence of which typhoid fever merely furnishes the occasion, as when the mouth is imperfectly cleansed. The parotitis appears most frequently in the third week, and generally on one side, though sometimes on both. It almost always becomes purulent, and discharges either externally or into the external auditory meatus, unless there is a timely incision. 2. Organs of Respiration. — Affections of the lungs are among the most frequent and important comjilications of typhoid fever, but are for the most part not a direct result of the typhoid infection. The bronchitis very often found in severe cases, and especially in patients who do not come till late under projier care, cer- tainly is chiefly dependent on the imperfect expectoration of the bronchial secre- tions and on the inhalation of inflammatory agents comuig from the mouth and throat. Numerous cases of typhoid of slight or average severity, under jiroper care, run their course without any considerable bronchitis. In many other, cases, and even severe ones, the bronchitis remains within moderate bounds, especially if the patient is brought promptly under proper care and treatment; but in severe cases, where marked disturbances of the nervous system arise, and the ])ationt in liis stupor expectorates little, swallows things the wrong way, and lies all the time on his back, passive and collajised, the occurrence of a severe, diffuse bron- chitis, especially in the lower lobes of the lungs, can hardly be avoided. Nor in such cases is there generally a mere bronchitis, but a more or less extensive catarrhal, lobular pneumonia, to be cla.ssed therefore under the so-called inhala- tion pneumonias (cf. chapter on lobular pneumonia). What was formei-ly termed " hj^iostatic pneumonia " is also almost invariatily to be put in this group. TYPHOID FEVER. 13 From tlie way in which these pulmonary disorders ai-Lse, we can understand why the bronchitis sometimes takes on a putrid character, and why the lobular infiltrations are, in severe cases, transformed into genuine gangrene. If such spots touch the pleura, they occasion the development of a pleurisy which is almost always purulent. In rare cases, pneumothorax may arise as a sequel to the perfo- ration of a gangrenous infiltration into the pleural cavity. Various circumstances promote the occurrence of pulmonary symptoms. Thus we find it especially easy for a severe bronchitis and its sequelas to be developed, in the case of elderly per- sons, or the kyphoskoliotic, or the corpulent, or patients who have previously suf- fered from emphysema or cardiac disease. The subjective thoracic symptoms, in typhoid patients who have pulmonary complications, are generally not very prominent. It is only occasioually that patients complain in the early stages of typhoid fever of pain, and of a sense of oppression in the chest, or of cough, or of a stitch in the side; and even when such symptoms exist, the physical examination may give comparatively insignifi- cant results. The severer pulmonary complications are seen mainly in those whose intelligence is more or less blunted, and who, therefore, make little com- plaint, are not much disturbed by the dyspnoea, and cough and expectorate little. A careful physical examination alone can enlighten us as to their condition. On auscultation, sibilant rhonchi are the chief signs observed in the milder cases. In the severer ones there are moist, fine, and coarse rales, especially numerous towaid the base of the chest. If there are abundant moist rales, we may infer that there is a lobular pneumonia, although this can not be demonstrated with certainty till the separate islets of infiltration unite into a more extensive solidification, so as to afford dullness on pei'cussion. In addition to the pulmonary lesions already mentioned, genuine croupous or lobar pneumonia does occur in typhoid fever. Probably this must be regarded as a direct result (localization) of the typhoid poison, although this croupous pneu- monia is not anatomically distinguishable from the common, genuine pneumonia. It often appears as early as the second week, and attacks the lower as well as the upper lobes. Liebermeister states that he has sometimes observed it during con- valescence. Especial interest attaches to those cases of typhoid fever which begin with a lobar pneumonia. Often there is at first not the slightest suspicion of a typhoid fevei', for the disease is regarded as an ordinary croupous pneumonia ; but it is usually to be noticed that the illness does not begin suddenly with a rigor, but more gradually, and that from its incipiency the constitutional symptoms, the headache and splenic tumor, are more prominent than is usually the case in pneu- monia. At the end of the first week's illness there is no crisis, but persistent fever. Now the pulmonary symptoms often retreat more and more to the background, while, on the contrary, diarrhoea and rose-spots appear. The spleen is enlarged. In short, the clinical picture of tyjahoid is developed. It is not unnatural to sup- pose, although there is yet no absolute proof of the fact, that in these cases, which are fittingly termed " pneumo-typhoid," the infection with the typhoid bacilli has taken place exceptionally in the pulmonary area, and that, therefore, the first pathological changes are developed in the lungs. Laryngeal Lesions. — The same causes which produce the bronchitis result also in a simple catarrhal laryngitis, with hoarseness. This is in severe cases accom- panied by superficial ulcers on the vocal cords or the posterior wall of the larynx. Sometimes, again, the lesion is due to mechanical causes, constituting the so-called ^'■decubitus laryngis." The disorders which attack the less superficial structures of the larynx are fortunately rare. Chief among them is a laryngeal perichon- dritis of the arytenoid cartilages. This complication is justly regarded as of bad 14 ACUTE GENERAL INFECTIOUS DISEASES. omen, and may lead to the rapid development of oedema of the glottis, ^\-ith great laryngeal obsti-uction and threatening suffocation. These severe laryngeal aifec- tions in typhoid are regarded by some authorities, especially by Kleb.s, as always the dii-ect effect of the infecting poison ; but in most cases they are probably due to an invasion of stapliylococci or some similar microbes. We have several times seen laryngeal croup in tyjjhoid fever, and it is a very dangerous symptom. We are inclined, however, to the belief that it was in every case a secondary disease. Among symptoms referable to the mucous membrane of the nose, epistaxis is important. It occurs in the beginning of tyjihoid with tolerable frequency, and is in one way not unfavorable, for it often mitigates the patient's headache. At a later period nose-bleed may become a very unpleasant complication, as it is some- times very difficult to check. We have even seen one fatal case due to persistent nose-bleed. Other nasal symptoms are exceptional. There is an old saying that typhoid never begins with a coryza. 3. Nervous System. — The old term " nervous fever," which is still used by the laity, shows how frequent and severe are the nervous derangements which occur in tj'phoid. In cases of any severity there is almost always a certain dullness of intellect, often amounting to apathy and somnolence. The patients give mono- syllabic and incomplete answers to all questions, and their statements about their previous history are often disordei'ed and contradictory. There maj' even be sopor or a deep coma in the worst cases. All cases of this sort in which there was a condition of intellectual enfeeblemeut were termed by the old physicians ^^febris nervosa stupida" in contrast to the ^'febi'is nervosa ver- satilis," that form in which abnormal mental activity or delirium predominates. In severe cases delirium is very frequent. It is generally worse at night, and at times when the patient happens to be left alone. Very often he tries to leave his bed, because of his delusions, and talks of persons and things with which he was formerly familiar; or he is very noisy and restless, sometimes shrieking from groundless feai-s. We may add that these diverse nervous symptoms frequently succeed one another, or appear in combination. Sometimes a soporose patient may be heard softly whispering to himself in " muttering delirium." Certain motor disturbances are often comljined with considerable impairment of consciousness. There is a slight twitching of the inuscles of the face and ex- tremities. The old authorities gave the name subsultiis tendinum to the sudden leaping into prominence of the sinews thus caused. It is best seen on the back of the hands. In severe cases the patient is sometimes observed to grind the teeth together; this is due to a cj-amp-like condition of the muscles of mastication, and is justly regarded as ominous. We often see persistent tremor of the extremities and lower jaw ; and it is especially in these cases, as we have demonstrated upon numerous patients, that the tendon reflexes and the mechanical excitability of the muscles are much increased. If deep coma comes on, the nuiscles become lax, the motions of the eye are not co-ordinated, and reflex excitability diminishes, or is wholly extinguished. Headache is one of the most constant symptoms in the beginning of the dis- ease. It is usually referred to the forehead or temples. The pain may be very violent, and sometimes takes on almost a neuralgic character. It almost always subsides in the second week. If we .seek the cause of these nervous symptoms, which are often so severe, we find that the anatomical changes in the nervous system, including the brain, bear no relation whatever to the severity of the symptoms observed during life. We sometimes meet with minute hajmorrhages in the cerebral meninges, or meningeal opacity or oedema, or a moist condition of the cerebral parenchyma ; but the con- nection of these and similar changes with the symptoms of the disease is often TYPHOID FEVER. 15 more than dovibtful. Nor can the microscopic alterations in the brain, which have been reported, be regarded as important and authoritative. It is only in very rare cases that large cerebral hasmorrhages or purulent meningitLs have been found. As to this last, we should always be very cautious in making a diag- nosis, as symptoms which would .seem to be most conclusively meningeal — such a.s stiffness of the neck, rigidity of the whole spinal column, and occipital head- ache — may appear in typhoid patients, and yet the autopsy show no trace of meningitis. One theory, which has Liebermeister for its chief supporter, and which has won a tolerably wide-spread acceptance among physicians, is that the nervous symptoms are chiefly a direct result of the febrile temperattu-e. It Ls impossible, however, for us to regard this view as universally true. The unprejudiced con- sideration of a large number of personal observations prevents it. Although it is undeniable that elevated temperature has a harmful influence on the nervous sys- tem, yet in numerous cases there is no relation between the height of the fever and the severity of the nervous derangements. There are cases in which the fever remains continuously high for days, while the jiatient feels perfectly comfortable and presents no symptoms of any important cerebral disturbance. The opposite class of cases is still more numerous, in which from the very start there is always a low temperature, and, notwithstanding, the most severe nervous symptoms arise. Frantzel has published very striking cases of this sort. Hence we must seek for some other special cause of the severe nervous .synip- toms, and according to our present views this cause must be the intoxication re- sulting from the siiecific infection. We know that all bacteria produce, by their own tissue-metamorphosis and the chemical processes which they excite in their neighborhood, cei'tain chemical matters which, especially in the case of the so-called "imthogenic bacteria," seem to be similar to the alkaloids (''ptomaines" and "toxines'"), and exei'cise a decided poisonous influence upon the body, and especially upon the nervous system. These products are formed by the tyjihoid bacilli, enter the blood, and are the chief cause of the nervous phenomena. The difference in the violence of the latter in different cases probably depends mainly on a difference in the amount, and perhaps also in the quality, of the toxines produced by the typhoid bacilli, and probably also in the different susceptibOity of individuals to the poison. The reason that the influence of these poisons is not much greater than it is, is that they are in part destroyed within the body and in part excreted with great rapidity, the channel of exit being mainly the kidneys. Thus is explained the interesting fact discovered by Lepine, Bouchard, and othei-s, that the urine of typhoid patients possesses poisonous properties not present in normal urine. That the appearance of the nervous symptoms is dependent not only on the material causes, but also on the susceptibility of the individual, is shown by the fact that certain patients are especially prone to exhibit marked nervous phe- nomena; for example, hard drinkers, " nervous '■ individuals, and also those who have suffered violent emotional disturbances shortly before the onset of the disease. Actual insanity is not very infrequent during the course of typhoid, or in con- valescence. It generally takes the form of melancholia. We have repeatedly seen patients in such a state that they would lie almost motionless in bed, with eyes open, and perhaps assert that they were dead! In other cases there is mental excitement, sometimes combined with hallucinations, or there is confu- sion of ideas. In one case, in a girl who was evidently predisposed to nervous dis- orders, we saw typical hysterical insanity break out during the fever. Sometimes the mental excitement at the beginning of a relapse terminates in actual insanity. 16 ACUTE GENERAL INFECTIOUS DISEASES. Few of the psychoses wliich arise during or at tlie end of typhoid outlast con- valescence. We have still to mention a number of nervous diseases that develop in the coui'se of typhoid or after its decline. Neuralgia is sometimes seen, as well at the beginning as at the end of the disease. It is most frequent in the regions supplied by the trigeminus and the occipital nerves. Great hyperaisthesia of the skin and muscles is not rare during convalescence. It attacks the lower extremi- ties by preference. Paralysis of single muscles (e. g., of the serratus magnus), or paralysis of a single extremity, has been repeatedly observed as a sequela. The paralysis is generally of the atrophic variety, and is probably, as a rule, due to neuritis. Ataxia and spastic paralysis of the lower extremities are rare sequelaj. Finally, there are sometimes developed, either in the course or at the conclusion of typhoid fever, the symptoms of a localized cerebral disorder (e. g., hemiplegia and aphasia), the anatomical cause of which varies. There may be a hasmorrhage or an eml)o]isni, and probably in still other cases a localized encephalitis. 4. Circulatory System. — Disturbances of the heart such as to produce striking anatomical changes are very rare. Endocarditis and pericarditis are, however, possible. Tlie slight mitral endocarditis sometimes found at the autopsy has no clinical significance. On the other hand, great weight is laid by some authors upon the parenchymatous or fatty degeneration of the heart. Tliey say it is often the cause of caitliac failm'e. We can not admit this, for experience shows that the two do not stand in any constant relation to each other. The pulse is almost always rapid, although often not so much so as the height of the temperature might lead one to expect. It averages from 90 to 110, and often more. When it keeps at 140 or higher, in adults, it is always an unfavorable symptom. This abnormal frequency is often in part due to the high temperature; but there are other factoi-s. Temperature and pulse do not correspond in all cases. Sometimes the pulse will have a normal or even subnormal frequency throughout the entire attack, despite the fever. Temporary accelerations are easily produced by mental excitement or bodily exertion, as by sitting up in bed. In convalescence the rate is frequently subnormal. Slight irregularities of the pulse are not rare, either in the acme or the decline of typhoid. Marked irregularity is always a grave symptom, although in many cases it passes off and the ])atient recovers. Dicrotism is so frequent that many elderly physicians still regard it as charac- teristic of the disease. It is often, however, equally marked in other acute dis- eases. Its cause is diminished arterial tension. The diminished cardiac activity may result in venous thrombosis, especially in the lower extremities. This sometimes causes swelling of one of the lower extremities during convalescence. The swollen member generally regains its normal size after some weeks. In other cases the thrombosis occurs earlier, and in patients who are still too vigorous to suffer from cardiac weakness, so that we are forced to the conclusion that there is some local specific cause. A possible, but fortunately infrequent, result of these thrombi in the lower limbs is pulmonary embolism and sudden death. In severe cases, which end in death, cardiac thrombi are sometimes found, with emboli in the lungs, spleen, kidneys, or other organs. QSdema of the ankles and legs is vei'v often seen in convalescents, especially when they first get out of bed. It is due to the weakness of the heart and changes in the vascular walls. Once we saw a general dropsy develop at the end of a severe attack in a girl of fourteen. The autopsy disclosed no other possible cause for it (ban the extreme atrophy and flabbiness of the heart. ,">. Skin. — The erujjtion seen in typhoid fever is characteristic. The rose-spots TYPHOID FEVER. 17 appear at the beginning of the second week, usually on the trunk, and chiefly on the abdomen. The number varies greatly. Rarely they are entirely absent, most often in elderly persons. Sometimes tb.ey arc very abundant, and extend to the thighs, the arms, and even to the neck and face. Often they vani.sh after a few days, but they may persist much longer. In the latter case they may become t^ a very slight degree petechial, so that they will not entirely disappear on press- ure. They often occur in successive crops. We have even seen several cases where new rose-spots kept coming for some days after the fever had disajjpeai'ed. As to other cutaneous eruptions, we may mention first of all that herpes la- bialis is so rare in typhoid that in cases of doubtful diagnosis it is a factor in excluding that disease. Miliai'ia, urticaria, and superficial pustules are sometimes observed. Occsionally little bluish spots appear, especially on the trunk. These used to be called " taches bleudtres " (pelioma typhosum) ; but later observations show that they are not connected with typhoid fever particularly. They are due to pediculi. We might use the term pelioma typhosum to designate the kind of vesicles which we have repeatedly seen on the abdomen in severe cases. They are about the size of peas, and have sero-ha;morrhagic contents. Boils and super- ficial abscesses are frequent, especially as disagreeable sequelaj in convalescence from severe cases. There are often abscesses of the sweat-glands in the skin of the axilla during convalescence. All these and similar cases of suppuration in typhoid fever do not depend upon the original cause of the disease, but upon secondary pathogenic germs, such as the staphylococcus or streptococcus, for whose entrance the typhoid process has merely prepared the way. Extensive ecchymoses are very rare, and are symptomatic of a general ha;morrhagic diathesis. Petechia? are fre- quent during recovery. They are generally seen in the follicles of the skin below the knee. There have been a few cases of gangrene in the lower extremities, especially in the toes. We saw in one patient an extensive gangi-ene of the skin of the abdomen. Its cause could not be determined. Finally, we must mention that bed-sores are prone to develop in severe or neglected cases. The localities most often attacked are the nates, the fui'row be- tween them, and the heels. A bed-sore may be so extensive, and accompanied by such undermining of the skin, as to be a dangerous or even fatal complication. The epidermis often scales off to a considei-able extent during convalescence after a severe attack of typhoid. Everybody knows how the hair falls out after the fevei", but it is sure to grow again. The nails also are not infrequently affected, becoming rough and brittle, or even falling off. 6. Muscles, Bones, Joints. — Zenker has discovered a degeneration of the volun- tary muscles which occurs in typhoid as well as in other severe diseases. It is called the " granular " or " waxy " degeneration. Whether it has clinical sj-mp- toms can not be determined. Perhaps it may explain the great muscular hyper- Eesthesia which is often observed, and the muscular pains, which may be very trying. Severe cases sometimes have hasmorrhages into the muscles, particularly the rectus abdominis. Lesions of the bones and joints occur but seldom. We have seen periostitis of the tibia, and of a rib, during convalescence. Swelling of the joints is equally rare. If there is a purulent arthritis, it is always due to some secondary infection {vide supra). 7. Genito-urinary Apparatus. — Genuine, acute, hasmorrhagic nephritis is a very rare complication. It does occur, however, and has even given rise to the estab- lishment of a special " renal form of typhoid fever " (nephro-typhoid). This name applies especially to those cases in which a severe acute nephritis is the predomi- nant symptom at the start, while at a later peiiod tiie course of the fever, the intestLnal symptoms, the rose-spots, etc., show the disease to be typhoid fever. 2 18 ACUTE GENERAL INFECTIOUS DISEASES. Nepliro-typlioid is aucalogous to pneumo-typhoid and tonsillo-ty]ihoid. A simple so-called febrile albumiuuria occurs very frequently at the acme of typhoid, and is not to be interpreted unfavorably. It is probably the result of that slight par- enchymatous degeneration of the kidneys which occurs in typhoid with the same frequency as in most of the other severe infectious diseases. There does not seem to be a direct relation between the albuminuria and the fever, although some authors assume it to exist. It is more likely that the renal epithelium is injui-ed by the noxious products which have been formed in the body and excreted by the kidneys. In other respects the urine presents the same peculiarities as in most other severe febrile diseases : its amount is diminished ; its color dark ; its specific gravity increased ; the excretion of urea greater than normal. It should be added that the uriue at the height of the disease presents Ekrlich's "diazo-reaction" in almost all cases.* Cystitis is not a rare develojjment toward the end of the illness. It is probably always secondary. In men, orchitis is sometimes observed. Women often have their catamenia at the beginning of typhoid. Later in the coui-se of the disease, and in convales- cence from severe attacks, the menses are often absent for several periods. In pregnant women there is considerable danger of abortion or miscarriage. Peculiarities in the Course of the Disease. The above statements show an almost inexhaustible variety in the possible com- plications of typhoid. Tlie course of the disease as a whole may likewise present many diverse forms and peculiarities. We shall attempt merely to cite the most essejitial. The numerous light and rudimentary attacks {ty2:>hi(s levissimiis) are fii-st to be mentioned. It was not recognized till lately that they belonged to typhoid fever at all (Griesinger). They used to have all sorts of names applied to them, the favorite term being "gastric fever." This light form lasts eight to fourteen days. The fever is moderate and often decidedly remittent. There is almost no proper fastigium. The typhoid symptoms are but slightly developed. There are no sevei'e pulmonai-y or cerebral symptoms. There is generally a moderate diarrhoea, the spleen is plainly enlarged, and often rose-spots can be found. The diagnosis of these cases is of covirse dilTicult in ])roportion lo the scanty develo])- ment of typhoid symptoms. It is best established by demonstrating an tetiological relation between these cases and others which are plainly typhoid fever. Abortive typhoid is justly distinguished by Liebermeister from tyiyhtis levin. The name belongs to cases which begia with severe symptoms and high fever, as if they were going to be grave, but in which these violent symptoms disappear after a few days and give place to a rapid convalescence. On the other hand, there are cases which for a long time cause so little subject- ive discomfort that the patient does not even go to bed (walking typhoid). It is not till quite late that there occui-s a sudden change for the worse, or some severe complication. Thus it has happened that people who were apparently healthy • This reaction consists in tlie rod coloration of tlie urine upon the addition of Elirlich'a reaj^cnt (cliiefly sulplianilic acid) and ammonia. For particulars, sec treatises upon chemical analysis, f Ehrlich's testis carried out as follows: Solution 1 consists of strong hydrochloric acid, one part, mixed with twenty parts of a saturated aqueous solution of sulphanilie acid. Solution 2 is a oue-half-pcr-cent. solution of sodic nitrite in water. A test-tube is one-eighth part filled with solution 1, and five to ten drops of solution 2 are added to this ; n quarter of the test-tube of urine is then added, and, lastly, enough ammonia to make it strongly alkaline. The deep-red color, which appears promptly, is not so characteristic as a green precipitate of phosphates, which appears at the bottom of tlie tube after standing for twenty-four hours.] TYPHOID FEVER. 19 have suddenly had all the symptoms of a severe ijeritonitis due to perforation and have died, the autopsy disclosing the lesions of the third week of typhoid fever. The individual circumstances are very important in weighing each ca.se, for they may modify the disease iu many ways. In children it is a remarkable fact that typhoid ulcers are much less frequent than in adults. This explains why intestinal hajmorrhage and peritonitis are much rarer in children. Severe cerebral symptoms are, on the other hand, very frequent. In severe cases children sometimes exhibit the peculiar symptom of a continuous penetrating screaming. In other, mild, cases the children are sop- orose. In the aged the diagnosis of typhoid is often very difficult, since the course of the disease is frequently irregular. Generally the fever is not very high, and it very seldom exhibits distinctly the type described above. The pulmonary or cere- bral symptoms predominate as a rule. In the corpulent, typhoid fever is often very severe, so that our pi-oguosis must always be rather grave, especially if pulmonary symptoms arise. Hard drinkers are also in especial peril in this as in all other acute diseases. Dangerous cardiac weakness is prone to appear. Severe cerebral symptoms are frequent. It is, however, surprising that true delirium tremens is relatively infre- quent, although so common in pneumonia. The influence of previous strong mental excitement and of certain already ex- isting diseases (cardiac disease, emphysema, kyphoskoliosis, etc.) has been already mentioned. Finally, we repeat that often the difl'erent epidemics present cei-tain peculiarities. For instance, in one the type of the disease will be severe, in another mild. In one epidemic relapses are comparatively frequent, in another e.xceptional. The same is true with regard to the frequency of the ajapeai-auce of certain symptoms, such as intestinal haemorrhage, pneumonia, or nephritis. In- deed, it has even been observed that those cases which occur during a given epi- demic in the same family or house or block sometimes present striking resem- blances to one another (''group typhoid" of E. Wagner and others). Eelapses of Typhoid Fever. Typhoid fever exhibits in many cases the peculiarity of repeating itself com- pletely after having run its entire course and disappeared. This process is called a relapse. It is in all probability the result, not of a fresh infection of the system from without, but of a renewed development, or possibly of a second generation, of the infectiovis germs already present. A typical relapse is like a first attack in all clinical and anatomical particulars, with this difference, that everything is more condensed, and lasts a shorter time than in the first attack. The interval between the two, during which there is no fever, lasts seven to ten days. It may be longer, and is often shorter. Sometimes the relapse follows immediately upon recovery. Indeed, it may even happen that, before the patient has completely recovered, his temperature begins to rise again in the characteristic step-like way. To such cases as this last the term recrudescence is applied. Except in the time of its beginning, it may be just the same as a genuine relapse. In the interval be- tween the two attacks many persons are perfectly comfortable, and appear to be fully convalescent. There is often, however, a slight evening rise of temperature. It is noticeable that the splenic tumor does not completely disappear after the first attack in many cases which are followed by a relapse. The relapse is (generally briefer, as we have said, than the first attack, seldom lasting more than fifteen to eighteen days. The temperature rises more rapidly, perhaps in two or three days. The fastigium is shorter, the decline more abrupt. 20 ACUTE GENERAL INFECTIOUS DISEASES. The absolute height of the temperature may be very considerable, even exceeding that in the first attack. Rose-spots appear as soon as the third or fourth day. The .stools become liquid, the spleen enlarges again, and all sorts of complications may arise. The danger occasioned by a relapse may, however, be overestimated. On the whole, a relapse is not so very dangerous, and it is especially noticeable that the subjective symptoms, such as headache, ai'e often slight. A severe relapse may follow a mild case. In other instances the relapse may prove merely rudi- mentary. The frequency of relapses varies considerably in different epidemics. In Leip- sic, we had relapses in about nine per cent, of all ca.ses, but in separate years the percentage varied between four and sixteen. Out of about five hundred cases we have seen three in which there were two successive and typical relapses. Diagnosis. — The diagnosis of ty]ohoid fever may be perfectly ea.sy, but, if the case be anomalous, or come under observation at a late period, it may be e,\- tremely obscure. Inasmuch as a search for the specific bacilli is too difficult and troublesome, for the practicing physician, the diagnosis of the disease must be made from its com-se and symptoms. Important factors are the gradual onset, then the height and couree of the fever, with no demonstrable localized disease, and the rose-spots. Less characteristic, but still of value, are the stools, the tj'm- panites, and the swelling of the spleen. Etiological factors, such as the occur- rence of undoubted cases of typhoid in the neighborhood, arc of gi'eat diagnostic value in obscure cases. Sometimes the diagnosis can not be established till the appearance of certain symptoms, like intestinal ha;morrhage, a characteristic mode of convalescence — viz., by lysis — or a relapse. It is an important i-ule not to make a diagnosis of tj'phoid after a single examination. It is generally neces- sary to observe the case accurately for several days before the diagnosis can be established. The differential diagnosis from other acute diseases, such as miliary tuberculosis, acute endocarditis, meningitis, etc., will be considered in discussing these diseases. Prognosis. — A perfectly favorable prognosis should never be made. Cases which seem the mildest may become dangerous. Yet, if there are good nurskig and good treatment, typhoid fever is not a particularly dangerous disease, and we may hope for recovery even in very severe attacks. The danger lies, first, in the severity of the infection, as shown chiefly (tliough not wholly) by tlie height of the fever and the intensity of the general symptoms. A further danger is the appear- ance of the complications already enumerated and discussed. Thirdly, the con- stitution and condition of the individual are important. The circumstances com- ing under this head have likewise been repeatedly mentioned above. All these factors must be carefully estimated before we decide as to the dang'er in each case and make our prognosis. The mortality in typhoid varies greatly in the separate epidemics. The severe cases are undoubtedly more frequent at some times tiian at othei-s. This renders it difficult to give statistics which are uTiiver.sally apjilicable. We may in general reckon on an average mortality of about ten jjer cent., and measure tiie severity of separate epidemics by this standard. Numerous observei-s agree that the treat- ment now in vogue has decidedlj' diminished the nioi-tality. It was formei-ly not rare for it to reach twenty or twenty-five per cent. Treatment. — A specific cure for typhoid — i. e., some remedy to destroy the specific cause of the disease within the system, or to render it harmlcs.s — is as yet unknown. Antiseptic and antizymotie drugs, such as quinine and antipyrine {vide hifra), do have a certain inliuence upon the fever, but they are not capable of essentially modifying the course of the disease as a whole, at least not in such doses as we dare admiuiuister. The continued internal use of car- TYPHOID FEVER. 21 bolic acid (^grains five to ten, gramme O'30-O'oO, or more, in the course of twenty -four hours) is the means chiefly recommended lately for this purpose; but we doubt if it is of much benefit. Liebermeister ascribes to iodine a demon- strable, although slight, beneficial influence. Other physicians had pre\'iously recommended it. Four to five drops of the following solution are given every two hours in a wineglass of water: Iodine, one part; iodide of potassium, two parts ; distilled water, ten parts. We have had no personal experience with this remedy. Calomel is also said to have a specific efi^ect on typhoid. Wunderlich and others have noticed that if a few rather large do.ses of calomel be given at the beginning of the disease, it will on the average i-un a lighter and more favorable course than otherwise would have been the case. Wxuiderlich lielieved that typhoid fever may sometimes be aborted by this method. Although we can hai'dly expect tliis, it is really an efficient means of procedure, which we have often found satisfactory, to give two or three powdei's, of five grains (0'30 gramme) each, of calomel, as the first prescription, to patients who come vmder treatment in the first week or the beginning of the second. As there is generally constipation, the laxative effect is also beneficial. Moreover, it often low'ers the temperature some- what. A moderate diarrhcea is not a contra-indication, but, if the bowels be very loose, the calomel should be omitted. Ergotine may be mentioned as another drug which is said to act specifically. It has been lately used, chiefly by French physicians, in doses of twenty to forty- five grains (l'50-3 g'rammes) in twenty-four hours. Again, subniti-ate of bisraiith is used (hy the French to the amount of four to eight drachms — grammes 15-30 pro die), and naphthaline in single doses of three to eight grains (O'l-O'o) or in the course of the day seventy-five grains (5"0). Wedoubt if these remedies will be popular long. In the present state of oui" knowledge the treatment of typhoid must still be chiefly general and symptomatic, and in one sense prophylactic. We must fight the symptoms ah-eady present, and fm-ther seek, as far as possible, to defend the patient from the attack of certain dangerous secondary disorders. Starting out with this view, the proper treatment of typhoid fever is a task of the highest im- portance, and by no means a thankless one. We will begin by considering the general ti'eatment. The sick-room must not be too warm, and must be frequently and thoroughly aired. The sick-bed must be well cared for. If pains be taken to prevent bed-sores, we shall obviate one source of pain and danger (vide supra), and save ovrrselves and the nurse much trouble. Those who are very sick should therefore be laid on an air-cushion, or, if possible, a water-bod. The patient should be told not to lie always upon his back, but to change now and then upon his side. The back, the region of the sa- crum, and the heel^ are to be often bathed with spirits of camphor or bi-andy. The minutest bed-sore is to be treated carefully. It should be cleansed twice a day (rinsed off with a weak solution of salicylic or carbolic acid), and done up Avith an ointment containing Peruvian balsam, 1-30.* If the bed-sore be extensive, dusting with iodoform is very efficient treatment. We should be particularly careful not to let the skin be undermined. If this has already occurred, we must be prompt in the use of the knife or drainage-tube. We can not recommend too strongly that the mouth should be kept clean. In a light case the patient can see to this himself, but otherwise the mouth and tongue must be frequently cleansed with a linen cloth wet in cold water or a solu- * The nnguentum balsami peruviani is made by mixing one part of balsam very exactly with thirty parts of the glycerite of starch (B. P.j. It is not officinal in Germany. — Trans. 22 ACUTE GENERAL INFECTIOUS DISEASES. tiou of borax (1 to 30). Perhaps we ueed hardly repeat the reason for this excess- ive cleanliuess. It lies in the causative relation between stomatitis and inflam- mation of the parotid gland, and of the middle ear. If the tongue and lips be dry, they may be touched with glycerine. The diet must he at once liquid and nourishing. Milk is excellent, and should always he ordered, but will, unfortunately, be taken by very few patients continu- ously. It is often better borne if coffee or a little braudj- be added to it. Cocoa made with milk may also be given for a change. In severe cases Nestle's food (Kinderinehl) has been often employed by us -^ritli benefit. Broth and soup, thick- ened with sago or rice, are also good. They may be made more nourishing by adding an egg to them. If the patient is veiy anxious to have more solid food, as often happens, we need not hesitate to give him a roll or rusk (Zwieback) that has been softened by soaking. If a patient becomes exceedingly enfeebled we should give him fine shavings of raw beef, regardless of the fever. A little dilute hydrochloric acid might be given with the meat. Beef-tea would be still better than the raw meat, and is to be strongly recommended. The various prep- arations of meat which are now made (meat-solution, meat-peptones, etc.j may be sometimes useful. Where the fever takes a sluggish coui-se, we must often begin to give stronger nourishment before the fever has ended. The best ch-ink is cold water, which the patient wonld often not think of using unless we offered it to him. Lemonade and similar preparations generally become distasteful in time. Drinks containing carbonic dioxide are to be avoided, because they increase the meteorism. Cold tea with milk is good. In severer cases we should give some good strong wine, such as port, Malaga, or Hungarian Avine. If the patient desires beer, we ueed not hesitate to give it in moderate amount. During conva- lescence we should be very careful about diet, since errors often have disagreeable consequences. We must wait till there has been no fever at all for seven to ten days before we allow a solid, animal diet, and return by degrees to common sorts of food. The general and dietetic treatment which we have thus far discussed is very important. Outside of this, it is our opinion that tliere is only one method of treatment to be chiefly considered — at least under tlie present limitations of our therapeutic ability. This method consists in the persistent use of cool baths, as first practiced by Brand in Stettin. We do not indeed believe that the indications for this method of treatment are exactly what its original promoter held them to be, and we think some of the minutias of the treatment should be changed. Yet there is at present no other single method of treating tyi^hoid fever which has so numerous and evident advantages for the patient. To carry it out in private prac- tice may often be more difficult than in a vi-ell-appointed hospital. However, even in private houses it will generally be possible to manage it, and we regard it as the duty of every physician who undertakes to treat a severe case of typhoid to try his best to have the baths employed. The gi-eat advantages of the ti-eatment by baths are: 1. The baths diminish the fever, if their temperature be only sufficiently low, by direct absorption of heat. The baths thus obviate, as far a-s possible, all the bad effects which might result fi'om a rise of temperature. 2. The direct influence of the baths u])on the nervous system is still more impoi-tant. The intellect becomes clearer, the apathy and dullness diminish. In fact, if baths be used, we do not see nearly so often as formerly the grave ''typhoid condition." It is thus evident that bathing not only causes an improvement in the subjective sensations of the patient, but brings in its ti'ain many other beneficial effects. The patient takes his nourishment better, does not so often swallow the wrong way, coughs more effectively, is easier to move, and liLs body and his mouth can be better cleansed. 3. The influence of TYPHOID FEVER. 23 the baths upon the respiratory orgaus is of the greatest importance. We refer especially to the stimulation to deeper inspirations, and the promotion of expec- toration. The best proof of the benefit of this influence is the circumstance that, if patients are subjected to baths fi'om the start, it is comparatively a rare thing for severe bronchitis, atelectasis, and catarrhal pneumonia to develop. 4. The good care of the skin, which the bathing makes possible, is not to be despised. Since this treatment has been introduced, betl-soi'es ai-e much rarer in tyjihoid than before. 5. Lastly, the baths are sometimes observed to have a diuretic effect. What has been said shows that the height of the fever is by no means the sole indication for the employment of baths, at least in our opinion. The condition of the nervous system and of the respiratory organs is also to be considered. It is true that numerous mild cases run a favorable coui-se without a single bath; but we should always remember that this treatment is not only directed against the symptoms already existing, but has also a prophylactic importance, since it tends to prevent any severe cerebral or pulmonary manifestations. We will pass on to the special method of carrying out balneo-therapeutics in typhoid. Full baths are generally employed, immersing the patient to his neck. The tub must stand, if possible, by the bedside. In hospitals, where there ai'e beds on rollers, it is a better way to wheel the patients into the bathroom. All who are severely ill should be lifted into the bath and there held and sujipoi-ted, to avoid any bodily fatigue. During the bath the skin should be gently rubbed. This averts unpleasant sensations of chilliness. The temperature of the water should not be set too low, especially for the first baths. We begin at 85° to 90° (34° to 26° E.), or, if the individual be elderly or sensitive, and timid, at even warmer temperatures. When the patient has become accustomed to the tempera- ture of the water, we can cool off the bath still further. Baths below 73° (18° to 20° R.) have scai'cely ever been used by us, and we believe that they are seldom needed. A very satisfactory average temperature is 80° to 85° (20° to 24° R.j. A bath lasts on the average ten minutes. If the patient feels very cold or very uneasy in the bath, it must be cut short. After the bath the patient is at once lifted into bed, wrapped up in a sheet previously made ready, and wiped dry, with rather vigorous rubbing of the extremities and back. The moist sheet is then removed. The patient is covered up rather warmly, and is given some hot broth or a sip of good strong wine. The effect of the bath upon the temperature is measured about half an hour later by the rectum. If the temperature be 2° to 3° (1° to 2° C.) lower than before, the result is deemed satisfactory. Often the differ- ence is greater, but in severe cases the fever may be so obstinate that the tempera- ture remits only a small fraction of a degree. In such cases it is sometimes per- missible to lower the temperature of the bath still more, or continue it a little longer. If cool baths are ill-borne, protracted baths of lukewarm water are some- times very efficient (Riess, and other). In so far as the height of the fever furnishes an indication for baths, we may accept, say 103 '6° (39 '8° C.) in the rectum, as the temperature calling for a bath. As a rule, baths should not be given oftener than every three hours, as otherwise they exhaust the patient. In many cases three or four baths a day are enough. At night we have given baths very seldom, when forced to by extremely high temperatures or other bad symptoms. It must be a mistake to wake a patient who is quietly sleeping, and put him into cold water, even if his temperatiu?e is above 104° (40° C). Likewise, in cases where the temperature shows considerable spontaneous remissions, there may be no use in inflicting a cold bath upon a patient who has high fever only temporarily. On the other hand, even if the temperature be not excessive, or even if it be normal, there is, as we have said, no 2i ACUTE GENERAL INFECTIOUS DISEASES. better remedy than the baths for severe pulmonary or cerebral symptoms. In such cases we often raise the temperature of the baths a little, and during them we have colder water poured upon the liead and back. If we do this, the ears must be stopped with cotton-wool, lost tlie cold water find its way into them. It is not always advisable to use baths, however advantiigeous this treatment may be, in lyjihoid fever. Tlicre are a number of contra-indications which can not be disregarded. First, the occurrence of intestinal hfemorrhago, however slight, and likewise the suspicion that peritonitis is developing, prohilut bathing. In these cases quiet i.s the very first requireinent of the patient, and the baths must be at once discontinued. Further centra-indications are great weakness or great sensitiveness, such that the excitement caused by the bath might do harm. Sometimes baths are followed by severe rheumatic (" rheumatoid") pains in the limbs, and often they seem to promote the occurrence of furunculos>s. In such cases it is often necessaiy to omit the baths, or at any rate to employ them less often and at a warmer tempei-ature. The same is true if a severe laryngeal affection develops, or otitis or nephritis. Nothing seems to us a gi-eater mistake than to attempt to establish a scheme for the treatment of typhoid by baths that sliall be always applicable. Here, if anywhere, the only correct way is to treat each individual case according to its special symptoms and circumstances. We shall now pass on to the consideration of the fm-ther symptomatic treat- ment of typhoid. The first question is whether the fever— that is, the elevation of bodily temperature, as such — demands special consideration. In general, we are of the opinion that the internal antipyretics are seldom indispensable. It is tiiie that by giving quinine (single doses of fifteen to twenty grains, gi-amme 1 to 1"50) or salicylate of soda (in amounts of a drachm or a di'achm and a half, grammes 4 to 6), the elevated temperature may often be considerably diminished; but whether the patient is thereby benefited is at least doubtful. Certainly the unpleasant accessory symptoms caused by the di-ugs mentioned — viz., vomiting, ringing in the ears, vertigo, and profuse perspiration — make the patient feel decidedly more imcomfortable than he was before. There is also some danger that these medicines may have an unfavorable influence upon the cardiac activity. Decidedly better than quinine and salicylic acid is antipyrine. This substance was synthetically produced by L. Knorr from phenylhydrazin and acetacetic ether, and was fu'st recommended by Filohne. In the dose of fifteen to thirty grains (grammes 1 to 2) it is a very efficient antipyretic. It may be given in wafers or dissolved in water, and it is easy to take. E.xceptionally there are disagreeable results, such as vomiting, an eruption resembling measles, or a rigor followed by a return of fever. In severe cases the dose must be repeated after two or three hours. More than eighty or ninety grains (grammes .5 to 6) as a maximum should not be given in one day. The general condition often improves binder the influ- ence of antypyrme. Especially is this ti'ue with regard to headache, restlessness, and other nervous sj-mptoms. Another very efficient antipyretic is acetanilide, which was lately discovered by Cahn and Hepp, and has already been largely introduced into medicine under the name of antifebrin. One advantage is that it is far cheaper than antipyrine. It is given in doses of four to eight or even fifteen grains (gramnie 0'25, O'n, I'O) either in wafers or in wine. It usually causes a decided lowering of the temperature, and seldom with any inipleasant effect, such as a chill. One disadvantage, however, is the frequent appearance of a peculiar bluish discoloration of the skin, which is probably dependent ujjon a change in the coloring matter of the blood, similar to tliat seen in poisoning from aniline. It is therefore probable that caution should be used in gi-sang the drug. Numerous other antipyretics, such as kairiu and thallin, have been proposed, but have not become popular. It is also improbable that a continued administration of TYPHOID FEVER. 25 small closes of thallin (two thirds to one grain, gramme 0'04, 0'06) eveiy hour would have a favorable influence upon the course of the disease, although this has been asserted. The newest antipyretic of all is phenacetiue, which was recommended by Kast and Hinsberg. Its dose is about fifteen grains (gramme 1). After all, it should be borne in mind that the only benefit from the internal antipyretics consists in the lowering of the temperature, while baths not only abate the fever, but possess numerous other advantages, a,s has been already shown. If we had to choose whether to treat typhoid fever e.Kclusively with baths or with antipyriue, and the like, we should certainly choose the baths. We do not by any means desire to banish the use of internal antipyretics from the treatment of typhoid, but only to make their employment more limited than has often been the case. We consider that they are actually indicated only where the fever is high and the employment of batlis is for some rea.son impos- sible or contra-indicated, or where the fever remains continuously high, despite bathing. In such cases it is often advantageous to combine the bath -treatment and the internal antipyretics; especially in the evening. If patients with a moderately high fever are made to take large doses of quinine and the like, without any satisfactory reason for it, we regard such ti-eatment as at auj' rate useless and often really injudicious. Tliis is, unfortunately, a common practice, and frequently its only permanent result is a disordered stomach. [Water or an acid drink should be given frequently by the nui-se without wait- ing for the patient to ask for it, unless the mind is unusually clear. Phenacetine seems to have proved itself less depressing to the heart than its predecessors. The antipyretic dose usual in this country is five grains. A strong protest should be entered against the routine or frequent use of any of these internal antipyretics. If the temperature seems, in itself, to cause restlessness and discomfort, an oc- casional dose may be given. When used early in the course of the disease, anti- pyretics may seriously embarrass the diagnosis in doubtful cases. The method of Brand has been slowly working its way in America of late years, and perhaps would have spread more widely and rapidly were it not that we have long been in the habit of frequently sponging our typhoid patients with alcohol and water.] Another important symptom which needs special ti'eatment is intestinal hemorrhage. It has been already mentioned that if this occurs, the baths should cease at once. Further than this, the chief remedies are ice and opium. Flat ice-bags are laid upon the abdomen. They should not be too heavy, and should, if possible, be suspended from a hoop. Internally, the patient is given every two hours a powder of one-half grain or one grain ( gramme O'OS to Q-Oo) of opium, either pure or combined with acetate of lead (opii, gr. ss., grm. 0-03 ; plumbi ace- tatis, gr. j, grm. O'Oo ; sacchari albi, gr. j, grm. 0-05). The object of the opium is to check peristalsis, and thus promote the formation of a clot in the bleeding vessel. Liquor ferri chloridi (five to ten drops in water every hour) is often employed, but is of extremely doubtful value. The baths can not be resumed till there has been no bleeding for at least three or four days— and then only cautiously. If peritonitis occurs, the treatment is much the same. Above all, opium must be used in still larger doses, but, mifortunately, as a rule, in vain. Per- haps surgical ti-eatment is destined eventually to be useful, viz., incision, cleansing, and drainage of the peritoneum. Its results thus far are not very encouraging. If there is considerable diarrhoea, we can give mistura gummosa [P. G., gum arable and sugar, each 15 parts ; water, 170 parts], tannin, subnitrate of bismuth, or small doses of opium. Constipation at the beginnmg of the disease is over- come by calomel {vide supra). In later stages we always try enemata first, to 2G ACUTE GENERAL INFECTIOUS DISEASES. produce an operation. If this does not succeed, then we must employ rliubarb or castor-oil. Great tympanites may be diminished by laying cold wet cloths or ice-bags upon the belly. Considerable amounts of gas may often be removed by introducing a long rectal tube. As to puncturing the greatly inflated intestines, a method practiced by some pliysicians, we have no pei-sonal experience. If there are severe pulmonary symptoms, baths and poui-ing on cool water are, as we have said, the best remedies. Internally we may try liquor ammonii anisatus [P. G., olei ani.si, 1 part; aquaj destillata;, 24 parts; aquaj ammoniae, 5 parts] and benzoic acid (grains ij to iij, gramme O'l to 0-2, in powder). If the pulse be very i-apid, we can j^ut an ice-bag over the heart. If at the same time the pulse is small and weak, we give stimulants, of which the best is camphor (vide infra). Digitalis (one-half grain of the leaves, gramme 0'03, two or three times daily) may also be employed if the pulse be rapid; but it should be u.sed witb great caulion. For nervous symjitoms the baths and douching are the most effective reme- dies. The head is meanwhile covered by an ice-bag. If thei-e be great excite- ment, as shown by excessive restlessness or delirium, small doses of morphine are often very usefvil. The conditions of collapse and cardiac failure, which sometimes appear rather suddenly, demand prompt and energetic treatment. Stimulants to be given in- ternally are some stronger kind of wine, camphor (two to five grains, gramme O'lO to O'JiO, in the form of a powder), musk (one half grain to one grain, gramme 0'0.3 to 0'05 at each dose), or spiritus aetheris [P. G., sether, one part; alcohol, three parts]. Subcutaneous injections act quicker and are much more C(mveu- ient. We may use either ether or camphor (one part camphor to four ])arts olive- oil, seven to fifteen minims, c. c. 05 to I'O, every one to two hours). To start up respiration, the best means is to pour cold water on the back of Ihe neck. Artifi- cial respiration also succeeds, in many cases, in revi\ang the breathing when it is about to stop. The nvimerous other complications and sequela; which may occur, but \\hich can not all be mentioned here, should be treated on general principles. The prophylactic measures to avoid the spreading of the disease can be only briefly referi-ed to. Of chief importance is careful disinfection of the exci-eta, which can be accomplished by pouring u]3on the stools a not too small amount of five-per-cent. carbolic solution. We should also take care that bed-pans, bed- clothes, linen, etc., are handled by other persons as little as possible. If there seems reason to suspect that the disease arose from bad water, of course the source of such suspected water must be cut off. PRecent experiments tend to show that the above solution of carbolic acid does not kill s]iores except after prolonged contact. The following are the measures of disinfection recommended by the American Public Health Association. It will be observed that they apply to all infectious diseases, and it seems well to give them here nearly in extenso, as the directions for disinfection in most text-books are far too vague. Disinfection of Excreta, etc. —The infectious character of the dejections of patients suffering from cholera and from typhoid fever is well established; and this is true of mild cases and of the earlier stages of these diseases as well as of severe and fatal cases. It is probable that epidemic dysentery, tuberculosis, and jjerhaps diphtheria, yellow fever, scarlet fever, and typhus fever, may also be transmitted by means of the alvine discharges of the sick. In cholera, diphtheria, yellow fever, and scarlet fever, all vomited material should also be looked ujion as infectious; and in tuberculosis, diphtheria, .scarlet fever, and infectious pneu- monia, the S2)uta of the sick should be disinfected or destroyed by fire. It seems TYPHOID FEVER. 27 advisable also to treat the uriue of patients side with an infectious disease with one of the disinfecting solutions below recommended. Chloride of lime, or bleaching- powder, is, perhap.s, entitled to the first place for disinfecting excreta, on account of the rapidity of its action. The following standard solution is recommended : Standard Solution No. 1. Dissolve chloride of lime, of the best quality,* in pure water, in the proportion of four ounces to the gallon. Use one quart of this solution for the disinfection of each discharge in cholera, typhoid fever, etc. Mix well and leave in vessel for at least one hour before throwing into privy-vault or water-closet. The same directions apply for the disinfection of vomited matters. Standard Solution No. 2. Dissolve corrosive sublimate and permanganate of potash in pure water, in the proportion of two drachms of each salt to the gallon. This is to be used for the same purposes and in the same manner as Standard Solution No. 1. It is equally effective, but must be left a longer time in contact with the material to be disin- fected — at least four hours. The only advantage this solution has over No. 1 con- sists in the fact that it is odorless. It costs about two cents a gallon. It is very poisonous, and will injure lead pipes if passed through them in considerable quantities. Solutions of corrosive sublimate should not be placed in metal re- ceptacles. Disinfection of the Person. — The surface of the body of a sick person, or of his attendants, when soiled with infectious discharges, should be at once cleansed with a suitable disinfecting agent. For this purpose solution of chlorinated soda, diluted with three parts of water, or Standai-d Solution No. 1, diluted with three parts of water, may be used. A two-per-cent. solution of carbolic acid is also suitable for this purpose, and, under proper supervision, the use of a solution of corrosive sublimate (1-1,000) is to be recommended. In diseases like small-pox and scai'let fever, in which the infectious agent is given off from the entire surface of the body, occasional ablutions with solution of chlorinated soda, diluted with twenty parts of water, will be more suitable than the stronger solution above recommended. In all infectious diseases the body of the dead should be enveloped in a sheet satiu'ated with Standard Solution No. 1, or with a five-per-cent. solution of car- bolic acid, or a 1-500 solution of corrosive sublimate. Disinfection of Clothing. — Boiling for half an hour will destroy the vitality of all known disease-germs, and there is no better way of disinfecting clothing or bedding which can be washed than to put it through the ordinary operations of the laundry. No delay should occur, however, between the time of removing soiled clothing from the person or bed of the sick and its immersion in boiling water, or in one of the following solutions ; and no article should be permitted to leave the infected room until so treated. Standard Solution No. 3. Dissolve four ounces of corrosive sublimate and one pound of sulphate of copper in a gallon of water. Two fluid ounces of this standard solution to the gallon of water will make a suitable solution for the disinfection of clothing. * Good chloride of lime should contain at least twenty-live per cent, of available chlorine. The cost of tlie solution is less than one cent a gallon. The sediment does no harm. 28 ACUTE GENERAL INFECTIOUS DISEASES. The articles to be disinfected must be thoroughly soaked with the disinfectinfr solution, and left iu it for at least two hours, after which they may be wrung out and sent to the wash. Clothing may also be disinfected by immersing it for four hours in a two-per- cent, solution of carbolic acid. Soiled mattresses, pillows, feather beds, and articles of this nature can not be effectually disinfected bj' sulphur fumigation, ownng to the fact that the gas does not penetrate to their interior ui sufKcient amount. For articles of this Idnd, and in general for articles of little value, which have been soiled by the discharges of the sick, destruction by fire will be advisable. Disinfection of the Sick-Room. — No disinfectant can take the place of free ventilation and cleanliness, and it is impracticable to disinfect an occupied apart- ment. Neutralizing bad odors is not disinfection. All surfaces should be thoroughly washed with Standard Solution No. 1, diluted with tlu-ee parts of water, or with a 1-1,000 solution of corrosive sublimate. Standard Solution No. 3, diluted in the proportion of four ounces to the gallon of water, may be used. The walls and ceiling, if plastered, should be brushed over ^s•itll ouc of these solutions, and subsequently washed over with a lime-wash. Especial care must be taken to wash away all dust from window ledges and other places where it may have settled, and thoroughly to cleanse crevices and out-of-the-way places. After this application of the disinfecting solution, and an interval of twenty-four hours or longer for free ventilation, the floors and wood- work should be well scrubbed with soap and hot water, and this .should be followed by a second more prolonged exposure to fresh air, admitted through open dooi-s and windows. As an additional precaution, fumigation with sulphurous-acid gas is to be recommended, especially for rooms which have been occupied by patients witli small-pox, scarlet fever, diphtheria, typhus fever, and yellow fever. All apertures into the room should be carefully closed, and not less than three pounds of sul- ])hur for each thousand feet of air-space should be bm-ned. To secure complete combustion, the sulphur, in powder or small fi'agments, and moistened with alcohol, should be placed in a shallow iron pan, and this should be placed on bricks in a tub partly filled with water to guard against fire.] CHAPTER II. TYPHUS FEVER. {Sjmtted Fever, Ship Fever.) Typhus fever is an acute infectious disease, perfectly distinct from ty])hoid fever, but formerly often confounded with it. The similarity of the two diseases, which led to their similar names, consists only in the grave genei-al condition, with fever, and in a number of complications, which may ajjpear in both. There is, however, an essential difference in the whole coui'se of the diseases, and espe- cially in the cii'cumstance that the intestinal lesion which is characteristic of typhoid is never seen in typhus. The chief distinction between the two affections, which Tnust undoubtedly lie in the difference in their causes, can not yet be dem- onstrated. We do not yet know the organized pathogenic agents of typhus fever,. although it must be presupi)osed that they exist. .ffitiology. — As to the way in which infection occurs, we have much less infor- mation even than in relation to tj-phoid. We regard it as an established fact that TYPHUS FEVER. 29 the disease never arises spontaneously, and tliat its appearance in a place previ- ously free from the disease is always to be referred to an importation of the patho- genic poison. It is likewise determined, through numerous obsei"vations, that typhus is one of the contagious diseases — that is, that the specific poison can be directly transferred from the patient to others around him. How it is transfeiTed we have no certain knowledge. Perhaps the poison is contained in the expired air; or, as is still more probable, in the scales of epidermis; or, perhaps, in the other exci-etions and secretions of the patient. We are equally ignorant through vrhat channel the infectious agent enters the system — whether it is inspired or swallowed. It is certain that the poison may be transferred in the clothes, etc., of the patient (fomites). Favorable hygienic surroundings decidedly diminish the contagiousness of typhus fever. For example, in the well-ventilated pavilions of the Leipsic hos- pital there have rarely been cases of transfer of the disease to physicians, nurses, or other patients. On the other hand, if the hygienic influences be unfavorable, typhus fever may appear in very widespread epidemics. Those terrible epidemics which have been described under the names of " famine fever,"' "camp fever" (Hungertyphus, Kriegstyphus), etc., were for the most pai-t tyi^hus fever. In the smaller epidemics it is often possible to trace the disease to some wretched, over- filled tenement-house. At present typhus fever appears constantly in Great Britain. Ii-eland has been notorious for many years as a breeding-place of the disease. It is also frequent in the eastern part of Germany (Posen, East Prussia and West Prussia, Silesia), in Poland, Galicia, Russia, and in parts of southern Em-ope. The isolated cases which occur every j^ear here and there in central Germany, though more or less numerous, are, almost without exception, to be referred to an importation of the disease. Typhus fever attacks by preference yomig adults of twenty to forty years ; but it occurs in children, and is comparatively frequent in elderly persons. There is no marked dependence of the epidemics upon any particular season of the year. As in the case of typhoid fever, a person who has once had the disease seems to enjoy immiiuity from any fresh attack. [The practical acquaintance of American physicians with typhus fever is, fortu- nately, limited. Many of the outbreaks which have occurred were ti-aceable to im- migTants, especially from Ii-eland. During our civil war the disease broke out neither among the armies in the field nor among the prisoners of war. A number of cases were re])orted at the time, but great doubt has since been thrown upon the correctness of the diag- nosis.] Course and S3nnptoms of the Disease.— If we try to sketch the characteristic behavior of typhus fever, especially as contrasted with typhoid, we may say that the disease begins much more abruptly and rapidly, and that the fever quickly becomes very high and the general disturbance very severe, but the illness lasts a shorter time, seldom more than two weeks, and generally passes by crisis into recovery. The length of incubation seems to vary. Mm'chison thinks it is usually more than nine days. Sometimes, though not invariably, slight prodromata precede by some days the actual oiitbreak of the disease. These are languor, anorexia, headache, and pain in the limbs. Then the regular illness beguis, as a rule, rather suddenly, and often with a pronounced rigor. With this the tem- perature rises quickly, and may on the very first evening reach 104° or 105° (40°-40-5° C). Vomiting is not rare, and may be repeated. A grave general condition, with fever, is developed in a few days. The patient feels exhausted. 30 ACUTE GENERAL INFECTIOUS DISEASES. There is often violent pain in the loins and extremities. Nei-vous symptoms soon appear: persistent and intense headache, vertigo, spots before the ej-es, ringing in the ears, and in many cases quickly inci-easing stupor and delirium. In severe cases the fever often reaches 106° (41° C), and may be even higher, and it is almost constant, with but slight morning remissions. The skin is hot and diy, the tongue dry and thickly coated, the respiration moderate, the pulse very rapid. We very frequently find in the chest the signs of an extensive broncliitis. Nasal catarrah and conjunctivitis also occur. Serious intestinal symptoms are generally absent, although there may be slight tympanites or diarrhoea. The spleen is almost always greatly enlarged. Onlj^ in a few epidemics is the .splenic tumor said to have been wanting (?). The urine is concentrated and scanty, and sometimes has a trace of albumen. On the third to the seventh day of the disease the characteristic eruption a\> pears. To this the disease owes its name of "spotted fever." The eruption con- sists of rose-spots, generally very numerous and widespread, upon the trunk and extremities, often also on the face. Sometimes the spots are larger, and may then bear great resemblance to a fresh eruption of measles. The skin between the .sep- arate rose-spots is not infrequently diffusely reddened. After two or three days the roseolas become haamorrhagic, and change into lighter or dai-ker petechia;. It is commonly only in the lighter cases that the rose-spots fade away without first becoming petechial. In rare though well-substantiated cases the eruption has been scanty, or even wholly wanting. Herpes does occur, but only seldom. The fever begins to abate in light cases as early a.s the second week, coin- cidently with an improvement in the general symptoms. Often this change is indicated about the seventh day by a considerable remission in the temperature. On the other haud, in severe cases, all the symptoms grow worse. The weakness increases. The nervous derangement reaches the extreme of a severe " typhoid state,"' expressed either by marked stupor, which sometimes passes into complete coma, or by violent delirium. Lobular pneumonia attacks the lungs, and the fever continues with unabated violence. These symptoms may end with death, but in favorable cases they decline rapidly. Sometimes this decline is preceded by a great rise in temperature (perturbatio critica) on the fourteenth to seven- teenth day, rarely a few days earlier or later. In such cases the temperature is apt to fall by crisis, sinking in a day or two, with but slight interruption, down to the normal level. Even in those cases in which the descent is by gradations it is always decidedly more abrupt than in typhoid. The eruption qiiickly fades, the patients gradually improve, and, as a rule, become completely and pei-manently convalescent. It is true that some observers have seen relapses, but they ai-e, at least in our present epidemics, extremely rare. Complications and Varieties in the Course of the Disease.— From what we have said of its coui-se, it is evident that the symptoms are essentially those of an intense general infection of the system. The sole demonstrable local lesion which is almost inva)'ial>ly pi'esent is the characteristic erujition, and this has evidently no causal relation to the severe s_>-mptoms of the disease. It is likewise extremely probable that most of the complications, which not infrequently arise in severe cases, are secondary, and occur in the way already described with considerable detail in the preceding chapter. They are just siich complications as are pos.sible in every severe general disease, and embrace otitis, parotitis, extensive lobular pneumonia, more rarely gangrene of the lungs, and pleurisy ; also f urunculosis, pui'ulent cellulitis, bed-sores, dysentery, icterus, etc. "Whether some of the local lesions which are obsei-ved may not be direct results of the pathogenic poison, we can not at present decide. Among these would come, first of all, the rare cases of lobar pneumonia and nephritis. Sequelae are, on the whole, rare, RELAPSING FEVER. 31 though sometimes there is a tedious ansemic condition, or neuralgia, pai'aly- sis, etc. The separate epidemics of typhus present considerable variety, not only as regards the occurrence of individual complications, but more especially in the general cour.se and character of the cases. For instance, some epidemics are dis- tinguished by the greater frequency of light attacks (tyjjhus exaufliematicus levissimus, unsuitablj' termed by some "febricula "). Here the entire attack runs its course in five to eight days. The fever is generally comparatively moderate; there are no severe general symptoms, and complications are exceptional. Diagnosis. — It may be very diiiicult for a time to distinguish typhus from typhoid. The following factors are of chief importance: 1. The onset is much more abrupt in tj^phus than in tyijhoid, and is often accompanied by a pronounced rigor. 3. In typhus, the nervous disturbances usually appear earlier and are more severe than in typhoid. 3. The rash is seldom so extensive in typhoid as in ty- phus, and in typhoid it liardly ever becomes petechial. 4. In typhus the pains in the loins and limbs are generally much more pronounced. 5. If we still find it hard to decide, the manner of recovery wiU almost always settle the question. Recovery in severe cases of typhoid is, on the average, much more tardy and gradual, by lysis. In typhus it occurs generally by the seventeenth day, and by crisis. The prognosis is chiefly determined by the severity of the fever and of the nervous symptoms. Extensive lobular pneumonia is the most frequent dangerous complication. The mortality varies greatly in the separate epidemics. It is some- times only six or seven per cent., but may rise to twenty per cent. Treatment is based on the same principles as Ln typhoid fever. There is no specific remedy. Besides good nursing, a judicious employment of baths is cer- tainly our chief reliance for lessening the severity of many of the symptoms, such as febrile, nervous, and pulmonary disturbances, as well as for averting many dangerous complications. For all details of treatment we may refer to the pre- ceding chapter. CHAPTER III. RELAPSING FEVER. {Relaj)sinrj Ti/plius— Fibris ncurrens.) .ffitiology.— This disease was first named by English pathologists relapsing fever, and by Griesinger febris reciirrens. It has a peculiar course, made up of separate attacks, and is fiu'ther of great interest because it is one of the fii'st infec- tious diseases in which the specific pathogenic organisms became known, and, being easily demonstrable in each separate case, were utilized for the speedy and certain diagnosis of the disease. Obermeier discovered in Berlin, in the year 1873, that in relapsing fever the blood, at certain times, invariably contains peculiar, thread-like micro-organisms. This discovery has since been universally con- firmed ; and it may be maintained that if once the presence of these " spirilli " be demonstrated in the blood, we are justified in making an absolute diagnosis of relapsing fever. In Germany the disease did not become epidemic till the year 1868. In 1872 and 1873 there were considerable epidemics in Breslau and Berlin. Its last exten- sive appearance was in 1879 and 1880, when it spread over most of northern and central Germany, and was accurately studied by numerous observei's. People of 33 ACUTE GENERAL INFECTIOUS DISEASES. the poorer classes were almost exclusively attacked, and especially the " tramps." The uncleanly deus where these people lodge were found everywhere to be the chief centers of infection. The precise manner of infection is as yet almost wholly unknown. All ob- servers agree that the disease is directly contagious ; but it can not be very con- tagious if the hygienic influences be good. At least the results of our late epi- demics would imply this. In the Leipsic hospital, where over two hundred and fifty cases were treated, and isolation could not be at all perfectly carried out, not one case of infection occurred. It is certain that the di.sease can be transmitted by direct inoculation with the blood of patients. This has been established by a Eussian physician by the experimental inoculation of healthy pei-sous. Doctors have been repeatedly inoculated at the autopsy of those who have died of relaps- ing fevei'. The disease may likewise be transferred by inoculation to monkeys, while other mammals seem to enjoy an immunity fi'ora it. [The first cases of relapsing fever observed in this country were in IrLsh immi- grants coming over in the same vessel in the year 1844. At several periods since then more or less limited outbreaks traceable to immigration Jiave oceui-red, but the disease has never acquired any foothold with us, and comparatively few physi- cians have ever seen it. So far as I can learn, only one case has ever been seen in Boston, and that was in the person of a physician from another city, who brought the disease with him and passed through it in the Massachusetts General Hospital.] Clinical History. — The stage of incubation lasts about five to eight days. It is only exceptionally that some slight prodromal symptoms present themselves just before the outbreak of the disease proper. As a rule, it begins .suddenly, with a more or less pronounced chill and intense constitutional symptoms. There are violent headache, great languor, anorexia, and especially marked pains in the loins and exti'emities. The temperature rises rapidlj', reaching generally 106° (41° C.) or higher as eai-ly as the first or second day. The skin is hot and dry, and usually quickly assumes a vei'y characteristic dirty-yellowish color. In Leipsic, we often saw herpes labialis, which seems, however, to have been rarer in epidemics else- where. The tongue becomes dry and thickly coated. Sometimes there is vomit- ing. The bowels are constipated, or there is a slight diarrhoea. The spleen be- comes I'apidly enlarged, being, as a rule, even larger than in typhoid or typhus. The liver is slightly enlarged. The chest i)resents the signs of a bronchitis, gener- ally moderate, but in exceptional instances severe. The pulse is much quickened. It is seldom that there are severe cerebral symptoms beyond a cei'tain apathy and stupor. We have seen delirium tremens sometimes, in drunkards. A very char- acteristic symptom, already mentioned, is the marked hyperajsthesia of the mus- cles, especially in the calves. After these symptoms, accompanied by persistent and generally very high fever, have lasted five days to a week, there is a critical decline of temperature, with pi'ofuse sweating. The patient now improves so rapidly and decidedly that he thinks himself completely cured, and generally gives little credence to the l)hysician's prophecy of a relapse. In rare but well-attested cases there lias been really but one attack. The rule is that, after about a week, a second attack occui-s, often a third after that, and, infrequently, even a fourth and fifth. In each of these, the above-mentioned symi)toms arc re])eated more or less completely and violently. As the only certain and constant sign of the recurring attacks (the so-called relapses) is a fresii rise of temperature, it will be well to consider their peculiarities at the same time that we describe the course of the fever. During the intervals of normal temperature the other objective symptoms of disease are usually absent, except an evident splenic tumor, and, not infrequently, the pecul- iar pale-yellow hue. RELAPSING FEVER. 33 Course of the Fever (see Fig-. 3).— The beginning of the fever in the first attack is, as we have said, almost always sudden, so that it may even in a few hours reach a considerable height. The fever lasts, as a rule, five to seven days, but not infrequently as short a time as three or four days, or as long as ten or twelve days. During this time it may keep a tolerably uniform height, but ofteuer there are considerable remissions, which may even come to deserve the name of pseudo-crises. In such cases the temperature sinks in the moi-ning to normal or even lower, so that we might believe the fever ended ; but in the even- ing the temperature rises again to its former level. These pseudo-crises are most frequent toward the end of the attack, but do occur sometimes in the very fii-st days. The absolute height of the fever is, as a rule, very considerable. Tempera- tures between 105'5° and 106'5° (41° and 41'5° C.) are very often observed, and in themselves are not especially ominous in relapsing fever. The highest tempera- ture we have observed was 107'9° (42'2° C). Sometimes the temperature is more moderate (between 102° and 104°, 39° and 40° C). The fever almost always ends at the close of the attack by crisis, only rarely by a rapid, gradual decline. The crisis is often preceded by an especially great rise the evening before ( perturhatio cntica) ; so that the subsequent fall of temperature is very considerable. It gen- erally occurs at night, and is accompanied by profuse perspiration. The fall may amount to 9° or 10° (5° to 6° C). The temperature .sinks almost always below normal, often as low as 95° (35° C.) or thereabouts. Once we saw it fall to 921' (33-4° C). To the first attack succeeds an interval during which there is no fever (apy- rexia), which lasts on the average about a week, sometimes a less time, and often a greater. The longest interval we have ever observed lasted seventeen days. 12 3 4 r, t; r ■; '.i ki n lo i:; u i". ii; n !■< I'l •.>'' ji -j-j -a e4 ■■BHBBBD ■■■rllBBVJIBBBHBBHBHI ^■■■■■■■■■^■■■■■■■■■■■■^■■■■■■■■WjBWHHBiilBHH ■■■■■■■■■■ ■■■■■ ■■■■■■■■ ■■■■■■ ■■■■■■HinaiMB ■■■■■■■■■ ■I— ■—IBllB ■■■•■■■■■■■■■I ■■■WB>*UIIBr«BMnK ■■■!■■ ■■ *■ Tot mTMW.mmmMmcr.^mimm ■■■■>■■■«'■■■■ ■■■■■HB« ■ ■IB «■■■■■ ■ BBBBIBHBllBBHBBHHmBH ■iUBBBBI P^TG. 3. — Example of the temperature curve in relapsing fever. During this interval the temperature, which, as a rule, is at first subnormal, rises to normal, and then generally remains there. Exceptionally there are slight evening exacerbations to above 100-5° (38° C). These may have no demonstrable cause, or may result from some complication, such as otitis, or a furuncle. Then comes another change, and generally a sudden one, ushei-ed in with a chill, and a new rise of temperature, the beginning of the second attack or first relapse. During this attack the fever has the same general peculiarities as in the first at- tack. Generally the first relapse is briefer by a day or two than the first attack ; but the reverse is sometimes true. We wUl add that we have observed not infre- 3 34 ACUTE GENERAL INFECTIOUS DISEASES. quently a rather high evening temperature (say 101*5°, S85° Cj for one or two days before the second attack began, as also before the third. Relapsing fever seems in many epidemics to have been made up of two attacks, so that not more than one tenth of the cases had a third attack. On the other hand, the majority of the cases in the last epidemic had two relapses. And in these cases the rule was for the interval between the second and third attacks to be one or two days longer than the first apyre.\:ia; but earlier eiiidemics seem to have had the second apyrexia, if there was one at all, briefer than the fii-st. The thii'd attack is set down in all reported eases as decidedly shortei- tlian citliei" of its predecessors. It lasts generally two or three days. Exceptionally we have seen it persist for four or even six days. A fourth and even a fifth attack may occur, but onlj' exceptionally. If they do happen, they are usually imperfectly developed, and often are limited to a fever of one day's duration. The more accurately and persistently we fake the tem- perature during convalescence, the oftener do we find slight rises of temperatui-e occurring at intervals late in the history of tbe case. These are probably to be interpreted as final, rudimentary attacks. The Spirilli. — The number of cases of relapsing fever in which no spirilli can be demonstrated in the blood, if the examination be accurate, has become so small that it can be disregarded when we compare it with the much greater number of cases where such demonsti'ation is made with ease and certainty. The best way is to get a drop of blood by pricking the skin, and examine it as it is, without mixing anything with it. There is no need of an immersion lens. "With a good Hartnack No. 8 [about .330 to 440 diametei-s, accorchng to ej"epiece] the spirilli are seen with perfect distinctness. We have often seen them plainly with a No. 7 [250 to 340 diameters]. It requires a little practice to make them out; but this is easily ol)- tained. Often the attention is first caught by little jogglings and motions of the red blood-corpuscles, and then we see the delicate, narrow threads. Their length equals about three to six times the diameter of the red globules (Fig. 4). They exhibit an active and almost continuous motion, like snakes. Often the whole thread bends upon itself, and then stretches out again. They are partly separate and partly tied up in knots composed of four to twenty individuals. The wliole number visible in one field varies greatly in individual cases, and has no direct relation to the severity of the case. Often it requires long searching to find a few, while in other cases there may be twenty or more in the field at once. A very inter- esting fact is that their appearance iu the blood depends upon the attacks of fever. On the first day of the attack we rarely find spirilli, and then only one or two. Upon .succeeding days their number increases. Shortly before the end of the attack — that is, before the crisis — they generally disap- jicar entirelj'; but even after the ci-isis they have been found, exceptionally and in very small nunibei's. They have very often been found by the author as well as other ob- servers during the pseudo-crisis described above, so that, after the temperature has be- come norma], the presence of spirilli makes it very probable that another rise of temjjerature is impending. The spirilli have thus far been found in the blood only, in the catameuia, in bloody urine, or in blood coughed up from the lungs, and Fio. 4.— Spirilli of relapsing fever in the blood. RELAPSING FEVER. 35 never in the organs or secretions (urine, milk, sweat, contents of herpetic vesicles). There can hardly be any doubt that the spirilli which appear in the separate at- tacks are to be regarded as separate generations. As to their manner and place of development we have as yet no knowledge. In the final, rudimentary attacks, we find few if any. If the patient dies during an attack, they are to be found in the blood after death. Artificial cultivations have not been very successful ; nor have pure cultures of them, to our knowledge, ever succeeded. Albrccht states that they will subsequently develop in blood taken from a patient during the interval when he has no fever. The blood is otherwise modified during relapsing fever. We very often find a slight increase in the white corpuscles. There is often a noticeable abundance of very small bodies, so-called granular elements (Kornchenbildungen). The signifi- cance of these (.the remains of white corpuscles ?) is still doubtful. There are, finally, peculiar cells, rather large, with fat-granules. They were demonstrated by Ponflck in the venous blood, and are said to come from the spleen. We also find fatty-degenerated endothelium in the blood. Complications are on the whole rare, and mostly secondary. Important among these are ti-oublesome ophthalmic disturbances, especially iritis and iridochoroid- itis. Sometimes parotitis, laryngitis, and pneumonia occur. Epistaxis is a not infrequent complication. It is usually profuse and persistent, and may even be dangerous. Sometimes there has been rather severe dysenteric trouble. In one case which ended fatally we observed a very peculiar intestinal lesion, consisting of haemorrhagic-necrotic foci in the colon and lower ileum. In severe cases acute haemorrhagic nephritis occurs with comparative frequency. At the autopsy an important and characteristic phenomenon is the wedge-shaped white sjsots which occur in the spleen, like infarctions. They have a clinical interest, as they may become the starting-point of pysemic conditions or of peritonitis. Splenic ab- scesses have been observed in a few cases. Variations in the course of the disease occur in this, as in all other acute infec- tious diseases. First there are mild, abortive cases, in which the attacks are few and brief. Then cases have been described resembling intermittent fever. Of chief importance is that severe variety of relapsing fever first observed in Egypt by Griesinger, and described as " bilious typhoid." There is no longer any doubt about the proper classification of this disease, for spirilli have been proved to appear in it, and it has even been shown that its inoculation upon anothei- per- son (!) produces a common case of relapsing fever. Bilious typhoid fever occa- sions successive attacks, like those of relapsing fever. The type is much more severe. As a rule, there appear marked icterus, grave nervous symptoms, hsemor- rhages into the skin and mucous membranes, and the termination is frequently fatal. The autopsy shows a greatly enlarged spleen, often containing infarctions and abscesses, and in some cases hepatic abscesses, septic nephritis, and similar lesions. The prognosis of ordinary relapsing fever is on the whole very favorable. In the last epidemics the usual mortality was only two to four per cent. The fatal cases could some of them be laid to wretched nursing In the remaining portion death resulted from complications, such as pneumonia and nephritis. The treatment must as yet be purely symptomatic. Antipyretic treatment is generally needless, since the fever is relatively brief and often quite intermittent. Moreover, most patients can not well endure cold baths, because the muscles are so painful. As a rule, good nursing and proper food amply suflice. If the mus- cular pains are very violent, we may order chloroform liniment as an embroca- tion. Complications are to be treated on general principles. We are not acquainted with any remedy that can influence the disease itself ae ACUTE GENERAL INFECTIOUS DISEASES. or avert the relapses. Largo doses of quinine, salicylic acid, etc., have been fre- quently employed for this purpose, but never with success. Lately there has been ascribed to calomel a favorable influence upon the general course of the dis- ease, and its use is said to diminish the number of attacks. We must await fur- ther evidence in support of this statement. CHAPTER IV. SCARLET FEVER. (Scarlatina.) We now begin the consideration of those acute infectious diseases which are usually embraced under the name of the " acute exanthemata." In this group are reckoned, besides scarlet fever, measles, rotheln, small-pox, varicella, and some- times also facial erysipelas. The point which these diseases have in common is that in all of them is developed a characteristic eruption, of slight clinical signifi- cance in itself, in most cases, but of thoroughly characteristic appearance in each disease, and hence of essential importance in diagnosis. A number of the acute ex- anthemata have this further point of mutual resemblance that they appear chiefly in children. These diseases are scarlet fever, measles, rotheln, and vai-icella. .ZEtiolog^. — Infection with the specific scarlatinal poison occui-s almost always by contagion, which takes place very readily. A single approach to a patient ill with scarlet fever may suffice to communicate the disease. There is no doubt that the disease may be transferred by objects which the patient has touched, such as linen, clothing, furniture, or toys. Persons who have been with the sick may be the means of transmitting the disease, although themselves unaffected. In Eng- land it has been thought that the contagium may be carried by milk. Numerous observations show that the scarlatinal poison is with great difficulty destroyed, and may keep its contagious powers for months ("tenacity ''). We can thus see how difficult, how impossible, it may be in an individual case to point out the source of contagion. Scarlet-fever patients can communicate the disease cer- tainly as late as the end of the desquamative period. Details as to the manner of contagion, or as to the specific poison itself, are as yet unknown. There have been repeated statements about the presence of l)acteria in the blood and in the tis.sues of scarlatinal patients; but it is very improbable that the specific poison of scarlet fever has been observed. This poison must, how- ever, be contained in the blood, and in the contents of the miliary vesicles, of scarlet-fever patients, for the disease has repeatedly been artiScially produced in healthy persons by inoculation with these fluids. Predisposition to scarlet fever is far less universal than is predisposition to measles or small-pox. In families with several children often only one or two fall sick, while the rest escape, although equally exposed. As age increases, liability to the disease greatly diminishes, although there are cases of scarlet fever among adults. The majority of patients are between two and ten years of age. Scarlet fever is rare during the fi ret year of life. It is an interesting fact that children with fresh wounds, either accidental or surgical, are especially liable to scarlet fever. An analogous and familiar fact is that women after delivery have a sti-ong tendency to the disease.* With very few exceptions a person is attacked but once, * In puerperal cases iji^iiuiiie scarlet fever and septic diseases were formerly often confounded. (Sec Chapter XVIII.) SCARLET FEVER. 37 so that, after the disease is over, an immunity from contagion is enjoyed; but there are exceptions to this rule. Scarlet fever is now spread over the entire globe. Here in Germany there are almost always some sporadic cases in the larger towns, while from time to time, especially in autumn, there are more or less extensive epidemics in one place or another. There is considerable variation in the different epidemics of scarlet fever, as in many other infectious diseases, in the general character of the disease, and above all iu the prevailing naildness or severity of the cases. Clinical History. — The period of incubation is about four to seven days, or is sometimes apparently shorter. There are hardly ever any decided prodromata The disease begins rather suddenly, with fever, often introduced by chilliness, and sometimes by a well-marked rigor. There is almost invariably a painful, scar- latinal sore throat. A further symptom, in all cases of any severity, is cerebral disturbance, generally rather intense. There may be headache, dullness, uneasy sleep, delirium, and, in smaller children, sometimes even convulsions. A very frequent and characteristic early symptom is vomiting, which may be repeated. The charactei'istic rash usually appears as early as the close of the fij-st day, or on the second, and begins on the neck and on the chest and face, soon becoming almost universal. The eruption consists at first of numberless small red points, crowded thickly together and soon united into a diffuse, intense, scai'let-colored erythema. The sniall and somewhat elevated points almost always correspond to the swollen hair-follicles. The diffuse redness is the result of an excessive hyperse- inia of the skin, and vanishes completely on pressure. The back usually presents the most vivid tint. In the face there is generally pallor of the lips and chin, pre- senting a very striking and characteristic contrast to the bright-red cheeks. If some object like the end of a pen-holder be di-awu over the red skin, there soon arise corresponding white lines, due to contraction of the blood-vessels. It is pos- sible thus to make letters or pictures upon the back of the patient. We should add, however, that this is not a peculiarity of the scai'latinal eruption, being seen in other erythematous eruptions. The rash persists for some three or four days, at first even increasing somewhat in vividness. It often appears more intense by artificial light than in the daytime. Meanwhile the severe general symptoms continue— the fever, the usually excess- ively rapid pulse, the cerebral symptoms, and the throat trouble. The spleen is often somewhat swollen, though seldom very large. Then the eruption begins to fade, the fever gradually ceases by lysis, the general condition and the difficulty in swallowing improve. With the end of the first week or the beginning of the second, the cases which run the typical course become fully convalescent. Wlien the rash disappears, the epidermis usually begins to peel off, in a very characteristic way, in pieces of considerable size. The exfoliation upon the hands and feet is especially pronounced, and the little convalescents often amuse themselves by peeling off the epidermis in strips. Cases which are apparently the mildest and most benign may have their convalescence interrupted by the occurrence of a secondary scarlatinal nephritis. There is no certain prophylaxis agauist this. We will now pass on from this general summary to a more complete considera- tion in detail of general and local symptoms. And we shall see how manifold are the clinical phenomena presented by scarlet fever. 1. Fever (oee Fig. 5). — Although in a few undeveloped cases there is no fever, or scarcely any. almost all cases of any importance have high fever. It is only exceptionally that severe cases are observed where the bodily temperature is little if at all elevated. As a rule, the fever rises rapidly upon the very first day, cor- responding to the sudden onset of all the symptoms, to about 104° or 105° (40°- 40-5° C). The next day it often becomes a little higher still, and then persists 38 ACUTE GENERAL INFECTIOUS DISEASES. with but slight variations, as a rule, so long as the eruption is at its height. Dur- ing this period a temperature of 105° or moi'e (40'.'>°-41° C.) is not infrequently ., ^ „ observed. When the eruption fades, ■■^ffiaHaramiHHHHHHiaHi ■■■■■■■■■^^■■■■■■i ■■■■■■■■■^^■■■■■■l ■■■■■■■■■■■■v«mbhShi ■Ml ■■■■■■■■■■■■■M«l ■(■■■■■■■■■■■KHI HI JJBHBHBHHHHni {{■■■■■■■■■■■■■Ml and the other symptoms decline, defer- vescence occurs. This happens but rarely by crisis, and that in the slight attacks. It is almost always by pro- longed lysis, as in typhoid, only more irregularly and more rapidly. If the fever lasts into the second week of the disease, it is almost always (though not without exceptions) caused by demon- sti'able com])lications. The most fre- quent causes are the pei'sistence of a severe sore throat, the occurrence of in- flammatory changes in the cervical glands, or a purulent otitis media. In Frc. 5.— Example of a normal scarlet-fever curve. closing what we have to say about the fever in this disease, we would empha- size the fact that the pulse is often very rapid, even considering the height of the temperature. 2. The Throat.— The throat presents the most constant local lesion of scarlet fever. Sore throat is only in the rarest cases wholly absent; but its form and intensity may vary extremely. The mildest variety is a simple, erj-thematous catarrh, without much swelling, but exhibiting a more or less intense reddening of the soft palate and tonsils, frequently associated with enlargement of the little mucous follicles. Sometimes minute hasmorrhages take place into the mucous membrane. In other cases the scarlatinal affection of the throat is from the start associated with considerable swelling of the parts, and especially of the tonsils, justifying the term "parenchymatous sore throat." Not infrequently small abscesses form in the lacunas of the tonsils or superficial spots of necrosis develop which leave behind them larger or smaller ulcers, and sometimes occasion considerable hajmorrhage. There may even be a circumscribed gangrene of the tonsils. By far the most important, because it is also the mo.st dangerous, of the afFec- tions of the throat resulting from scarlet fever is the so-called scarlatinal dipii- theria — that is, a diphtheritic inflammation of the tonsils and soft palate. This usually develops on the third, fourth, or fifth day of the disease, replacing a simple inflammatory condition of the parts. Whitish, dirty-colored spots develojj on the tonsils, the arches of the palate, and the uvula. These rapidly increa.se in size, and cause a dry necrosis of the mucous membrane and subsequent ulceration. The process is a truly diphtheritic one — that is, there is an inflammation combined with an extension into the diseased tissues of a fibrinous exudation. It is especially characteristic of scarlatinal diphtheria that there is almo.st invariably a considerable swelling of the cervical lymph-glands, except in those cases which die very quickly. It is true that the glands are usually somewhat enlarged in the milder forms of iiharyngitis accompanying scarlet fever, but they seldom attain the size obsei-ved in the true diphtheritic process. In this there is an inflammatory and cedematous infiltration affecting often not only the glands themselves, but also the surrounding connective tissue, so that in severe cases the whole cervical region and the floor of the buccal cavity presents a firm and usually a very painful enlargement. It should be adde'l that the severity of the throat symptoms and the extent of the glandular swelling are not always com- SCARLET FEVER. 3'.> mcnsurate. Almost always the scarlatinal diphtheria is associated with a marked stomatitis, and very often alsowitli a severe purulent or even diphtheritic rhinitis. At the alas of the nose and the corners of the mouth there are often superficial ulcers from this cause. Otitis is also a frequent complication of scarlatina {vide infra). The swelling of the lymph glands in the throat very often terminates in suppuration. Tlie influence upon the general condition of the patient of the scarlatinal diphtheria is apt to he considerable, apart from the marked local dis- comfort. The constitutional symptoms are often as severe as in septicemia or pyaemia. Many cases end fatally in a few days, while others pureue a more tadious course, lasting perhaps several weeks before death comes. These are often associated with pysemic processes in other parts of the body. With regard to the pathogenesis of the throat troubles seen in scarlet fever, the more simple forms are in all probability directly associated with the scarlatinal process — that is, they are direct sequences of the affection. As relates, however, to the severer forms, and in especial the diphtheritic variety, it is at least very probable that these are not a direct result of the scarlatinal poison, but are due to some secondary infection which takes place at the spot of the primary scarlatinal angina. But we are almost obliged to suppose that there is some intimate con- nection between the two varieties of infection, else why should this peculiar secondary disease, the scarlatinal diphtheria, be so often conjoined with scarlet fever? Yet the fact deserves emphasis that the diphtheria seen in scarlet fever has no eetiological connection with genuine primary diphtheria (see the chapter on this latter disease), although the pathological anatomy is almost the same in both diseases. From a clinical standpoint the two present several important points of difference. In particular the scarlatinal diphtheria, in contrast with the primary form of the disease, seldom spreads to the larynx. Laryngeal croup is therefore but rarely seen in scarlet fever, and perhaps when it does occur it is to be ex- plained by an actual complication of the scarlatina with genuine diphtheria. The severe dyspnoea which sometimes develops in the course of scarlet fever is probably caused by an inflammatory oedema of the glottis. Another important clinical distinction between genuine and scarlatinal diphtheria is that paralysis of the soft palate, the ocular muscles, and other parts is scarcely ever a sequel of scarlatinal diphtheria. The definitive answer to the question of the primary and the secondary varieties of infection in scarlet fever must be postponed until the individual germs corresponding to the same are accurately known. At present we have but a single noteworthy item of information, which is that there is present in scarlatinal diphtheria a peculiar " chain-forming micrococcus," discovered by Loffler in the necrotic mucous membrane, the lymph-glands, and even in the blood. This, per- haps, is the occasion of the secondary disease. It may be added that, in puerperal scarlet fever, affections of the throat are noticeably infrequent or trivial, but the same question arises v/hether here scarlet fever and other diseases have not been confounded. In addition to the redness there is often a variable degree of swelling. These latter cases form a connecting link between the ordinary variety and those cases of parenchymatous sore throat where the tonsils are intensely swollen and the soft palate and uvula are more or less oedematous. There may be small suppurat- ing spots in the crypts of the tonsils, or these organs may suffer from larger abscesses, necrosis, or even gangrene. When the neci'osed portions slough off, there may in rare cases occur a considerable haemorrhage from the tonsils. Often chronic hypertrophy of the tonsils remains after these severer forms of inflammation. These graver varieties are almost always accompanied by swelling of the sub- 40 ACUTE GENERAL INFECTIOUS DISEASES. maxillary lymph-glands. Tlie neighboring connective tis.sue will then often present diffuse iiililtratiou and ccdematous swelling. This swelling may in severe cases involve the floor of the mouth and the entire neighborhood of the throat. The sevei'ity of the trouble in the tliroat does not always coiTOspoiid to that in the lymph-glands. Very frequently the swelling of the lymph-glands and the neigh- boring structures ends in the foi-mation of abscesses. The croupous and diphtheritic inflammations of the throat arc the most impor- tant and justly the most feared. We believe that it is a mistake to speak of a '■ complication of scarlatina with diphtheria." The diphtheria of scarlet fever has, from an etiological point of view, no relation to the common genuine diphtheria. It is a throat trouble having a direct connection with the scai-latiual process as such. It can, indeed, from its outward appearance,* be distinguished with diffi- culty, if at all, from the primary, genuine variety (q. v.); and therefoi-e, from an anatomical point of view, it must be termed a croupous or diphtheritic inflam- mation. Scarlatinal diphtheria may be united with any of the above varieties of angina, either api)earing at the veiy beginning of the illness, especially in very severe cases, or not till later, at the end of the fii'st or even in the beginning of the second week. It is almost always the sign of a severe attack, and is therefore generally associated with high fever and grave general symptoms. The secondai-y swelling of the cervical lymphatic glands and the surrounding connective tissue generally attains a severe grade, and it is often very painful. Here, as in the other varieties of severe angina, there is almost always a simultaneous, intense stomatitis, and fre- quently a purulent coryza. There are often superficial ulcers on the alae nasi and at the corners of the mouth. This form of diphtheria has one peculiarity of great interest and clinical importance. Unlike primai-y diphtheria, it seldom extends to the lai-ynx, so that it is only in rare cases of scarlet fever that there are symp- toms of laryngeal croup. A further important clinical difference between these two forms of diphtheria is that in scarlet fever there is scarcely ever any subse- quent paralysis of the soft palate or of the muscles of the eye. A dangerous, but fortunately a rare, complication is oedema of the glottis. This may quickly cause death from suffocation. We may finally mention that puerjieral scarlatina is said to have in many cases extremely slight tlu-oat complications, oi' none what- ever. 3. We proceed by a natural sequence to the consideration of the affections of certain parts adjacent to the throat, troubles which must bo regarded a.s chiefly the result of direct extension, or of a conveyance of the inflammatory process from the throat. The stomatitis we have already mentioned, as well as the disturbance in the neighboring lymph-glands t and the sun-ounding tissue. Parotitis is not rare in severe cases. Of especial importance is the scarlatinal inflammation of the middle car, which often results in permanent deafness. This inllammation usually arises at the time of desquamation, but it may occur earlier. It is either a simple catarrh of the middle ear, or, in severe cases, an actual diphtheritic process. The deafness and eai-ache are easily overlooked, as the other symptoms of the patient occupy the attention, so that the ear trouble is lirst recognized by the occurrence of perforation of the tympanum and subsequent purulent otorrhcca. After this declines there very often remains behind, as we * In microscopic prcparntion.s, however, according to Ilcubner's investigations, there are evident differences between genuine primary diphtheria and that of scarlet fever. t It should be retnarked that not infrequently there is also in scarlet fever a slight univei-sal swell- ing of the lymph-glands (back of the neck, a.xilla, groins, etc.). SCARLET FEVER. 41 have said, permanent deafness. Statistics have shown that four or five per cent, of all cases of deafness are referable to an attack of scai-let fever in childhood. The otitis is seldom immediately dangerous, but yet cases of purulent meningitis have been observed to follow it. We have already spoken of the purulent or even diphthei'itic rhinitis which almost always accompanies the scarlatina] sore throat. In rare cases there may also occur a purulent conjunctivitis, which is most probably the result of a direct conveyance of iufianimatory secretions. The tongue iu scarlet fever deserves special mention. The first coating cleans off, and then the tongue usually presents a very characteristic appearance. It is diffusely reddened and covered with little elevations corresponding to swollen papilla3 (straAvberry tongue, scarlatinal tongue). 4. The characteristic eruption, as developed in the great majority of cases, has been described above. It remains to describe certain variations from the usual appearances. First, the eruption may be rudimentaiy. It is then not pronounced, and visible only on a limited portion of the body (face, trunk, or extremities). Variations from the tyjie are not rare ; sometimes the papules are more strongly developed {scarlatina papulosa) ; very frequently there are little vesicles (scarla- tina niiliaris). This latter form of the eruption appears by preference upon the trunk, but it also may come upon the extremities, and is often brought out by ex- cessive perspiration, or by wrapping up the patient too warmly. Many epidemics are noticeable from the frequent appearance of this miliary form. More rarely the rash has a spotted look, resembling the eruption of measles {scarlatina varie- gata). Tbei'e niay be minute ecchymoses, which are not ominous. Well-devel- oped cases of haamorrhagic scarlatina are, however, very dangerous, because here the general infection of the system is almost always exceedingly severe ; and there is besides, as a rule, a general hasmorrhagic diathesis. Other cutaneous lesions, especially herpes and urticaria, are not so very unusual in connection with the scarlatinal eruption. Furunculosis has been repeatedly observed after the rash fades. Desquamation generally begins as soon as the rash has completely disappeared, but may not occur till a few days or even one or two weeks later. Its extent corresponds in general to the severity of the eruption, although extensive desqua- mation may follow a rudimentary eruption. It is seldom bran-like or furfura- ceous, as in measles. The rule is for it to be in lamellse, so that, as we have stated, quite large strips of epidermis may be detached entire. In rare cases an oedema of the skin appears after scarlet fever, which can not be shown to depend upon nephritis {vide infra), but may perhaps be due to an abnormal permeability of the walls of the cutaneous blood-vessels following the eruption {hydrops scarlatinosus sine nephri.tide). Kidneys. — Next to the severer forms of throat trouble, the most ijnportant and dangerous complications are located in the kidneys. They may appear as early as the acme of the disease, as in many other infectious diseases. The urine has a trace of albumen. In rare cases the amount of albumen may be considerable. The appearance of the urine is generally not miich changed, and the microscope reveals but few abnormal constituents. There are some white and red blood- globules, a few hyaline casts, sometimes one or two renal epithelial cells. This initial albuminuria very rarely gives cause for alarm. The genuine scarlatinal nephritis scarcely ever develops much before the end of the second or the beginning of the third week. Sometimes it comes even later. In one case under our own observation it did not begin till the thirty-third day of the disease. It may therefore be regaj'ded to a certain degree as a localized re- 42 ACUTE GENERAL INFECTIOUS DISEASES. lapse. It may be so mild as to cause no subjective sjTuptoms whatever, and would be unnoticed if the urine were not carefully examined. On the other hand, it may be accompanied by the gravest symptoms, and soon terminate fa- tally. It may follow either severe cases or the mildest, so that the rule sliould be to examine the m-iue in every case of convalescence from scai-let fever as often and as accurately as possible. No exact statement can be made as to the frequency of this complication, for it is much more common in some epidemics than in others. The development of nephritis is often marked by a fresli rise of temperature. The elevation may be slight or it may reach 104° (40" C). According to our own experience, the fever often comes a day or two earlier than the changes in the urine. As the nephritis goes on, it is very often accompanied by a moderate fever with remissions. This fever may be almost wholly absent, especially in mild cases. Tiie pulse generally becomes harder, and is sometimes quickened; but in many cases it will be slow, and it is sometimes irregular. Among other objective symptoms, the first to excite notice is generally a slight puffiuess of the face, which is usually pale. The eyelids, particularly, present an evident oedema. In the milder cases this oedema remains limited, while in others it gradually increases in e.xtent and degree, involving first, as a rule, the dependent parts of the trunk, and later the extremities. Severe cases develop a pronounced ana- sarca. There are then, usually, effusions into the serous cavities, especially ascites and hycb'othorax. The hydi-othorax is frequently combined with severe bron- chitis, and then may occasion extreme dyspnoea. The urine exhibits the most important changes. These may be insignificant in the milder cases, but are very pronounced in the severe ones. The amount is much diminished. Sometimes there will be for several days almost complete anuria. In cases of any severity the urine is turbid, dark, often evidently bloody, with increased speciflc gravity (about 1015 to 102.^), and containing a large amount of albumen. The sediment is genei-ally abundant, and exhibits numerous hyaline casts of various lengths and diameters. To these may be attached red or white blood-corpuscles, detritus, granules of hcematoidin, or bacteria. In cases of some duration the casts are often moderately fatty. Very frequently there are found noticeably long and broad waxy casts, which are opaque and yellow. In many cases of scarlatinal nephritis the urine is peculiar in having very many white blood-corpuscles, either isolated or adhering to the casts. These un- doubtedly originate for the most part in the kidneys. Red globules, some of them in the form of colorless rings, are found. They are usually present in small numbers, but may become more abundant, especially for a day at a time. Renal epithelium is frequently seen, but not invai-iably nor in veiy large amount. It must be mentioned, in conclusion, that in some i-are instances the autopsy dis- closes quite a marked nephritis, although the urine was apparently normal during life, or at least was not very abnormal. Uraemic symptoms are not infrequent. Tliey may be of all degrees of severity. They will be described in detail under diseases of the kidney (vide infra). The ui-aemia may be so severe as to cause convulsions, coma, and death; but it is remarkable with what frequency children recover from what seems to be the most pronounced inwmia. The duration of scarlatinal nephritis varies greatly according to its severity. In cases which run a favorable coui-se, the urine is generally abnormal for two to four weeks, or even longer. Death may be due either to urremia or to dyspnoea. The latter cause is the more frequent one, and may depend upon the ascites and hydrothorax, or upon pneumonia (vide infra). Sometimes deatli comes from cardiac faQure, which may now and then be very suddenly developed. The nephritis may go on into chronic renal disease, but this is rare. SCAELET FEVER. 43 Pathologically, the kidneys present, in a more or less pronounced degree, the lesions of ordinary acute hfemorrhagic nephritis (vide infra). It is sometimes astonishing to see how apparently insiguiHoant the lesions are, in spite of the grave clmical symptoms. In such cases there is usually a so-called glomerulo- nephritis (Klebs), in which the lesions are chiefly confined to the walls of the capillaries and to the epithelivim of the glomeruli. If the nephritis has been of some weeks' duration, we generally fliid that well-marked hypertrophy of the left ventricle has already developed, as was first pointed out by Friedlander. We have ourselves observed it, and have even been able to demonstrate it repeatedly during life. 6. Joints. — When desquamation begins, or even earlier, pain and swelling may attack a certain number of the joints. This trouble was formei'ly called scarlatinal rheumatism, but now is usually known as scarlatinal synovitis. It is generally mild and quite temporary. The articular inflammation may, however, be severe and even purulent. This is usually a part of a general pyaemia, as evinced by such other lesions as empyema and subcutaneous abscesses; and they all seem to be caused by the above-mentioned " chain-forming " micrococcus, which swarms in the pus found in all the afl^ected parts. We have seen a few instances of excessive pain in the muscles of the thighs, accompanied by a moderate, diffuse swelling. 7. Another important complication of scarlet fever is pneumonia. In severe cases lobular pneumonia sometimes appears as early as the first stage of the dis- ease; but it occurs more frequently in connection Avith the nephritis. The respu-ation may be very seriously interfered with by it. Inflammations of serous membranes in the chest — viz., endocarditis, pericarditis, and pleurisy — are more rare. They may or may not be accompanied by disturbances in the jouats (vide supra). Quite severe intestinal symptoms, such as diarrhcea, may appear. These are generally the result of a catarrhal inflammation of the intestinal follicles. Dysentery is less frequent. The enlargement of the spleen has been already mentioned. The liver is also sometimes found to be considerably en- larged. Variations in the Course of the Disease.— The diversities of the clinical picture in different cases of scarlatina will be understood when we consider the variety and number of the disturbances thus far cited. It is to be added that the general course of the disease may exhibit numerous peculiarities, of which it is hardly possible to give an exhaustive presentation. We will content ourselves with a cursory statement of the most important deviations from the typical course. 1. Rudimentary Forms. — To this class, in which the disease does not reach a perfect development, belong first the cases of simple sore throat with no erup- tion, or at most an extremely faint and partial one {scarlatina sine exanthe- tnate). Sometimes even the sore throat is hardly to be seen, and there is noth- ing but a brief and slight fever with mild symptoms of general disturbance. The recognition of these cases as scarlatinal is possible only when we consider their cetiological relation to other undoubted cases of scarlet fever. We had an excel- lent opportunity to observe them when the disease broke out in the children's wards of the hospital at Leipsic. The diagnosis is sometimes confirmed by a slight though evident desquamation, affecting the hands, feet, legs, and back, or by an acute nephritis, which may follow the mildest attacks of this sort. Many cases of acute nephritis, though apparently wholly spontaneous and primaiy, must be regarded as aetiologically scarlatinal. 2. Rudimentary but Pernicious Forms. — Under this head belong those attacks of .scarlet fever where the eruption is scanty or absent, while from the very start the most violent general symptoms appear. There is a very high fever, enormously 44 ACUTE GENERAL INFECTIOUS DISEASES. rapid pulse, and delirium. Such cases must be the result of an uncommonly severe general infection. They usually end in speedy death. Other cases, ending fatally in a few days, have a well-developed rash without other localized disturbances. 3. Severe Forms ivith a more Protracted Course. — In these cases the long duration is not the exclusive result of especial complications, but is likewise due to the severity of the intoxication. One variety is the so-called typhoid form of scarlatina, with persistent high fever and severe constitutional .symptoms. An- other variety is the hajmorrhagic form briefly mentioned above, in which there ai'e extensive hajmorrhages into the skin and into the mucous and sei'ous mem- branes. This form may run an extremely acute course. Further, in all pernicious forms, there may be severe local complications, particularly diphtheritic or gan- grenous sore throat, inflammations of serous membranes, etc. Attacks of this sort are often not produced by the poison of scarlet fever alone, but by secondary complicating processes. While speaking of scarlatinal diphtheria it has already been pointed out that secondary infection of the body may result, principally originating from the diseased throat, and occasioning sometimes a grave septic condition of the whole body, sometimes local disease of distuict parts. 4. In extremely rare cases relapses do occur. After the fii-st illness a fre.sh eruption breaks out with all the other symptoms of scarlet fever. In anomalous cases, running a severe course, there is sometimes, at an advanced stage, a fresh, imperfect eraption (generally in spots>, which Thomas has termed a pseudo-relapse. Diagnosis. — The diagnosis of scarlet fever is made in most cases from the char- acteristic eruption taken in connection with the other .symptoms. We should, however, bear in mmd that exceptionally other eruptions appear which exhibit the closest resemblance to that of scarlet fever. 1. After the use of cert;dn drugs, especially atropine (belladonna), quinine, antipyrine, morphine, chloral ; and like- wise after the ingestion of crabs, fish, etc. 2. As a symptom of other infectious diseases, such as typhoid fever, small-pox; and, above all, in septic diseases (vide infra). In an anomalous case factors of importance for diagnosis are the aetiology and the occurrence of desquamation or of a secondary ne])hi'itis. The prognosis must in every case be guarded. From what has been said of the course of the disease, it is evident that, even in cases which are at first appar- ently the most favorable, dangerous complications may appear later, particularly nephritis. Treatment. — The majority of those cases of scarlet fever which take a typical course will recover completely without our aid. In these the task of the physi- cian, so far as treatment is concerned, consists in arranging the details of hygiene and the general care of the patient. The sick-room should be cool, and the diet rather strict, consisting mainly of milk. Broths and eggs may also be allowed. We should see that the skin and the mouth are kept clean. To change the linen frequently, if done with propei- precaution, is not only permissible, but very desir- able. The favorite practice of rubbing the skin with fat pork has some merit, and is especially to be recommended if the skin be harsli and dry after the erui)- fion has faded. [From the moment that the disease is declared the patient should be thoroughly anointed daily with carbolized va.seline, lard, or the like; and this should be kept up until desquamation has ceased. Not only is the comfort of the patient pro- moted, but the danger of the spread of the infection is thereby greatly lessened.] The scarlatinal disease of the throat must be ti-eated with the greatest attention, the main duty of the physician in this regard being to prevent, if possible, the ingress of the above-mentioned secondary infection. It is therefore our opinion that in every case of scarlet fever the greatest pains should be taken from the very commencement of the disease to maintain complete disinfection of the mouth SCARLET FEVER. 45 and throat. Larger children may use a gargle (two-per-cent. sohition of chlorate of potash, one- or two-per-cent. solution of carbolic acid). Inhalation of cai'bolic- acid spray is also to be recommended where ijracticable. If there is prosti-ation, or if the child be young or willfu], we must cleanse the mouth and throat at short intervals, by means of a spray-apparatus, vnth disinfectants, such as carbolic acid or permanganate of potash in solution. Sometimes it is a good plan to let the patient swallow slowly a half-teaspoonful of a solution of potassic chlorate (about 1 to 40) every half-hour or oftener, with the object of contributing to the local disinfection of the throat. If scarlatinal diphtheria nevertheless develops and the cervical lymph-glands begin to increase fm-ther in size, there is reason to hope, according to the experience of Taube and Heubner, that parenchymatous injections into the tissue of the tonsils or the palatine arches may yet check the spread of the secondary infection. About 6 minims (a Pravaz syringe half full) of a three-per-cent. solution of carbolic acid may be injected twice daily upon each side by means of a long hollow needle and a subcutaneous syringe. If the nose be likewise affected, the chief thing to do is frequent cleansing and syringing while the head is bent forward. We should be on the watch for the possible occurrence of otitis. In this particular the physician is often guilty of sins of omission. Much harm may be averted by a prompt cleansing of the ears, or, if need be, by insufflation of air into the middle ear, or paracentesis of the membrana tympani. Inflammation of the glands in the neck, if severe, is prone to pass on to sup- puration, and must then be trejited surgically. When the swelling has just begun, or is still moderate, we may try to cure it by rubbing in iodoform ointment (1 to 15) two or thi-ee times a day. Ice is generally not so well borne as wann applica- tions (poultices or warm bran-cushions). If there be continuous high fever, accompanied by rather severe constitutional symptoms, a moderate employment of the cold-water treatment is strongly to be recommended. The baths seldom need to be cooler than 81° to 88° (22°-25° R.), and are to be employed two or three times daily, or oftener in severe cases. If the nervous disturbance be serious, or if the respiration be impaired, the patient should be douched with cold water during the bath. At the same time wine or strong coffee is to be given as a stimulant, or, if cardiac failui-e and signs of collapse appear, the best remedy is subcutaneous injections of camphor. We are con- vinced that internal antipyretics, such as antipyrine, may usually be dispensed with, although in private practice we may be obliged to employ them. If the pulse is abnormally rapid, and there is danger of cardiac failure, we can employ, besides stimulants, an ice-bag placed over the heart. Digitalis may also be tried cautiously. The scarlatinal inflammation of the joints is sometimes improved by salicylate of soda (forty-five to sixty grains, grm. 3 to 4, in one dose [!]). Sometimes, how- ever, this remedy has failed us. We know of no means to avert the nephritis. In justice to himself, the physi- cian must always at the start point out the possibility of its occurrence, and must avoid as far as possible errors in diet or exposure to cold on the pai-t of his pa- tient. He may thus escape blame. For the treatment of the nephritis and its results, see the section on renal diseases. We must likewise refer the reader to the appropriate chapters for the treatment of other possible complications of scar- let fever. The patient must, as a rule, keep his bed three or four weeks, even if convales- cence be uninterrupted. [This injunction is rather extreme. Nephritis is as likely to follow a mild as a severe case, and occurs sometimes in spite of every precaution. The physician 46 ACUTE GENERAL INFECTIOUS DISEASES. should use his discretion as to the length of time the patient is kept in bed, care- fully guarding against exposure to cold and impi-udence in diet.] The disease is so dangerous that, whenever a case occurs in a family, isolation is absolutely demanded, and, if possible, all the other children .should be sent away. If this advice be disregarded, we can reject all responsibility for any further cases and their results. [Scarlet fever is a disease at once so highly contagious and so common that it may betaken as the type of its class. Its hygienic treatment and tiie measures needful to prevent its spread consequently deserve moi'e minute detail. The sick room should be at the top of the house, if possible, and exposed to tlie south ; every unnecessary article of furniture and all ornaments should be re- moved beforehand, carpets, curtains, and stuffed or upholstered furnitm-e being included. A window should be kept open constantly, top and bottom ; in cool weather a fire should be burning; in warm weather ventilation is fm-thered by placing a gas-burner or large kerosene lamp near the tliroat of the chimney. Outside the door of the sick-room a sheet moistened with a disinfectant solution should be carefully hung. Only those whose pi-esence is absolutely necessary are to be allowed in the sick-room, and the physician, when his visit is completed, should pass directly out of the house. A convalescent should be kept away from all who are liable to coTitract or con- vey the disease until desquamation has entirely cea.sed. Several wai-ni soap-baths should be given before the child emerges into every-day life, and it should finally be dressed in uncontaminated clothing. For further directions as to the disinfection of the room, the clothing, and the excreta, see pages 36, 27.] CHAPTER V. MEASLES. {Morbilli.) .SItiology. — In contrast with the malignancy of scarlet fever is the compara- tively benign nature of measles, a disease of childhood which is but little feared even by mothers. It is so wide-spread, and the susceptibility to it is so Tuiiversal, that measles passes for an almost unavoidable bvit comparatively insignificant an_ noyance. Indeed, few escape it ; and probably the reason that adults have mea- sles so much less frequently than children is simply that most adults have already suffered from it in childhood. A second attack of measles in the same individual may occur, but it is certainly extremely rare. [In highly civilized countries measles has prevailed so long that it would seem that a relative resistance against the poison has been acquired. The fi'iglitful rav- ages of the disease when it was planted in virgin soil, as among the Fiji Islanders not many yeai's ago, apparently bear out this view. The susceptibility to measles is greater and more widespi-ead than is that to scarlet fever — that is to say, fewer individu;ils I'cach adult life without having experienced an attack of the former than of the latter. ] Measles generally comes in epidemics. Sporadic cases are exceptional. In this respect measles differs decidedly from scarlet fever. The rapid spread of the disease when it has once broken out is a result of its great contagiousness. If one child in a family is attacked, the others almost always take the disease. The in- fection may be transferred even by well people and by means of ai-ticlcs -n-ith which the sick have come in contact. We ai'e not yet acquainted with the spe- MEASLES. 47 cific poison of measles, althoug-h its existence is to be taken for granted, nor with the details of its transmission. Still it seems most probable that the poison is inhaled through the mouth and nose, and that this is the reason why its effects are usually first developed in the respiratory passages {vide infra). The disease can be artificially ]>r()duced by inoculation of healthy children with the blood or liquid secretions (if those suffering from it. Clinical History,— The length of the stage of incubation is tolerably uniform. It is ten days to the beginning of the first symptoms, and thirteen or foui-leeu days to the breaking out of the eruption. These figures have been established by the observations of Panum, the opportunity having been afforded upon the first introduction of the disease into the Faroe Islands. As a rule, there are no espe- cial i^rodromata during the period of incubation except some slight elevations of temperature. At the end of ten days the initial stage * begins, generally suddenly, and with an abrupt rise of temperature to 102° or 104° (39°-40° C). At the same time the characteristic catarrhal symptoms appear: nasal catarrh (coryza), to be recognized by the abundant nasal secretion, the frequent sneezing, sometimes also by nose-bleed ; more or less severe conjunctivitis, recognizable by the photo- phobia, the reddening of the eyes, and the increased flow of teai-s; and, lastly, symptoms of a catarrh of the upper part of the respiratory tract, usually modei-ate, but nevertheless causing hoarseness and a slight cough. With all this the gen- eral condition is disturbed, the children are restless, have headache, and eat little. Symptoms of a mild sore throat are not infrequent, but are very far from being so prominent as in scarlet fever. These initial symptoms last, as we have said, three or four days. Then the eruption begins (stage of eruption). This is very often preceded for a day or two by a peculiar, usually spotted, reddening of the hard and soft palates, termed " eruption uijon the mucous membrane." The true eruption of measles begins almost always in the face, on the cheeks, forehead, and around the mouth (con- trasting with the characteristic pallor of the chin in scarlet fever), and spreads from there rapidly downward over all the rest of the body. The eruption consists at first of little papillse, coi-responding to the follicles. These are soon surrounded by a pale-red, slightly elevated border, and in many cases become confluent. Per- fectly flat elevations, of various sizes and of extremely irregular, dentated, round- ish, or angular shape, develop. These are often so tliickly crowded together as to touch one another, but usually limited portions of normal skin intervene between them. Within each raised spot the little follicular pax3illa3 remain visible. With the beginning of the eruption the fever rises, having been, as a rule, slight during the last days of the initial stage. It attains about 104° or 105° (40°- 40 5° C). In thirty-six to forty-eight hours the eruption reaches its full devel- opment and its greatest extent. The fever and the catarrhal symptoms also per- sist for the same length of time. Sometimes we find a slight swelling of all the lymph-glands. Then follows a decline of the fever, usually rapid, and indeed almost by crisis, while the eruption after a short period of full development begins gradually to fade during the two or three days following. At the same time the catarrhal symptoms diminish. A more or less extensive desquamation of the epidermis begins, scarcely ever in large pieces as in scarlet fever, but in little scales, "like bran." After eight or ten days, if the disease runs a normal course, the patient is fully convalescent. * We consider the term "initial stage" more correct tlian "prodromal stage." The "prodromal symptoms " are the first slight symptoms which occur during the time of incubation of an infectious disease, while the symptoms presented by measles before the breaking out of the eruption are a part of the already developed disease. 48 ACUTE GENERAL INFECTIOUS DISEASES. After this brief descriijtion of tlie usual course, we must consider more closely some of the symjitoms and possible complications. The fever (see Fig. (!) of measles exhibits, as has been already implied, a tolera- bly typical course. It begins with a rather marked and rapid rise upon the com- mencement of the disease. On the morning of the second day there is usually a marked remission, often to normal. In the last two days of the initial stage the fever is moderate, very rarely being so high as at the beginning. With the erup- tion there is a new, rapid rise, usually higher than the initial one, .so lliat we may well divide the fever into two periods— the prodromal fever and the ei-uptive fever. This latter is but brief and does not persist, as in scarlet fever, during the entire duration of the eruption. It falls by crisis when the rash has attained full de- velopment. There may, to be sure, be slight elevations of temperature during the next day or two; but, if the fever is considerable and persistent, it is always a sign that complications have arisen, probably iji the respiratory apparatus. The eruption usually assumes the form described above, but may present manifold varieties. Sometimes its de- velopment is rudiuientarj'. Sometimes it does not begin in the face, but on some other part of the body. This is generally regarded as a sign that the case will be anomalous in other ways as well. The individual six)ts may be smaller than usual, and may remain en- tirely separate from each other (mor- billi pajmlosi). In other ca.ses the eruption is so confluent [morhiUi con- fluentes) that it resembles the eruption of scarlatina. The formation of vesi- cles (morbilli vesicidosi) also occurs, but much more rarely than in scarlet fever. Ha»morrhagic measles are also observed, but usually only in the form of small, capillary bleeding, and in cases that otherwise run a perfectly favorable course. Very rare cases have indeed been described, with a general lia^morrhagic diathesis and bad symptoms, resembling hasmorrhagic scarlatina. It is doubtful whether the " black measles " of the old writei-s was actually measles at all. In addition to the proper eruption of measles, other eruptions sometimes develop — among others, vesicles, wheals, and pustules. The complications of measles are for the most part exaggerations, or abnormal varieties and extensions, of those troubles which are observed during the usual mild course of the fever. As in scarlet fever {vide supra), we often have to deal with the effects not of the original, but of secondary infection. Compared with the great ma.iority of mild attacks taking the typical course, cases pi-esenting com- j)lications of any severity are rare, and much less frequent than in scarlet fever. Epidemics are only now and then distmguished by unusual severity. Often quite grave eye diseases are developed, particularly blennorrhagic con- junctivitis, keratitis, and iritis. Marked inflammation of the mucous membrane of the nose, throat, and lar- ynx may prolong the course of the disease. These are often merely exaggera- tions of the usual catarrh. Otitis media likewise sometimes occui-s. A laryngitis of mai'ked intensity, with considerable swelling of the parts involved, may pro- Initial Fever. Eniptivp Fi Eruption MEASLES. 49 duce much discomfort, oi' even symptoms of stenosis ("false croup"). Actual croupous and diphtheritic lesions of the throat and larynx also occur (diphtheria of measles). This last is indeed much rarer than scarlatinal dijihtlieria, but may have the same unhappy termination. It is worth mentioning tliat sometimes genuine laryngeal croup is observed in measles, unaccompanied by lesions of the pharynx. It is, however, in the lungs that the most fi-equent and important of all compli- cations in measles occur. The usual mild bronchitis becomes very intense, ex- tends into the bronchioles (capillary bronchitis), and then results, for the most part, in a more or less extensive, lobular, catarrhal pneumonia (q. v.). This is almost always to be suspected when moist i-ales are heard in abundance over a large part of the chest, and when there is at the same time persistent fever and pro- nounced difficulty in respiration, with cough or dyspnoea. We get decided dull- ness on percussion only when the separate centers of infiltration are more than usually confluent. Genuine lobar, croupous pneumonia appeare much less often than the lobular variety. It attacks one lobe, or several, is attended by high fever, and may end with a well-marked crisis. The foregoing pulmonary symptoms usually appear at the height of the dis- ease, and persist after the eruption fades. They may delay convalescence for weeks. In other cases measles will seem at the start to run a normal couree, the temperature will have already fallen, and then come new fever and the appear- ance of decided pulmonary disturbance. This is always to be regarded as a grave complication ; and especially in feeble children it may lead to death, with the symptoms of impaired respu-ation, or of constitutional exhaustion. Marked intestinal symptoms sometimes appear, particularly an excessive diar- rhoea, due to intestinal catarrh. It is characteristic of measles that in severe cases such a diarrhoea may assume a pronounced dysenteric character, indicated by blood and slime in the dejections, symptoms which usually depend upon the develop- ment of follicular colitis with ulcerations. Now and then still other complications may present themselves, of which a full enumeration is impossible. Nephritis does occur, but far less often than in scar- let fever. A simple albuminuria during the acme of the disease is not infrequent, but as a rule has no especial clinical significance. We should mention gangrene of the cheek, the so-called noma, as a complication, which is very rare but appai'- ently characteristic. Peculiarities in the course of the disease are much rarer in measles than in scarlet fever. Yet we see, on the one hand, unusually mild or rudimentary cases, in which either the rash or the other local symptoms are remarkably slight, and on the other hand, abnormally severe cases. These latter are distinguished by the unusual height or persistence of the fever, by the severe constitutional and nervous symptoms, and further by the early appearance of complications. Such cases have been termed "typhoid measles." We have already mentioned the severe form of haemorrhagic measles. We should notice the clinical relation which measles bears to some other in- fectious diseases — to whooping-cough and tuberculosis. Measles and pertussis (q. V.) may follow each other in the same individual at a short interval, some- times one and sometimes the other taking the initiative ; epidemics of the two dis- eases prevail with comparative frequency at the same time. Tuberculosis is like- wise to be mentioned as an important sequela of measles. Its frequent appearance at the close of measles is of course to be explained by supposing either that, in children who are already the victims of tubercle, the further extension of the tu- berculosis is favored by measles, or that the catarrhal inflammation due to measles leaves behind it an especial predisposition to infection with the tubercular poison. 50 ACUTE GENERAL INFECTIOUS DISEASES. The diagnosis of measles, as of the other acute exanthematous diseases, is based chiefly upou tlie eruption. Personal experience does more to sharpen tlie percep- tion than can the fullest descriptions. We can merely suspect the disease during the initial stage unless an epidemic prevails. If, beside the characteristic catarrhal symptoms, the above-mentioned eruption on the mucous membrane of the palate exists, the diagnosis becomes tolerably certain. We should consider that erup- tions similar to that of measles appear in other diseases, more especially in riitheln, scarlet fever, typhus fever, in the beginning of smallpox, and in syphilis. Furthermore, we need to exclude eruptions due to such drugs as antipyriiie, tur- pentine, and balsam of copaiba. In doubtful cases we shall be enabled to form a decided opinion by the other symjitoms, and, above all, by the further course of the disease. Prognosis. — We have already remarked how favorable in general the prog- nosis is, but we must here repeat that all epidemics do not exhibit the same benign character, and that in every case the physician must bear in mind the pos- sibility of complications, and particularly the danger of severe pulmonary dis- turbances. Treatment.— The patient should in general be kept somewhat warmer than in scarlet fever. Even in what seem to be the mildest cases the child should be kept in bed till desquamation is over. The sick-chamber is to be somewhat dark- ened, on account of the photophobia which usually exists at flret. In this way, normal cases run on favorably without any especial therapeutic interposition. The catarrhal symptoms, however, should always be heeded, since to disregard them may lead to their becoming aggravated. The chief requisite is cleanliness. At regular intervals the eyes, the nasal cavity, and the mouth should be washed out with lukewarm water. If, despite all this, certain disturbances appear in a worse form than usual, or if complications develop, these must receive especial attention. Severe eye troubles should be treated according to the usual ophthalmological practice; and here unguentum hydrargyri oxidi flavi (1 to 100) [U. S. P. is 40 to 420] and atro- pine are chiefly employed. The treatment of croupous trouble in the throat or larynx will be fully described in a later chapter. For the pulmonary troubles, lukewarm baths, combined if need be with rather cool douches, constitute the most efl'ectual remedy, which we should employ if it is in any way possible. We thus evoke deeper inspirations and promote expectoration, and tliereby contribute largely to preventing the development, or the aggi-avation, of severe lung trouble. Inhalations of steam or of medicated fluids are often advantageously cond^ined with the baths. To substitute the cold pack for the baths is in general justifiable only when the baths are not practicable. Still, the pack does good. If em- ployed, it should be kept up for three hours at a time, two or three times a day. The breathing will be improved, and usually the child will go quietly to sleep. We are not acquainted with any internal remedies for the lung troubles which are at all reliable. In rare instances the excessive accumulation of nmcus in the bronchi requires tlie administration of an emetic. As expectorants we may try ipecac, liquor ammonii anisatus, or benzoin. If considerable intestinal disturb- ance arises, we must employ small doses of opium, or calomel, or subnitrate of bismuth. We hardly need to say that, whatever else is done, the sti-ength of the patient should be kept up as much as possible by giving wine, broths, milk, eggs, etc. For at least two or three weeks after the disease has ended, the child must be very carefully watched. As the disease is usually so mild, prophylaxis is not very strenuously attempted. If one child in a family is attacked, it is probably already too late to isolate the others, and it is even an advantage to the family to have all the children finish at ROTHELN. 51 once what they will hardly be able eventually to avoid. We would make an ex- ception in favor of isolation if the disease prevailed in a severe form. [It is not customary with us to insist so strongly upon isolation and thorough disinfection as in scai'let fever. But the tendency of the present day is toward a wide application of the principles of preventive medicine. It is certainly of no advantage to a child to contract the measles. Delicate children, especially those with tubercular predisposition, should be carefully guarded against it ; and, even if it is decided that it is not worth while to attempt to confine the disease to one member of a family, every precaution should be taken against infecting other families. Under suspicious circumstances, consequently, children are to be kept away from school and from contact with others. If there is any reason to fear the development of tuberculosis, everj' possible hygienic means should be employed in order that full vigor may be regained.] CHAPTER VI. ROTHELN. ( German, Measles.) RoTHELN is a disease similar to measles, but distinct from it, although formerly often confounded with it, and perhaps with scarlet fever as well. The observa- tions of Steiuer, Thomas, and others leave now no room to doubt that these dis- eases are distinct, for epidemics occur in which all cases present the characteristic peculiarities ascribed to rotheln. But the best proof is that children who have had rotheln are not infrequently attacked by genuine measles later. It may indeed be very difficult in an individual case to decide which disease is present ; but that rotheln does exist, as an independent form of disease, can be denied by those alone who have never seen it. After an incubation of about two or three weeks the disease begins with the appearance of the eruption. Initial symptoms preceding the eruption are either wholly absent or at most last for half a day. The eruption is decidedly like that of measles, but its individual spots are smaller. They are seldom larger than small peas and circular, being only exceptionally as dentated and irregular in outline as are the macula3 of measles. They appear on the whole face, the head, the trunk, and the extremities, are pale red (sometimes deep red), but slightly elevated, and are not apt to become confluent. In rare instances, small vesicles develop upon the macules. The soft palate sometimes exhibits, as in measles, a faint macular eruption at the beginning of the disease. After two to four days the eruption fades. There is usually no decided desquamation. Other symptoms of disease than this eruption are slight. Fever in many cases appears to be entirely absent. As a rule, there is for a day or two a slight eleva- tion of temperature, reaching 102° (39° C.) at most. Tokens of a moderate catarrh of the conjunctiva, the nasal mucous membrane, the throat, and the larynx are also observed — viz., photo]5hobia, nasal discharge, and cough. Often, the cervical lymph-glands are more or less swollen. The constitutional disturbance is gener- ally so slight that the child can hardly be kept in bed. Important complications hardly ever occur. The prognosis of rotheln is therefore perfectly favorable, and the employment of any special treatment is needless. 52 ACUTE GENERAL INFECTIOUS DISEASES. CHAPTER VII. SMAXiL-FOZ. ( Variola. Varioloid.) .ffitiology. — Small-pox has been known for centuries, althouffh formerly often confounded with other diseases.* It is one of the most dreaded acute infectious diseases, and in earlier times it has destroyed thousands in its pestilential progress. It was the discovei-y of the possibility of prophylactic inoculation, and the ever- increasing spread of this precautionai'y measui-e, which first robbed the disease of some portion of its ten-ors. Numerous statements have been made about the occurrence of micro-organisms in the variolous eruptions on the skin and mucous membranes, but we are com- pelled to say that we are not yet acquainted with the specific, organized poison of small-pox, however strongly justified we may be in assuming its existence. Bac- teria can in fact easily be demonstrated in the eruption of variola, but most of them come from the suiTounding atmosphere, and have no relation to the specific variolous processes. The foci of bacteria found in the internal organs (liver, spleen, kidneys) are also due, as their discoverer, Weigert, himself supposed, to tJie secondary ingress of other varieties of micro-oi-ganisms, and are not directly asso- ciated with the variolous process, the diseased condition of the skin furnishing a ready entrance for infectious inatter. Predisposition to variola, except as diminished by vaccination (vide infra), is universal. The disease may appear at any age, even /);, utero. Women are believed to be especially liable to it during pregnancy and child-bed. It is said that persons ill with another acute infectious disease, such tas scarlet fever, measles, or typhoid fever, are, for the time being, tolei-ably secure from infection with small-pox; but this rule has exceptions. The same individual rarely takes the disease a second time. A case of vai'iola is always the result of transmission of the poison to a healthy person from one who is already ill with it. The specific poison certainly is most abundant in the diseased portions of the body and in the pus of the suppiu-ating pocks, as well as the crusts and scales which are left when these have dried up; but the disease is also contagious in its earlier stages, before the pustules develop, and even, according to a few observations, during the stage of incubation. Cer- tainly the variolous poison is very volatile — that is. it is prone to disseminate itself through the air in the neighborhood of the patient. In oi-der to catch the disease it is not necessary to touch the patient, but merely to remain in his vicinity. In many cases we can not, howevei', determine witli exactness the mode of trans- mission, since the contagion may either be direct or by means of objects and utensils with which a patient has come in contact — for example, the soiled linen. The dead body is capable also of transmitting the disease. In general, numerous instances point to a considerable " tenacity" in the poison. The precise manner of infection is not yet Icnowni. It is most probable that the poison is drawn into the lungs with the inspired air. It has been demonstrated tliat the disease can be transmitted to healthy persons by direct inoculation of the contents of the variolous pustules. It is stated that monkeys and other animals may be successfully inoculated in the same way. Whether inoculations with the blood of the sick will reproduce the disease is not * The very name small-po.v {petiti Ce'role) is signifieaat of its confusion with syphilis, whicli was termed the " great po.\." SMALL-POX. 53 yet settled. The secretions (saliva, sweat, urine, and aiilkj do not apparently con- tain the infectious matter. Course of the Disease. Variola and Varioloid.— The stage of incubation lasts some ten to fourteen days, often a somewhat sliorter time, seldom longer. During this period prodromal symptoms are absent or insignificant. The disease itself begins suddenly with what are usually very characteristic initial symptoms — rigor, fever, headache, and intense pain in the loins. It is only in comparatively few cases that one or another of these symptoms is slight or wanting. The constitutional symptoms may be very severe — a dry tongue, stupor, wakefulness, delirium. The fever continues intense for some days. The pulse is much quickened. There is almost total anorexia, and often there is vomiting. There is constipation, or, more rarely, diarrhoea. Frequently there is a slight sore throat, and sometimes a slight bronchitis. The spleen is enlarged in most of the severe cases, and the urine often has a trace of albumen. In women, menstruation occurs in a remarkably large number of cases. The proper variolous eruption does not at once appear, but from the second day other characteristic efflores- cences are not rare. These are termed the initial rash of small-pox. We may find either a diffuse or macular erj-thema, extending in varying degree over the trunk and extremities, or a haemorrhagic eruption with small spots appeai'ing by preference upon the hypogastrium and the inner surface of the thighs (in the so- called femoral triangle of Simon). It is noteworthy that this particular region is said often to remain free from the proper variolous eruption. The erythema soon vanishes, but the petechiaj remain visible for some time. The initial stage, just pictured, lasts usually three days. Severe symptoms occurring at this time do not exclude the possibility that the further course of the disease may prove favorable, while mild symptoms are of good omen. At the end of the third or on the fourth day the temperature makes a decided fall, and the regular variolous eruption begins to be developed upon the skin — the stadium eruptionis. During this period an evident difference among the separate cases becomes manifest. This distinction can not indeed be always drawn with a narrow line, but it is noticeable enough to justify the establishment of two types of variolous disease. We refer to the division into a severe form (variola vera), and another, mild form (varioloid). The variola proper has a well -developed eruption with many pustules, and, as a result of this, a second stage of fever {stadium suppurationis). "Varioloid has a much more scanty eruption, and little or no suppurative fever. We must now discuss these two forms separately. Variola Vera. The eruption almost always begins in the face and upon the hairy scalp, ap- pearing somewhat later on the trunk and arms, and last of all upon the legs. It begins in the form of little red dots and spots, which develop in about two days to small papules {stadium floritionis). If the hand be passed over thickly set and weU-developed papules of variola, a peculiar soft, satin -like feeling is perceived. On the points of these papillse a little vesicle forms. This keeps growing larger and larger, its contents become turbid and purulent, till at last, on the sixth day of the eruption and the ninth of the disease, the development of the genuine pust- ule of variola is complete {stadium suppurationis). The pustule usually presents upon its summit a little dimple (" Pocken-nabel "), and is surrounded by a red border or "halo." Where the pocks are especially close together, as in the face, the skin between them is diffusely swollen, and the consequent burning and pain are excessive. The countenance becomes much disfigured. Often the eyes can not be opened because of the oedema. The hands also are apt to be intensely affected, 54 ACUTE GENERAL INFECTIOUS DISEASES. especially the back of the hands, and also all parts which have previously been injured in any way (pressure or friction of clothing, etc.). The immunity of the skin in tlie so-called femoral triangle has been already mentioned. At the same time with the eruption upon the skin, or even somewhat earlier, a perfectly analogous efBorescence develops upon the mucous membranes. The chief placas for its appearance are the mouth and throat, the tongue, the soft pal- ate, the nasal cavity, also the larynx, the trachea, and the upper part of the oesopha- gus. In the vagina and rectum it is rare and scanty. In this unicous efflores- cence, however, there are no proper pustules, but small, superficial ulcere. These result from the macei-ation of the uppermost layers of the mucous membrane. They sometimes become confluent. The annoyance produced by this eruption in the mouth and throat is, of course, very great. The pocks in the larynx manifest themselves by hoai-seness, and occasionally by symptoms of stenosis. As we have said, the beginning of the eruption is the signal for a noticeable fall in the tempei'atui'e. But in true variola the fall does not reach the normal, or only temporarily. The other symptoms likewise remit, especially the head- ache and lumbar pain. When, however, the suppuration begins, the fever rises once more, and there are fresh symptoms of constitutional disturbance. This is the time for the dreaded attacks of delirium, during which the patient must be vigilantly watched, lest some untoward event happen. Now, too, complications may arise {vide infra). On the twelfth or thirteenth day of the disease the pustules begin to dry up (stadium e.vsiccationis). The pmnilent contents of the pustules, part of which have burst, form yellow crusts, the swelling of the sldn subsides, and, a few days later, the crusts and scabs begin to fall off. With the beginning of desic- cation, the fever declines ; the local as well as the constitutional symptoms become daily slighter, and convalescence follows. The healing of the pustules is frequently accompanied by an extremelj' troublesome itching. After the scabs have been cast off, the skin presents pigmented spots, which pei-sist for months. Wherever the cutis vera has itself been destroyed by the suppuration, a scar is inevitable. Thus arise the familiar scars of small-pox, which continue visible through life. "Very often, after the end of the disease, there is almost complete alopecia. The hair often grows again, but not always. Varioloid. The distinction between varioloid and variola vera is not in kind, but in de- gree. Varioloid is only a milder form of variola. There is, as we have already said, no sharp boundary-line between the two. Varioloid is most often observed in those whose susceptibility to the variolous poison has been diminished by vaccination (vide infra). As above mentioned, the behavior of the disease during its initial stage will not permit us to decide positively whether variola or varioloid will be developed. It is true that if the symptoms be especially mild, we may guess that it will be varioloid ; and. likewise, the appearance of the initial erythema already spoken of is regai'ded as a favorable omen. Shortly after the pocks begin to appear, the decLsion can almost always be made with certainty. In varioloid the eruption is rather scanty. It is often irregular, and does not by any means always begin, like that of variola, in the face, but often on the trunk. The individual pocks are in no way different from those of variola ; but it often happens that they do not pass through all the regu- lar stages to full suppuration, but undergo resolution before this occurs. Such cases, where there is nothing beyond papillae or vesicles, are sometimes spoken of SMALL-POX. 55 as variolois verrucosa seu miliaris. The scantiness of the eruption and the limited amount of suppuration have for their corollary an absence, or at least a very slight development, of the suppurative fever. When the eruption appears the temperature usually falls by crisis to the normal level and remains there. The desiccation may begin as early as the eighth or tenth day of the disease, so that the whole duration of varioloid is con- siderably shorter than that of variola. Grave complications are very exceptional. The pocks may develop upon the mucous membranes, but liere, too, they are scanty and not vei-y vigorous. Course of the Fever, Symptoms presented by Separate Organs, and Com- plications. 1. Fever {vide Fig. 7). — In the initial stage, as we have said, the temperature rises rapidly as a rule, with a pronounced rigor; and during the fii-st days it very often reaches 104° to 106° (40°-41° C). It sinks on the thu-d to the sixth day, when the first papillas develop, and now, in the case of varioloid, falls rapidly to normal, and remains there. In variola the decline is slower and less complete; and with the beginning of suppuration the temperature begins to rise again. The violence of this suppurative fever is usually in direct proportion to the severity of the eruption. It has manifold fluctuations, but seldom lasts, in severe cases, less _;mi »■;■■■■■■■■■■■■■«■ aiiiBliliniiSii!l5EiSa3ESSS33B!! "-iHHHHHHHilHHHHmwnlHMIOBIHHHBSHHHHH SBBBSBSiiS^aBBBBBEBBiafifiUirSBBB "aaB !SiIHB Hnr Initial Fever. Suppurative Fever. Eruption. Fig. 7.— Example of the temperature curve in true sraall-pos. than a week. Temperatm-es of 104° (40° C.) and higher are common. The fever declines by lysis. In case of approaching death, the temperature may be ex- tremely high, even reaching 108° or 109° (43°-43° C). 2. Skin. — We have already described the macroscopic appearance of the erup- tion. It remains to mention briefly the histological phenomena. The first de- monstrable changes are in the cells of the deeper layers of the rete Malpighi. As a result of the variolous infection, the cells perish, are swollen by the lymph which escapes from the papillary blood-vessels, and are transformed into flalry. homogeneous masses without nuclei ("coagulation necrosis "of Weigert). The lymph becomes more and more abundant, and crowds the cells farther and far- ther apart. These are thereby finally changed into threads and membranes, forming a distinct net-work in the vesicle. This explains why, if such a vesicle be pricked, its entire contents are never discharged at once. Great numbers of white corpuscles escape, along with the lymph, from the blood-vessels, and finally render the contents of the original vesicle purulent. Proliferative processes occur 56 ACUTE GENERAL INFECTIOUS DISEASES. in the suri'ounding epithelial cells, which are still intact, and thus the margin of the vesicle becomes elevated, while the dead portion in the center sinks in. Thus the pock becomes umbilicated. If a portion of the papilla itself suppurates, a scar must be left on healing. If the process remains limited to the epithelium, complete regeneration takes place, and the .skin reassumes its normal appearance. Certain secondary complications, which sometimes attack the skin, remain to be mentioned : abscess, phlegmon, eiysipelas, gangrene, and bed-sores. None of these are directly due to the specific variolous intoxication. 3. Resjnratonj Organs. — The disturbances here are in part symptoms of the specific process of the disease, and in part secondary. The frequent occurrence of secondary symptoms in small-pox is easy to undei-stand (com])are the chapter on lobular pneumonia). Of the primary symptoms, we should mention genuine pocks in the larynx, the trachea, and the larger bronchi. As sequels to these, more or less severe secondary disorder are veiy frequent : laryngeal ulcerations, which may even lead to laryngeal perichondritis and oedema of the glottis ; diffuse bron- chitis ; lobular pneumonia, often of great extent, due to the inhalation of solid matter into the lungs, and frequently accompanied by pleurisy. It should be especially noticed that lobar, croupous pneumonia is not rare. Whether tliis be likewise secondary or a direct result of the variolous poison is not yet known. 4. Digestive System. — The genuine pocks often develop, as stated, in the mouth and pharynx, and likewise in the upper part of the a?sophagus. They are not observed in the mucous membrane of the stomach or intestines. The active diarrhoea sometimes seen depends upon catai-rh of the intestine. Dysentery is rare. The eruption in the mouth and throat may result in severe secondary trou- bles, purulent otitis, parotitis, pharyngeal diphtheria, etc. The spleen is almost always considerably enlarged, and often the liver, but in a less degree. 5. Circulatory System. — Pathological changes in the heart are rare, if we except the slight parenchymatous degeneration of its nmscular fibers, common to almost all severe infectious diseases. Sometimes there is a slight endocarditis (q. v.), which is probably secondary. Pericarditis is rather more frequent. 6. Organs of Special Sense. — Genuine variolous pustules occur upon the eye- lids and the conjunctiva. Later in the disease there may be keratitis, iritis, or choroiditis. We have already mentioned the relative frequency of aiu-al disturbances, par- ticularly purulent otitis media. 7. Ai'ticular swelling may appear in the suppurative stage. The shoulders and knees are most apt to he attacked. Periostitis also occui-s. 8. Nervous System. — We find no pathological changes corresponding to the severe nervous derangements manifested during the disease. After the small-pox is over, spinal diseases sometimes occur, with either paralysis or ataxia. Westphal has demonstrated as their cause, in some cases, numerous disseminated centers of inflammation in the spinal coi'd. 9. Albuminuria is quite frequent in severe attacks, but genuine nephritis is a verj' rare complication. Anomalies in the course of the disease ai-e manifold. Wc do not speak of the two tyi)i■' tine cultures, and iuvariably causes erysipelas in the rabbits and the human beings that are inoculated with it. Facial erysipelas is most apt to attack the ■ >?/ young, and seems to be somewhat more fre- -' quent in women than in men. The laity erro- neously regard catching cold and getting f right- ly ened as frequent causes of the disease. If we except the predisposing causes above mentioned ^ ._. — viz., coryza, slight scratches, cuts, etc. — we y^ usually iind no cause of which we can feel cer- .'/y tain. Often endemic influences are important. vJ^JJjjigi ' It has been long known that traumatic erysipe- las can get so secure a footing in particular hos- FiG. 8.— The cocci of erysipelas. x700. .. , i ii t i i Section through a lymph-vessd in the sl£in. pitals or wards that every wounded person ti'eated in them is in danger of this disease. But the apparently idiopathic variety is sometioies remarkably frequent in partic- ular places. Likewise several members of one family may have facial erysipelas simultaneously. In neai'ly all such cases the sufferers are infected from some common source, for direct contagion is certainly exceptional. Direct inoculation can, however, as has been proved, convey the disease from a patient to other pci-- sons or to animals. In contrast with the behavior of the acute eruptive diseases, erysipelas is pecul- iarly apt to attack the same individual over and over agam. Tliere are persons who have facial erysipelas about every one or two years. Often the explanation of this apparently lies in some chronic disease — e. g., chronic ozasna — which makes infection easy, but in other cases no cause can be discovered. Marasmus seems to predispose to erysipelas. At least we have observed that erysipelas occurred with relative frequency, in the Leipsic hosi)ital, in patients suffering from the last stages of phthisis or cancer, or similar diseases. Clinical History.— In many cases the first subjective symptoms are simultane- ous with the cutaneous swelling, and these are chiefly local. There is pain and a sense of tension in the skin. Soon subjective symptoms of fever also appear, such as general malaise, anorexia, and headache. In' other cases the disease starts with more violent coustitutional symptoms : there is an initial rigor, with violent head- ache and great languor. Almost at the .same time, or sometimes two or three days later, the patient notices that the face is swollen. In rare instances the disea.se begins with sore throat. We saw three almost simultaneous cases of facial ery- sipelas in one family, where a severe sore throat lasted for four or five days pre- ceding the appeai'ance of the cutaneous disorder. The erysipelatous process in the slcin is almost always circumscribed at first. It usually starts on the nose, less often upon the cheek, the ears, or the hairy scalp. The skin becomes considerably swollen, grows red, smooth, and shiny, and feels hot. The redness and swelling keep spreading. There is usually a shari), elevated ridge, perceptible to sight and touch, separating the diseased from the still healthy portion of the skin. As long as the erysipelas is spreading, we see stretching out from its border, or somewhat removed from it, small red streaks and spots which ERYSIPELAS. 63 gradually increase in area and intensity, and fijially coalesce. Any decided fold in the skin may hinder for a time the extension of the disease. The naso-labial folds are particulai-ly apt to limit it. The border of tlie hairy scalp frequently forms a terminal line ; but the whole scalp may be attacked, the Lnflammation stopping only when it reaches the nape of the neck. It is only in a relatively small num- ber of cases that it spreads farther yet, attacking the back, the arms, and the an- terior surface of the trunk, or even extending to the feet. This Ls known as ery- sipelas migrans. The facial erysipelas may be healed long before the disease ceases to extend over the other parts of the body. When the spreading process is about to cease, the inflammation usually becomes decidedly milder, appears only in isolated spots, and finally stops completely. In most cases, only the face, the ears, and a part of the scalp are attacked. It is not a rare thing for vesicles or bullte to form in the portions of skin at- tacked. Such cases are called erysipelas vesiculosum or erysipelas bullosiim. The serum may change to pus in these blistere, and then we have erysipelas jmstido- sum. Exceptionally the infiltration of the skin becomes so intense as to result in a localized necrosis or gangrene — erysipelas gangroenosuni. The parts most apt to be attacked by this are the eyelids. Microscopic examination of the skin shows a marked hyperemia of all the blood-vessels and a very considerable infiltration of both the skin and the subcu- taneous connective tissue with serum and cells. In those parts where vesicles are formed there are many dead and disintegrated epithelial cells in the rete Malpighii. The presence of great numbers of the specific chains of micrococci has been ah-eady mentioned. The inflammation in any one spot usually ends four or five days after it has made its appearance there. There is usually much attendant desquamation. The face is often left with a finer complexion than it had before. The other symptoms, of which the constitutional disturbance and the fever are chief, correspond pretty closely to the severity and extent of the cutaneous lesion. It is comparatively seldom that this correspondence does not exist. The fever in facial erysipelas tisually rises rapidly at first, and to a considerable height. We have seen but few cases where the high fever was delayed till a day or two after the skin was attacked. The temperatures observed in erysipelas are often extreme : 106° (41° C.) is not at all rare. The highest we ever saw was 107'2° (41 -S" C). While the erysipelas continues or is spreading, the fever is sel- dom continuous, nor are the remissions insignificant. Pronounced intermissions, even down to normal, are very frequent, but are followed again by a rapid and great rise of temperature. The fever may terminate with a genuine crisis. In in- tense cases of considerable extent, or in erysipelas migrans, the termination is more apt to be by a more or less gradual lysis. We have seen the cutaneous in- flammation in erysipelas migrans still extend itself a little, in a rudimentary form, after the fever had completely ceased. The headache is often intense, and seems to result not merely from the inflam- mation of the scalp, but from disturbances of the circulation in the underlying parts. Other severe cerebral symptoms are also relatively fi-equent. The patient may be very restless, excited, and wakeful. At night there may be mild or even violent delirium ; or there may be decided stupor. All these symptoms are in chief part due to the constitutional infection, or, to speak more accurately, to the intoxication caused by the infection ; but they also justify a surmise, as we have said, that there is a cu'culatory derangement in the meninges and the brain itself, resulting from the inflammation of the scalp. In drunkards, delu-ium tremens is not infrequent. One of the most constant symptoms in facial erysipelas is gastric and intestinal 64: ACUTE GENERAL INFECTIOUS DISEASES. disturbance. There is usually comi>lete anorexia. The tongue is thickly coated. Vomiting is frequent, not only at the beginning but during the course of the dis- ease. There is constipation ; or there may be quite severe diari-hcea. Tbere is no pathological lesion kuown corresponding to these clinical symptoms. The entire duration of the disease varies greatly in different cases. A very light case may get well in a few days. Most cases of average severity last a week or ten days. Erysipelas migrans may continue for many weeks. We liave sev- eral times seen a relapse come on after a number of days of comijlete apyrexia. Either the face would be once more attacked, or some portion of the skin which had previously escaped. Local complications are comparatively rai-e in erysipelas. Tlie lymphatic glands of the throat and back of the neck are very frequently somewhat swollen, but seldom attain great size. Bronchitis and lobular pneumonia may develop in severe cases, but are not at all characteristic. Some observers call attention to the occurrence of pleurisy, endocarditis, and pericarditis; but these complications also are probably secondary. The spleen is usually slightly swollen. Sometimes there is an icteroid hue. The urine frequently contains a small amount of albumen, and in severe cases of erysipelas acute hajmorrhagic nephritis is not so very rare. Swelling of the joints has been repeatedly observed. It is more frequent in the severe surgical forms of erysipelas, which are combined vnth universal septic and pysemic conditions of the system. Piu-ulent meningitis may complicate an ery- sipelas located in the head, but it is very rare. We should be exceedingly cautious about asserting its existence even when the cerebral symptoms are very pro- nounced. Cutaneous complications are relatively frequent. We have seen herpes labialis quite often, and a number of cases of urticaria. Of much greater importance are the cutaneous abscesses which occur in severe cases. These are due to a phleg- monous or even gangrenous inflammation of the connective tissue. Their most frequent seat in the face is the eyelids, as already stated ; and in that case the eye may itself be endangered. At the close of .severe cases of erysipelas migrans, numerous abscesses may develop in the skin of the trunk and extremities, delay- ing convalescence. The diagnosis of erysipelas is almost always easy when once the cutaneous lesion has developed. Phlegmonous inflammation of the skin and lymphangitis are to be eliminated; but this is always possible, with proper care. After a single examination, we may confound it with acute facial eczema of great severity, or even with a marked urticaria. Chief attention should be paid to the characteristic border of erysipelas and to its manner of extension. The prognosis of facial erysipelas, when it attacks a healthy person, is very favorable. In drunkards a severe case may be complicated by delirium tremens, and the issue be unfavorable. We saw one case end fatally because of gangrene in the eyelids, followed by purulent inflammation of the orbital connective tissue. Erysipelas migrans may so exhaust the powei-s of feeble patients as to become dangerous. The prognosis of surgical erysipelas is relatively moi-e imfavorable, but can not be considered here. Treatment. — In a case of not more than average severity no special treatment is needed. To lessen the local discomfort, we u.sually cover the skin with pow- dered starch, or anoint it witli olive-oil, carbolized oil, or vaseline. An ice-bag on the head is agreeable to most patients. If we wish to prescribe something, we may choose an acid mixture, as follows: Acid, muriat. dil., parts 8; syrup, 15; aquae, 120. M. In severe cases, however, the high fever and the nervous symptoms may demand our interference. The remedy to be chiefly recommended is cold baths, DIPHTHERIA. 65 of which two or three may he given in a day, and which most patients bear very well. The exhibition of quinine, antipyriue, or antifebrin is seldom called for. as there is a tendency to great spontaneous intermissions in the fever. If the facial inflammation proves to be part of an erysipelas migrans, the chief indication for treatment would be to check the unceasing advance of the disease; but, unfortu- nately, the means recommended for this purpose too often fail. It used to be customary to cauterize the skin along the border of the erj'sipelas with nitrate of silver, but this has been almost entirely abandoned as useless. Hueter recom- mends the injection of a two-per-ceut. solution of carbolic acid beneath the skin at a little distance from the border of the inflammation. Although this is cer- tainly a rational method of treatment, we have seldom seen any brilhant results from it. Of more benefit seems to be the newly recommended scarification of the diseased sm-face, followed by the application of a solution of corrosive sublimate. For internal use we mention fii-st Pirogotf's camphor treatment. The patient takes every hour or two three grains (0'15 grm.) of powdered camphor and drinks' large quantities of hot tea, to promote perspiration. In severe cases this method deserves a trial. Numerous other internal remedies have been recommended ; but we need not enumerate them. We have not seen any influence upon the ex- tension of the disease exerted by large doses of salicylic acid or benzoate of soda. In England a prominent remedy is liquor ferri chloridi (in the form of tr. ferri chlorid.), given to the amount of di-achms jss.-ijss. in the course of the day (6-10 grm.). In the severe cases the main point, after all, is to maintain the patient's strength by nursing and food. If cutaneous abscesses form, they should be opened promptly, when they usually soon heal. CHAPTEE X. DIPHTHERIA. {PijiMheritU. Croup. Cynanche contagiosa,) .Etiology and General Pathology.— Clinically, " diphtheria " means a certain Avell-cliaracterized, siseciflc, acute, infectious disease, the chief visible lesion of which is a croupous-diphtheritic inflammation of the phar3mx and upper air-pas- sages. In a purely pathological sense, however, the terms " croupous " and " diph- theritic" have a broader meaning. They denote a certain form of inflammation which may occur in the mucous membrane of almost any part of the body. It is frequent in the intestine and bladder. There is great diversity in the causes which may produce it. The pathological characteristic of croupous-diphtheritic inflammation consists in the formation of a fibrinous exudation. This may either be a croupous mem- brane, which is grayish white, rather firm, elastic, and can he lifted off with com- parative ease from the mucous membrane upon which it rests, or it maybe a diphtheritic infiltration with necrosis of the tissues. Here the exudation is more or less deeply imbedded within the proper structure of the mucous membrane itself. There is no essantial difference between croup and diphtheria; diphtheritic inflammation is the severer form of the disease, croupous inflammation the milder. In diphtheria the flbrinous exudation is preceded by a necrosis of the epithelium and of the underlying tissues of the mucous membrane as well, while in the case of croupous exudation the necrosis is limited to the epithelium. The croupous m.embrane never rests upon an intact mucous surface, but replaces the epithelium, which has already been totally or in very large part destroyed. Flaky remnants 06 ACUTE GENERAL INFECTIOUS DISEASES. of the epithelium, no longer nucleated, are sometimes found in the meshes' of the fibrin. The preceding' destmction of the epithelium is essential to the occurrence of fibrinous, ci'oupous inflammation. The fibrinous exudation can be formed in those places only where the cause which excites the inflammation kills the epithe- lium at ihe same time. Apparently the epithelial cells have little if any share in the formation of the exudation. It is more probable that the matei'ial for the fibrin comes from the fibrinogen of the irLflammatory matter which transudes througli the walls of the vessels, and also from the disintegrated migratory white blood-globules. These last are abundant tliroughout the deposit itself, and still more numerous in the entire tissue of the mucous membrane beneath the croupous or diphtheritic exudation. If recovery takes place in croup, all that is needed after the exudation has been cast off is the renewal of the epithelium, wliich can be accomplished through the exclusive agency of the remnants of epithelium left along the borders of the diseased spot. lu diphtheria, however, the entire necrotic portion of mucous membrane must slough off, a line of demarkation being foi-med, and cicatricial tissue replaces the necrosed portion. The above is a bare outline of the present views about croupous and diph- theritic inflammations. They have been reached gradually through the labors of E. Wagner, Weigert, and others. We have not yet touched ujjon the a?tiological factors; but what precedes renders it evident how manifold they may be. for many causes which destroy the epithelial layer of the mucous membrane, and at the same time pi-omote inflammation, may excite croup. We have mechanical causes, such as impacted fasces, gall-stones, renal calculi ; chemical irritants, caus- tics, like ammonia and the acids; and, finally, a number of specific, infectious, dis- ease-producing poisons. Among these is the specific poison of diplitheiia proper. Beyond a doubt the diphtheritic poison is organized. To demonstrate this, however, has been tluis far extremely difficult, for there are in the diseased spots a great number of diverse micro-organisms, originating in the mouth and thi-oat, and really secondary to the diphtheritic process; but, although they of course are entirely different from the specific " diphtheritic bacteria," it is veiy hard to sepa- rate them. The latest systematic investigations of Loflier have made us acquainted with a bacillus which can be found in most cases of diphtheria, while at other times it is very rarely foiuid in the mouth. Lofiler's bacilli are little cylinders with a peculiar club-like swelling at their ends. In croupous membranes they are found in colonies. Inoculated upon animals, they have a decidedly pathogenic power, and produce a disease similar to diphtheria. That the.y constitute the long-sought diphtheritic poison is therefore probable, but it is by no means con- clusively proved. Diphtheria is chiefly a disease of childhood. It is much less frequent in those over ten years of age than in earlier life. In the larger towns sporadic cases are occurring all the time, but now and then the cases become so numerous as to be endemic or epidemic. As to the precise way in which a human being becomes infected the opinions of physicians differ. We think it most pi-obablc that the poison reaches the pharynx along with the inspired air or in some other way, and here penetrates into the mucous membrane. It is very rare for the larynx to be the point of entrance {vide infra). It first excites a local disturbance, to which the general infecticm of the system (vide infra) is only a sequel. At the same time secondary infection plays often an important part in diphtheria, just as in many other infectious diseases. The seat of the jirimary diphtheritic process promotes and perhaps gives the fii-st opportunity for a colonization of other varieties of micro-organisms ; and these change for the worse the original character 'of the cUsease. It is especially probable that many cases of so-called " septic diph- theria " {vide infra) are due to a complication of the primary simple diphthei-ia DIPHTHERIA. 67 with a septic infection. A confirmatory and remarkable fact has been discovered by Loffler. He has found in the diseased tissues of the throat, and also in the in- ternal viscera, in severe cases of diphtheria, the same " chain-building micrococcus " with which, as the cause of certain severe forms of scarlatinal angina (see p. 39), we have already become acquainted. Accoi-ding to A. Frankel, this organism is identical with the streptococcus pyogenes. The original source of the infectious material is probably always some other case of diphtheria. Sometimes a direct, immediate transmission of the poison (contagion) is extremely probable — e. g., due to coughing, or to sucking out bits of membrane after tracheotomy. The latter is a comparatively frequent cause of the disease in physicians and nurses. The infection is often spread by some person who may himself escape the disease, or by fomites, playthings and other objects, to which the poison is adherent. The potency of the infectious matter is not easily destroyed by such extei-nal influences as desiccation or changes of tempera- ture. In other words, it possesses great " tenacity." As to what extent the dipR- theritic poison may have a power of independent reproduction outside the body — e. g., in the ground, or in the floor of dwellings — we remain in complete igno- rance. Finally, we should notice that of late attention has been called to the possibility of catching diphtheria from diseased animals. Poultry, doves, and calves have diseases that are at least similar to diphtheria. [While it seems in the highest degree probable that the poison is usually purely local at the start, cases occur which suggest that constitutional infection through the pulmonary blood-vessels may precede the local manifestations. Infection through the alimentary canal is not probable, though its occurrence can not he positively denied. There are still points in the a?tiology and pathology of this affection which are involved in obsciu'ity. Much has been said and written in this country and in England about the relations of filth and diphtheria. That filthy surroundings contribute a soil favorable to the development of the poison, and at the same time diminish the resisting power of the human organism, can not be doubted; but, as long as the parasitic theory of infectious diseases prevails, sewer-gas and the like must be classed among the predisposing or accessory causes. Some of the frightfully virulent epidemics of diphtheria in sjiarsely settled country districts and on the Western plains are difficult to explain under the theory that each case is mediately or immediately the result of a previous case; these difficulties will, however, doubtless be cleared away in time.] Clinical History.— The incubation is rather brief, seldom exceeding two to five days. The disease itself almost always begins with general malaise, headache, fever, and pain on swallowing. Little children, however, often do not complain of this last symptom, and in older children the sore throat may not be very troublesome at first. It is therefore a very important rule for the physician to examine the throat carefully in every child who presents ill-defined general symp- toms. If diphtheria is beginning, we find redness of the soft palate, and more or less swelling of the tonsils. Upon the inner surface of the latter, and perhaps mon the arch of the palate and the uviila also, are spots covered with a grayish- white coating, which is quite firmly adherent to the mucous membrane. They are less frequent upon the posterior wall of the pharynx and the hard palate. Then- extent varies greatly in different cases. In the mildest they are chiefly confined to the tonsils, attacking the soft palate or the tonsillar surface of the uvula but lit- tle if at all. In severer attacks the spread of the false membrane during the first days of Ulness is rapid. Almost invariably there is a very early and consider- able swelling of the lymph-glands at the angle of the jaw. The constitutional symptoms persist. The children are restless. There is complete anorexia, and G8 ACUTE GENERAL INFECTIOUS DISEASES. frequently vomiting. The tempei-ature-curve is not typical. It is irregular, but is often rather elevated, reaching 104° (40° C.) or more. On the other hand, fever may be slight or almost absent, even in the woi-st cases. Tlie pulse is very rapid. The urine may have a trace of albumen. In mild cases the local and constitutional symptoms remain moderate; and at the end of a week or ten days there is decided improvement, with ra]nd convales- cence. In severe cases, however, dangerous symptoms appear, perhaps early ; the croupous inflammation involves neighboring organs, or a severe constitutional infection is developed. The diphtheria very frequently extends into the nose. This "diphtheritic coi-yza," though not in itself dangerous, is usually a sign that the case is a severe one. The inflammation of the nasal mucous membrane may be simply nmco- purulent, but it may also be croupous. It is betrayed by the abundant purulent dischai'ge. Excoriations and superficial ulcers are usually soon produced at the edge of the nostrils. There may be nose-bleed. A much more dangerous complication is the extension of the process into the larynx. This creates a mechanical hindrance to respiration, which pi'oves fatal in a great many cases, as the child's larynx is so small. Formerly "croup" — i. e., croupous inflammation of the larynx — was regarded as a different disease from diphtheria. Many specialists iu children's diseases still maintain this view ; but it is in direct opposition to the teachings of pathological anatomy as well as of the clinical symptoms. We grant that there are cases where the pharynx is slightly affected, while the croupous inflammation of the larynx is extreme; and once in a great while tlie diphtheritic infection results in croupous laryngitis and trache- itis alone, the pharynx escaping disease. Still the proposition that there are two distinct diseases, " croup " and " diphtiieria," is absolutely untenable. In the over- whelming majority of cases the throat is fii-st affected and then the larynx. We should also considej- how easily slight lesions in the pharynx might be over- looked, especially if located upon the posterior surface of the soft palate or upon the epiglottis. Cases of what is called " ascending crou]),'' in which the lal•J^^geal affection precedes the appearance of the disease in the pharynx, are, to say the least, very exceptional. Usually hoarseness is the first indication that the diphtheria has attacked the larynx. Then follows the peculiar, harsh, ringing-, "croupy cough," so dreaded by the parents, and, finally, there are signs of beginning laryngeal stenosis. Respira- tion is not much accelerated, but is labored, and the accessory muscles of respira- tion are called more and more into action. The child becomes more restless and anxious. Its face grows pale and livid. The chief cause of the dyspnwa is un- doubtedly the mechanical stenosis due to the croupous deposit. Paralysis of the laryngeal muscles may perhaps be a factor. If portions of the false membrane become partially detached, they may act like valves, being sucked in at each inspu'ation, and pushed aside by the curi-ent of expired air. If stenosis occui-s, respiration becomes noisy, resembling snoring. Inspiration, particularly, is pro- longed and "sawing," and is attended by marked depression of the larynx toward the sternum. An important diagnostic point is the di-awing in during inspiration of the supra-sternal region, the epigastrium, and the lower part of the sides of the thorax. This is the direct result of the obstructed flow of air into the lungs. As the lungs do not expand enough to correspond to the inspiratoi-y dilatation of the thorax, the parts mentioned are forced in by atmos])heric pressui-e. The degree of dyspnoea may vary at different times. The false membrane may be loosened and coughed up, rendering respiration ea.sier for a time, till fresh exudations or dis- placements of membrane cause renewed distress. Recoveiy is still jiossible. The membrane may be expectorated and no more be formed. Uufortunatcly, this DIPHTHERIA. C9 happy termination rarely occurs. In most cases the symptoms of suffocation in- crease m.ore and more, respiration grows quicker and more superficial, and the child becomes more and more stupefied by the excess of carbonic dioxide in the blood. The pulse gets very small, rapid, and irregular. There are mild convul- sions and then death. The autopsy in these cases discloses usually that the croupous inflammation has extended into the larger bronchi or even into the smaller. The lumen of the bronchioles may be almost completely occluded by false membrane. There is also sometimes a genuine croupous inflammation of the pulmonaryparenchyma. Lobular pneumonia in the lower lobes is much more frequent, however. It is probably secondary and to be regarded as a pneumonia from inhalation. During life the pulmonary complications may be suspected, but can hardly be diagnosti- cated. If we hear abundant moist rales over the lower lobes we are usually justi- fied in supposiag that lobular infiltration exists, even if there be no dullness on percussion. The croupous bronchitis as such gives rise to no especial auscultatory signs. If it is very extensive and reaches into the smaller bronchi, it may prove fatal, even if there be no laryngeal stenosis. This is more apt to occur in adults. Another danger from dii^htheria is through the general infection of the system, which may cause a fatal result. Although diphtheria does seem to start as a local disease, yet infectious matter (or poisonous substances) are certainly absorbed from the primary lesion into the general system. These exert theu- deleterious influ- ences mainly upon the nervous system. We have already pointed out (p. 66) that the exact interpretation of these phenomena is rendered difficult by our inability as yet to distinguish between the effects of the primary and of the secondary infection of the body. Of especial practical importance are those cases in which we see the child sink into somnolence, and finally into complete sopor; its pulse becomes weaker and weaker, and more and more rapid, reaching 200 or more, and at last there is " paralysis of the heart " and death. All this occurs without any great degree of laryngeal stenosis. Such cases of severe constitu- tional infection, or " septic diphtheria," are most frequent when the local disorder in the pharynx is of unusual intensity, and the croupous exudation is replaced by deeper-reaching, necrotic, or even gangrenous inflammation within the mucous membrane. This has been called " gangrenous diphtheria." In such cases, also, the cervical lymxjh-glands are usually intensely inflamed. It must be noted that, exceptionally, a comparatively mild local disorder may co-exist with the worst general symptoms. A question of great interest, but which can not yet be answered, here presents itself. It is whether the constitutional symptoms are in every case directly dependent upon the diphtheria, or whether the diphtheria is not re-enforced by a peculiar, secondary, septic infection, proceeding from the diphtheritic ulcerations. We regard the latter view as probable. In adults the constitutional infection is a prime factor of danger, for in them laryngeal stenosis is less apt to occur, as the parts are so much larger than in children. As to the part which the other organs play ia diphtheria, we should mention that the process may extend not only into the nose and larynx, but into the Eu- si-ohian tube and the middle ear. It may also attack the anterior portion of the mouth, the gums, and the lips, or it may travel through the nose and the nasal ducts to the conjunctivae. Very exceptionally the croupous process extends into the oesophagus. The infectious matter may be transferred, by the finger or in some similar way, to excoriations or accidental lesions of the skin, and excite diph- theritic exudations upon them. The frequent cases of inflammation of the eyes probably originate in the same manner, and also the diphtheria of the external genitals seen in children. With regard to other organs, it should be mentioned that there is not infrequently a splenic tumor. Intestinal complications (diar- 70 ACUTE GENERAL INFECTIOUS DISEASES. rhoea) are generally rare; nor is swelling of the joints frequent. The heart and kidneys, however, always need watching. It has already been stated that in severe cases of diphtheria the pulse becomes remarkably small and rapid. It is also often irregular. Further, even in cases that otherwise seem mild, sudden cardiac failure may occur, ushered in by excessive rapidity of the pulse, and often proving quickly fata,l. This misfortune often happens at a time wlien con- valescence seems to be fully established. Small islets of myocarditis are fre- quently found in diphtheria, but it is probable that the collapse is not so nmch due to them as to derangement of the cardiac nerves, particularly the vagus (vide infra). Eenal disturbance betrays itself through the greater or less degree of albuminuria existing in most of the severe cases. It usually appears when the disease is at its height, less often at a later period. We often fijid a few casts in the uj'ine, but seldom much blood. QDdema is rare. At the autopsy there is generally little macrosco]5ic alteration of the kidneys. The microscope reveals the ordinary degenerative fliaiiL:cs of acute nephritis {vide infra). The Nervous Sequelae of Diphtheria.— The convalescent from diplitberia is liable to be attacked by certain nervous sequelae. Of these, diphtheritic paralysis is the most important. It appears about one or two weeks after the tliroat trouble ceases, or perhaps earlier, and it is quite as likelj' to follow mild cases as severe ones. It attacks the soft palate by preference. The tone becomes nasal and deglutition difficult. The naso-pharynx is imperfectly cut off during the act of swallowing, and with each attempt liquid regiu'gitates through the nose. Usually the pharyngeal mucous membrane is anajsthetic at the same time, and deprived of its reflex excitability. There may also be paralysis of the vocal cords upon one or both sides, and this again is frequently combined with anaesthesia of the mucous membrane of the throat. There may be pai-alysis of the ocidar muscles, of which those controlling accommodation are most apt to be affected, rendering tlie vision for near objects imperfect. Paralysis of the muscles of the ti-unk and extremities is least frequent, but it may be very exten.sive. Sometimes several of these parts are paralyzed simultaneouslj-. Thus we see quite often paralysis of the soft palate and of the muscles of accommodation combined. In some cases there is well-marked ataxia of the lower limbs with or without paresis. This i-entlers the gait very uncertain and tottering, the tendon reflex is almost always abolished, while sensation is affected slightly if at all. Very rarely diphtheria is followed by contracture of the hands or other parts, by difficulty in articulation and paresis of the bladder. A paralysis of the pharynx is sometimes left behind, so that the children have to be fed for weeks through an oesophageal tube. It is a remark- able fact that not only in almost every case of the nervous disorders which we have mentioned, but often also in individuals who have entirely escaped them, there is no patellar reflex after diphtheria for weeks or even months. Witli regard to the pathological state, it is probably a degenerative condition of the corresponding pei'ipheral nerves, not only in the post-diphtheritic paralysis, but also in the cases of post-diphtheritic ataxia. This' harmonizes with the usually favorable termination of the nervous sequelaj of diphtheria. But there is one pai-alysis which is highly dangerous — that of the heart, as already mentioned. It may occiu- suddenly during convalescence. Probably it is analogous to the other nervous derangements, and the result of degeneration in the fibers of the pncumogastric. Diagnosis. — The physician will seldom mistake a case of actual diphtheria if he pays proper attention. The characteristic deposit and the severe general and 'ocal symptoms make the diagnosis certain. It is much more common to take other foi-ms of sore throat, particularlv in adults, for diphtheria. The most decep- tive are follicular and necrotic tonsillitis (vide infra). We must not suppose that DIPHTHERIA. 71 every white spot upon the tonsils is diphtheritic. The above-mentioned form.s of sore throat are, however, frequent during epidemics of diphtheria, and even, as we have often observed of late years, in families where there are simultaneously cases of genuine dii^htheria; so that the thought is suggested that they may aetiologically have some relation to true diphtheria. It is at any rate advisable not to omit proper precautionary measures, especially if there are children about. [Wheu the membranes are confined to the nose, the diagnosis may be more or less difficult; but it is especially in cases in which the nasal mucous membrane is involved that we encounter great swelling of the glands at the angles of the jaw. There is also apt to be a thin, acrid, bloody, or sero-purulent discharge. Jacobi states that while diffuse pharyngeal injection may or may not point to imminent diphtheria, marked local congestion is either traumatic or diphtheritic. An examination of the urine should never be neglected in doubtful cases: in diph- theria a trace of albumen is very common ; in simple or follicular sore throat albumen is very rare, if indeed, it occurs at all.] Prognosis. — The unfavorable prognosis of the disease is universally known, even by the laity. The very fact that the best developed and healthiest children so often fall victims to it associates the name diphtheria with the saddest mem- ories. There are indeed many mild cases which recover in a week or two, and severer ones which end happily in three or four weeks ; but in most cases, where the process extends into the larynx, or the sjonptoms of a severe constitutional in- fection occur, medical interference has, unfortunately, no power to control the unfavorable issue. What the dangers are, and how recognized, can be well enough inferred from the preceding description of the symptoms. We will only remind the reader how carefully the physician should watch the behavior of the heart, since danger is apt to arise from this soui'ce, even when the case seems otherwise to be taking a favorable course. Treatment. — If we take the ground that diphtheria begins as a merely local process, then local treatment of it certainly seems rational, at least at first. Un- fortunately, the practical result bears out the theory very imperfectly. An actual and complete destruction of the croupous exudation is but seldom possible; and the attempt to accomplish this in a struggling child is so difficult and disagreeable that to-day most physicians have entirely abandoned the application with a brush of caustics or other substances to the throat. If it does, nevertheless, seem de- sirable to try energetic local measures at the commencement of the disease, the best agents to choose ai'e a concentrated solution of argentic nitrate (1-10), or a solution of corrosive sublimate (1-1,000), or a mixture containing equal parts of carbolic acid and alcohol. If the disease has already made some progress, we may well spare the patient needless tortvire and consider that, by destroying the mucous membrane and by wiping off the exudation, we are likely to contribute to a fur- ther extension of the diphtheritic process. The author has not used energetic local treatment for years, regarding it as a useless disturbance of the patient. We do not, therefore, regard active local interference as justifiable except at the very beginning of the disease ; but we do believe that both then and at a later period it is extremely desirable to disinfect the mouth and throat as thoroughly as possible. Although this has little effect upon the diphtheria itself, it is at least a factor in preventing secondary septic infection, and thus of great therapeutic importance. Adults and older children should rinse the mouth and gargle fre- quently, using disinfectant solutions, e. g., of potassic chlorate or carbolic acid. Often, however, gargling proves painful. Inhalations are very appropriate. Tliey are usually well borne when either lime-water (diluted with equal parts of distilled water) or simple salt solution is used, while the stronger disinfectants, such as a one-ijer-cent. or two-per-cent. solution of carbolic acid, often cause a T2 ACUTE GENERAL INFECTIOUS DISEASES. burning sensation. Nevertheless, it is advisable to keep up a carbolic spray in the neighborhood of the patient. We may sometimes try rinsing out the mouth with a fountain syringe, using for the purpose a weak solution of salicylic acid or some similar antiseptic. The frequent introduction of a few tcaspoonf uls of cold water into the nose has also been recommended as an appropriate treatment — " cold nasal bath." We shall mention only a few of the numerous other remedies which have been recommended. There is another local remedy, papayotin, wliich is obtained from the milky juice of a certain i)lant, and has the pi'operty of digesting albu- men. If a diphtheritic exudation be frequently touched with a tive-per-cent. solu- tion of this, it will sometimes disappear rapidly ; but the drug can not be .shown to have an active influence upon the disease itself. Of internal remedies, we should mention potassic chlorate, which has been much vaunted as a specific, when given internally in rather large doses. We recommend it, but it should be used as follows: a half-teaspoonful of a two- or three-per-cent. solution should be slowly swallowed about every half-hour. The aim is to obtain, not a constitu- tional, but a local antiseptic action. It should not be given in larger amounts than drachm j-jss. (grm. 5-6) in twenty-four hours, lest it cause hcemoglobinuria or other toxic symptoms. Several physicians have lately recommended spirits of turpentine very highly, one half to one teaspoouful being given several times a day. It has not become popular. The same may be said of the internal use of potassic iodide. Injections of pilocarpine have .ilso been praised. They are said to promote the detachment of the false membrane; but then' efficacy is doubtful. [The tincture of the chloride of iron is much used in this country in the treat- ment of diphtheria, and appears to be of real service ; but it must be given in large doses. The following prescription is recommended by Jacobi, whose experience has been very large, for a child of two yeai-s: I? Tinct. ferri chloridi 3 ij ; Potas. chlorat gi-. xx ; Glycerin. j)ur ? j ; Aquae | v. M. S. : Teaspoonful every fifteen, twenty, or thirty miimtes. Turpentine is better as an inhalation than by the stomach; a teaspoonful or two of the oil can be poured in water kept at the boiling point by an alcohol-lamp. The whole air of the room is thus charged with the remedy. No drug should be used which disordere the stomach. Tablet triturates cont;iining one one thou- sandth of a grain of corrosive sublimate can be allowed to melt in the mouth with the greatest freedom, and seem sometimes to exert a distinctly beneficial local action. The dose is, however, too small to secure the systemic effects of tl^e di-ug unless the case is a mild one and free from notable dysjihagia.] If the larynx is attacked, and the consequent laryngeal stenosis threatens to cause suffocation, tracheotomy is our only resort. It is never indicated by the disea.se itself nor by the sevei'ity of the case, but only by pei-sistent obstruction of the larynx. It is therefore not invariably easy to decide whether ti'achcolomy is called for in any particular case. If the general condition be bad and respiration already impaired, it may be very difficult to detei-mine whether laryngeal stenosis exists. Tracheotomy will be of no avail if the croup has ah-eady extended to the bronchi, or if the dangerous condition of the patient is due to the severity of the constitutional infection or to incipient paralysis of the heart. This explains why the results of ti-acheotomy are not remarkably brilliant. On an average, only DIPHTHERIA. about one third or one fourth of the cases operated upon get well; but even this number is enough to make us prize the operation very highly. How it is per- foi'ined, and in what the after-treatment consists, must be learned in the text-books on surgery. The attempt to expel the false membrane from the larynx by inducing vomit- ing is still often made, but seldom succeeds, and tortures and exhausts the child. Warm baths with cold douches may prove very beneficial. They excite deep res- piration and more vigorous coughing, and also tone up the whole nervous system. The wet pack is also often employed, and sometimes with great benefit. Outward applications upon the throat arc of little use. In general, we prefer the cold, wet compress to the ice-bag and ice-poultice, which ai-e likewise often em- ployed. [Dr. Geo. W. Gay says ("Phila. Med. Times," 1884): "Not a single case of pseudo-membranous laryngitis has ever recovered in the Boston City Hospital without operation." In twenty years tracheotomy has been done one hundred and eighteen times with thirty-nine recoveries. Four, if not five, successful cases were practically moribund at the time of operation. • Lovett and Munro bring the Boston City Hospital statistics down to Jan. 1, 1887. Tracheotomy for croup was done three hundred and twenty-seven times, all the cases but thirty dating from 1880. There was recovery in ninety-five, or 29'05 percent. " The following table shows the recovery rate incases operated upon within one, two, three, and four days after the beginning of the obstructed respiration " : Day of operation. Number of cases. Recovery. Per cent, of recovery. 1 3 3 4 123 80 33 7 40 24 8 1 32 5 28-0 25-3 14-0 "Since Dr. Gay's article was written there have been two recoveries from moderate dysxsnoea without operation. ... Of forty-two patients under two years of age only three recovered." Intubation, as devised by Dr. O'Dwyer, is a procedure which makes a distinct advance in the treatment of laryngeal stenosis. In permitting the free access of air to the trachea, intubation may save life without resort to the serious operation of tracheotomy; or it may tide over a time until tracheotomy becomes absolutely necessary or imtil the consent of the parents can be obtained to the use of the knife. In hopeless cases it may promote euthanasia. Of eight hundi-ed and six cases collected and analyzed by Dillon Brown two hundred and twenty-one re- covered, 27'4 Tpev cent.] In most cases of septic diphtheria, ti'eatment usually proves completely futile. We must seek to avert cardiac paralysis as well as we can by stimulants, such as wine, camphor, and strophanthus, and endeavor to improve respiration and the condition of the nervous system by lukewarm baths combined with douches. Finally, we repeat that the physician should never neglect to maintain the patient's strength, as far as possible, by proper nourishment. The nervous sequela3 of diphtheria are best treated with the constant current. As an internal remedy, iron is good, and also nux vomica or strychnine. The last may be given subcutaneously, if desired, in doses of gr. -gV-^V (grm. 0-001-0-002). [Diphtheria is a disease which involves commonly much exhaustion, and too much stress can hardly be laid on the importance of administering the maximum 74 ACUTE GENERAL INFECTIOUS DISEASES. amount of nourislmioj^t in the most assimilable and easily swallowod forms from the stai't. It is also important to give stimulants early in most cases, not wailing for signs of exhaustion. Enormous quantities of brandy cau often be given to small children without the slightest toxic effect. No general rule cau be laid down; the requirements of each case must be studied and met. When painful deglutition interferes with nutrition, peptonized milk, eggs, brandy, and the like, must be given by the rectum. Ecctal alimentation and stimulation are also to be resorted to in cases of i)ost-diphtheritic paralysis of the oesophagus.] CHAPTER XI. INFLUENZA. {La Orij)iH.) Influenza is a specific, acute, infectious disease which is especially dis- tinguished by the enormous extent of its epidemics. While often yeai-s and decades pass without any especial attention being called to the disease, suddenly cases of it -will appear with such frequency that the lai-gcst part of the population are attacked, and the disease may better be described as pandemic than epidemic. Pandemics of influenza can be traced back with certainty into the sixteenth century. In the present century the influenza during the yeai-s 1830-33 travereed almost all ot Asia and of Europe, then later there appeared numerous smaller epidemics, but these aroused general attention so little that the disease, upon its last pandemic appearance in the winter of 1889-'90 was almost unlmown. .ffitiology. — Although we have every reason to suppose that the true cau.se of influenza is the infection of the body with a specific, organized pathogenic germ, yet this latter has as yet evaded discovery. It is evident that we have to do with some micro-organism which at certain times appeai-s over an immense territory, the spores of which are probably scattered by the wind over large areas and are inspired with the atmosj^heric air by human beings. Many observations upon the appearance of the disease in isolated institutions (convents and the like) ren- der it quite XJi'obable that the poison may also be can-ied by a person suffering from the influenza to regions previously unaffected. Nevertheless, this contagious manner of spreading plays no great role in comparison with the dii-ect infection from the outer world, this latter mode being everywhere possible during an epi- demic of influenza. There is scarcely any reason for spealdng of especial prcdisjiosing causes of influenza, inasmuch as at the time of a well-marked epidemic llic overwhelm- ing majority of the population are attacked, both the healthy and the diseased, the vigorous and the feeble. Sex certainly makes no difference, and age only to this extent, that the disease is seen more rarely m little children under one year old than in older children and adults. That catching cold has no special a?tiological significance is c\-ident from the fact that influenza often appeai-s in patients who are already sick in bed. It should finally be mentioned that animals also, and in particular horses, may be attacked l)y the influenza; but, nevertheles.s, it is as yet a doubtful question whether all the diseases in animals which are desci-ibed under this name are actu- ally identical with genuine influenza. Sjnnptoms and Clinical History.— The best general idea of the extremely mani- fold symptoms of the disease is to be obtained if we bear in mind that the influ- INFLUENZA. 75 enza causes both a marked infectious (or toxic) general constitutional disturbance of the body, and also certain local lesions with local symptoms. The clinical picture therefore varies greatly according to the predominance of one or the other group of symptoms, and also according to the sjjecial form of the local disease. The onset of influenza is generally rather sudden. As a rule the marked cases begin with i-ather high fever, ushered in with a chill, violent headache, marked constitutional depression, and usually considerable pain in the back and loins. The weakness of the patient may be so great that, even if a vigorous individual, he will at once take to his bed. Severe nervous symptoms, such as stupor and de- lirium, are exceptional. Sometimes, but not very often, there is initial vomiting. The pains in the back are often associated with jsains in the muscles and joints. Oppressive pain in the eyes is quite characteristic also. This is particularly felt upon moving the eyeballs, and therefore is probably located in the external muscles. The spleen is sometimes somewhat swollen, but any great increase in its size is exceptional. If the clinical symptoms as the case progresses are mainly limited to the above- named constitutional symptoms — fever, languor, headache, pain m the muscles, we may speak of a typhoid form of the disease. Usually, however, certain local symptoms put in an early appearance, and it is especially the respiratory appa- ratus which is attacked. The precise sjTnptoms vaiy considerably in different cases. Sometimes the upper portion of the respiratory tract, the nose, larynx, and trachea are involved ; sometimes, from the start, the smaller bronchi. In the first instance there is marked coryza or hoarseness, in the other case there is cough, due to a dry bronchitis, which can be easily detected upon auscultation, and which involves especially the lower portion oif the lungs. If these local symptoms out- weigh the constitutional, the case is described as belonging to the "catarrhal form of influenza." Sometimes the influenza is localized in the digestive apparatus. This "gastro- intestinal form " is much rarer than the catarrhal. In this case, in addition to the more or less strongly characterized constitutional symptoms, there is marked dis- turbance of the stomach and intestines, as shown particularly by nausea with per- sistent vomiting, diarrhoea, abdominal pain, etc. In one case we observed jaun- dice. We may also mention in this connection the appearance of an initiatory pharyngitis. The already mentioned pains in the back, loins, and extremities may persist with unusual violence, and this peculiar form of the disease is known a^ the "rheumatoid." Probably the muscles and the muscular attachments are the chief seat of these pains, which may be so violent that the patient does not know how to lie, and sometimes keeps up a continual moaning. The loins, in particular, may be the seat of most acute pain, also the upper ai'ms, the knees, the thighs, and the eyes. Objective changes in the painful parts, such as swelling of the joints, are scarcely ever seen, nor are the nerve-trunks as a rule especially sensitive to pressure. The painful muscles are usually weaker than normal. The grouping of the clinical varieties of influenza under the four forms already named renders it easier to obtain a general idea of the manifold symptoms of the disease, but this division into separate forms must not be carried out too strenu- ously, for in reality numerous cases of tlie disease occur which present transition forms and combinations of the various groups of symptoms. Moreover, in all the forms a distinction must be made between mild and severe attacks, for in influ- enza, just as in most other infectious diseases, there are numerous rudimentary and mild cases as well as the fully developed ones, and some could not be properly interpreted but for the presence of the epidemic. 70 ACUTE GENERAL INFECTIOUS DISEASES. The duration of the disease is best determined by the duration of the fever. In the very mildest cases there may he no fever whatever, or simply a slight evening rise of temperature. As a rule, there is a moderate fever, say between lOl-S" and 103° P. (38-5° and 39-5° C), although higher temperatures even to 104° F. (40° C.) and more are not infrequent. In the beginning of every severe attack the fever rises abi-uptly. After a duration of several days, say four to seven, it may fall again in a manner appi-oaching a crisis. More frequently, especially when there exists diffuse, catarrhal trouble in the lungs, the fever ends by lysis. With com- parative frequency there are found to be noticeable deviations in the temperature curve; thus, for example, the high fever of the onset sinks on the second or third day, to be followed by an almost afebrile period of one or two days, whereupon a marked rise of temperature ensues. With this change in the temperature there are usually also corresponding variations in other symptoms. We see, then, tjiat the dm-ation of simple, uncomplicated influenza is in the mild cases about three or four days, in the severer cases about seven to ten days. To be sure, we should also consider in this connection that convalescence is often sur- prisingly slow, so that the after-pains (as it were) of the disease are felt for weeks. These consist, for instance, in a certain degree of debility, and in painfulness of the muscles. Sometimes also there are complete relapses, so that directly oi" a short time after the disease has ended the symptoms begin anew. The special form of the disease may change in this case, so that, for example, tlie relapse of an influenza with predominant constitutional symptoms assumes the pronounced catarrhal form. Again, during the same epidemic it is not very rare for a patient to suffer from two attacks of influenza separated by a considerable interval of time. Complications and Sequelae. — Wliile all the symptoms of influenza which we have thus far described arc the direct effects of the original pathogenic cause, the majority of the frequent complications are undoubtedly dependent ujjon the in- gress of secondary infection. The system when attacked by influenza is greatly exjjosed to these secondary influences, and almost all the dangerous and tedious cases of influenza become such only because of a mixed infection of this sort. This is particularly true of the lungs, in which secondary disease occui-s most fre- quently — sometimes even in the first days of illness, but also in other cases later. The conditions here are similar to those seen in measles and Avhooping-cough. The .simple, mild catarrh belongs to the original disease; the severe pulmonary affections are, however, invariably secondary complications occasioned l>y new pathogenic influences. These influences are not always the same. According to the investigations of Ribbert, Finkler, and others it is chiefly the pneumonia dip- lococcus and the streptococcus which are the true excitants of the secondary pneu- monia seen in influenza. These cases of pneumonia are either extensive catarrhal pneumonia especially afl'ectiug the lower lobes, or more rarely croupous pneu- monia with its characteristic sputum. The whole picture is then ovei-sbadowed by the pulmonary affection. The patient is ojipresscd for breath, has a severe cough, looks pale and cyanotic, and suffers from high fever. These symptoms ]5ersist for two or three weeks, and then gradually abate. It is in this way that influenza becomes dangerous for elderly and feeble or sickly persons. With noticeable frequency, pleurisy with effusion is conjoined with the influenza pneu inonia. The cxud.ation is generally serous, but exceptionally it is purulent. Complications in other organs are less frequent. We should mention chiefly purulent otitis media and keratitis and other .severe diseases of the eye. We have sevei'al times obseiwed cases of acute nephritis, but this has always pursued a mild course. Among cutaneous eruptions herpes labialis is a frequent phenomenon in all forms of influenza, even the milder. Other exanthems, such as urticaria and DYSENTERY. 77 roseola, are much less frequent. Many of the complications named may continue even after the fever and all other symptoms have ceased, so that they must be re- garded as sequelae. This is particularly trae of the diseases of tlie ear and eye and of persistent bronchitis, but only rarely of a pnei'.monia assuming' the chronic form. An important and for the patient a troublesome and painful sequel is furunculosis, especially if the separate boils are located in the axilla or near the anus. Very often neuralgic pains in the distribution of the trigeminus or in the course of the sciatic or other nerves will persist for a considerable time after the influenza has ceased. But these pains may sometimes be located in the muscles; thus, for example, the frequent, persistent, and troublesome pain in the eyes. Diagnosis, — The diagnosis of influenza is in general not diflicult if one has to deal with a well-marked case. The characteristic initial symptoms of fever, head- ache, and pain in tlie loins are to be considered first of all. Their onset is much more rapid than, for example, in typhoid fever. Later on the pain in the various muscles as well as the catarrhal symptoms are the most characteristic phenomena. The diagnosis is very uncertain in many mild rudimentary cases. Often it is merely the fact of the prevailing epidemic that justifies one in calling these influ- enza. Nevertheless, one should be very careful not to make a diagnosis too quickly, and it is indubitable that during the time of an epidemic many cases are wrongly called influenza. Prognosis. — For an individual who is healthy and vigorous, influenza is not a dangerous disease, even in its severer forms ; for elderly persons or invalids it may, however, be a serious afl'ection. Patients with heart disease or pulmonary disease, or those suffering from chronic nervous troubles, sometimes succumb to it; so that the general mortality at the time of a great epidemic of influenza is always con- siderably increased. The above-enumerated pulmonary complications are by far the most dangerous ; less often is a fatal termination caused by general or cardiac wealoiess. Treatment. — No speciflc remedy for the disease is known. Many physicians maintain that the exhibition of calomel at the beginning of the attack decidedly shortens its course, but confirmatory experience is wanting. In general we must, therefore, pursue a purely symptomatic method of treatment. For the initiatory fever, the headache, and the pain in the loins, antipyrine is sometimes a good remedy, and the same may be said also of quinine, phenacetine, and antifebrin. These drugs are also prescribed for the pei'sistent pains in the muscles which come on later. Soothing liniments and ointments may be employed, with friction, for the same purpose. The treatment of the jjulmonary complications is according to the established methods. Morphine is mainly used for the troublesome cough. Apomorphine, senega, and other expectorants may be employed, and, if indicated, external remedies such as an ice-bag or dry cupping. If the patient becomes very feeble, stimulants such as champagne and strophanthus are demanded. CHAPTER XII. DYSENTERY. .Etiology. — By " dysentery " is meant a disease of the colon, which appears sporadically, but more often in epidemics; it is excited by infection with an organized pathogenic poison, about which we have as yet no further knowl- edge; and the infection is probably at first a local one. The true home of dysentery is in warmer and tropical countries, where the disease is much more 78 ACUTE GENERAL INFECTIOUS DISEASES. violent and wide-spread than here. For example, the mortality among- the soldiers of the Anglo-Indian ai-my due to dysentery is said to be thirty per cent, of the entire number of deaths. In our climate most of the epidemics occur at the end of summer and in auturim. Endemic influences are certainly important. The condition of the soil in some places is evidently very favorable for the develop- ment and dissemination of dysenteric germs, and that of other places is equally unfavorable. There can be no other explanation of the immunity of some localities contrasting with the great prevalence of the disease in othei-s. How infection occurs we do not yet know. Dysenterj' does not seem to be directly contagious; but that it can be spread through the medium of the fajcal dejections of the sick — e. g., from privies, chamber-vessels, and bed-linen — is very probable. Many cases were formerly referi'ed to catching cold or to some error in diet; but we must, of course, regard these merely as predisposing influences. The objective pathological lesion of the colon, in all severe cases, consists in a pronounced croupous-diphtheritic inflammation. The remarks as to the general pathology of such inflammations made in the preceding chapter are equally ap- plicable to the analogous dysenteric inflammation. In this case, too, there is first a destruction of the epithelium and then the formation of a fibrinous exudation occupying its place, and penetrating down into the tissue of the mucous mem- brane itself. At the same time there is an intense purulent infiltration of the mucous and submucous tissue, accompanied by extensive ecchymoses. In the most virulent cases the macroscopic appearances are marked thickening of the whole wall of the intestine, congestion of the serous layer, and the convei-sion of the inner surface into a mottled, dark-red, irregularly roughened area of ulcera- tion. The disease may be confined to the rectum and the sigmoid flexure, but in severer ca.ses it involves the entire colon as far as the ileo-ctecal valve, or even extends to the lower portion of the ileum. Besides this severe form of diph- theritic or even gangrenous dysentery, there is a milder variety, termed catarrhal dysentery. In this the mucous membrane is found in a state of intense purulent inflammation, with ecchymoses. Even here little masses of croupous exudation, which can be torn off, have replaced the epithelium; but thcj- never form cou- tlnuous layers of great extent. There is no sharp boundary-line between the two forms, the milder catarrhal-croupous and the severer diphtheritic dysentery. Numerous transitional and combined varieties exist. We must remark, in conclusion, that precisely the same anatomical changes as are presented in true dysentery may i-esult from other causes. Important among these is persistent ftecal impaction in the rectum, which, by a purely me- chanical effect upon the epithelium, may excite a diphtheritic inflammation in the mucous raemljrane. And any severe constitutional disease whatsoever, such as typhoid fever, measles, small-pox, septicasmia, or phthisis, may be attended by a so-called '"secondary dysentery.'' This is most frequent in hospitals. Whether it has the same a-tiology as genuine dysentery is uncertain. Clinical History.— Throughout the entire illness the most prominent symptoms are intestinal. There may be first of all some slight irregularity of the bowels for a few days, and then appears a moderate diarrhoea. The stools are at first feculent, although thin, and number two to six daily. After a few days the dis- charges increase in frequency, and become extremely characteristic. The stools are very frequent, occurring ten to twenty, and even sixty or more, times, in twenty-four hours. In severe cases there may be a distressing and almost constant desire to evacuate the bowels. After every opei-ation, and to some extent during it, there is tenesmus attended by intense burning pain in the anus. The stools soon lose their usual feculent character in great part if not entirely. Tliey become scantj', so that not more than about half an ounce is evacuated each DYSENTERY. 79 time. For the most part they usually consist of a sero-mucous fluid, in vrhich are suspended numerous shreds and particles of varying size. These are blood- stained bits of mucus, little coagula of blood, and necrosed pieces of mucous mem- brane. One or another of these constituent parts may predominate, so that there may be slimy, purulent, or bloody stools, or all sorts of combinations of tliese varieties. We often find, besides, a few small masses of fasces, usually covered with mucus. We sometimes see numerous clumps of mucus, resembling- sago or frog's spawn ; they are probably mucous casts of the follicles. Under the micro- scope the greater part of the dysenteric discharge is seen to consist of pus-corpus- cles and blood. There are also cylinder epithelium and an enormous amount of detritus, and the bacteria of putrefaction. A purely dysenteric stool has no bad odor, except that in the worst cases of gangrenous dysentei-y the discharges become blackish and extremely offensive. The rectal tenesmus may be accompanied by a cramp-like pain during micturi- tion. There are often violent attacks of colic. The abdomen is usually rather tense, and tender on pressure along the line of the colon, but without tympanites. The anus may be red, inflamed, and excoriated. Gastric symptoms are on the whole infrequent, if we except the complete anorexia which e.Kists in all severe cases. Sometimes there is repeated vomiting. Occasionally hiccoughs prove dis- tressing. The tongue usually has a di-y, greasy coating. The symptoms just depicted last about a week or ten days. If the case is of much intensity, the general condition is also greatly affected. The patient seems much collapsed, and is very languid and feeble, with a small and rapid pulse. The skin becomes cool and rough, the voice weak and hoarse. There is pain in the muscles. The patient wastes away. The temperature has little that is char- acteristic or typical. In many cases there is no fever at all, and the temperature may even be subnormal. In most cases, however, there is an irregular fever, seldom exceeding 104° (40° C), and having remissions. In the woi-st cases the general weakness may increase more and more, and death occur ; but with us a favorable termination is much more frequent. The distress gradually diminishes, the stools assume more and more of a feculent char- acter, the patient becomes stronger, and after one and a half to thi-ee weeks con- valescence is established. It may be a long while, however, before a patient com- pletely recovers from a severe attack. A third possibility is the transition of the acute into a chronic dysentery. In this the symptoms of a chronic colitis, usually attendsd with cachexia, may persist for months and years. Mild, rudimentary forms of dysentery also occur, presenting less violent intes- tinal symptoms, and recovering at the end of a few days. In these cases, too, great sensitiveness of the intestine to disturbing influences freqiiently pereists for quite a long time after the illness. There may be exacerbations of the disease, and relapses. Complications of dysentery, localized in other organs, are rare, at least in epidemics here. Abscess of the liver is mentioned oftenest by physicians in warm climates, and probably is best explained as the result of metastasis by way of the portal system. Articular disturbances also occur, and inflammation in the serous membranes. A few cases of peritonitis due to perforation have been observed, and a combination of dysentery and a " general scorbutic diathesis " has been de- scribed. The diagnosis is rarely very difficult. It is based exclusively upon the intesti- nal symptoms and the character of the stools. It is only the cases of secondary dysentery which occur in the course of other severe diseases that can easily escape observation. The prognosis is mainly influenced by the character of the epidemic, which, as 80 ACUTE GENERAL INFECTIOUS DISEASES. we have said, is in our climate usually benign. There may he danger, particu- larly to elderly people, from hodily weakness and collapse. Treatment. — Prophylaxis demands that the isolation of the patient and the dis- infeclioii of the stools be as comj)lete as possible. The healthy must be very care- ful during an epidemic not to catch cold, and to avoid erroi'S in diet, for experi- ence shows that an opposite coui'se pi'edisposes to the disease. The patient must be kept warm, and must not leave his bed, even if the attack be mild. The diet must be rigorous. If the strength is fair, thin porridge, milk, and broths suffice for some days. To a feebler person we should give somewhat sti'onger nourishment from the start, e. g., eggs, peptonized meat, and wine. Most patients bear liquids that are lukewarm better than those which are cold. As to drugs, the habit of almost all experienced physicians is to give at first a mild laxative. Although opium does not usually control the cUarrhcjca and tenes- mus at all, it is the rule for decided improvement to follow the exhibition of the laxative. During the first days, or, if need be, later, we give two to four table- spoonfuls of castor-oil daily. If this medicine is very disagreeable to the patient, we can replace it by a strong infusion of rhubarb (10-100). In southern countries large doses of calomel (gr. x to xv, grm. 0"5-l) are customary, and are highly praised by the physicians there. Further on in the disease we may content our- selves with giving mistura amygdala ; or we may administei- bismuth in the follow- ing mixture: Bismuthi subnit., parts 5; mucilaginis acacise, syrupi simpl., aa 15; aqvise destil., 120 — to be shaken before taking. But if the disease should get woi-se again, we should always try a laxative. Emetics at the beginning of the disease are often employed in the tropics, but seldom with us. Ipecacuanha {radix antklysentericct), given in large doses of fif- teen to thirty grains (1-2 gi'm.), is even regai-ded by many as a specific. Numer- ous attempts have been made at local treatment by cnemata. Yet no brilliant results can be claimed for any of these methods or medicines. A decidedly pallia- tive effect can be obtained from the injection of thin starch to which twenty or thirty drops of laudanum have been added. Suppositories of cocoa butter con- taining extract of opium often mitigate the tenesmus. Other injections, are recom- mended, each to measure | ij to iijss. (grm. 60-100), and to contain either argenti nitrat., gr. j to vj (grm. 0"0j-0'30), or plumbi acetat., gr. ij to viij (grm. 0"l-0'5), or potassii clilorat., gr. xv to xx (grm. 1-1'5). Many other solutions are used. The success of this treatment is, however, dubious. In all cases the margins of the anus must be protected from inflammation l)y frequentlj' washing and anointing the skin. The treatment of wealaiess and collapse is hy the usual stimulants — wine, ether, camphor, and the like. In chronic dysentery the main point is to persevere in a strict control of the diet. We may exhibit astringents, such as tannin and columbo. Subuitrate of bismuth is also given, and nitrate of silver and acetate of lead. And in these chi'onic cases a long-continued and thoi-ough use of rectal irrigation with fluids containing some mild astringent or disinfectant may have a good effect. [Sporadic dysentery is a self-limited disease, and, as has been shown by Flint, runs its course within ten days without mcdicatioti. Treatment, howevei-, adds to the comfort of the patient and shortens the course. It is not customary with us to use daily laxatives. If there is any doubt as to whether the intestines have been emptied, a saline should be given, the action of which should be followed by opium in sufficient doses to allay pain and tenesmus. Subsequent action of the bowels is best obtained by simple large enemata. In weak persons castor-oil is to be preferred to salines. In epidemic dysentei-y active treatment is much more important. Laxatives CHOLERA. 81 are contra- indicated by sero-sanguinolent dejections or by asthenia, but enemata can be freely used. Stimulation is often required ; nutrition must be carefully looked after, such articles being chosen as are digested and absorbed by the upper portions of the intestinal tract, leaving as little residue as possible to pass on to the inflamed colon. Opium is often demanded and tolerated in lai-ge doses, and astringents, such as the acetate of lead, gallic acid, and the pernitrate of iron, are of service. In acute dysentery the patient should be instructed not to yield to the desire to go to stool if he can help it, and tenesmus can often be much diminished by simple irrigation of the lower bowel with water, which may be warm or cold, whichever the patient finds more agreeable. Chronic dysentery is one of the most difficult maladies with which we have to deal. In its treatment a sea voyage, or removal for at least some months to a climate other than that in which the disease originated, is of far more value than drugs. Amcebic Dysentery. The amceba coli, first found by Losch in the stools of a dysenteric patient, has received very careful study at the Johns Hopkins Hospital, and forms the subject of a most exhaustive and valuable monograph by Councilman and Lafleur. The living organism is readily seen, and recognized especially by its active amoeboid movements on the warm stage of the microscope. If the fasces contain small gelatinous masses, these will be found to provide the most fruitful field for search. The numbers of the organisms vary widely in different cases, and even in the same case, from day to day. They are said to be present in this form of dysentery alone, and have been found in secondary abscesses of the liver and the lung, alike after death and during life. They should be sought for in all obstinate cases with dysenteric symptoms. The prognosis is uncertain, and the cases are apt to drag along with exacerba- tions and remissions of the symptoms. But recovery does take place. There is notable danger of the formation of secondary abscesses, in which event re- covery is hardly to be hoped for. The only treatment which seems to have been of much service — beyond a general hygienic and supportive regimen — consists in the use of copious injections into the intestinal canal of solutions of quinine, in the strength of one, to one thousand or even five thousand. Losch found that contact with a solution of the latter strength for one minute suffices to kill the CHAPTER Xin. CHOLERA. (Asiatic Cholera.) Historical Remarks. — The home of genuine Asiatic cholei-a is India. The first epidemic with which we are accurately acquainted, and which was very wide- spread, occurred in 1817. The disease was probably endemic there at an earlier period. In the next few years the cholera spread in all directions, and reached Astrakhan by way of Persia. Between 1830 and 1832 the disease made its fb-st great epidemic progress over Europe. Invading all European Russia, it reached Germany in 1831, and France and England in 1832. Then came many smaller epidemics up to 1838, when there was a complete cessation till 1846, in which year the disease, again starting from Asia, overspread Europe. There have since then 82 ACUTE GENERAI. INFECTIOUS DISEASES. been epidemics in many places, but we can not here enter into the particulars of them. The last time that cholera occurred to any extent in Germany was in 180(5, during the German-Austrian war. No one has forgotten the somewhat \Molent epidemic which prevailed a few years ago (1883 and 1881) in France and Italy. .ffitiology. — Some time ago it had become evident that the real cause of cholera consists in the infection of the system by a specific micro-organism. Koch was, however, the first to succeed in the search for the poisonous agent. He was in charge of the scientific expedition sent out by the German Government in 1883 to Egypt and India for the purpose of investigating the disease. Koch found in the intestines of all the victims of cholera who.se bodies he examined a certain kind of micro-organism which he named the comma bacillus. It is shorter than the bacillus of tuberculosis, but somewhat thicker, and it is usually bent in the shape of a comma, or even like a semicircle (see Fig. 9). In the culture-preparations, the special peculiarities of which we can not give in detail, the conmia bacilli gi'ow into long spiral tlu-eads, resembling the spirilli of recurrent fever. Exam- ined in a liquid, the individual bacilli are seen to make vigorous movements. They flourish best at a temperature between 86° and 10i° (30° and 40° C). Below 61" (16° C.) they cease to grow, but they are not killed even by a greater degree of cold. The free access of oxygen is absolutely ijidispensable to their growth. They nmltiply very rapidly in liquids — e. g., broth or milk— and they may, under favorable circumstances, retain their vitality for many weeks, while they can be readily destroyed by desiccation. In this again they resemble the genuine spirilli, which can maintain then" existence only in fluids. An endogenous formation of spores, as we shall see below to be the case with the anthrax bacilli, does not take place, but Hueppe has established by actual observation that frequently two small spherical bodies appear on some indeterminate spot of the above-mentioned spiral threads, by which the continuity of the thread is interrupted. This process goes on until finally the thread is replaced by a considerable number of very minute round cells, which are apparently united to one another by a kind of jelly (forma- tion of zoogloea). It is certain that the round cells do not subdivide. The way in which they are formed corresponds with quite similar processes in other spiro- chsetas. They are called " arthrospores," and perhaps represent a permanent form of the comma bacilli; for they resist desiccation and other injurious influences much better than do the comma bacilli themselves. By a process of growth the sphei-ical bodies may, under favorable circumstances, give rise in their turn to new comma bacilli. These discovei-ies of Koch have since been confirmed by all competent investi- gatoi-s, while the various alleged refutations of Koch's results have proved errone- ous. It has been shown that in every case of genuine Asiatic cholera the comma bacilli are present in the intestine, and that they are never found undei- any other circumstances. Even the last postulate which was needed to show their patho- genic significance has been fulfilled. Rietsch and Nicati, followed by Koch him- self, have succeeded in producing cholera in a guinea-pig by introducing into its duodenum pure comma bacilli. Investigation as to the origin of cholera must, therefore, now meet this culmi- nating question: Under what circumstances and through what chr.unel do the comma bacilli penetrate into the human system, and in what manner do they there excite the characteristic processes of the disease? There can be no doubt that among us Eurojieans, and probably everywhere except in India, tbe cholera is invariably imported. It is equally certain that tlie dejections of cholera patients, which are rich in comma bacilli, are the chief if not the only agent by which the disease is spread. The bacilli w-hich escape into the outer world with the stools ■ CHOLERA. 83 find abundant means to prolong their existence. They continue their growth upon moistened bed-clothes, or in water which contains a sufficient amount of organic substances, or in food, such as fruit or milk, or in moiot earth ; and the ways by which they can in turn enter the system of a healthy human being are infinite in number. It is easy to under- stand why certain i^ersons — e. g., laundress- , x es and nurses — are more liable to infection / / 1 / i than others; and it is equally intelligible 1 k'iI'''''^" />i\Jy I I that the spread of the disease should often ' -^/''''■f''?,'[j ,'-'»'• _ bear a relation to certain outward circum- ,1 T'/* ^ .//Xi i-f stances. The fact has long been a familar j^ ' \f;>f'''.i\ '^~/ one, that the cholera almost always pro- I j "Jh'',''' ''/, ' '£''^' I gresses along the world's most frequented j'/'l'L'-''' ~ /^ "-rv > i highways, and that it never travels faster / /'^ '^>'-J5'" ij^ S'H '''.,, \ than the means of human intercommunica- ^, i' ',' '^Jij ',i^>, yj y '\ 'J ^/j, i< V/ tion render possible. This is important, , i TJ''^^'m' u' -<' ''-^ '? / ; !■ because it shows plainly that the germs of \\\\' "/ i!'\ ■ i" ' J'''7 ( ' ' \ the disease are not disseminated by currents 'J''-' i' o '', .f ,\ '^ of air. It is easy to understand that the \l ,''\ il , u, ^,) iji^yi distribution of the disease should sometimes ) ' / (/ A'/// correspond with that of water destined for '/ / ' personal use. Apparently in every case the ^■«ehVe7a™d™j?e«on\v^rc^'S^dtT;i"fo';-Tw^ disease-producing poison enters the intesti- arelt'a '' eoo dfimeters.'''' '^"^'"'P'''' '""''"' nal canal, for the comma bacilli are found exclusively in the intestine, never in the other internal viscera; and this is true not only in the early but also in the later stages of the disease. We must therefore suppose that the bacilli are swallowed, and, if not destroyed by the gastric juice, develop their pathogenic functions in the intestine. In apparent agreement with this is the frequently observed fact that gastric catarrh, however acquired, existing at the time of an epidemic, always predisposes to the disease. The views thus far expressed are opposed by Pettenkofer. He ascribes to the condition of the soil, varying with time and place, the chief role in the spread of cholera. He doubts whether the poison as contained in the stools is as yet effi- cient. It must, he thinks, undergo further development in an appropriate soil before it can acquire fresh pathogenic potency. His main argument is drawn from the fact that certain places, particularly those on rocky soil, enjoy immu- nity; the rarity of attacks iipon shipboard is analogous. He points out that in cholera as well as in typhoid (g. v.) there is an evident harmony between the frequency of the disease and the varying stand of the water which underlies the surface of the ground. Further investigations, which will now for the first time have a firm foundation, afforded by the discovery of the comma bacillus, must decide how much influence the condition of the soil does exert upon the dissemi- nation of the pathogenic poison. As it is, we feel certain that to give exclusive prominence to the condition of the soil, and to deny the possibility of infection in any other way, is to put a violent interpretation upon the observed facts ; while the correctness of the above-stated views of Koch is becoming more and more probable. With regard to the constant presence of other micro-organisms than the comma bacilli in the intestine and the internal viscera of the victims of cholera, as claimed by Emmerich and others, we must regard them as associated appear- ances which have nothing to do with the true choleraic process. Most cholera epidemics happen in the months of summer. Liability to the dis- ease is very wide-spread, although some remarkable exceptions are seen. Sex is unimportant. Age has more influence. The disease occurs in sucklings, but. 81 ACUTE GENERAL INFECTIOUS DISEASES. as a rule, is more rai-e among children than among adults. Elderly people are very apt to take the disease, while of typhoid fever the opposite is true. Most authors lay great stress upon predisposing causes. Among these, taking cold is not so important as are errors in diet and mild attacks of gastro-iutestinal catarrh, which are shown by numerous obsei-vations to predispose strongly to the disease {vide supra). The stage of incubation seldom lasts over one to three days. Clinical History. — As is the case in most acute infectious diseases, the intensity of the illness varies between the extremes of mildness and severity, so that usually a correct interpretation of the mildest cases is rendered possible only by the fact that an epidemic exists. These insignificant cases are called simple choleraic diarrhoea. The symptoms are those of a violent acute intestinal catarrh; the dejections are watery, rather large, painless, and number about three to eight in twenty-four hours. Thei-e is considerable malaise, complete anorexia, and thii-st, and there may already be indications of severer choleraic symptoms — vomiting, slight pains in the calves of the legs, and diminished secretion of urine. Many cases recover after a few days or a week, but in others the first mild diarrhoea is succeeded, at the end of about one to three days, or rai-ely later still, by a severe attack of cholera. In such cases we speak of a " premonitory diarrhoea of cholera." The mild form is succeeded m a gradual transition by the cases designated as "cholerine." Cholerine exhibits the symptoms of a violent, rather sudden cholera morbus. It often begins at night. To the diarrhcea, which now and then displays even at this time the characteristics of pronounced cholera, vomiting is soon added. The accompanying constitutional symptoms are rather severe. There is great languor and depression. The voice grows weak, the extremities are cool, the pulse is small and accelerated, painful cramps occur in the calves of the legs, the urine grows scanty and perhaps albuminous. The whole attack lasts about a week or two, till recovery is complete. The course of the disease is not infre- quently vai'ied by repeated improvements and relapses. From these cases of medium severity there is again a continuous line of transi- tion to the pronounced severe form of cholera proper. Statistics as to the fre- quency of the separate forms can not be given, since many of the mUder cases escape observation. The true attack of cholera may begin suddenly with the severest symptoms. As a rule, however, it is preceded, as already stated, by a fii-st stage of brief pre- monitory diarrhoea. This, after one to three days, is replaced with equal sudden- ness by the severe symptoms of the second or " algid stage," or " cholera asphyxia." Its first symptoms are the abrupt appearance of great bodily weakness, chilliness, and vertigo. The characteristic gastro-intestinal symptoms soon declare them- selves. The diarrhoea grows very violent. At short intervals there ai-e copious painless dejections, which at first retain somewhat of a feculent character, but very soon present a characteristic i-esemblance to " rice-water" or '"whey." A single stool will measure a little less than half a pint (grm. 200 1. The stools have no color and almost no odor. They are watery, and usually deposit a finely granular, grayish- white sediment upon standing. Their reaction is neutral or alkaline. Only one or two per cent, is solid matter, with a little albumen and a relatively large amount of sodic chloride. In many severe cases the dejections contain more or less blood. The microscope reveals epithelium, triple phosphate, and numerous micro-organ- isms. Of these last a part are the comma bacilli, and a part are bacteria of putrefac- tion, etc. If the comma bacilli be demonstrated, of coui-se the diagnosis is absolute. To accomplish this we take a coagulum of mucus from the stool, and, spreading it CHOLEKA. 85 upon a cover-glass in as thin a layer as possible, carefully warm the glass by pass- ing it repeatedly through a flame, in order to dry the mucus and fix it in its place. The preparation is then stained with an aqueous solution of methyl blue. If the bacilli be very abundant, the microscopic examination suffices for their demon- stration, although complete certainty about their identity depends upon their behavior in pure culture-preparations. These must therefore be instituted in all doubtful cases; but it would lead us too far if we entered upon the particulai-s relating to such cultures. These excessive evacuations are but very rarely ahsent or nearly absent. They are more apt to fail if death occurs at the end of a few hours — cholera sicca. [In cholera sicca the intestines after death contain the characteristic rice-water material which, perhaps owing to paralysis of the muscular coat, was not expelled during life.] The appearance of the diarrhoea is soon followed by frequent though rarely distressing vomiting. The vomitus consists in part of ingested liquids and in part of an actual transudation through the mucous membrane of the stomach and intes- tine. Hiccoughs may accompany and follow the emesis. In addition to these prominent digestive symptoms of vomiting and profuse diarrhoea there are complete anorexia and excessive thirst. The tongue has a thick, dry coat. The abdomen is usually flat and soft, or it may he concave and hard. Sometimes we may feel fluctuation in the intestines, due to their being filled with fluid. There is not much real abdominal pain ; what there is, is described as a " feeling of heat and pressure " around the umhilicus. At the same time very severe symptoms develop in other organs. The cii-cu- latory system is chiefly affected. The action of the heart may be stimulated at the beginning of the attack. The patient complains of jsalpitation and great precordial anxiety. After a brief time, however, cardiac weakness appears, and continually increases. The action of the heart becomes very weak, and the heart-sounds feebler and feebler. The pulse at the wrist grows very small, and is usually somewhat accelerated. In a severe case the pulse vanishes completely after a few hours. This collapse of circulation makes itself quickly evident in the appearance of the patient. The face and extremities grow cool, and then ice-cold; the complex- ion becomes partly livid and partly a bluish gray ; the lips are almost black. The surface temperature may fall below 95° (35° C), while in the rectum febrile tem- peratures may often be observed, reaching 102° (39° C.) and higher. The eye and cheek grow very hollow, the skin becomes wrinkled, and loses all its elasticity. The voice grows hoarse and feeble (voice of cholera). Respiration is laborious and superficial. The mind may remain unclouded to the end, but usually there is great apathy, and all acuteness of perception is impaired. But few patients are restless and excited. Reflex action is much impaired. One characteristic symptom is the cramps in the muscles. These are usually very painful, and consist in tonic contractions of the muscles, particularly those of the calf of the leg, hut also those of the toes, thighs, arms, and hands. The cramps occur spontaneously or upon the least provocation, last a few minutes, and recur at short intervals. The precise reason of their occurrence is not yet known. It may be the effect of poison (vide infra). They can be observed in other severe acute diseases, although most marked in cholera. They sometimes occur in cholera morbus. In a well-developed attack of cholera there is almost invariably oliguria or anuria. The urine, if any be secreted, is concentrated, with abundant sediment, and very often contains albumen. In many cases not one drop of urine reaches the bladder for days, and this condition persists till death or recovery. 86 ACUTE GENERAL INFECTIOUS DISEASES. The symptoms thus far depicted, if taken as a whole, represent the algid stage, •which seldom lasts more than one or two days. In many cases death occurs during this period. It is ushered in by the tokens of exti'eme general prostration, and may take place after a few hours, or more frequently in the second half of the first day. But in other cases the " stage of reaction " succeeds. This may be a true compensatory period, leading directly to convalescence. The evacuations become less frequent and more feculent, and the vomiting ceases. Tlie pulse becomes stronger, the cyanosLs and coolness of the extremities diminish, and an abundant perspiration is not infrequent. After a few days urine is again excreted, which is almost invariably quite albuminous, and usually contains casts and red blood-globules. If convalescence be uninterrupted, however, the urine verj' soon becomes perfectly normal, and after a week or two the patient is to be regarded as completely recovered. Departures from this favorable course of the stage of reaction are frequent. Recovery may be interrupted by repeated relapses into the previous condition, and sometimes with a fatal result. Or, instead of convalescence, there is developed a severe third stage, usually with fever. This stage ordinarily bears tlie generic name of cholera typhoid, although it is subject to manifold variations in its clin- ical symptoms as well as its exciting causes. Cholera t^^^hoid may present an actually typhoidal general condition with severe fever. There is a considerable elevation of temperature, headache, and dullness. The pulse is full and rapid, the face flu.slied. The skin, particularly that of the extremities, sometimes presents the so-called cholei-aic ei'uption, in the form of an erythema, roseola, urticaria, or the like. This variety of cholera typhoid ends after a few days in recovery, or else passes into one of the follo^ving conditions. A second form of cholera typhoid is distinguished by the development of the most diverse local inflammations. Thus, there may be a severe dysenteric or diph- theritic inflammation of the small and large intestine, attended by oflFensive puru- lent and bloody stools. Pneumonia is also possible, as well as purulent bronchitis, diphtheritic inflammation of the larynx, pharynx, bladder, and female genitals, parotitis, and sometimes erysipelas and pyajmia. And when we consider that, besides all these conditions, the usual intestinal symptoms, or those of choleraic nephritis, may exist also, it is evident how varied the clinical picture may be. The development of these local affections frequently lays the foundation for numerous sequelsB. Choleraic nephritis gives rise to the third or ura>mic variety of cholera typhoid. The secretion of urine is almost suspended. The little that is still passed contains numerous casts, albumen, and frequently renal epithelium and white and red blood-globules. Somewhere toward the end of the first week, or possibly earlier, there are grave nervous symptoms, to be regarded as uremic: first there is head- ache and vomiting, then sopor and coma, or delirium and convulsions. Most of these cases are fatal. Pathology. — We are now acquainted with the manifold symptoms and varieties of the disease. If we seek for the pathological changes which control the ])rocess, and endeavor to find some correspondence between them and the symptoms, we shall be disajipointed. At least, in its early stages, cholera is merely a severe local disease of the intestine. We find the serous layei- of the coils of the small intes- tine rose-red from congestion. The mucous membrane is in a state of catarrhal inflammation: it is swollen, reddened, and at first covered with a layer of tough, transparent mucus; but very soon an abundant transudation flows info the canal, so that the intestinal coils are filled with a large amount of clear fluid, looking like " rice-water " or " gruel," and so devoid of bile as to indicate the suspension of CHOLERA. 87 its secretion. The signs of inflammation of the mucous membrane now grow more pronounced. The solitary follicles and Peyer's patches become swollen, wilh edges of a vivid red, and frequently there are many small ecchymoses in the mucous membrane. The extensive desquamation of the epithelial lining of the intestine has also been regarded as important, because it was regarded as in part the cause of the copious transudation. Still it may be questioned whether the desquamation is not, at least to some extent, a post-mortem change. In yet later stages of the disease the intestinal trouble very frequently assumes a croupous- diphtheritic character. The surface is necrosed and ulcerated in many places, and the contents of the intestine are no longer colorless, but sanious and bloody, with a foul odor. Otherwise most of the post-mortem lesions coi-respond to what was obvious at the bedside. The muscles exhibit an early and pei-sistent rigor mortis, and fre- quently contract in such a way as to throw the corpse into some unusual posture. All the internal organs are remarkably dry, pale, and anaemic. The left ventricle is contracted. The blood lies mostly in the large veins, the right side of the heart, and the cerebral sinuses. It is thickened, is but little clotted, and is said to resemble the juice of bilberries or huckleberries. The spleen is not enlarged— an exception to the rule in infectious diseases. The kidneys present marked passive congestion, most pronounced in the cortex. The microscope reveals a greater or less degree of parenchymatous neplu-itis, with great destruction of the epithelium. If death takes place at a rather advanced stage of the disease, the tissues have lost their characteristic di-yness, and the most diverse local lesions, including nephri- tis, may be found to have occasioned death. If we search for the connection between the pathological changes just de- scribed and the cause of the disease, or again between these lesions and the clini- cal symptoms, the first point to guide us is that the comma bacilli are found only in the lumen of the intestine, and never in the blood or in other parts of the body. The intestinal sj'mptoms are satisfactorily explained by this abnor- mal state of the intestine, but for all the other grave symptoms we have to seek some special cause. The desiccation which the body undergoes as a result of the excessive liquid dejections can not fail to affect the tissues, but can not fully explain the symptoms, for at least the circulatory disturbances and the cardiac failure may develop before large evacuations have occurred. It has also been settled beyond question by means of the newer investigations that precisely the worst symptoms of cholera, namely, the muscular cramps, the subnormal tem- perature, and the changes in the blood, are occasioned by the chemical results of tissue metamorphosis in the comma bacilli, that is, by the so-called toxines. Many of these have been already isolated chemically by Brieger. In this connec- tion the fact discovered by Hueppe is of the greatest interest, that the lack of oxygen which the bacilli in the intestinal canal must experience favors the abundant production of toxines. As to the complications which occur in the later stages of the disease and which are embraced under the genei'ic name of cholera typhoid, we regard them as mainly secondary. The choleraic process itself does not cause them, but is merely the occasion for their appearance. The examination of the intestine in such cases shows that numerous other varieties of bacteria follow closely upon the comma bacillus, gaining entrance to the system by treading in its footsteps. The diagnosis of a pronounced case of cholera has no difficulties at the time of an epidemic. We must always be somewhat cautious about sporadic cases, for violent intestinal disturbance, simulating perfectly the milder forms of cholera, may be excited by other causes. In this connection we should mention the cholera morbus common among us; and poisoning, particularly acute arsenical 88 ACUTE GENEEAL INFECTIOUS DISEASES. poisoning, may give rise to symptoms wonderfully like cholera. But now tliat Koch's discovery has been made, the diagnosis of all such doubtful cases becomes perfectly certain if we can demonstrate the presence of comma bacilli in the stools {vide siqjra). We have no doubt that this demonstration will also lead us to a decisive conclusion as to the aetiologieal importance of mild cholei-aic attacks. The prognosis should always be guarded at the beginning, even if the symptoms be mild, for, as already mentioned, a simple diarrhoea may prove to be '' premon- itory " of a severe attack of cholera. During the real attack the prognosis grows graver in proportion as the case presents the characteristics of asphyxia and cyanosis. The mortality in many epidemics is frightful. All the inhabitants of a house or street may in a brief period be swept away. Minute statistics are diffi- cult to give. If we count the typical cases alone, the mortality is not infrequently fifty to seventy per cent. In about two thirds of the fatal cases death occui-s during the first days of the stage of asphyxia, and in about one third during the second period, known as '" cholera typhoid." The influence of the diet and the hj-gieuic surroundings of the patient before his iUness is important. A greater proportion of children and old people perish than of the middle-aged. Treatment. — The measures to be taken to prevent the spread of the disease, when it has once started in a place, we can not here discuss. We can merely say that the greatest care should be taken to have the ingesta pin-e, jjarticulai-ly the milk and water, that the further extension of the disease may be hindered simply by isolating the localities attacked as completely as possible, or at least regulating intercourse with them veiy strictly. We must tiy to prevent the communication of the disease by isolating individuals attacked, and by disinfecting the dejections with five-per-cent. carbolic solution, and likewise disinfecting everjihing that may have been contaminated by the excreta, such as linen and bed-clothes, for which dry heat is the agent. We must content oui-selves with a brief mention of these facts. It is very important to disinfect the stools as promptly as possible^ since Wood has discovered the remarkable fact that the cholera bacilli in the intestine, because of tlie lack of oxygen there, become much more sensitive to ex- ternal influences although they produce more toxine, as stated above. Individual prophylaxis is of the greatest importance. It has been proved again and again that a mild intestinal catarrh will predispose to cholera, and will aggravate the attack if cholera does occur; so that the slightest gastric or intestinal distm-bance at the time of an epidemic of cholera demands the greatest attention both as to diet and medicine. We may well quote from the last proclamation of the Prus- sian Department of Public Improvement (Cultusministerium), that, "by exercising and promoting cleanliness and moderation, each person will not only best pro- tect himself, but also most efficiently support the efforts of the authorities in behalf of the common weal." [The \'ital importance of the serious treatment of a beginning dian-hoea during a cholera epidemic can not be too strongly insisted on. Rest, simple diet, and a little medication will, in the vast majority of instances, entirely prevent serious consequences. The apparently trifling character of the symptoms is apt to lead people into a false security. Those who can leave an infected district should do so without delay. With reference to the prevention of an epidemic, a pure water supply and strict cleanliness in its broad sense possess far more virtue than cordons of troops or measures of quarantine. It is more pi-acticable to destroy the soil than to keep out the seed in these days of constant and rapid international communication. The systematic disinfection of all cholera discharges or articles soiled by theni should be a matter of coui-se.] CHOLEEA. 89 The drug chiefly used at the beginning of cholera is opium, which forms the chief constituent of the various ''cholera drops." The best form is the tincture, in doses of ten to twenty drops, or gr. J to j (003-005 grm.) of powdered opium, repeated every two or three hours. A more complicated formula is: Tr. opii, 1 grm.; vin. ipecac, 3; tr. valerian, asth. [P. G. : valer., part 1; sps. EetherLs, 5], 10: ol. menth. pip., gtt. V. M. S. : Twenty to thirty drops. Or we may give tinctui-a opii benzoica [an elixir of which two hundred parts contain one part of opium, four of benzoic acid, and two parts each of camphor and oil of anise]. The opium treatment approved itself in the last epidemic, although a few physicians regai-d it as irrational, and prefer to give at the beginning of the disease one or two good-sized doses of calomel (gr. v to viij, grm. 03 to Ooj. Cantani and other Italian physicians praise highly enemata of a solution of tannin (warm water, previously boiled, two quarts (2,000 gi'ammes); tannin, gr. xlv-.xc (3'0-6'0); acacise, | ij (500); tinct. opii, gtt. 30-50) or some disinfectant. Hueppe advises large doses of salol internally. When the attack is fully developed we usually continue the use of opium. The patient is wrapped up in warm blankets and subjected to friction ; or warm oil may be rubbed into the skin. Hot tea may be given, or strong coifee, or broth, or mulled wine. Hot baths, to which mustard may be added, have proved bene- ficial in repeated instances. Vomiting is to be controlled by morphiiie or ice. The painful cramps in the calf of the leg require subcutaneous injections of morphine. The feebler the action of the heart becomes, the more energetic must be the stimulants employed. We may give champagne, or inject camphor or ether. The attempt has been made again and again to make good the loss of fluid by injecting a solution of common salt beneath the skin or into the veins. Samuel recommends for this purpose a solution containing six parts of sodic chloride and one part of sodic carbonate in one thousand parts of water, at a temperature of about 100° (38° C). Finally, injections have been made into the peritoneal cavity of a 0'5 per cent, solution of sodic cliloride, or in other cases of a 0'3 per cent, solution of sodic carbonate, and, it is claimed, with benefit. Great caution must be exercised about the diet, not merely during the attack itself, but for a considerable time afterward. At first we can allow only thin por- ridge, niilk broths, and possibly a soda biscuit. It is advisable to administer dQute hydrochloric acid with the food. The treatment of cholera typhoid varies greatly, of course, according to the kind of attack. The separate affections should receive their customaiy treatment. [In the first stage, absolute rest, opium, and lumiJS of ice by the mouth ad libi- tum are the chief measures on which reliance is to be placed. It should be remem- bered that the entire function of the intestinal tract is revereed ; thus, instead of an absorbing, it has become an excreting surface. In the stage of collapse the nervous system is more or less paralyzed, the blood is damaged by the loss of its watery constituents, and the circulation of that fluid is greatly impeded. The subcutaneous or gastric absorption of drugs is conse- quently delayed or suspended. The utility of any active internal treatment dur- ing this stage is very questionable. Certainly narcotism by opium is highly un- desirable. Mild external stimulation and the tentative administration of ice and small quantities of champagne or food are, at all events, not likely to do harm. Nature sometimes reasserts herself when the conditions are seemingly desperate, and the third stage, or that of reaction, comes on. In this stage, careful nursing and a sensible .symptomatic but in no way meddlesome treatment are most like- ly to be followed by good results.] 90 ACUTE GENERAL INFECTIOUS DISEASES. CHAPTER XIV. MALARIAL DISEASES. {IntiriinttLiit F.r.r. JA r. r .in,l A,jii,:. ,Sir(iM/> Ferei:) iEtiology and Pathological Anatomy.— Mai ai-ial poisoning is the best example of a purely " miasmatic " affection. The poison which produces the disease is without doubt localized in certain places, in which every human being is liable to become its victim. But if an infected person comes to a place free from malaria and not naturally favorable to its development, there is no danger that he will cause the disease in others. The disease is never caught through contact with the patient. It is not at all contagious ; the malarial poison, after it has once penc- trated into the body, has practically no opportunity to escape again in an eflicieut form from the diseased system into the outer world. But the blood of a patient injected into a healthy person may transfer the disease (Gerhardt and others). If we except the polar zones, there are few regions where malaria is not endem- ic in certain parts, at least from time to time, if not constantly. There is, how- ever, great variation in the virulence as well as in the number of cases. While the common forms of intermittent fever are very frequent in Germany, in numerous places, yet the grave forms of the disease are very rare. Other lands are notorious for the sevei-e malarial diseases, e. g., Hungary, the lands lying on the lower Danube, the Roman Campagna, the Pontine marshes, Sicily, and numerous dis- tricts in other parts of the world, chiefly tropical. Numerous observations have only served to confirm the statement that the soU is the true home and cradle of the malarial poison, and that the virus, escaping thence into the lower strata of the atmosphere, may be taken into the system, probably during inspiration. Pei-- manent dampness of the soil is essential to the development of the malarial poison. This explains why marshy districts are so often malarial. The ground must not be covered by a great amount of water, but must during the dry season lie ex- posed to the atmospheric air. The access of air to the moist soil seems to be a second essential condition for the development of the malarial germs. A third influential factor is the temperature of the air, as proven by the great prevalence of the disease in southern countries and in the suunner season. With regard to the nature of the malarial poison, the work of late, and in especial of Italian, investigators (Marchiafava and Celli, Golgi, and others), has led to interesting conclusions. According to these authorities, the generators of malarial disease, the malarial "plasmodia," belong to the lowest cla.ss of animal life, the protozoa, and to that subdivision known as sporozoa. The plasmodium enters the blood and penetrates the red blood-corpuscles, where it has a lively amoeboid motion. It evidently lives upon the tissue of the red corpuscles. The hfemoglobin of the latter is thus changed into melanin, a substance which ap- parently contains no iron, and the black granules of which are usually seen in the body of the plasmodium. After the red globule occupied by the plasmodium is completely desti-oyed, the micro-organism becomes free in the blood-current. Particles of pigment collect in its center, while on its periphery new generations are formed by splitting and subdivision. These new bodies appear to be mainly present in the spleen, liver, and marrow during the afebrile interval; while at the time of the paroxysms of fever they enter the blood once more and penetrate into the red globules. It is a very interesting fact that the different forms of in- termittent fever, and in especial the tei-tian and quartan varieties, pi'obably owe their development to different kinds of plasmodia, in which the developmental phases occupy different lengths of time. We can therefore by means of inocula- tion transfer from one human being to another only that variety of intermittent MALARIAL DISEASES. 91 which the first patient exhibits, whether tertian or quartan. The quotidian type is probably due to the development of two cases of tertain fever in the same in- dividual, side by side; whereby each separate tertian owes its development to a special generation of the Plasmodium. It is Golgi's view that the severe tertian forms of malaria are caused by a special variety of Plasmodium, which is distin- guished by the appearance of crescentic forms of development. Although no one has yet been successful in establishing this view of the Plasmodia by means of pure cultures and inoculation of the same, yet the relation of the Plasmodium to malaria seems evident from the fact that in every patient with malaria the Plasmodia can be easily demonstrated in the blood (even without any staining), while these same forms are never detected in the blood except in malaria. The way in which the plasmodia enter the human body is not yet known. It may be by inhalation or by the stings of insects. The investigations with regard to the plasmodium of malaria have also ex- plained the long-recognized fact that in chronic malaria large amounts of pigment collect in the internal viscera. These deposits are most abundant in the spleen, which in the chronic varieties of the disease develops into a firm, hard tumor; but they are also found in the bone-marrow, liver, bi-ain, and kidneys, leading finally in the liver and the kidneys, in frequent instances, to processes of chronic degen- eration and inflammation. It is especially noteworthy that in those patients who present the most marked cerebral disturbances (pernicious comatose fever, vide infra), the cerebral capillaries are found to be completely occluded with pigmented Plasmodia. [Periodical fever is very widely distributed ha the United States, and in the southern portions occurs in severe though not in the severest forms. Some regions which were formerly free from it are no longer so, and, vice versa, some regions which were greatly subject to it are now exempt ; these changes are closely con- nected with the clearing and upturning of virgin soil largely impregnated ^^^th decaying vegetable matter, and with the subseqiient cultivation of the same for considerable periods of time. The poison does not extend far above the surface of the ground, as is shown by the relative safety of sleeping in the upper as compai-ed with the lower story of a house ; during the night the poison seems to exist in greater intensity than during the day. Attacks are more liable to occur during the spring and autumn than at other seasons. The hopes which have been entertained in some quartei-s that malarial regions might be rendered healthy by large plantations of the Australian eucalyptus globu- lus, a rapidly growing tree which absorbs immense quantities of water, do not seem likely to be realized in the light of French experience in Africa, and in that of the Trappist monks in Italy.] Klebs and Tommasi-Crudeli have made extensive investigations as to the nature of the malarial poison. We must regard it as organic. The authorities just named state that the true cause of malaria is a specific variety of bacillus. They found peculiar bacilli and their spores both in the earth of malarial regions and in the adjacent strata of the atmosphere; and, by infecting rabbits with these, they were able to induce attacks of fever, swelling of the spleen, and the charac- teristic formation of pigment matter (I'lde infra). Before this, bacilli and spores had been found in the blood and spleen of patients suffering from malaria. It can not yet be said just how much significance these discoveries have. [To Laveran really belongs the credit for the discovery and accurate descrip- tion of the Plasmodium. His work in Algiers has been substantiated by observers in widely separated malarial regions, and, at the same time, no very important additions have been made to it. It is difficult to overrate the diagnostic and therapeutic importance of this dis- 92 ACUTE GENERAL INFECTIOUS DISEASES. covery. The ordinary intermittents are usually easy of diagnosis, but the remit- tent forms often simulate typhoid fever, wliile the pernicious foi-m may resemble ursemia or intracranial disease. Especially in pernicious cases life may be saved by prompt and appropriate treatment, which must be based, of course, on accurate diagnosis. The following details may be of use to those who are not familiar with the method of blood examination. The finger tips should first be scrubbed with a naU-brush, and soap and water, and then washed in alcohol or ether, to obviate the danger of mistaking minute particles of dirt for the pigment-granules derived from the destruction of red blood-corpuscles. A portion of a drop of blood is then to be i-eceived on a scrupulously clean object- or cover-glass, and squeezed out between the two, so that a thin layer of blood with separation of the individual corpuscles is secured. The amoeboid forms of the plasmodium retain their movements for a number of minutes in a warm room, much longer, of course, with a warm stage. The presence of pigment granules in the red corpuscles may be the readiest indi- cation of the presence of the organism. The crescentic forms are found more especially in chi'onic cases which have been under treatment by quinine, as is stated by Osier. Many of the other forms can be found in the blood only dui'ing a paroxysm. The editor has seen them in abundance in a cachectic malarial patient from Panama, and failed to find them again after a single large dose of quinine, which terminated the chills. In dried and stained specimens it is easier to detect the organisms, but amceboid movement is, of course, lost.] Liability to the disease is very wide-spread. No race, no age, no sex, enjoys immunity. It is a noticeable fact that those who have had the disease once are all the more apt to have it again. Former patients, although they feel perfectly well in a non-malarious region, are very liable to fresh attacks, or at least much discomfort, as soon as they re-enter an infected district. The time of incubation does not seem to be constant. It is put at from six to twenty days, but may be shorter. We shall consider below chiefly the common forms of intermittent, such as appear among us in Germany, contenting om-selves with a very brief description of the severer forms. Varieties of Malarial Disease. 1. Intermittent Fever.— This is the simplest form, and has for its especial char- acteristic the relative brevity of the febrile attacks, which almost always exhibit a remarkably uniform type. A febrile attack of this kind is frequently the very fli-st symptom of the disease. In other cases the pai-oxysm of fever is preceded by a prodromal stage lasting several days, during which the patient feels languid, has no real appetite, complains of headache and pain in the back of the neck and in the limbs, and often even thus early presents a slightly yellowish complexion and an enlarged spleen. In the typical attack of intermittent fever there arc three stages. The attack begins with a chill. Tliere is pronounced malaise, attended by intense chilliness and more or less shivering. The skin is cool and pale, the face may be somewhat livid. The temperature of the interior of the body is elevated, and rapidly rises higher. In by far the gi'eater number of ca.ses the attack occui-s in the morning, or at least before noon, and but seldom latei" in the day. This cold stage varies greatly in length, usually lasting an houi- or two. The chilliness is followed by the hot stage. The skin grows burning hot, the face flushes, the pulse, which was before small, becomes full, and the action of the heart is excited. At tii'st the temperature continues to increase, and reaches in this stage its maximum for the attack. It is exceptional for it to remain under 10i° (iO° C), MALARIAL DISEASES. 03 and by no means rare for it to toucli 106°, or even 107° (41°-41'5° C). This stage almost always lasts longer than the preceding, generally about three to five hours. The temperature may begin to fall as early as the latter part of the hot stage, but may persist till the beginning of the third stage. In this, sweating, stage the skin grows moist, and there is soon a profuse gen- eral perspiration. The patient begins to feel much better. In a few hours the temperature usually becomes normal, and, after lasting in all about eight to twelve hours, the attack is over. It may be shorter or rarely longer. Usually, however, the temperature keeps on sinking slowly, so as to be still subnormal even on the next morning, pei'haps not above 97° (36° C). There are certain peculiarities in the temperature-curve which we have our- selves observed. The elevation of temperature is almost invariably more rapid than its decline. The rise is most rapid during the fii-st hours of the cold stage, and slower during the Brst portion of the hot stage. The ascent is but very sel- dom interrupted. During the hot stage, when the fever is highest, in the neigh- borhood of 106° F. (41° C), there are not infrequently two little summits to the fever-cui've, if the temperature be taken at short intervals. But the temperature may for hom-s remain the same. The temperatiu-e generally begins to fall some little time before the perspiration is evident. The decline is slow. It may be per- fectly continuous, or it may be interrupted by fresh elevations, which are some- times slight and sometimes considerable. In many cases the descent is by steps, the temperature remaining the same for half an hour or an hour, and then abruptly falling a couple of degrees and remaining for a time at this new level. The chief characteristic is not, however, the natui-e of the single attacks, but the peculiar manner of their repetition. If the case is not under treatment, the single attacks keep reciu'ring for a time, either daily, as in the quotidian variety, or every second day. This latter type of tertian intermittent fever (cf. Figs. 10 and 11) is probably the most frequent. There may exceptionally be still longer ■«■■■■■■■■■■■■ ■«■■■■■■■■■!■■■ ■■■ ■■■■■■■■■■■H BBSSBBBSiimBSB S||jagS|JISB8BBB klsiBBsis^B IIIIIIHIlllllll Sli9!§||iEsSla EfM'HBWHHBinnnHWH BSSSffiSiglBSBBBB ■■■»■■■»!■■■■■ Fig. 11. — Tertian intermittent fever. [Uhinin 2'0 = Quinine, 30 grains.] afebrile intervals. Thus we have quartans, quintans, etc. If there are two at- tacks in one day, a rare event among us, we have a double quotidian. If there is a violent attack every second day, and on the Intervening days there are milder 94 ACUTE GENERAL INFECTIOUS DISEASES. attacks, it is a case of double tertian. Very often the attacks do not recur at just the same time of day, but a few hours earlier each time. Less frequently they are latei". This peculiarity is expressed by the tei'm " anticipating " or "retard- ing," as the case may be — e. g., a retarding tertian ague. In cases of long stand- ing, the paro.xysms may finally lose all regularity, so that the fever is described as "erratic." Next to the febrile attacks, the swelling of the spleen is the most constant and important symptom. It is usually considerable and capable of demonstration by percussion and palpation. At first the tumor inci-eases with every fresh attack, and diminishes but little during the intervals. After the patient is freed from his attacks of fever the spleen may continue enlarged for some time. It is tender on pressure. The liver may likewise be swollen, but this is less constant and also less important. Certain changes in the skin are very characteristic, chief among which is a ])eculiar yellowish-browu discoloration. This is due to an abnormal deposition of pigment in the skin. Herpes on the lips or uose is seen very frequently during the attacks. We have seen one case of lierpes on the cornea. Mention has also been made of urticaria, purpura, and other eruptions. Other internal organs than those already spoken of are rai'ely much disturbed. One symptom should be mentioned, which we have ourselves seen several times, viz., a quite marked acute dilatation of the heart dui'ing the attack. There were no bad I'esults, and the normal condition was soon re-established. We may hear durmg the attack functional cardiac murmurs of a blowing character. Thoracic exam- ination, isarticidarly if made during the attack, may afford the signs of a dry bronchitis. Sometimes thei'e is considerable diarrhcsa, or other evidence of intes- tinal derangement. Catarrhal jaundice is confined to the severer cases. Some- times the urine has a moderate amount of albumen. Genuine nephritis is met with only in the graver varieties of the disease. The increased excretion of urea on the days of the fever results, as in any fever, from the increased destiiiction of albumen. Severe pain in the cervical and upper dorsal vertebras is regarded as characteristic of intermittent. Besides the typical attacks, I'udimentary and modified ones are not rare, in which the separate stages are ill defined, or in part wanting. We are most apt to see this in cases which have been already treated with quinine. Children do not have a true rigor. They merely become pale or livid. They may ijreseut marked nervous sym])tonis. 2. Pernicious Intermittent Fever.— This dangei-ous form occurs only in the true malarial districts, and Ls often preceded by a few attacks of a mildei- charac- ter. Then appear, in addition to the more or less perfectly marked stages of the febrile attack, other graver symptoms which not infrequently end in death. Severe nervous symptoms are most frequent. There may be unconsciousness, coma, delirium, or epileptiform or tetanic convulsions. None of these symptoms persist longer, as a rule, than does the common sort of an attack, and in a favoi-able case vanish completely when the sweating, which is usually profuse, begins. The great danger comes from the recurrence of the attacks. A second form of ])erni- cious intermittent fever causes violent gastro-intestinal symptoms, which may almost exactly imitate the algid stage of cholera, with vomiting, diarrhoea, and col- lapse; or there may be severe cardialgia, dysentery, and the like. In the so-called pernicious intermittent with jaundice, intense jaundice appeai-s during the attack, with vomiting and diarrhoi'a, and sometimes the gravest nervous symptoms. There are certain very peculiar forms, in which local diseases, such as pleui-isy or pneumonia, can be demonstrated durmg every attack, but vanish -w-holly or in part when the temperature declines, only to appear again during the next attack. MALARIAL DISEASES. 95 [The pernicious form occurs in isolated cases wherever the ordinary variety of the disease prevails, but is much more common in the Southern and Western States, and there varies in frequency in different years. Periodicity in the attack is not always observed. The pernicious character is not always manifested in the first attack, one or more mild paroxysms being often precedent. In this country the algid form of pernicious periodic fever is often called '"congestive chills," and this form is more common than the comatose or another form not mentioned by the author — the hcemorrhagic. In the latter the blood escapes from the kidneys, and less constantly from the mucous membrane. During the late civil war the mortality in the white soldiers of the United States army from pernicious malarial fever was 23'91 per cent.] 3. Remittent and Continuous Forms of Malarial Fever.— These are generally severe, and are seen, like the preceding, only in the worst haunts of malaria. The proof that they have the same aetiology as intermittent fever lies in the fact that they are sometimes developed out of the milder forms ; but it is to be noticed that many types of disease which physicians in the tropics desci-ibe as malarial affec- tions have not yet been pi'oved to our satisfaction to have an actual identity of origin with the common intermittent fever. The symptoms of this variety are likewise those of a severe constitutional infection. Gasti'o-intestinal sj'mptoms may predominate; or there may be such grave nervous symptoms as coma, delir- ium, and convulsions; or there may be jaundice, hematuria, and even a general hasmorrhagio diathesis ; or various local disorders may exist, such as pneumonia, nephritis, and hepatic and splenic abscesses. The fever is high, but without any sort of regular intermissions, maintaining for one or two weeks a remittent or a tolerably coutinuous type. Milder forms may end in recovery after eig-ht to four- teen days, but often death ensues at this time, or even earlier. [The remittent form apparently shows a greater intensity of the poison or a greater susceptibility of the individual. In the United States army, from 1861 to 1866, its mortality was twelve times as great as that from the intermittent form.] 4. Chronic Malarial Cachexia. — This occurs in the true malarial regions, and affects not only people who have had frequent attacks of pronounced intermittent or remittent fever, but also those who have never had acute attacks. The condi- tion is chronic. It may exhibit a genuine intermittent character. The patient usually has a decidedly yellowish, malarial complexion, and almost always the spleen is evidently enlarged. There are no regular febrile attacks, but merely symptoms of general debility, anorexia, tendency to diai-rhoea, or, more rarely, constipation, vertigo, wakefulness, frequent perspiration, pains in the muscles and joints, dyspnoea, and palpitation. There may be such nervous symptoms as trem- bling, paralysis, and mental disturbance ; or we may see intestinal symptoms and jaundice. Dropsy occurs ; also epistaxis, cutaneous ecchymoses, and other signs of a scorbutic condition. The spleen and liver gradually become greatly hyper- trophied and melanotic. At the same time there may be an irregular fever, approaching either an intermittent or a remittent in type. Finally, secondary diseases are possible — e. g., tuberculosis, amyloid, or dysentery — and these may prove the immediate cause of death. The milder forms may be cured, but seldom unless the patient abandons for ever the malarial district. 5. Masked Intermittent. — This is the designation of cases where, although there is no fever, certain other disturbances arise in regular intermittent attacks. Chief among these is neuralgia. ' Its favorite seat is the supra-orbital branch of the trigeminus. It may occur in the other branches of the same nerve, or in the sciatic, the anterior crural, the nerves of the brachial plexus, and elsewhere. Car- dialgia and enteralgia may occur in the same way. These attacks last from thirty minutes to several hours, and are frequently associated with all sorts of constitu- 96 ACUTE GENERAL INFECTIOUS DISEASES. lional symptoms, but, as we have said, ave afebrile. There may be a splenic tumor, which aids diagnosis; but this sign may be wanting. Numerous other intermittent disordei-s besides neuralgia have been described as masked intermittent. The list includes anaesthesia, convulsions, and paralysis; also intermittent hajmorrhage, oedema, cutaneous affections, and intestinal symp- toms. We must add, however, that those who have described disea.ses of this sort, some of which seem strange enough, have not always been as critical as they ought, and have omitted to prove satisfactorily that such cases should be referred to malarial poisoning. Diagnosis. — It is often very diiBcult to diagnosticate a case of intermittent fever at the fii'st visit, particularly in a place where malarial poisoning is infrequent. The history of the case is by no means always enough to put one on the nght track; and a single examination of the patient may prove equally negative in its pi'actical results, whether it is made during the febrile stage or in the intei-val. Continued observation, however, will almost always disclose the regularity of the febrile attacks, the splenic tumor, the characteristic complexion, and the herpes; and our diagnosis becomes evident. Still it is not very exceptional for an inter- mitting fever to be taken at fii-st foi' an intermittent malarial one. while event- ually some quite different disease is found to produce the symptom. Pysemia may give rise to mistakes of this land; also purulent phlebitis, acute ulcerative endocarditis, and even tuberculosis. We should be veiy cautious in making a hasty diagnosis of " u-regular intermittent fever." Our own experience has taught us that almost invariably the case turns out to be something else. Where there is doubt we may, in addition to a careful consideration of all the symptoms and a thorough physical examination, be aided by the therapeutic action of quinine (vide infra). If a high fever of intermitting type is affected bj' large doses of quinine but temporarily if at all, then a diagnosis of malai-ial intermittent fever is rendered doubtful. Treatment. — Malarial poisoning is one of the few diseases upon which we can make a direct attack with assured success. In quinine we possess a remedy which probably acts upon the very cause of the disease, and the therapeutic efficiency of which is undisputed. Quinine is therefore the sovereign remedy in all fonns of malarial poisoning, and is often the only drug employed. In the mild cases, which are the only kind that occur among us, we do not usually give the remedy upon the instant that the patient comes under treatment. It is best to wait for one or two attacks, partly to make sure of our diagnosis, and partly to learn what the type of the fever is, whether quotidion, tertian, anticipating, or recurring at the same hour. And in most cases this delay works no harm to the patient. Dur- ing the attack itself there is seldom any use in special treatment. Of course, the patient must stay in bed and be kept warm during the cold stage, and have lighter coverings dm-ing the hot stage. During the afebi-ile interval the patient may be up if he feels strong enough and is careful. Quinine is given about five or six hom'S before the next attack is due. It is best to administer one large dose of twenty to tliirty grains (l"5-2 grm.\ either in solution or in capsules of seven grains (0-50 grm.) each. If the quinine be given in powder or capsules, it is a good way to follow it with a few drops of muriatic acid, to promote its solu- tion in the stomach. Often one large dose prevents the next attack. In other cases it does occur, but with less subjective disturbance, no chill, and more moderate fever. We must then give another 'large dose before the second at- tack is expected. If the attack does not take place, then we may give for several days quinine to the amount of eight grains (0 '5 grm.) jjer d^eJ?^. After all, re- lapses are possible, even at the end of several weeks; but they yield readily to quinine. MALARIAL DISEASES. 97 Judging from our own experience, conchinine is the only one of the other prep- arations of cinchona which is as efficient as quinine. It costs onlj' half as mucli, and is prescribed in just the same way. A disadvantage is that it is more apt than quinine to excite vomiting. All the other preparations of Peruvian hark, such as chinoidine and cinchonine, are much more uncertain in their action. In the treatmeut of pei-nicious intermittent fever, of the inasked forms, of the remittent and continued fevers, and of malarial cachexia, the cliief remedy is like- wise quinine, given in sufficient doses. Baccelli has shown that sometimes in pernicious fever the direct injection of quinine into a vein may save life. In all cases of considerable duration it is also of the greatest importance to remove the patient from the malarial region, if it can possibly be done. This often proves to be the only way to avoid relapses and attain a perfect cui-e. In cases of longer stancUng, quinine sometimes loses its power. Then we resort to arsenic. It is frequently employed in malarial cachexia and in intermittent neuralgia, either alone or combined with iron. We give gtt. v to viij of Fowler's solution two or three times a day m water. It is still better to give pills of arseni- ous acid containing gr. 3-V-3V (0 '002-0 "OOS) and gradually increasing to a daily dose of gr. ^— i (0 -010-0 -012). It maybe added that arsenic is also said to have a prophylactic virtue : a long-continued use of it is stated to render a person proof against malarial poisoning. It may also be mentioned that a favorite remedy for chronic malarial cachexia among the Italian peasants is a decoction of lemons. It is even highly praised by local physicians. A iiuely sliced lemon is put with three glassfuls of water and boiled down to one glassful. We will not speak of the numerous other remedies recommended, such as eucalyptus, piperine, xjilocarpine, berberine, and many others, for they can be entirely dispensed with. The management of the severe varieties of malarial disease involves sympto- matic treatment as well as the administration of quinine. We can not enter into the particulars. In combating the grave, nervous, intestinal, pulmonary, and renal symptoms, the dropsy and the anEemia, the physician must conform to tlie general rules of treatment. [There is nothing to be gained by allowing a patient to have an unnecessary chill. If there is a reasonable probability that his paroxysms are due to malaria, a prompt effort should be made to cut them short. Four houi-s is the shortest time that it is safe to allow for qumine by the stomach with probability that the expected chill will be prevented. The drug acts much more promptly when given hypodermically. The hydrobromate is preferred by some to the sulphate for subcutaneous use on account of the necessity of using acid to dissolve the latter, and the consequent risk of abscess. Such a risk should have no weight if the physician has any suspicion that he has to deal with the pernicious form of the disease. If the stomach is irritable, the remedy can be given by enema. Quinine can also be given by suppository, though it may thus produce some irri- tability of the rectum. But the impossibility of disguising the bitter taste of the remedy or of making children swallow capsules renders this a valuable means of treatment sometimes in infants and young children. Warburg's tincture is an antiperiodic which does good service in cases which do not yield to the ordinary methods of treatment. , The hypodermic injection of pilocarpine is reported to abort an impending chill. Some prefer divided and smaller to the single and large dose of qiiinine or one of its substitutes, a difference of view which is of minor importance. In the remittent forms boldness in the use of quinine is required. Cinchonism should be induced as promptly as may be, and maintained to a mild degree for several days; the quantity of the drug can then be gradually diminished. 7 98 ACUTE GENERAL INFECTIOUS DISEASES. The treatment of the peruicious forms of periodic fever presents itself under three main heads : 1. The prevention of pernicious paroxysms. 2. The treatment of tlie paroxysm when present. 3. The prevention of a recurrence. 1. We have seen that very frequently the pernicious character is manifested after the occurrence of one or more mild attacks; consequently, in localities and seasons marked by the occurrence of grave cases it is an imperative duty to treat every mild case promptly and energetically, a course which unquestionably saves many a life. 2. The management of the paroxysm differs according to the form which it assumes; in other words, is largely symptomatic. Benaiss (Pepper's ''System of Medicine ") says : " The cure of a congestive chill is one of the mo.st difficult prob- lems the physician can possibly encounter." Heat externally, opium and chloro- form by the mouth, and morphine and atropine subcutaneously, nutrition by the stomach or rectum, according to circumstances, and alcoholics if the action of the heart is feeble, are the measures of widest application. Whatever the type of the attack, a weak heart calls for alcoholic stimulation. Cinchonism is always to be induced as rapidly as possible. In the comatose form it is to be remembei-ed that the cerebral and other nervous symptoms are not due to congestion, but probably to a combination of the malarial and secondary blood-poisons. To quote Bemiss again : " Efforts to nourish the patient must never be relaxed. One must see many of these cases before he can realize how of ten they recover from conditions apparently hopeless when promptly treated and properly nourished." The hfemorrhagic form, like the othere, demands cinchonism and careful nutri- tion, but also hasmostatics. Purgative doses of calomel are indicated in some cases of each form, but should not be given in a routine manner. 3. Prompt cinchonism is the chief means of attaining the third aim of treat- ment. Removal to a healthy locality should be secured if possible, and the general condition of the patient requires careful attention. It remains to add that those going to a malarial region can often avoid con- tracting the disease by taking advice of a local physician as to hygienic precau- tions, and by moderate divided doses of quinine.] CHAPTER XV. TYPHO-MALARIAL FEVER. [This is not a distinct disease, but expresses a combination in the same indi- vidual at llic same time of the effects of the special poison causative of ejj r \ "^ They may remain dried uj) W~~ j ^^*!L' V ^\ for years, and then be brought to further develop- ment if placed in favorable conditions of heat and moisture. If the spores are transferred to animals, they develop into bacilli, and Fig. 12a. -Anthrax bacilli. (From Koch.) 650 diameters. ^, from there is scarcely rOOm to the blood of a guinea-pig B, from the spleen of a mouse after doubt that men and animals three hours' culture in the aqueous humor. . /. • i? i are quite as often infected by spores as by full-grown bacilli. There are facts which render it not improb- able that the anthrax bacilli exist in other places than the bodies of men or ani- FiG. 12b Anthrax bacilli ; spore formation and spore germination. (From Koch.) A, from the .spleen of a mouse after twenty-four hours' culture in tlie aqueous humor, spores arranged like strings of beads in tiie tilaments. O.j0 diameters, i?, germination of the spores. 050 diametei-s. C, the same, with a higher power. 1G50 diameters. mals, and may there complete their circle of development. Such places are marshes, the banks of streams, and the like. If it is possible for them to be carried by high water to the pasture lands, we have an explanation of those sudden endemic appearances of anthrax which sometimes occur in places pre- viouslj' free fi-om the disease. Anthra.K in animals is of great practical importance, because its favorite victims are the herbivorous domestic animals — viz., the cow, sheep, and horse. Among these it is terribly destructive. It is remarkable that the carnivora enjoy almost complete immunity. The disease usually runs a very acute course in ani- mals. Indeed, it often seems like apoplexy; the appai-ently healthy animal sud- denly falls, suffers for a few minutes from convulsions and dyspnoea, and dies. Other cases have a somewhat longer and more intermittent coui-se, but in these also recoverj' is very rare. MALIGNANT PUSTULE. 119 Probably human beings are infected in most cases by direct inoculation. Shep- herds, fanners, butchers, and otliers who come in contact with animals suffering from anthrax, are liable to infection through any little wound or scratch upon the hands. Very often the disease is caught from hides, hair, or other parts of dead animals. In workshops and factories where wool and hides have been used which came from diseased animals, anthrax has repeatedly occiu-red. Curriers, rope- makers, paper-makers, and those who handle horse-hair and wool, are all exposed. Anthrax has also earned the name of " rag-pickers' disease. " Another way of infec- tion, supposed to happen among animals as well as men, is through the sting of insects — e. g., flies — bringing the poison from diseased animals. It is not likely that the virus can be absorbed through the unbroken skin, or by the lungs. It is certain, however, that the intestine may afford ingress to the infectious matter. Koch has proved this by putting spores in the food of sheep. Intestinal mycosis in man {vide infra) may very possibly be due to a similar mode of infection. Many cases of poisoning from eating meat have been referred to the ingestion of the flesh of animals who died from authi-ax. Clinical History. — Anthrax in man has two distinct forms. These may appear in combination. The first begins with a local disorder of the skin at the point of infection — viz., the malignant pustule, or anthrax carbuncle. The second and rarer form presents the symptoms of a severe acute constitutional infection. An accompanying cutaneous disorder is sometimes observed. 1. The malignant pustule usually comes on the hand, the arm, or the throat, and appears from three to seven days after infection. A vesicle forms at the infected spot, grows rapidly, becomes excoriated, and usually takes on a charac- teristic appearance, being of a dark-bluish or black color. The suiTounding parts become diffusely swollen and red. Secondary vesicles may surround the original one. The swelling becomes more and more extensive. Inflamed lymph- vessels or veins radiate in red lines from the pustule, and the neighboring glands are also affected. These appearances are accompanied by fever, and more or less prostration. In a favorable case the swelling subsides, the scab falls off, and there is at last complete recovery. But in other cases the constitutional infection becomes more and more prominent, and eclipses the local disorder. The fever and prostration increase. Severe intestinal symptoms appear, or else stupor, delirium, and other nervous disturbances; and death may ensue after a few days' illness. 2. Intestinal Mycosis. — A better name would he intestinal anthi-ax. A quite different picture is presented by this second form, which gets its name from the marked intestinal lesions. In this the cutaneous disorder, if it exists at all, is insignificant, compared with the severe constitutional disturbance. It is only within a few years that the labors of Buhl, Waldeyer, E. Wagner, Leube, and others have shown that attacks of this kind have any connection with anthrax. So few cases have thus far been observed that it is impossible at present to give a definite and complete description of the disease. In cases of this sort the attack is usually rather sudden, heginning with chilli- ness, vomiting, headache, and languor. The diagnosis is usually very obscure at flrst, unless the calling of the patient suggests the possibility of anthrax. On careful examination, we may find some places where the skin is broken, or pos- sibly a small characteristic pustule. In a case which came under our own obser- vation a pustule had existed on the back of the right hand for some weeks before severe symptoms appeared, but had not attracted the attention of the patient at all. In this case, therefore, the constitutional infection seems to have come from the local disease. But in other cases cutaneous troubles, in the form of small car- buncles may occur secondarily in the course of the disease. Hasmorrhages into the skin and mucous membranes also occur. 120 ACUTE GENEEAL INFECTIOUS DISEASES. Of other symptoms, the gastro-intestinal deserve to be mentioned first. Vomit- ing occurs frequently, and also a moderate, painless, and sometimes bloody diar- rhoea. There is usually severe dyspnoea, and a marked sense of oppression in the thorax, but without objective pulmonary signs. Very soon there is collapse; the nose and extremities grow cool; the pulse is rapid, but small; and there is livid- ity. In a few instances tetanic or epileptiform convulsions have been obsei"\'ed. The temperature is seldom much elevated. It may be subnormal. In a few days the prostration becomes comjilete, and death ensues. Milder forms apparently occur, but here the diagnosis may not be absolutely certain. We have seen a few such cases originating in a rope-walk where Russian hair was used. The constitutional symptoms were only moderately severe, the fever was mild, and recovery occurred after about two or thi'ee weeks. Pathology. — In the fatal cases of anthrax the intestinal lesions are the most characteristic. Besides the signs of catarrhal inflammation, we find peculiar lesions in the mucous membrane of the small intestine, and sometimes in the upper portion of the colon. These consist of dark, infiltrated spots, with hemorrhages, the spots being somewhat larger than a silver dime. The microscope reveals numerous collections of anthrax bacilli, situated cliiefly in the lumen of the blood-vessels. The spleen is usually only moderately enlarged, but dark and con- gested. There may be ecchymoses in the kidneys, the brain, and the serous mem- branes. Often there is swelling of the lymph-glands. In one case which we saw, with slight intestinal lesions, the mesenteric glands were considerably en- larged, and the bronchial lymph-glands were jierfectly enormous. The bacilli are found in all the organs mentioned. The diagnosis of a malignant pustule is seldom difficult, particularly if atten- tion be directed to the a?tiology. All doubt is over if we find the bacilli. The cases of intestinal mycosis may be more obscure. Here, too, the demonsti-ation of bacilli in the blood is, of course, of the greatest importance, but reports have thus far Ijeen scanty of endeavors to find them during life in man. Treatmenti — 1. Prophylactic inoculation. Toussaint and Pasteur were the fu-st to show that the virulence of anthrax bacteria can be artificially diminished by certain external influences. If the bacilli are kept under cultivation foi- several weeks at an unchanging temperature of 106° to 107'5° (42°— 13° C), they pre- serve their external appearance completely, as well as their ability to grow, but gradually lose their power of infection. Inoculations made with this "vaccine virus " produce at most an insignificant disturbance. But what is csjjccially re- markable is that the animals thus vaccinated are said to enjoy immunity thereafter from infection with actual anthrax. Pasteur was tlie first to make this a.ssertion ; and he proposed that the prophylactic inoculation of sheep and other animals liable to anthrax should be undertaken on a large scale, promising the farmei-s that very great benefit would result. This promise has not yet been completely fulfilled, although there can be no doubt that in general Pasteur was cori-ect. Ex- periments instituted by Eoch and others have shown that, although Pa.steur's vac- cination protects against the ai-tificial inoculation of anthrax, it does not, at least as now performed, afford immunity from the natural anthrax, which usually results from infection within the intestine. French investigators have lately made known new methods of producing an artificial diminution of the growth and virulence of anthrax bacilli, and in part also of other varieties of bacteria. Chauveau has found that cultures of anthra.x bacilli exposed for several days to an atmospheric pressm-e of three to twelve atmospheres, or to compressed oxygen, lose a portion of their virulence; and that animals inoculated with bacilli thus at- tenuated gain an immimity to inoculations with the original anthra.v poison. The statements of Ai-loing are very remarkable. He says that the du-ect play of sun- TEICHINOSIS. liil light, or even of a concentrated artilicial light, upon the cultures exercises a re- straining influence upon the growtlj and poisonous properties of the hacilli, and that inoculation material weakened in this way may be employed for the i^rotec- tion of animals. 2. The treatment of malignant pustule is surgical. Cauterization is often tried with such materials as caustic potash, nitric acid, or carbolic acid; but it should always be borne in mind that such manipulations may easily contribute to a local extension of the anthrax poison. For the same reason one should hesitate to incise or to excise the pustules. We are therefore usually obliged to confine our- selves to the prescription of a suitable position for the affected membei-, and the application of an ice-bag over the diseased spot. The treatment of intestinal my- cosis must be purely symptomatic. We may ti-y the effect of calomel, salicylic acid, stimulants, and baths. CHAPTEE XXIII. TRICHINOSIS. ( Trlchiiialous disease.) The Natural History of Trichinae.— The trichina spiralis, one of the class of round worms or nematoda, has long' been known to occur occasionally in the mus- cles of men and certain animals ; but it was not until 1860 that Zenker showed that trichina are capable of exciting in man a dangerous and sometimes fatal dis- ease. Since then numerous individual cases and quite extensive epidemics have been reported; and the labors of Virchow, Leuckart, and others have taught us the anatomy and mode of development of this peculiar parasite. The trichina appears in two shapes — as intestinal trichina and as muscular tri- china. The intestinal form is a small white worm, visible to the naked eye. The female is 3-4 mm. long, the male only 1-1 '5 mm. They have well-developed digestive and sexual organs. The male is distinguished by two little processes at the tail. The muscular trichina (vide Fig. 13) is a small worm O'7-l mm. long. It is found coiled up among the muscular fibers, inside a connective-tissue capsule, which is often calcified. The events in the life of the trichina are remarkable. If living muscular tri- chinse reach the human stomach, viz., through the eating of trichinatous pork, the capsules are dissolved, and the trichinEe, thus set free, grow in two or three days into sexually perfect intestinal trichinas. In the uterus of the impregnated female the eggs develop into embryos, which are born already hatched. The birth of em- bryos begins seven days after the ingestion of the muscular trichinae, and seems to continue for some time. A single female is said to produce more than one thou- sand embryos. These latter begin their ti-avels soon after birth, and reach the vol- untary muscles. As to the routes they choose we are still somewhat in doubt. Some authorities state that the trichinae penetrate through the walls of the intes- tine and the abdominal cavity into the connective tissue. Others afBrm that they enter the lymphatic vessels, or exceptionally the blood-vessels. They penetrate into the primitive fibers of the muscles, and cause them to disintegrate. Finally, they coil themselves up, attain the size of muscular trichinae in about fourteen days, and become encapsulated. Each capsule usually contains but one, although it may inclose as many as four! The capsule is formed partly by an excretion from the trichina, and partly from the reflex hyperplasia of the surrounding con- nective tissue. The process of development is now complete. The muscular tri- chinae seem, unlike the intestinal form, to have a very long lease of life, and usually 122 ACUTE GENERAL INFECTIOUS DISEASES. endure till the death of their host. They are often found accidentally at autopsies. They are most abundant in the diaphragm, the intercostal muscles, the muscles of tlie larynx and throat, and iu the biceps. iEtiology of Trichinosis — The only cause yet known for trichinatous disease in man is the ingestion of trichinatous raw or underdone pork — e. g., smoked ham. Swine are pre-eminently subject to trichina^. They probably become infected in various ways, e. g., from the fceces of human beings and swine suffeiing from tricliinosis, or through the ingestion of the trichinatous flesh of other swine. The waste of slaughter-houses is often fed out to swine, and the disease thus disseminated. Many affirm tliat swine are also infected by eating rats infested with trichinae. Clinical History. — The symptoms in man corraspond in general to the developmental and vital proces.ses of the trichiuaj, as above depicted. In indi\ndual cases, however, the separate stages are quite often obscured, probably because all the parasites do not develop simul- taneously, or because there aj-e relapses. The firet symptoms are gastro-intestinal. At the commencement there is a feeling of pressure in the epigastrium, with nausea and vomiting. Later, diarrhoea is prominent, becoming in some cases so violent as to remind one of cholera. It is not impossible, although rai-e, to find in- testinal trichinae in the stools. Sometimes there is con- ;•' ^" stipation instead of diarrhoea. In some cases the initial I ,' gastro-intestiual symptoms are but slight. Frequently, ; ' even in the beginning of the disease, there is complaint of pain and stiffness iu the muscles, too early for it to be due to the migrations of the trichiuEe. The genuine severe muscular symptoms, due to the ' myositis pi-oduced by the trichinaj in the muscles, do I not begin till the second week, or even later. In many I cases, where the invading parasites seem to be relatively ;i few in number, the muscular symptoms ai-e slight, or ■'} wholly absent. In the more severe cases, however, they ;' may be extremely violent and distressing. The muscles Fro. 13.— (From Heller.) An become swollen, firm and hard, verv tender on pressure, isolated primitive bundle , . .. i mi , . . ^ • i ■,-, with two tree trichina} in and very pamtul. ihe patient avoids all movements femma.^Mudf eu/arg^eT"' ^'"^ contraction of the muscles as much as possible, lying, with fle.xed arms and with legs either extended or like- wise flexed, motionless in bed. The patellar reflex almost always disappears, and ontestuigthe electrical reactions there is found a considerable diminution of mus- cular excitability to both the galvanic and faradic currents, sometimes associated with delayed contractions, and abnormally long duration of the same after the stimulus ceases (Eisenlohi-). The masseters and the pharyngeal and lai-yngcal muscles are attacked, so that there is difficulty in mastication and deglutition, and hoarseness. The participation of the motores oculi causes pain in the eyes. The condition of the diaphragm, iutercostals, and abdominal muscles causes serious difficulty in respiration. There is distressing dyspna?a, and expectoration is so hampered that secretions accumulate in the air-passages. Some of the fatal cases of trichinosis are principally due to this impairment of respiration. The condi- tion may be aggravated by diffuse bronchitis or lobular pneumonia. TRICHINOSIS. 123 Third in the list of important symptoms comes oedema. It appears, toward the end of tlie first week, in the eyelids. Somewhat later it involves the upper and lower extremities. What produces it is not quite clear. It has been regarded as ill part inflammatory and in part the result of occlusion and thrombosis of the smaller lymphatics. Cutaneous ei-uptions also develop — e. g., vesicles, wheals, petechias, and pustules. Frequently there is profuse perspiration, consequent upon which' abundant crops of miliaria or sudaniiiia may appear. In well-marked cases there may be quite high fever and other severe constitu- tional symptoms in addition to the local disturbances already discussed. The temperature may for a time reach 104° to 106° (40°-41° C. ); but the fever is seldom continuous for any length of time, being usually interrupted by fre- quent and considerable intermissions. There are also a rapid pulse, headache, stupor, and other symptoms suggesting typhus or typhoid fever. In fact, the fii'st casein which trichinosis was recognized at the autopsy (by Zenker of Dresden) had been regarded before death as typhoid. The urine may be albuminous ; and, in rare instances, nephritis is seen. The duration of the disease varies wddely. There are mild cases often unrec- ognized, which get well after slight symptoms have lasted two or three weeks. More pronounced cases occupy six to eight weeks, or even a much longer time. Of the more severe cases about one third prove fatal, usually from the fourth to the sixth week. Sometimes death is caused by the severity of the constitutional dis- turbance, but usually from disabled I'espii'ation. Even if the case ends favorably, recovery is often very tedious. Pathology. — The autopsy reveals little that is characteristic excepting the changes in the muscles. There are sometimes the signs of hsemori-hagic catarrhal inflammation of the small intestine. The spleen is not enlarged. Very often the liver is decidedly fatty. What should cause this in trichinosis has not yet been determined. The lungs often present islets of lobular pneumonia, or even sometimes of gangrene. The trichinse are found in the muscles, begmning with the fifth week. They can be recognized by the naked eye as little whitish lines. We have already named the muscles chiefly infested. Under the microscope we see the fibers in which the trichinae lie transformed into a fine granular mass. The nuclei of the muscular fibrillaj are greatly increased in number in the neighborhood of the coiled-up parasite. Finally, the sarcolemma collapses, and becomes greatly thickened upon its external surface by a hyperplasia of connect- ive tissue. The muscles also present many other degenerative changes, such as a flaky disintegration, waxy degeneration, and the formation of vacuoles. There is furthermore a marked increase of nuclei in the interstitial tissue of the muscles. Within the intestines are sometimes to be found, even after several weeks' illness, numerous living intestinal trichinas — a fact of importance from a therapeutic point of view. Treatment. — The trichinas may still be alive in pork that has been smoked or salted or half-cooked — e. g., many sausages are unsafe. The only possible prophylaxis, as far as the individual is concerned, is therefore to avoid all such food. A real protection for the public against the disease is also afforded by governmental microscopic inspection of meat, as already established in many places. When an individual has become infected with trichina, if it is possible that intestinal trichinae still are present, the treatment must always begin with the exhibition of purgatives, such as compound infusion of senna, calomel, or castor-oil. Of the remedies which are calculated to destroy the intestinal ti-ichinae, glycerine, which was fu-st recommended by Fiedler, seems to be the most efHcient. It must be given in rather large doses, say a tablespoonful every hour. Other 124 ACUTE GENERAL INFECTIOUS DISEASES. drugs are much less reliable, but we will name among them benzine in the close of one to two drachms (grm. 4 to 8) in capsules, and picric acid in pills — the daily dose being 5 to 8 grains (grm. 0'3-0'n). Later on, when the invasion of the muscles has already begun, we are unfortu- nately almost without resource. The muscular pains can be alleviated by nar- ct)tics, particulai'ly morphine subcutaneously, poultices, and chloroform-oil as an embrocation.* Protracted warm baths are excellent. Antipyrine and salicylic acid are also said to do good in many cases. * Generally one part of chloroform to ten of olive-oil. It is not officinal in Gcrniany.bul is weaker than the linimentum chloroformi (U. S. P.). — Tkans. DISEASES OF THE RESPIRATORY ORGANS. SECTION I. Diseases of the A'ose* CHAPTER I. CORYZA. (Snuffles. Ehinitis.) Etiology. — The well-known symptoms of coryza depend upon a catarrhal Inflammation of the nasal mucous membrane. Although this catarrh may often be due to infectious influences, still we can not deny that it is one of those dis- eases which may be caused by taking cold. Daily experience teaches us how often coryza follows an evident exposure to cold, like wetting the feet. We may men- tion its contagiousness as an argument in favor of its infectious character, and this may be illustrated by the fact that it may be conveyed by handkerchiefs, kissing, etc., but an experimental transmission of common coryza has not yet been successful. Coryza may also arise from the action of chemical u'ritants or mechanical irri- tants, like dust, on the nasal mucous membrane. The iodine coryza, which occurs ' from the internal use of iodine, is especially noteworthy. In this form iodine can easily be detected in the nasal secretion. The idiosyncrasy of many people to ipecacuanha is also well known, the very smell of it setting up a coryza. A severe coryza is the chief symptom, too, in hay fever,t which is probably due to the action of the pollen of certain grasses on the respiratory mucous membrane. * Special treatises on the pathology and therapeutics of nasal diseases are to be found in the follow- ing works; Michel, " Krankheiten der Nasenhiihle." Fraenkel, "Diseases of the Nose," in " Ziems- sen's Cyclopedia." Stork, " Klinik der Krankheiten des Kehlkopfes, der Nase, und des Kaoheus." Schech, " Krankheiten der Muudhohle, dos Eachens, und der Nase." Moldenhauer, " Krankheiten der Nasenhohlen," etc. + The disease called hay fever {catarrhus cestiviis) is of frequent occurrence in England and North America, although rare with us in Germany. It usually affects men in middle life, less often women. Some individuals are peculiarly liable to the disease. For them an attack may be produced merely by walking across a meadow or near a grain-field at that season when the grasses are in bloom, i.e., about May to July. As already intimated, it is supposed that the grains of pollen e-xcite the disease, being diffused in tlie air and thus drawn into the nostrils. At any rate, they have repeatedly been found in the nasal secretion and also in the tears of affected persons. The symptoms consist in a very severe coryza, with burning of the nose and violent sneezing. The erectile tissue of the nose is probably acutely swollen. Usually these symptoms are accompanied by a well-marked oonjuncti^itis with (edema of the eyelids. In severer eases there is furthermore a oataiTh of the larynx and bronchi. There is frequently a tendency to violent attacks of asthma ("hay-asthma"), especially at night (see the chapter on bronchial asthma). The treatment consists first in avoiding tlie cause by change of residence, as by going to the sea-shore. For the nasal catarrh douches are chiefly recommended, such as a solution of 1 part of quinine to 500-1,000 parts of water, or a solution of carbolic acid. The administration of iodide of potassium might be tried, particularly where there is asthma. (125) 126 DISEASES OF THE RESPIRATORY ORGANS. Finally, we must bear in mind that coryza may often be only a symptom of an- other disease like measles, syphilis, or glanders, and that severe purulent Luflam- matiou of tlie nasal mucous membrane may be excited by the presence of the seci-etion from a gonorrhoeal or bleunorrhoeal conjunctivitis. The symptoms of coryza are in most of the milder cases of a local nature only. The secretion is troublesome; at first it is scanty and mucous, but later it becomes more abundant and watery; and sometimes it is ))urulent. The nasal passages are not infrequently closed from the swelling of the mucous membrane. The patient necessarily has to breathe through the mouth, which explains the well-known nasal speech. This closure of the nares may give rise to dangerous attacks of dyspnoea in children, especially in infants, who have to breathe through the nose when sucking at the breast. The sense of smell is always diminished. The local sensations of pain and burning are due chiefly to a mild inflammation of the skin of the nostrils and upper lip set up by the irritation of the secretion. The irri- tated condition of the inflamed nuicous membrane occasions a feeling of tick- ling and itching in the nose, and frequently by a reflex action violent sneezing. The symptoms are more severe if the cavities adjacent to the nose are attacked by catarrh, and if in them accumulations of secretion occur. Marked pain m the forehead occurs in catarrh of the frontal sinuses. The sinuses of the ethmoid and sphenoid bones, and the antrum of Highmore, may also be implicated. Much more frequently a severe coi-yza sets up an inflammation in adjacent mucous membranes. Thus we find following a coryza a conjunctivitis, an affection of the ear, a sore throat, or a lai-yngitis. In persistent coryza an eczema is not infrequently excited on the skin of the upper lip, and mention has already been made of the fact that coryza may sometimes act as the exciting cause of an ery- sipelas. In severe coryza we may sometimes have quite a marked general disturbance, and often slight elevations of temperature. The "coryza fever" in children, for instance, is well knoMni. Treatment. — Special treatment is usually unnecessary, for most cases recover of themselves in a few days. With abundant secretion, especially in fresh cases, Hager's " coryza remedy " [as an inhalation] is worthj' of trial; this consists of ten parts each of alcohol and carbolic acid, and five parts of ammonia-water. A snuff of calomel is also greatU' praised. When the secretion forms abundant dry scabs, an attempt should be made to wash them out by injections of warm fluids, like warm milk. The upper lip and the nostrils should be smcarc-d with vaseline or simple ointment to protect the skin from the action of the secretion. Only in the rare cases of a severe purulent catarrh can an energetic local treatment of the nasal mucous membrane be necessary. Here we may use douches, sprays, or inhalations of astringents like tannin or alum, or we may apjily caustics like nitrate of silver. CHAPTER II. CHRO^^IC RHINITIS. (Rhinitis chronica hypertrophica and atrophica. Ozccna.) 1. Chronic Rhinitis. — It is in many cases impossible to determine the causes of hypertrophic rhinitis. Sometimes the condition seems to develop as a sequel to frequently repeated nasal catarrh, although in this case the relation is often revei-sed — it being the chronic rhinitis which occasions a predisposition to the frequent acute exacerbations of the catarrh. Certain diatheses (anaemia, scrofula) CKRONIC RHINITIS. 127 appear to influence tlie development of the disease. This is aLso true of occupa- tions which expose the individual to dust or smoke, and sometimes of malforma- tion of the nose (for in.stance, deviation of the septum) and perhaps also of heredi- tary predisposition. The anatomical changes consist in a slow but progressive swelling and hyper- trophy of the mucous membrane. This seems spongy, and of a red or reddish- gray color. The greatest change is almost always found over the inferior turbi- nated bone, and next to that over the middle. In advanced cases the mucous membrane presents rough, uneven swellings, and even polypi. These changes are often visible upon inspection of the nostrils anteriorly, but they may escape discovery until a rhinoscopic examination of the posterior choanse is made. The disturbance occasioned by chronic hypertrophic rhinitLs may be very con- siderable. Nasal respiration is obstructed, the voice nasal, the senses of smell and taste impaired. The nasal secretion is for the most part increased, but it may be diminished. Often there is a tendency to nose-bleed. Many patients complain also of headache. The frequent involvement of neighbormg organs is important. This applies particularly to the ear. Deafness is caused both by the obstniction of the open- ings of the Eustachian tubes, and not infrequently also by extension of the catarrh to the lining membrane of the tubes and the middle ear. Very frequently the disease is associated with chronic naso-pharyngitis or pharyngitis. The visible portion of the nose is not infrequently affected, as shown by redness and swelling of its tip. A fact of especial interest is that such a diseased state of the nasal mucous membrane may give rise to reflex neuroses (Voltolini, Hack, and othei-s). Al- though, in our opinion, many of the specialists on the nose go too far in this du'ec- tion, there is no room for doubt that attacks of migraine, vertigo, certain vai-ieties of headache, and, above all, many forms of bronchial asthma, may bear a close relation to diseases of the nose. We shall revert to this point later on. (See especially the chapter on bronchial asthma.) The treatment of chronic hypertrophic rhinitis, in order to be successful, de- mands complete destruction and removal of the hypertrophic portions by means of the galvano-cautery. For particulars, we must refer to the directions of spe- cialists. In milder cases, however, benefit may follow the insufiiation of a powder composed of one part of nitrate of silver to ten or twenty of common starch, or applications of lunar caustic may be made. 3. Chronic Atrophic or Eetid Rhinitis. Ozsena Simplex.— This frequent and peculiar form of chronic rhinitis is the cause of that well-known condition which is characterized by a peculiar and extremely disagreeable odor from the nose, which is therefore usually termed ozana. from the Gi'eek word o^eiv, to stink. The disease consists in a slow, progressive atrophy not only of the mucous membrane with its vessels and glands, but finally also of the bones, and this atrophy is not preceded by hypertrophy. Thus the nasal cavities become abnormally large. The tur- binated bones grow smaller and smaller, so that finally they are represented merely by narrow ridges. Furthermore, the scanty purulent secretion has a tend- ency to dry up and form adherent greenish-yellow scabs and crusts, which undergo a peculiar putrefactive decomposition and give rise to the unbearable stench. It is possible, but not yet demonstrated, that a specific kind of bacterium plays a part in the process. The ozsena generally develops in childhood. It usually begins insidiously, but in other cases apparently is a sequel of some acute disease, such as measles. Anaemia and scrofula deservedly rank as important predisposing causes. The subjective symptoms are often not marked. This is partly explained by 128 DISEASES OF THE RESPIRATORY ORGANS. the fact that the patient has usually completely lost his sense of smell, but for that very reason the discomfort of his friends may be the greater. The feeling of dryness in the nose may prove annoying, and there are often comi)laiiits of headache and of jjres.sure in the eyes. Inasmuch as the naso-pharyux and the posterior pharyngeal wall are almost always implicated in the process, the patient often sufPei's from hacking and a tendency to cough and vomit. Such portions of the secretion as are swallowed sometimes give rise to a consideraljle chi'onic disturbance of the stomach. Upon physical examination we are first struck by the unusual breadth of the nostrils. With the rhinoscope the extent of the atrophy is still better seen. The mucous membrane is pale or slightly red, and covered with dry scabs. Sometimes superficial ulcers are formed. Usually, as we have said, the superior iiortion of the pharyngeal mucous membrane shares in the disease. The posterior wall of the pharynx is seen to be atrophied, smooth as if it were varnished, and often covered with crusts. The process may involve the soft palate, and even the larynx, and not infrequently the disease is associated with inflammation of the middle ear. It should be added that the true ozsena must not be confounded with other processes which likewise give rise to a foul smell from the nose. Tuberculous disease of the nasal raucous membrane and nasal bones is not rare, particularly in "scrofulous" children (Demme); nor should we forget the syphilitic affections of the nose, tertiary and hereditary syphilis. Treatment. — The treatment of oza3na can be made effective only by the aid of local applications as prescribed by specialists. Even then tlie treatment is a prolonged one, and demands nuich patience on the part of both patient and physi- cian. Besides local applications, we must also bear in mind the necessity of consti- tutional treatment, especially in syphilis and tuberculosis. The object of local treatment is to remove the secretion in order to get rid of the bad odor. Nasal douches, with disinfectant solutions like ijermauganate of potassium (1-3,000) or carbolic or corrosive sublimate, are here most useful. Tiie solution is carefully injected into the nose, or the fluid is allowed to run gently into one nostril from an irrigator while the patient keeps his head bent forward; it then runs through the naso-pharynx and out through the other nostril. The patient soon learns to retain the fluid in the pharynx and eject it from the mouth. All nasal douches must at first be used with care and under the eye of the physi- cian. The fluid should be injected at the lowest pressure possible, so that none of it may enter the adjacent cavities or the Eustachian tube. Furthermore, all solutions used as a douche must be luke-warm — 90° to 95° (25°-28° R.). Besides the regular use of douches, painting and the insufflation of powders, like boracic acid, aceto-tartrate of aluminum, etc., are sometimes employed. The insertion of tampons of dry absorbent cotton is to be recommended; under their use the secretion dries less easily and the odor is diminished. These tampons should be changed daily. It is advantageous to medicate the tampons with a one-])er-cent. solution of creolin or with Pervivian balsam or some similar drug. Tincture of iodine is also recommended. Of late many attempts have been made to treat chronic nasal catarrli by the galvano-cautery. With regard to the details of this as well as of other methods, we must refer to special treatises ou the subject. NOSE-BLEED. 129 CHAPTER in. NOSE-BLEED. (ErUta.rk:) Although in many cases nose-bleed is only a symptom of some other disease, still we are justified in a short description of it, partly because frequently repeated nose-bleeds often first call our attention to some other existing disease, and partly because the treatment is of practical impoi-tance. Many persons are subject to habitual nose-bleed, which comes on either from slight causes, from violently blowing the nose, from physical exertion, from over- heating, or even without any special cause. This habitual nose-bleed is sometimes, but by no means always, the sign of a general hasmorrhagic diathesis, which is hereditary in many families. (See the chapter on Hajmophilia.) In other cases the nose-bleed is the result of some clu-onic disease. It occurs especially in leu- kaemia, in disease of the heart, in contracted kidney, and as a symptom of the so- called hemorrhagic diseases, like scurvy, purpura hEemorrhagica, etc. It is also not uncommon in acute febrile diseases, like tyjihoid and scarlet fever. Finally, diseases of the nose itself may give rise to hasmorrhage. The occm-rence of nose-bleed as a form of so-called " vicarious menstruation " has often been described, but we must always be very guarded in admitting it as a fact. In many cases nose-bleed is a very transitoi-y symptom, wholly without danger, and in one sense it may even be advantageous. When there is headache, or a feeling of fullness in the head, there is often relief after an epistaxis. Nose- bleed is dangerous, however, when it takes place in those who are already weak and aneemic, or when it is so persistent and abundant as to cause a marked general anaemia. The latter is recognized by the pallor of the face, by the appearance of general weakness, by vertigo, tinnitus, and a weakened pulse. In such cases the physician's interference is always necessary. In every case of nose-bleed it is important to examine the posterior wall of the pharynx in order to see whether the blood is not flowing backward from the posterior nares. The haemorrhage is often thought to stop when no more blood comes from the nostrils, and yet the blood keeps flowing posteriorly. In every severe nose-bleed rest is the chief thing to be enjoined, and the patient must be told to avoid unnecessarily blowing, wiping, or drying the nose. By quietly and persistently closing the nostrils with a handkerchief a thrombus is often formed without any further medication, and the bleeding stops. The apph- cation of cold water (iced water), in which a little vinegar may be put, is a good thing. If the bleeding does not stop, we may next try a tampon of common absorbent cotton or styptic cotton in the nostril from which the blood comes. If this does not succeed, the posterior nares must be plugged by means of a "Bel- locq's canula." In case of emergency we may use an elastic catheter, which is passed through the inferior meatus into the pharynx and out by the mouth. The tampon is fastened to the catheter and brought up into the posterior nares by drawing the catheter back through the nose. Internal remedies to check the blood are very uncertain in their action. Ergotine, in one-grain pills (grm. O'OS), every three or four hours, is the first one to employ, if we wish to try to check the bleeding by this means. 130 DISEASES OF THE RESPIRATORY ORGANS. SECTION II. Diseases of tub Lakvxx. CHAPTER I. ACUTE LARYNGEAIi CATARRH. {Acute Laryngitis.) jEtiology. — Taking cold plays a prominent part in the aetiology or acute laryn- geal catan-h, as every one knows. Its influence can not properly be wholly denied, since the more intimate relation between taking cold and the origin of a catarrh is still unknown. The disposition to laryngitis differs very much in different people, so that some take a catarrh much more easily and more fre- quently than others. Besides cold, direct irritants which attack the laryngeal mucous membrane often set up a laryngitis ; among these are in particular the inhalation of smoke and of injurious gases and vapors. Many laryngeal cataiThs, too, arise from excessive speaking, shouting, or singing, particularly if other injuri- ous influences act on the larynx at the same time. Finally, laryngitis may appear as a complication or as a secondary affection, in other diseases, especially in measles, less frequently in typhoid, scarlet fever, and erysipelas. Catarrh of the larynx is very often combined with catarrh of the nose, the pharynx, and the larger bronchi. Symptomatology. — Although the symptoms of laryngitis usually make the diagnosis easy and certain, yet an accurate understanding of the extent and intensity of the catarrh can be obtained only by a laryngoscopic examination.* which therefore should be employed in every severe case. The laryngeal mu-ror shows a decided reddening and swelling of the mucous membrane, varying with the intensity of the catarrh, and most marked on the true and false vocal cords and between the arj-taanoid cartilages. We often see .small collections of uuicus here and thei-e on the membrane. In individual cases different parts of the larynx are especially affected. In intense inflammations superficial erosions are often met with, especially on the vocal cords. In other ca.ses the mucous mem- brane shows a gi-ayish-white coloring in some places, due to a thickening of the epithelium. Small haemorrhages in the mucous membrane are also occasionally seen. Very often we see on phonation an incomplete closure of the glottis, so that a little oval space is left between the vocal cords. This slight " catarrhal paresis of the vocal coi-ds" is probably of muscular origin, and depends chiefly upon an affection of the thyro-arytaenoid muscles. Of the other symptoms of laryngeal catarrh, hoai-seness is particularly to be mentioned, for in many cases the diagnosis of laryngitis may be made from this alone. It is either due directly to the anatomical changes of the cords, or to the paresis just mentioned. Tlie degree of hoarseness is of course very different in different cases, and varies from a simple " roughening " or " deadening " of the voice to a complete loss of voice (aphonia). * More extensive observations on laryngoscopy and on many details of the patliology of laryngeal iliseases, which have been carefully investigated by specialists and which can not be mentioned here, are to be found in the following works: Tiirck, "Klinik dor Krankhcitendes Kehlkopfes," ISiiG. Seineleder, " Laryngoskopic," 1863. Tobold, " Laryngoskopie," 1874. Stiirk, " Klinik der Krank- heitcn des Kehlkopfes, der Nase, u. des Eachens," 1880. Mackenzie, " Disea-ses of the Throat and Nose," 18S0. B. Fracnkel and v. Zicmssen, " Diseases of the Laryn.\," in Ziems-ien's " Cyclopaedia." Gottstcin, " Krankheiten des Kehlkopfes," third edition, 1890. SchrOtter, " Vorlesungen uber die Krank- heiten des Kehlkopfes." ACUTE LAEYNGEAL CATARRH. 131 The cough in laryngitis may be very severe, and is often recognizable by its harsh, hoarse ring as a " laryngeal cough." It is at first usually dry, and later on it is associated with a scanty muco-purulent expectoration, which is sometimes tinged with blood. Pain in the larynx is generally only moderate. The subjective symptoms con- sist chiefly of a disagreeable feeling of itching, burning, and dryness in the throat. After prolonged speaking, however, the pain in the larynx may sometimes be quite severe. External pressure on the larynx is often somewhat painful. Difficulty in swallowing, when it occurs, is usually due to an accompanying pharyngitis, but it may also be dependent upon an afCection of the epiglottis and the arytaenoid cartilages. The general health is afl'ected in very different degrees. Many patients feel quite well except for the hoarseness, while others are affected with considerable debiUty, mild headache, and even at times slight febrile disturbances. Dyspnoea is not present in the common laryngitis of adults, even if there is decided swelling of the false vocal cords or of the ai-y-epiglottic folds. There is, however, a severe form of acute laryngitis, the so-called laryngitis hypoglottica acuta gravis {chorclitis vocalis inferior), affecting not only children, but adults, in which well-marked symptoms of suffocation may be present. In this form there is an acute, very well marked swelling of the mucous membi-ane in the in- ferior, " sub chordal," laryngeal space, which leads to a stenosis. In children, however, on account of the greater nai-rowness of the child's larynx, symptoms of stenosis are not rare even in the milder forms of laryngitis, and therefore they have led to the establishment of a special disease, the so-called false croup. The false croup Qaryngitis stridula) of chilcb-en usually follows a slight coryza. A harsh, hollow, ringing cough comes on, almost always suddenly and usually at night, by which the child is awakened out of sleep. The paroxysms of coughing are broken by long-drawn, noisy inspirations. The child is anxious and restless, the respiration is labored, the pulse is rapid. Such attacks recur several times during the night. The next day the child is quite lively, plays about, and has at most a slight cough. The nest night, I'arely sooner, the same severe attacks are repeated. After that there remains, as a rule, nothing but a slight catarrh, which completely disappears in a week or two. These sudden attacks have their origin partly in a marked swelling of the mucous membrane, occurring during sleep, partly in a neglected accumulation of secretion, and probably often also in a reflex spasm of the glottis. No other anatomical cause than a simple catarrh of the larynx is apparent, and on examining the pharynx, and, if possible, the larynx also, we find no trace of that diphtheritic process which is usually present in true laryngeal croup. It is remarkable that many children, and sometimes several children of the saaie family, have a specially marked predisposition to false croup. The statement, therefore, that a child has had the croup several times almost always means that it has had this form of false croup just described. Acute laryngitis lasts only a few days in mild cases, and a week or more in severe cases. With improper care and unreasonable conduct on the patient's part an acute catarrh may run into the chronic form. We hardly ever see a fatal result in adults, even in the severe form, or in the false croup of children. The treatment of acute laryngitis requires that especial attention be paid to the removal of all injiu'ious influences. In every severe laryngitis the patient should stay in his room, and chikh-en are better off in bed. The patient should talk as little as possible. In all severe cases smoking, too, is to be forbidden. It is a good plan to furnish plenty of warm drink. Hot milk, mixed with Seltzer or Ems water, is readily taken by most patients. If there is an inhaler at our disposal, we 132 DISEASES OF THE RESPIRATORY ORGANS. may let the patient inhale simple steam, or a one- or two-per-cent. solution of c immoii salt Inhalations of astringents are usually unnecessary. The patient may also hreathe steam without any special apparatus. When there is marked ii-ritation from coughing' we may give a little morphine. With more marked local symptoms, especially if there is nuich pain on swallowing from swell- ing of the epiglottis and the mucous membrane over the aryttenoid cartilages, the patient may suck pieces of ice slowly. In severe cases of acute laryngitis, with evident symptoms of stenosis, ice must he energetically used as an internal and an external application. Sometimes, too, a few leeches applied in the region of the larynx afford distinct relief. Among external applications a mustard plaster over the front of the neck is to be recommended when there are marked local sjTnp- toms. Cold, wet compresses about the neck are also of advantage in all eases. In the false croup of children we should use, as a rule, the same treatment as has just been described. The child should take warm drink, and a mustard paste or hot poultices should be applied to the neck. We should be rather cau- tious with regard to the favorite treatment with emetics, such as ipecac and sul- phate of copper, although it can not be denied that they sometimes work very well. These means are entirely sufficient for the treatment of acute laryngitis. It is only exceptionally that we fuid ourselves led to employ Ln acute laryngeal catan-h an energetic local treatment of the lai-yugeal mucous membrane, like painting with a 1-15 solution of nitrate of silver. We must bear in mind that a rational hardening process is of distinct prophy- lactic value in persons, especially in children, with a recognized tendency to laryngitis, sore throat, etc. The best method is to bathe the neck and chest with cold water regularly morning and night. [A mild emetic can do no possible harm in false croup, and very often cuts the attack short. The application of a sponge, moistened with water as hot as the child will beai", to the region of the larynx deserves mention.] CHAPTER H. CHRONIC LARYNGITIS. {Chronic LarijnijMl CiiUii-rli.) .ffitiolo^. — Chronic laryngitis develops from an acute catarrh, or comes on gradually from the action of injurious influences on the larynx (see the preceding chapter). Chronic larj-ngitis, therefore, is in many cases a disease arising from the occupation, and is seen especially in singei-s, public speakers, criei-s, inn-keep- ers, etc. It is very frequent in drunkards, and in such cases it is almost always a.=sociated with a chronic pharyngitis. It is freqviently stated that too long a uvula sets up a chronic laryngitis by constant irritation of the entrance to the larynx, and that if the uvula is amputated the disease is cured. Symptomatology. — A laryngoscopic examination is very desirable in acute laryngeal catarrh, but it is the physician's absolute duty to make one in every chronic laryngitis, for only too frequently a persistent hoarseness is referred simply to catarrh when the laryngoscope gives quite another cause for it, such as paralysis of the vocal cords or new gro^vths. Furthermore, we must always re- member that a chronic laryngitis may be a complication of tuberculosis, syphilis, or chronic nephritis. On the other hand, those physicians who make a specialty CHRONIC LAEYNGITIS. 133 of laryng'olog'y often neglect a careful and satisfactory examination of the rest of the body when there are laryngeal troubles. The laryngoscopic appearance in chronic catarrh may be so like that in an acute catarrh that we can not distinguish between them without the history obtained from the patient. The redness of the mucous membrane, however, is usually less intense, and the vocal cords have more of a dirty grayish-red appear- ance. Quite frequently in persistent catarrhs a thickening of particular parts of the mucous membrane is developed, especially of the folds between the arytaenoid cartilages. This swelling is of practical importance, because it furnishes a me- chanical hindrance to the closure of the arytaenoid cartilages, and in that way contributes to the development of the hoarseness. We also find limited and marked thickening of the epiglottis, the false vocal cords (especially in public speakers and preachere), and the true vocal cords. Tiirck has described a peculiar form of chronic laryngitis, in which rough prominences are formed in the middle of the true vocal cords, under the name of chorditis tuberosa. We not infre- quently find in chronic catarrh superficial erosions, especially on the true vocal cords. Superficial but very painful fissures occur upon the posterior wall of the larynx between the aiytrenoid cartilages. We also very often see a disturbance of motion of one or both vocal cords, due sometimes to muscular paresis and some- times to mechanical conditions. The other symptoms of chronic laryngitis are hoarseness, cough, and abnormal sensations in the lai'ynx. The hoarseness is of every degree, from mere rough- ness, frequent " cracking " of the voice, to almost complete aphonia. The cough is ringing, hoarse, deep, and rough. The expectoration is scanty, usually simjDly mucous, but sometimes a little bloody. The subjective sensations in the laiynx are a feeling of burning and itching, and of dryness and tickling. They usually increase after any protracted use of the voice. We must also mention as a very rare but practically important and peculiar form of chronic laryngitis the chorditis vocalis inferior hypertrophica (Gerhardt), or laryngitis hypoglottica chronica hypertrophica (Ziemssen). In this form there is a very gradual hypertrophy, and finally a contraction of the mucous and espe- cially the submucotis connective tissue in the inferior lai\yngeal space. More rarely the same changes are seen in the upper part of the larynx. The special symptom of the disease, besides a chronic hoarseness, is the appearance of a gradu- ally increasing stenosis of the larynx. The respiration is always labored, the inspiration noisy and protracted. In many cases there are at times such attacks of suffocation that life can be prolonged only by tracheotomy. The diagnosis can be made only by the aid of the laryngoscope. We see beneath the glottis a little fissure surrounded by the thick and swollen mucous membrane of the laryngeal walls. The precise aetiology of this disease is as yet unknown. It appears to have nothing to do with syphilis, contrary to the former belief. The treatment of chronic laryngeal catarrh is always a tedious and laborious task, the success of which depends in great measure upon the good will and energy of the patient. In the first place, then, we should endeavor to remove as far as possible those injurious influences which have excited and kept up the catarrh. It is often easier to give good advice here than to follow it. Neverthe- less, it is the task of the physician to impress upon the patient the urgent neces- sity of taking care of the larynx, and to foi'bid as far as possible all protracted speaking, singing, staying in smoke or dust, smoking, and drinking alcoholic liquors. Local treatment takes the second place. Among the most useful means to employ are inhalations of astringent solutions, like a one-per-cent. solution of 134 DISEASES OF THE RESPIRATORY ORGANS. either tannin or alum. When there is great sensitivene.ss of the larynx, the patient may also inhale narcotics, a mixture of fifty parte of cherry-laurel water with a thousand parts of water, or a four-per-cent. solution of bromide of potas- sium. The inhalations should be used two or three times a day, and last about five minutes each time. Direct applications to the larynx are much more effective than inhalations, but these can be employed only by the aid of a laryngeal mirror. Of these we use, first of all, nitrate of silver, at first in a weak solution (one to thirty); later in a more concentrated form (one to ten, or even one to five). The.se applications are made every two or three days. Besides nitrate of silver, the larynx may also be painted with pure tincture of iodine, or with iodine and glycerine, or with concentrated solutions of alum or tannin. Where the secretion of mucus is considerable ,beneflt will be obtained from inhalations of turpentine, or of oleum pint or oleutn x>ini pumilionis (P. G.). Water-cures are also often prescribed in chronic catarrh of the larynx. These are so far of advantage that, from the greater care which the patient takes, and from the good air, the catarrh improves. Empirically, we prescribe, especially for " full-blooded " patients, the cold sulphur springs, like Nenndorf, Eilsen, or Weilbach, or the sulphate of sodium waters, like Carlsbad and Marieubad, while we send those of delicate constitutions to Ems, Salzbrunn, Salzungen, Reicheuhall, or Ischl. The treatment of lai'yngitis hypertrophica, when it leads to stenosis, must be mechanical. Schrotter, in particular, has devised sevei-al methods in order to dilate the stenosis gradually by the inti'oduction of bougies and harder dilators. The details of this treatment are to be found in the later special works referred to above. CHAPTER III. LARYNGEAL PERICHONDRITIS. iEtiology and Pathological Anatomy.— The inflammation of the perichon- drium of the laryngeal cartilages is in very rare cases apparently a primaiy disease. It is much more frequently secoudarj' to other laryngeal affections, especially tuberculosis and syphilis of the larynx. Fm'thermore, it develops secondarily in severe acute diseases, most frequently in typhoid fever, more rarely in small-pox, diphtheria, etc. Superficial ulcerative processes in the mu- cous membrane often precede the perichondritis in these cases, and the ])articipa- tion of the perichondrium in the inflammation arises from their gradual deep- ening. Anatomicallj', we have to do as a rule with a purulent inflammation, which usually leads to the formation of circum.scribed abscesses. Most laryn- geal abscesses have their origin in the perichondrium.* The perichondrium is m part destroyed by the abscess and in part elevated from the cartilage. The cartilage then becomes necrotic, breaks in pieces, and is expelled in small particles or in masses. Perichondritis occurs most frequently in the cricoid and arytajnoid cartilages, much more i-arely on the internal or external surface of the thyroid cartilage. Hence we distinguish an internal and an extei-nal perichondritis. A perichon- di'itis of the epiglottis has also been repeatedly observed. Symptomatology. — In the rare cases of primary perichondritis, marked laryn- geal symptoms are speedily developed in a person previously he;ilthy. These * Pure submucous abscesses, the so-culled phlegmonous laryngitis, occur only in very rare cases. CEDEMA OF THE GLOTTIS. 135 symptoms are pain and tenderness on pressure over the larynx, hoarseness, and cough ; and to them are usually soon added the signs of a dangerous stenosis of the larynx. In secondary cases, which occur almost always in patients who are already seriously ill, the symptoms of stenosis are often the first to point to a severe disease of the larynx. On laryngoscopic examination, besides tlie general redness and swelling in particular places, we can sometimes recognize a circumscribed protrusion of the mucous membrane caused by the abscess. We often find, besides, a considerable collateral oedema of the sm-rounding mucoiis membrane, which ojdema frequently has a greater share in tlie production of stenosis than has the primary affection itself. The dreaded oedema of the glottis (oedema of the ary-epiglottic ligament) in typhoid, tuberculosis of the larynx, etc., is usually due to perichondritis of the cricoid or arytaenoid cartilages. Finally, we can see with the laryngoscope, especially m perichondritis arytanoidea, a considerable disturbance of motion of the affected arytenoid cartilage, and also of the vocal cords. In the later stages, if the abscess has been opened, or if it breaks of its own accord, and the whole cartilage or a pai't of it is expelled, we can make out the extent of the destruction that results more accurately by the laryngoscope. Laryngeal perichondritis terminates fatally in a great number of cases from the development of stenosis. In other cases the most threatening symptoms may be averted for a time, but the primary disease, such as tuberculosis, finally comes to an unfavorable termination. In the rare cases in which recovery occurs after primary perichondritis or after the termination of the primary disease, such as typhoid, this recovery is often incomplete, since a chronic stenosis of the larynx remains from the ensuing cicatricial contractions. The diagnosis is usually obscui-e during the first period of severe symptoms of stenosis, since it is difficult to make a laryngoscopic examination, and it is also not always easy to determine the condition. We are usually justified, however, in maldng the diagnosis, if in those diseases which we have mentioned, in which we know by experience that a perichondiitis quite frequently occurs, the danger of suffocation arises in addition to the other laryngeal symptoms. It is of prac- tical importance to recognize stenosis of the larynx with certainty, for it demands a speedy therapeutic interference. Treatment. — In the beginning of the affection we may try to reduce the inflam- mation by the internal and external application of ice or by leeches ; but if ste- nosis of the larynx occurs, surgical interference is usually necessary, for only in very rai-e cases do we see the abscess open of itself and a subsidence of the dangerous symptoms follow. In the majority of cases the patient can be saved from suffocation only by the timely performance of tracheotomy. The laryngeal abscess has been repeatedly opened internally by laryngologists with favorable results. If a chronic stenosis of the larynx remains after a favorable termina- tion of the disease, either the patient must wear a tracheal canula all his life, or the attempt may be made to dilate the stenosis gradually by the methods referred to in the preceding chapter. CHAPTER IV. CEDEMA OF THE GLOTTIS. The practical importance of the subject demands a brief special description of oedema of the glottis, by which name we mean oedema of the entrance of the lar- ynx, especially of the ary-epiglottic ligaments. We have already learned to recognize laryngeal perichondritis as one of its most frequent causes. In less 136 DISEASES OF THE EESPIRATORY ORGANS. deeply seated inflammations in the larynx and its neighborhood, however, oedema of the glottis may sometimes develop as a dangerous comj)lication, especially in cases of laryngitis occurring in the course of severe acute diseases, like typhoid, small-pox, or erysipelas, or in inflammations of the larynx arising from severe mechanical or chemical irritation, like hot steam or corrosive substances, or from wounds of tlie larynx, or, finally, from foreign bodies in the larynx. The col- lateral 03dema in angina Ludovici, in intense inflammations of the parotid gland, or the tonsils, etc., may in rare cases extend to the aiy-epigloltic ligaments. Finally, oedema of the glottis occurs in rare cases as a complication of geuei-al oedema of the body, as a result of Blight's disease, disease of the heart, emphysema of the lungs, etc. CEdema of the glottis has been repeatedly observed to come on quite suddenly, especially in Bright's disease. The chief symptom of oedema of the glottis is dyspnoea, which comes on as a result of the stenosis of the entrance of the larjmx, and is sometimes extreme. At tu'st this is chiefly on inspiration, but it soon comes on with exph-ation also. Respiration, especially inspiration, is accompanied by a loud laryngeal stridor. As a result of the incomplete entrance of the air, the efforts at inspiration in- volve the neck, the epigasti-ium, and the sides of the thorax. We see with the laryngoscope, if the examination be successful, an oedematous swelling of the ary- epiglottic ligaments, and often a swelling of the epiglottis and the false vocal cords. Sometimes we succeed in feeling the swollen jjarts with the finger. If the dyspnoea reaches a degree which threatens life, an operation is the only thing which can afl^ord relief. Laryngologists attempt to reduce the swelling by long incisions in the oedematous parts. If this does not succeed, ti-acheotooiy must be performed. If the immediate danger to life is thus averted, further treatment should be directed to the disease which has given rise to the oedema. CHAPTER V. TUBERCULOSIS OF THE LARYNX. {Laryngeal Phthisis. Consumption of the Larynx.) .ffitiology. — Since tuberculosis of the larynx is in most cases combined with tuberculosis of other organs, especially of the lungs, we must refer to the descrip- tion of tuberculosis of the lungs for the general Eetiology and pathology of the disease. A particular description of the special appearances in laryngeal tuber- culo.sis, is, however, justifiable, because tuberculosis may at times begin in the larynx and may remain isolated there, at least for a time ; and, furthermore, in many cases of laryngeal tuberculosis, which are evidently combined with jiulmonary tuberculosis, the laryngeal symptoms ai-e predominant in the clinical picture of the disease. Many physicians have, wrongly as we think, disputed the fact that tuberculosis can begin in the larynx. Clinical experience not infrequently teaches us that men, who up to that time were apijarently in good health, are attacked with hoarseness, the disease being at first thought to be a common laryngitis, hut at last, by its later course, proving to be a tuberculosis. In s])ite of the most careful examination, there are not to bo found at first the slightest physical signs of disease in the lungs, and not till later do the manifest signs of a pul- monary tuberculosis succeed the symptoms of a lai'^nigeal affection. In such cases it seems to us an affectation to claim that there is a primary pulmonaiy tubercu- losis which could not be made out at first. Everything is much more in favor of the opinion that the tubercular poison, the tubercle bacilli, may sometimes first TUBERCULOSIS OF THE LARYNX. 137 fix upon the larynx, excite the first symptoms of tubci'culosis there, and only later attack the lungs. In the majority of cases of laryngeal tuberculosis the symptoms are devel- oped, of course, secondarily in the course of chronic pulmonary phtliisis. We shall see that in these cases the disease of the larynx is to be considered as the result of an infection of the mucous membrane of the larynx by the tuberculous sputum which passes over it. In about one fourth of all cases of pulmonary tuberculosis this complication occurs, if we include all the mild diseases of the larynx. Marked and extensive tuberculosis of the larynx is much rarer, however. Pathological Anatomy. — In its anatomical appearances the laryngeal affection which complicates pulmonary phthisis or occurs primarily is at first usually a simple catarrh of the mucous membrane, which does not differ in any remarkable way from any other lai-yngeal catarrh. Shallow erosions, too, on the vocal cords or between the arytajnoid cartilages have nothing characteristic in them- selves. In fact, it is even hard to decide whether tlae simple laryngeal catai'rh and superficial ulcers in the larynx, which often occur in phthisical patients, are really in every case specific tubercular affections. Perhaps they are often only the result of the mechanical irritation from the frequent cough or of the chemical irritation from the sputum. This question is to be decided fhially onlj' by the discovery of the special tubercle bacilli in the laryngeal affections of phthisical patients. The more marked changes in the larynx in phthisical patients, however, are without doubt always of tubercular origin. In these we find a characteristic tubercular infiltration, with the formation of miliary tubercles in tlie mucous and submucous tissues. When the infiltrated parts break down, extensive ulcers are formed which always extend farther, and whose favorite seat is on the arytsenoid cartilages, the vocal cords, and the epiglottis. From the latter the iilcers not infrequently extend to the back of the tongue. In severe cases we often find a marked collateral ojdema in the neighboring parts accompanying the inflam- mation, and sometimes the tubercular perichondritis which has already been de- scribed. Clinical Symptoms. — In the beginning of tubej-culosis of the larynx the lai"yn- goscope usually shows nothing but the appearances of a simple catarrh. In the later stages, however, most of the special signs of the destructive tubercular pro- cess, like ulcers, infiltration, etc., can be very satisfactorily made out. In fact, we often get in this way a better picture of the disease than we do at the au- topsy, for the hyperasmia and swelling of the parts are much diminished in the cadaver. The other clinical symptoms of tuberculosis of the larynx vary very much with the extent and intensity of the process. Sometimes they consist merely in mod- erate roughness and hoarseness of the voice, but in other cases they increase to the most painful condition which is ever seen in any variety of tuberculosis. This is especially apt to be the case if the ulceration involves the epiglottis and the arytaenoid cartilages. Swallowing is then extremely painful, so that the uutriticn is very often impaired, and painful attacks of coughing frequently occur. If severe ulcerations attack the vocal cords, and their free mobility is affected to a marked degree, the hoarseness increases, and finally reaches a complete aphonia. Death finally occurs from general inanition, or, exceptionally, from oedema of the glottis. The diagnosis of tuberculosis of the larynx is not difficult if pulmonary phthisis is already known to be present. When attention has been called to it from the onset of hoarseness or from some disturbance in swallowing, we recognize 138 DISEASES OF THE EESPIEATOEY ORGANS. the character and seat of the changes by the aid of the laryngoscope. The diag- nosis, however, may present much difficulty in cases where we are not sure that an affection of the lungs co-exists. As has been said, the symptoms at first are not unlike those of a simple catarrh, and the suspicion of the existence of tuberculosis is first ai'oused from the stubbornness of the disease, the condition of the patient, some inherited taint, the onset of fever, and the remarkable emaciation. With the changes in the larynx which have been described the distinction between tuberculosis and syphilis may be very difficult. In syphilis of the larynx, how- ever, we find that co-existing changes in the pharynx are much commoner than in tuberculosis, and the cicatricial fonnation which is usually visible fur- nishes, besides, a very characteristic evidence of syphilis. The diagnosis of tuber- culosis of the larynx, however, is made perfectly certain in all doubtful cases by the discovery of tubercle bacilli in the patient's expectoration or in the secretion from the ulcer, which often can be easily obtained by the aid of a fine laryngeal brush. In regard to the laryngoscopic appeai-ances, we may also say that a thick infiltration of the epiglottis with a partial ulceration of the same is an appearance which is almost exclusively confined to tuberculosis. The same is true with regard to a marked projecting infiltration of the inter-ai-ytaenoid re- gion. For the general treatment of tuberculosis the reader is referred to the con- sideration of pulmonary tuberculosis. We shall here discuss merely the local treatment. This is in the milder forms the same as for simple laryngeal catarrh. There is no doubt that even genuine tuberculous ulceration of the larynx may be healed. Nevertheless permanent cures of this sort are exceptional. Of coui-se very much depends upon the general condition of the patient, and upon the co- existing state of the lungs. For local treatment insufflations of iodoform and iodol were for a time strongly recommended, but they are now for the most part abandoned. Of late the best results, comparatively speaking, have been reported from the local employment of lactic acid, in a solution of thirty per cent, to eighty per cent, and preceded by cocaine, and of menthol in a twenty-per-cent. solution in oil. But all these methods of treatment demand considerable dexterity. Inhalations are for the most part merely palliative. We have always obtained the best satisfaction in this regard from inhalations of Peruvian balsam. It is our conviction that for any true advance in the treatment of laryngeal tuberculosis we must look to surgery, and not to endo-laryngeal manipulations, which are always unsatisfactory even in the best hands, but to a complete excision of the diseased tissue by means of laryngotomy. In advanced cases it will usually be found advisable to employ merely palliative treatment. The constant use of cracked ice, and especially a lavish employment of narcotics, form the best means of lessening the pain and the difficulty in swallow- ing. Subcutaneous injections of morphine a quarter of an hour before each meal often afford great relief. Besides this, we can paint the larynx with strong solu- tions of morphine, blow in powdered morphine, or let the patient inhale solutions of morphine or bromide of potassium. Cocaine, which is an excellent local anaesthetic, excels all these, however, in potency (von Am-ep). If we paint the ulcerated mucous membrane at the entrance of the larynx with a ten- or tvrenty- per-cent. solution of cocaine, in a few minutes such an anajsthesia of the affected parts ensues that swallowing may take place without any pain. The following formula may be used : B Cocaini muriatis gr. xv-xxx fl-0-20) ; Alcohol 3 ss (2-0) ; Aquae destillatae ^ 3 ij (8'0). M. PARALYSES OF THE LARYNGEAL MUSCLES. 139 Unfortunately, the action of cocaine is extremely transitory, so that the paint- ing must be repeated over and over again. CHAPTER VI. PARALYSES or THE LARYNGEAL MUSCLES. 1. Paralyses in the Distribution of the Superior Laryngeal Nerve.— The supe- rior laryngeal nerve, arising- from the vagus, is the sensory nerve for the mucous membrane of the upper portion of the larynx down to the glottis, and also for the mucous membrane of the epiglottis and its neighborhood. Besides this, it also supplies motor fibers to the crico-thyroid muscle. Clinical experience rendere it probable that the superior laryngeal nerve also supplies the depressors of the epiglottis, the thyro-epiglottideus, and the arytasno-epiglottidei muscles, and per- haps also the aryttenoideus muscle. The last three muscles mentioned, however, perhaps derive some motor fibers from the recurrent nerve also (the inferior laryngeal nerve). Paralysis of the crico-thyroid muscles and of the depressors of the epiglottis is seen most frequently after recovery from diphtheria. It is usually a part of a more extensive paralysis, and, in addition, is frequently associated with anajsthe- sia of those parts of the mucous membrane which, as we have seen, derive their sensory fibers from the superior laryngeal nerve (von Ziemssen). Paralysis of the thyro-epiglottideus and the arytseno-epiglottidei muscles is recognized by the immobility and the erect position of the epiglottis, which is directed toward the back of the tongue. Paralysis of the crico-thyroid muscles makes the voice rough, and especially renders the production of high tones impossible, since for this purpose we need the action of this muscle as a tensor of the vocal cords. The detection of this paralysis by the laryngoscope is extremely difRcult. Its chief signs are a con- cavity of the edges of the vocal coi'ds, a lack of visible vibration in them, and perhaps, in unilateral paralysis, a higher position of the vocal cord on the sound side. For paralysis of the arytajnoideus muscle, vide infra. 2. Paralyses in the Distribution of the Inferior Laryngeal or Eecurrent Nerve. — The recurrent nerve supplies with sensory fibers the mucous membrane of the inferior cavity of the larynx below the glottis, and it is the motor nerve for all the laryngeal muscles except the crico-thyroid, and except possibly the depressors of the epiglottis {vide sxipra). The muscles innervated by it are arranged according to their function in the three following groups: a. The openers of the glottis— the posterior crico-arytsenoid muscles alone. 6. The closers of the glottis— the lateral crico-arytEenoids and the arytasnoideus (transverse and oblique). c. The tensors of the vocal cords— the thyro-arytajnoids, which act usually as closers of the glottis, but which very often produce the fine differences in tension in the vocal cords which are necessary in singing and in modulations of speech. They accordingly have the same task as the coarser- working crico- thyroid muscles, which are innervated by the superior laryngeal nerve. The motor fibers for all these muscles have their special origin in the accessory nerve, from which they pass into the trunk of the vagus, and from this into the laryngeal nerves. Most of the paralyses of the recurrent nerve are of peripheral origin. Except 14(1 DISEASES OF THE RESPIRATORY ORGANS. in the pure muscular pareses (vide supra), wliich arise not infrequently in the course of other lai-yngeal affections, peripheral paralyses of the vocal cords occur with the greatest relative frequency from an abnormal pressure on the trunk of the recurrent nerve, especially in aneurism of the arch of the aorta, which may cause a left-sided paralysis. Tumors of the bronchial glands, cancer of the oesophagus, thyroid or mediastinal tumoi-s, and, in rare cases, even large pericar- dial effusions, may also cause a paralysis of the recurrent on one side. Paralyses on the right side are seen quite frequently in contractions at the apex of the right lung and in the rare cases of aneurism of the subclavian artery. The paralyses of the laryngeal muscles, which are sometimes met with after recovery from dijih- theria {q. v.), also belong to the peripheral pai-alyses of the recm-rent nerve, and theu" cause is to be found in a degeneration of the branches of the affected nerves. In other cases the paralysis of the recurrent nerve is duo to an aifection of its fibers in the vagus or even in the accessorius. Excluding certain injuries from operations, these affections are usually due to new growths which cause a paralysis of conduction. Paralyses of the recurrent nerve also arise from aifec- tions of the nucleus of the accessory nerve in diseases of the medulla, in the different forms of acute bulbar paralysis, in chronic bulbar paralysis, in midtiple sclerosis, etc. The frequent hysterical paralyses in the distribution of the re- current nerve are to be regarded as cerebral. Finally, paralyses of the laryngeal muscles are sometimes observed for which we ai-e not in a position to find any cause. 1. Complete Paralysis of the Recurrent Nerve. — Paralysis of all the laryngeal muscles supplied by the recui-rent nerve occui-s quite frequently in the pressure paralysis of the trunk of the recuri-ent, or of its fibers in the vagus. With the larj-ngoscope (see Fig. 14) we fuid the vocal cord on the jiaralyzed side in a middle position, often falsely called a "cadaveric ijosition,'' and completely motionless on respiration, and also on phonation. On pho- nating as strongly as possible, the vocal cord on ' ^ ^ '' the sound side passes beyond the median line, „ , , ,„ „ ^ „ •.■ the aiTta3noid cartilage also crosses the line, and Fio. 14.— (From ZiEMSSEN ) Pofiition '' ... . , ,. . on inspiration in paralysis of the consequently the glottis IS pvit in an oblique posi- left vocal cord, or paralysis of ,. mi ',■, , ,. i:™i,4. conduction in the recurrent nerve, tion. The other symptoms are sometimes so sllglit that without a laryngoscopic examination we do not even think of a paralysis. The speech, howevei-, is usually not pure; it often breaks into a falsetto, and the patient is easily tired by speaking. With bilateral paralysis of the recurrent nerve, which is very rare, we find both vocal cords motionless in a middle position. Complete aphonia exists, and it is impossi- ble to cough, since in coughing we have to make at first a complete closure of the glottis. Tliere is no dyspncca, however, if the patient keeps quiet. 2. Paralysis of the Dilators of the Glottis, tae Posterior Crico-arytsenoid Muscles, — Bilateral paralysis of these muscles is a very rare phenomenon, but clinically it is of the utmost importance, since it results in a condition of mo.st marked inspu'atory dyspnoea. This condition develops gradually, and usually ■without any cause that has been satisfactorily determined. There is probably some afPection of the nerves themselves which fijially leads to the paralysis.* In most cases the disease lasts for years. The dyspnoea may increase, especially from external causes, to severe attacks of suffocation, and tracheotomy is frequently * It is remarkable, liowcver, that a purely mechanical hindrance to the dilatation of the glottis may occur from the formation of anchylosis in the crico-arytsenoid articulation. PARALYSES OF THE LARYNGEAL MUSCLE3. 1^1 necessary. In paralysis of the dilators of the glottis the respiration Ls so changed that inspiration only is difficult, protracted, and noLsy, while expiiation is free and unhindered. This depends on a valve-like ac- tion of the vocal cords. They are drawn together by the dilatation of the thoi-ax on inspiration, while the current of air in expiration easily pushes them aside. Phonation is usually entirely undisturbed. With the laryngoscope (see Fig. 15) we find the glottis changed to a small slit, which grows nar- i'^^'' rower instead of wider on inspiration. The prognosis is usually unfavorable. Only in the hysterical can these aijiwrently severe condi- Fio i5.-(FromZiEMssEN.)-Complete ^ ... . bilateral para.ysis of the posticus tions appear and chsaijpear again m a short time. at the momeuc of inspiration. 3. Paralysis of the Thyro-arytaenoid Muscles,— The paralysis or paresis of these muscles, which run into the vocal cords, and which are their chief tensors, is one of the most frequent of the paralyses of the laryngeal muscles. It occurs especially in acute and chronic catarrh of the laryn- geal mucous membrane, and is often the chief cause of the accompanying hoarse- ness. It also frequently develops as the result of an habitual over-exertion of the voice in singers and public speakers, and it is one of the commonest causes of hysterical aphonia. Paralysis of the thyro-ary tsenoid muscles may be bilateral or unilateral. It is fre- quently associated with a paresis of the other closei-s of the glottis, the arytajnoidei and the crico-thyroid muscles. With the laryngoscope (see Fig. 16), in the ordina- ry bilateral paresis of the thyro-arytsenoid muscles, we see that on phonation the glottis does not close completely, but that an oval space is left between the vocal cords. In unilateral paralysis the affected cord shows a concavity of its edge. The voice is always more or less hoarse and low and the speech is strained. In many cases, after a cure of the original catarrh, a complete recovery from the paralysis may follow by taking- good care of the voice. Hysterical paralyses are diagnosticated by their sudden disappearance and reappearance, usually after some psychical disturbance. They are quite common in children of the age of ten to fourteen years, especially in girls. (See the chapter on hysteria.) 4. Paralysis of the arytsenoideus muscle is rarely an isolated phenomenon. It is sometimes seen in laryngeal catarrh or in hysterical aphonia. The voice is quite hoarse, and with the laryngoscope (see Fig. 17) we find on phonation that the whole anterior part of the vocal cords closes well, but that the cartilaginous glottis remains open as a triangular gap on account of the imperfect motion of the arytasnoid cartilages to- ward each other. When the thyro-arytasnoids are paralyzed with the arytaenoideiis, the glottis shows on Fm. 16.-(From Zt^MssEN.WPa- pl^onation a narrow hour-glass opening (see Fig. 18). ralysis of both internal thvro- Both the anterior and the posterior portions of the course of au acute'iaryngitis^ glottis fail to close, while the vocal processes take their usual median position on phonation from the normal tirrning of the arytenoid cartilages inward by the action of the lateral crico-ary- taenoid muscles. 5. Paralysis of the lateral crico-arytsenoid muscles, as an uncomplicated con- dition, has never been observed with certainty. Some cases of a complete and simultaneous paralysis of all the closers of the glottis have been described, how- ever, in which the vocal cords are immovable laterally and the glottis remains abnormally wide open. 142 DISEASES OF THE RESPIRATORY ORGANS. We may expect success from the treatment of paralysis of the vocal cords only when the primai-y disease is capable of cure. If caliirrhal or other diseases of the Fig. 17.— (From Ziemsses.) Paraly- sis of the arytojnoideus in acute laryngitis. Fio. 18.— (p'rom Zikmssen.) Bilateral paralysis of the thyro-arytfenoids combined with paresis of "the ar>'t- tasnoideus. larynx co-exist, we must first ti-eat these by the methods already mentioned. Paralysis from the compression of tumors, etc., may be relieved in rare cases by extirpation, or by partial resolution of the tumors when of strumous origin. In catarrhal, diphtheritic, and the so-caUed " rheumatic " pareses — that is, those which occur without any assignable cause — and also in all hysterical aphonias, electricity often works very well. A very rapid recovery sometimes occurs in hysterical paralyses, but it is not always permanent. We commonly employ ex- ternal faradization of the neck or galvanization through the larynx, combined with frequent changes of the current. Ziemssen has made electrodes for the endo- laryngeal irritation of single muscles. Internally we may prescribe preparations of iron and small doses of quinine, especially in ancemic patients. Subcutaneous injections of strychnine are also of advantage, in doses of gr. nV to gr. | daily (grm. 0-003 to O'Ol). Methodical efforts at speaking and breathing are of great service in hysterical aphonia. CHAPTER YII. SPASM OF THE GLOTTIS. (Millui's Ast/ima. Thyinic AMhma.) .ffitiology, — Spasm of the glottis is a disease which occui-s almost exclusively in children under three years of age, and which consists of attieks of spasmodic closure of the glottis, and consequently of most severe dyspnoea. Boys are more frequently attacked by this disease than girls, but the cause of this is wholly unknown. The old name of thymic asthma arose from the idea that the at- tacks were due to an increase in the size of the thymus gland, but this opinion is wholly unfounded. The relation between spasm of the glottis and rachitis is remarkable, but it is miexplained. Nearly two thirds of all the children who suffer from spasm of the glottis are rachitic, but the opinion which was once held that spasm of the glottis has a special relation to the rachitic craniotabes is not clearly proved. The fact that it is often combined with eclamjisia, in that the attiicks of spasm of the glottis are aggravated by eclamptic attacks, and that the two alternate with each other, is an argument in favor of a centi-al origin for the disease. In the cases which come on, as they often do, at the time of denti- tion, we think it possible to assume a reflex origin for the spasm, just as we may in tho.se cases which seem to follow a laryngitis due to taking cold. Symptomatology. — The single attacks usually come on suddenly by day or by DISTURBANCES OF SENSIBILITY IN THE LARYNX. 143 night, either without auy cause or from some external influence, like crying, swallowing fluid, or some psychical disturbance. They usually begin with a deep inspiration, followed by complete cessation of respiration. The child becomes pale, cyanotic, looks anxiously about, rolls his eyes, and makes strained and labored efforts at respii'ation. In severe cases there is a temporary loss of con- sciousness, and tonic and clonic spasms in the muscles of the extremities and the trunk, as has been mentioned. The attack lasts from some seconds up to two minutes. In very severe cases the attack may be immediately fatal. As a rule, however, the spasm passes off, deep, noisy inspirations follow, and in a short time the child is completely well. The severity of the attacks varies, moreover, in different cases, and it varies very markedly, too, iu the same child. Sometimes we have only one attack or a small number of them, while in other cases they may come on ten or twenty times a day, and even oftener, and may last with varying intensity for months. If the child reaches his third yeai- the disease almost always disappears, but quite a large number of the children who suffer from spasm of the glottis die beiore that age, either in the attack itself or from other affections. Pure spasm of the glottis hardly ever occurs in adults, but similar attacks are sometimes observed in hystei-ia. The treatment must be especially directed to the child's general condition. The child is usually pale and emaciated, aud if we succeed in improving its nutri- tion with iron and cod-liver oil, the attacks become less frequent, milder, and finally may wholly disappear. The cliild should also be kept in moderately warm air and guarded from any exposure to cold. Internal remedies to prevent the recm-rence of the attacks are very uncertain in their action. We may employ bromide of potassium, ten to thirty grains daily (grm. 5-2 0); musk, ten drops of the tincture every hour or two ; oxide of zinc, etc. In the attack itself the child must be raised up. The face should be sprinkled with water, or, if the attack be of long duration, a cool shower-bath should be given. Friction should be applied to the skin, aided by mustard, or a mustard plaster to the chest and calves. If the attacks are very frequent and intense, we must use narcotics, either inhalations of chloroform or subcutaneous injec- tions of morphine, with care, in doses for a child of -jV to -jJj of a grain (grm. O'OOl to 0-005). CHAPTER VIII. DISTURBANCES OF SENSIBILITY IN THE LARYNX. DiSTUEBANCES of sensibility in the laryngeal mucous membrane have been observed especially in the distribution of the superior laryngeal nerve, in the epi- glottis, and in the superior cavity of the larynx above the glottis; but in rare cases they are also observed in the lower portion of the larynx, which is supplied with sensory fibers by the recurrent nerve. They are most frequently associated with motor disturbances, particularly with hysterical paralyses, but they are also quite often found in paralyses of diphtheritic origin. Anajsthesia of the larynx is rec- ognized by the lack of sensation which the patient shows when we touch special parts of the larynx with the point of a sound. The choking and coughing reflexes are almost always absent, so that we can touch the whole enti-ance of the larynx with the finger without causing discomfort. The absence of the reflexes may sometimes be dangerous, especially in severe diphtheritic and bulbar paralyses, for, as a result of it, small portions of saliva may 14-1: DISEASES OF THE RESPIRATORY ORGANS. reach the larynx in swallowinj^, and fail to he couffhed up, but may be drawn do^NTi into the lungs, where they set up a bronchitis and a lobular pneumonia. This danger is especially great if at the same time the patient can nrit cough forcibly, as is frequently the case in imperfect closure of the glottis. Hysterical anaesthesia is the only form where there is no fear of the development of inhala- tion diseases in the lungs. An effective prophylaxis against the dangerous condition just described is possible only by feeding patients, who have much weakness in swallowing and coughing, by means of the oeso])hageal tube. CHAPTER IX. NEW GROWTHS IN THE LARYNX. Since new growths in the larynx are of interest rather to specialists and sur- geons, we will here only glance briefly at them. We must remember especially, however, that they can he recognized only by the aid of the lai-yngoscope. It unfortunately often happens that a patient is treated for a long time without success for a "' chronic laryngeal catarrh," until the laryngoscope finally shows that a new growth is the cause of the hoarseness. It is of especial importance, however, to make a diagnosis as early as possible, pai'ticularly in carcinoma, since the earlier the operation is done the better is the chance for success (vide infra). A. Benignant New Growths in the Larynx. 1. Papilloma is one of the commonest new growths in the larynx. It forms glandular, cauliflower-like excrescences, which are visually situated on the ante- rior part of the vocal cords, rarely on the false cords. The base of the swelling is broad or pediculated. We do not know the special cause of then- origin. They sometimes develop upon an existing chronic catarrh. 2. Fibroma in the larynx is comparatively common. The tumors kno\vn as '"laryngeal polyiai" are usually fibromata. They are generally situated on the Fios. 19 and 80.— (From Ziejissen.) Pediculated flbromata. vocal cords and form whitish or reddish-brown swellings, from the size of a pea to that of a cherry, and are usually pediculated (see Figs. 19 and 20). People who use their voices very much are especially liable to the formation of fibromata. 3. Cysts and''nmcous polyjii " rarely occur. They are probably due to the retention of the secretion in a mucous gland from the stoppage of its orifice. We find them in the ventricles of Morgagni, on the epiglottis, etc. The symptoms which are excited by benignant tumoi-s in the larynx depend partly upon the situation and partly upon the size of the new growth. Small polypi may exist wholly without symptoms, and are found only by chance on NEW GROWTHS IN THE LARYNX. 145 laryngoscopic investigation. Usually, however, the presence of hoarseness, press- ure, and itching in the larynx, or respiratory disturbances, when the tumor is a large one, are the symptoms which give occasion for an examination. B. Maugnant New Growths. Carcinoma of the Larynx. Cai'ciuomata develop usually in old people, either primarily in the larynx or secondarily from affection of the neighboring organs. In the first case the vocal cords or the ventricles of Morgagni ai-e the points most frequently attacked. An extension of the disease to the larynx is seen especially in cancer of the tongue or pharynx, rarely in cancer of the oesophagus. The symptoms of cancer of the lai'ynx develop slowly. Hoai-seness, disturb- ance in swallowing, pains in the larynx often shooting up into one ear, ih^ appearance of respiratory symptoms, and finally the signs of general weakness and emaciation which are seen in almost all forms of carcinoma, form the picture of the disease. The diagnosis is possible only by the aid of the laryngoscope. Besides this, a digital examination may at times be of diagnostic value by the detec- tion of the characteristic hardness about the entrance or in the neighborhood of the larynx. A general description of the laryngoscopic appearances can not be given on account of the diverse character of the cases. We see the uneven, injected new growth, covered with mucus and often ulcerated, and besides this at times the sec- ondai'y appearances of catarrh, a developing perichondritis, etc. With a little care the diagnosis is usually tolerably easy. It may be difficult, however, at times, to distinguish it from tuberculosis or from syphilis. We may be aided in such cases by the discovery of the tubercle bacilli or by the results of anti-syphilitic treatment. All the other organs of the patient therefore must always be carefully examined. Sm-gical treatment is the only one for all laryngeal new growths. We must refer to the special works for all the details. Laryngologists have devised numer- ous instnm:ients for the removal of benignant polypi, by which, under the guid- ance of the laryngoscope, the new growth is cut, snared, squeezed, or torn off. The performance of the operation is made much easier by the advantage of the local anajsthesia of the laryngeal mucous membrane due to painting with cocaine (see p. 138). Nevertheless we fii-mly believe, about these growths as well as about tuberculosis of the larynx, that the " endolaryngeal " opei-ations should be more and more superseded by laryngotomy. — Carcinoma of the larynx can be cured only through removal of the tumor by splitting the larynx or by its total extirpa- tion. The former operation is comparatively free from danger, while total extir- pation has met with success as yet in but few instances. If surgical interference is no longer practicable, we can only endeavor to mitigate the suffering of the patient by means of morphine, cocaine, and other narcotics. 146 DISEASES OF THE RESPIRATORY ORGANS. SECTION III. Diseases of the Trachea axd the Bnoxrin. CHAPTER I. ACUTE CATARRH OF THE TRACHEA AND THE BRONCHI. {TraclieUis and Acute Catarrhal Ilro/icJiitis.) iEtiology. — Acute catarrli of the larger air-passages, of the ti-acliea, and larger bronchi, is a frequent disease, and it may often arise from taking cold. It is con- ceivable that the inhalation of cold, damp air sometimes directly atfects the mucous membrane of the u]5]3er air-passages. Bronchial catarrh is very often associated with a coincident catarrh of the larynx, and more rarely of the pharynx. In the ordinai-y mild forms the catarrh is usually confined to the trachea and the first large branches of the bronchi, while the finer bi-onchi remain healthy. More intense inflammation of the bronchial mucous membrane is the result of active mechanical or chemical irritation. A severe bronchitis develops after the inhalation of noxious gases, nitrous and sulphurous oxides, chlorine, bromine, etc., as is often observed in operatives. The inhalation of smoke and dust, especially vegetable dust, works in the same injurious fashion, ami the foUowei-s of many trades and employments, like millers, coUiei-s, etc., are especially subject to disease from this cause. In this form of bronchitis the catarrh often extends to the finer bronchi. The bronchitis which develops in the coui'se of other acute and chronic diseases is still commoner than the primai-y forms already mentioned. It is often due to infectious causes, like certain infectious diseases, especially measles, whooping- cough, and influenza. In the.se chseases broncliitis is one of the most constant local affections, and is probably immediately dependent upon the pi-imary infec- tion. Bronchitis, however, develops secondarily in most of the other acute in- fectious diseases, and is largely due to the inhalation of noxious substances from the upper part of the air-passages. This is the explanation of the bi-onchitis in diphtheritic processes in the pharynx and larynx, in so far as it does not depend upon a direct extension of the disease, and also of the bronchitis in small-pox, etc. Bronchitis may also be met with in all other forms of severe disease, because re- tention of secretion, inflammation, thrush, etc., arise in the cavity of the mouth and phai-ynx, and from them chemical or organic irritants may easily be inhaled into the bronchi. The imperfect expectoi'ation in all severe diseases is a still more haj'mful factor than this inhalation. The secretion remains in the bronchi, processes of decomposition arise in the stagnating mucus, bacteria collect and lead to a bronchitis, and finally to a lobular pneumonia which is so often found (vide infra). The swallowing and inhalation of portions of saliva, which easily decom- pose, is also a frequent cause of secondaiy bronchitis. We do not know how far we may claim that infectious agents act as a cause of primary bronchitis, yet it is not improbable that many cases have such an aetiology. It is especially likely that many cases of bronchitis due to " catching cold " really have something infectious about them, and that the preceding exposure to cold has merely lowered the natural powers of resistance, and thus permitted, or at any rate promoted, infection. Finally, we must mention that an acute bronchitis is sometimes merely an ex- acerbation of a previous chronic bronchitis. The predisposition to acute bronchitis varies in different persons. We do not ACUTE CATARRH OF THE TRACHEA AND THE BRO^'CHI. 147 know definitely on what ground such an increased predisposition to broncliial dis- ease rests, nor why we meet with it sometimes in the weak and anajraic, and at other times in the so-called " f ull-Vjlooded " persons. Bronchitis is more frequent in children and old people than in those in middle life. Most of the cases occur in the spring and autumn. Symptoms. — Pain in the chest may be present in some cases of simple catarrhal bronchitis, but usually only in a moderate degree. In severe tracheitis patients often have a painful feeling of soreness in the neck and behind the upper pai-t of the sternum, and this is increased on coughing. The mucous membrane of the bronchi, apparently, has no nerve-fibers which are sensitive to pain, and the pains in the chest which are often present in bronchitis are, as a rule, muscular pains in the intercostal muscles, diie to the severe paroxysms of coughing. Cough is ojie of the most constant symptoms of bronchitis, and by it usually the attention of the patient or of the physician is fu-st called to the existing thoracic affection. The cough may of course be due to a laryngitis, if that is also present. Thei-e is no doubt, however, but that a cough may be excited in a reflex manner from the mucous membrane of the trachea and of the larger as well as of the finer bronchi. Experiments have shown that the jDoint of bifurcation of the trachea is especially irritable, and many severe paroxysms of coughing may be due to an irritation of this very spot from the accumulation of secretion. The intensity of the cough, moreover, is very different in individual cases, which is due in part to the degree and extent of the bronchitis and in part to the reflex irri- tability of the person affected. The expectoration consists of the secretion from the inflamed mucous mem- brane. . Its abundance and consistency vaiy very much in the different cases. We distinguish a catarrh with an abundant secretion, and the so-called "dry catarrh." In the latter only a little viscid sputum is expectorated, but in the former the expectoration is more abundant and muco-purulent. Very often in the beginning of the disease the expectoration is scanty and viscid — the sputum criidimi of the old physicians; and later it becomes more abundant, more fluid, and more purulent — the sputum coctum. In catarrh of the finer bronchi the expecto- ration may contain little mucous or muco-purulent casts of the bronchi. A simple catarrhal expectoration shows nothing peculiar under the microscope. The pus- corpuscles are often swollen, and show more or less marked fatty degeneration. A slight admixture of blood may occasionally be present in severe bronchitis, but it usually has no special significance, being at times merely the result of severe fits of coughing. A more marked and persistent admixture of blood is seen in the catarrhal sputum in some cases of intense bronchitis in di'unkards, so that we may even speak of a " hsemorrhagic bronchitis. " Dyspnoea is visually entirely absent in simple bronchitis, but marked shortness of breath may be noticed in extensive catarrh of the finer bronchi. Physical Examination. — We may obtain direct evidence of the condition of the tracheal mucous membrane, with due practice, by the larjnjgoscope. We see a reddening of the membrane, and sometimes an abnormal abundance of secretion on it, if there is a tracheitis. Other methods of physical examination are at our service for judging of the changes in the bronchi. Inspection of the thorax shows nothing abnormal in the milder forms of bron- chitis. The resph-ation is somewhat accelerated and the expiration prolonged in severe bronchitis, especially if the finer bronchi are affected. Percussion in uncomplicated bronchitis shows nothing abnormal in the pulmonary resonance. Auscultation, too, shows nothmg unusual in many cases of mild catarrh limited to the trachea and large bronchi, but in the cases where the smaller bronchi are the seat of the catarrh and there is a marked accumulation of secretion in them, 14S DISEASES OF THE EESPIRATOEY ORGANS. we hear, besides the vesicular respiration, the so-called rhonchi which almost wholly hide it. In dry bronchitis we speak of humiuLng or buzzing sounds, sonorous rhonchi, or slirill, whistling sounds, sibilant rhonchi, according to their pitch. These sounds are probably due to stenosis, and are caused by the passage of the au" thi-ough narrow portions of the bronchi. The narrowing- occurs in part from the swelling of the mucous membrane, in part from the accumulation of secretion. The masses of secretion themselves, if they are set in vibi'atioii at the same time, may possibly take part in the production of the humming noises. If the amount of secretion collected in the bronchi is more abundant and of a more fluid consistency, it gives rise to "moist rales" on the passage of the air. These are distinguished as " medium " or " small moist rales," according as they occur in the larger or smaller bronchi. Other symptoms of disease are often present besides those already mentioned as being du-ectly due to the bronchitis. The general health is usually disturbed in a severe bronchial catarrh. The patient does not feel well, and has less appe- tite than usual. A moderate amount of fever is often present, especially toward evening. An Increase of temperature above 103° or 103° (139° C.) is rarely seen except in children. The patient sometimes complains of headache, which is in- creased by severe coughing. The separate forms of bronchitis are distinguished chiefly by the degree of extension of the catarrh. 1. The Milder Forms of Acute Bronchitis. — In most cases of simple primary bronchitis, as well as in many mUder attacks of secondary bronchitis, the catai-rh is limited to the raucous membrane of the larger bronchi. Exposure to cold and other injurious influences are frequent causes of the primary form. The s^-mp- toms are moderate. The cough, however, may be quite troublesome. Often fever is absent or but slight. Upon auscultation, particularly over the lower lobes, but sometimes over the entire lungs, and usually with some symmetry of distribution, are heard numerous rather coarse wheezing or rattling sounds ; but in many cases, as we have said, there may be nothing abnormal heard, so that the diagnosis will have to rest merely upon the subjective discomfort in the chest, the cough, and the expectoration. With proper care, simple primary bronchitis runs its course in a few days, or at the most in a few weeks, and ends in complete recoveiy. If the patient exposes himself recklessly, or the setiological factors continue to be active, the disease may however prove to be very tedious, and finally develop into cluxinic bronchitis. 2. The Severer Febrile Forms of Acute Bronchitis.— Sometimes acute bron- chitis assumes a severer form, whether because the influences which give rise to it are unusually violent, or because it is due to some special and as yet little known cause (perhaps infectious). In such cases the symptoms are more mai-ked, the bronchial rales more abundant, the general condition of the patient worse. Not infrequently there is fever for several days, or even for oup or two weeks, the type being u-regularly remittent, but the temperature seldom exceeds 102° or 103° (39° to 39'5° C). The avilhor has not infrequently noticed that there is more liability in the severer forms of acute bronchitis to have the disease mainly limited to one lobe, or at least to one lung, but the disease may be diff'use. This form of the dis- ease also has a favorable prognosis except in fcol>le or elderly pei-soiis. 3. Catarrh of the Finer Bronchi— Capillary Bronchitis.— A simple i^rimary bronchial catai'rh rarely extends to the finer bronchi in adults. The secondary bronchitis, however, which develops in other severe diseases (vide sujjra), often extends into the ultimate divisions of the bronchi, and finally leads to the forma- tion of nodules of lobular pneumonia — "catarrhal pneumonia" (vide infra). We recognize the implication of the finer bronchi by hearing the high, shrill, whist- ACUTE CATARRH OF THE TRACHEA AND THE BRONCHI. 149 ling rhonchi [sibilant rhonohi], or the abundant small, moist rales. Respiratory symptoms may be quite marked in extensive catarrh of the liner bronchi. Res- piration is evidently accelerated, and expiration is usually prolonged. There is often quite a severe cough. The expectoration is muco-purulent and usually not very abundant. Capillary bronchitis in children is of great practical importance. Every bron- chitis in young children has, as experience tells us, a tendency to attack the smaller bronchi. Extensive bronchitis is seen especially in weak children who are rachitic or predisposed to tuberculosis. Children have an especial predisposi- tion to be attacked with bronchitis at the time of the fii-st dentition, but it is also seen at an even earlier age. The parents' attention is usually called to the disease by the appearance of a cough, which is excited especially by the child's crying. Small cliildren never expectorate, for they swallow the secretion which is coughed up into the pharynx. The rapidity of respiration is very striking, it being increased to sixty or eighty, or even more, in a minute. The respiration is also labored, but it is usually super- ficial, and in severe cases irregular. There is generally a distinct respiratory play of the alas nasi. We often see a retraction of the lower lateral portions of the thorax on inspiration as a result of the imperfect entrance of air into the smaller bronchi. The expiration is frequently noisy and groaning in children. We hear extensive small, moist rales over the lungs. In severe cases the child becomes restless, anxious, perhaps markedly pale and cyanotic, and finally apa- thetic and stupid. In such cases, however, we have no longer to deal with simple buonchitis, but catarrhal pneumonia has already developed. The disease almost always runs its course with fever, the temperature rising to 104° (40° C.) and over. The pulse is increased to ISO or 140 or more per minute. The duration of the disease is seldom less than two or thi-ee weeks, and it may last much longer. Death may ensue, especially in ill-nourished childi-en, partly as a result of general weakness, and also directly from the imperfect respiration. In such cases we find at the autopsy not only diflfuse bronchitis, but also almost always lobular pneu- monia. In many cases a gradual recovery finally takes place in spite of the most severe symptoms. The secondary bronchitis in children complicating measles, whooping-cough, diphtheria, etc., has the same tendency to involve the finer bronchi and to lead to lobular pneumonia. In conclusion, we must mention that acute bronchitis in old people also readUy attacks the finer bronchi, and may be dangerous pai-tly from the general exhaus- tion, partly from the occurrence of respiratory symptoms, as in lobular pneumonia. Diagnosis. — The diagnosis of bronchitis presents no special difliculty. It is obtained directly by the discovery of rhonchi on auscultation. If these fail, we conclude that there is a mild catarrh of the larger bronchi from the presence of cough and expectoration, if no cause for the cough is to be found in an affection of the larynx. The question is more difficult, but it must always be considered, whether a given bronchitis is a common primary catarrh or secondary to some other affection. This question naturally can be decided only by a very careful examination of the body. We must always remember, fm'thermore, that severe pulmonai'y affections may be at first quite latent and show objectively merely the signs of simple bronchitis, while later pneumonia, a tubercular affection, or some- thing similar, develops. A bronchitis which is unilateral, or in which the signs are to be found in circumscribed localities, must therefore be regarded as suspi- cious. It has long been known that bronchitis in the apices of the lungs, the " apex- catarrh," is often the first objective change to be met with in pulmonary phthisis. We can only conjecture, and not pronounce with certamty on objective evidence. 150 DISEASES OF THE RESPIRATORY ORGANS. whether nodules of lobular pneumonia are present or not in diffuse bronchilis affecting the liner bronchi. From what has been said, it is clear that we should be cautious in our prog- nosis regarding every severe bronchitis, especially in children and old people. The prognosis in the milder forms of bronchitis is of cour.se always vei-y favor- able. Treatment. — The prophylaxis of primaiy bronchial catarrh consists in the removal of all the injurious influences mentioned which, as experience shows, may give rise to a broncliitis. A careful hardening of the skin to the effects of a change in temperature is of service in persons, particularly childi-en, who have a special tendency to bronchitis, as we have already said in regard to the prophylaxis of laryngitis. It is very important to remember, in this connection, that we can also be successful in our prophylactic measures against secondary bronchitis. Keep- ing the mouth and pharynx clean, lu-ging deep inspirations, and aiding expectora- tion by the timely use of tepid baths and shower-baths, may often prevent a bron- chitis or keep it within bounds, while it would sm-ely develop if the iiatieut were neglected. Simple hygienic measures suffice in the treatment of mild cases of acute bron- chitis. The patient should be kept warm, should remain in his room, or, if there be any fever, in bed. Diaphoretic remedies have long been praised as especiallj' potent in the treatment of acute bronchial catarrh. The patient, therefore, should drink hot tea, pectoral tea* (Brustthee), or elder tea, etc., or hot milk mixed with Seltzer, a remedy whose efficacy is frequently praised by the patient. Local treatment of the mucous membrane by inhalations is usually illusory, for only the smallest ijart of the inhaled fluid reaches the bronchi. We may, however, always prescribe inhalations of wai-m steam, or a one- or two-per-cont. solution of common salt, especially with a dry cough and a secretion which is hard to loos3n. Otherwise we must employ symptomatic treatment. A mustard plaster or a cold, wet compress about the chest does good service with severe subjective thoracic symptoms. In bad cases a few dry cups may be very useful in adults, but local abstractions of blood are never necessary in simple bronchitis. If there is trouble- some irritation on coughing, so as to disturb the rest, we may prescribe small doses of morphine, five to ten grains of Dover's powder (grm. 0'3-0'5), fifteen to twenty drops of cherry-laurel water, codeine, etc. When expectoi-ation is diiRcult, we may use the so-called expectorants — ii^ecac, chloride of ammonium, apomor- phine, etc. We have already repeatedly mentioned the use of tepid baths and shower- baths, indicated in severe diffuse brouchitis developing secondarily in the course of other acute diseases. Tepid baths with shower-baths, two or three times a day, are also to be used as a most powerful remed.y in severe cases of cai)illary bronchitis in children. The baths assist expectoration and guard against the possibility of tlie development of lobular pneumonia. Wet packs applied to the thorax or over the whole body are serviceable. Children are wrapped to the neck in a sheet which has been pre- viously dipped in water at a temperature varying with the degree of the fever from 68° to 77° (16° to 20° R.) and well wrung out. It is well to leave the arms free. A dry woolen blanket may be wi-apped around the moist sheet. This pro- cedure must be repeated three or four times a day. As to other remedies, we use * A favorite German household remedy, consisting of an infusion of eight parts of althaja, three parts of licoriec, one part of orris-root, four parts of colt's-foot, and two parts eaeh of mullein and anise- Bocd. — TUANS. CHRONIC BEONCHITIS. 151 tlie same as in adults. With -weak children our care must be to keep up the strength by furnishing the most nourishing food possible and giving small amounts of wine. An emetic is sometimes indicated in cases with an abundant accumulation of mucous in the bronchi, and is of good service. As experience has shown, we should use opiates for small children only with the greatest care. Senega and benzoin may be used as expectorants. In the bronchitis of old people our chief aim should be to keep up and improve the patient's strength. We prescribe liquor ammonii auisatus, infusion of senega, etc., to aid expectoration, which is usually difficult, since the cough is feeble. Tepid baths may be of advantage, but they must be used with care. CHAPTER II. CHB.ONIO BRONCHITIS. {Chronic Bronchial Catarrh.) .Etiology. — Chronic bronchial catarrh may develop gradually fi-om external causes, or in rare cases it may follow an acute bronchitis. The same noxious influences which excite an acute bronchitis may, by the frequent repetition of their action, result in a chronic bronchitis. In a large number of cases severe chronic bronchial catarrh is not an independ- ent disease, but occurs as a complication or a result of other diseased conditions. The combination of chronic bronchitis vrith emphysema of the lungs {vide infra) is the most common. A large number of cases also are the result of some form of heart disease, like valvular disease or myocarditis, or of disease of the vessels, leading to stasis in the pulmonary circulation, and finally to a chronic catarrh of the bronchi. Chronic bronchial catarrh in renal diseases also depends, in part at least, upon circulatory disturbances. Finally, we find a more or less extensive chronic catarrh of the bronchi in other chronic affections of the lungs and pleura, as in tuberculosis or pleurisy. Chronic bronchitis is seen especially in adults and old people, and more fre- quently in men than in women. Pathological Anatomy. — Chronic bronchitis is characterized anatomically by a marked venous hypersemia of the bronchial mucous membrane. The whole tissue itself is often thickened, and the surface of the membrane is swollen. In old cases, however, we finally meet with an atrophy of all the layers of the mucous membrane. One of the most frequent results of a chronic bronchitis is a cylin- drical dilatation of the middle and lesser bronchi — ^Ijronchiectasis. This arises gradually from the loss of elasticity of the diseased bi-onchial walls, increasing their tendency to give way, as well as from the pressure of the stagnating secre- tions. Symptoms and Course of the Disease.— The symptoms which are due to chronic bronchitis are disturbances of respiration, cougli, and expectoration. To these should be added the results of a physical examination. The cough is of very different severity in different cases. Usually it is worse early in the morning, in the evening, and at night, than in the daytime. The amount of expectoration is also subject to great variations. In many cases there is a dry cough (catan^he sec, vide infra), in which only small amounts of tough, viscid sputum are expectorated. In other cases the expectoration is more abun- dant and muco-purulent, and sometimes excessive and quite thin. Microscopic- ally, it has no special characteristic ajspearances, but it contains only the usual 152 DISEASES OF THE RESPIRATORY ORGANS. elements of sputum — pus-corpuscles mbced with ijavement epithelium, often many bacteria, sometimes needles of fat acids, and rarely a few pointed octahedral crys- tals, the so-called asthma crystals {vide infra). Small amounts of hlood may be seen in severe chronic bronchitis, but they do not have any bad significance. Dyspnoea of moderate degree may also be present in uncomplicated and exten- sive bronchitis. In the cases in which it is severe, however, it is usually due to other conditions affecting the heart or lungs. Physical JExamination. — The percussion in bronchitis shows no special change. At most the resonance may be somewhat tympanitic from the relaxa- tion of the lung-tissue, especially in the lower and posterior portions of the lungs, or, with an abundant retention of secretion in the bronchi, it may be a little diminished. Auscultation may give either rhonchi, whistling, hissing, humming, etc., or moist i-ales, according to the extent of the catarrh and the amount and consistency of the secretion. The sounds are usually to be heard over the whole lung, or especially over the lower lobes, because here the catarrh is usually most marked, and retention of secretion is most apt to occur. The respiratory murmm* in some places may be quite obsciu-ed by the i-ales. Otherwise it is vesicular, sometimes exaggerated, sometimes rough and indefinite. Expiration is usually prolonged. The respiratory murmur may be much diminished, or even entirely suppressed in places where the bronclii are stopped by secretion, which happens most frequently in the lower lobes. Except in mild cases, we usually distinguish several different forms of chronic broncliial catarrh, which may run into one another. 1. The dry chronic catarrh (catarrhe sec of Laennec) is the form in which the mucous membrane has only a very slight secretion. The cough is usually very troublesome and labored, but the patient raises merely a little tough sputum, or none at aU. On auscultation we hear sibilant rhonchi, but no moist rales. This form of catarrh is usually associated with pulmonary emphysema, and asthmatic attacks are also frequent. The disease is stubborn, and usually lasts for years. 2. The so-called bronchial blennorrhoea is that form of chronic bronchitis in which we find a very copious secretion from the mucous membrane. The cough is therefore associated with a very abundant and quite thin expectoration, the amount of which in the twenty-four hours may exceed a pint (half a litre). The expectoration runs together in the sputa-cup and usually separates on standing, the more purulent portion sinking to the bottom, and the sero-mucous portion, which is usually frothy on the surface, remaining at the top. Numerous moist rales are heai'd in the limgs, especially in the lower portions. These diminish if large amounts of sputum are coughed up. Anatomically, the bronchi are almost al- ways found dilated in this form of chronic bronchitis. 3. The so called serous bronchorrhcea ("catarrhe pituiteu.v" of Laennec) is quite rai-e but very interesting. It is characterized by the expectoration of a very large amount of frothj', purely serous, thin sputum. The cough usually comes on in very violent paroxysms which last from half an hour to an hour or more. The respiratory symptoms are quite severe, especially during these atta<'ks, and have given rise to the old and useful term ''asthma hinnidiun." The expectoration collected in twenty-four houi-s may amount to one or two quarts (litres). Ex- amination of the lungs usually gives very abundant and extensive moist i-ales. The resonance on percussion is normal or a little diminished, from the accumula- tion of secretion. The special cause of this peculiar disease is quite obscure. It is either an independent, very chronic trouble, which may last for years with a varying coui-se, or it may occur secondarily in other affections, especially in chronic contraction of the kidney. We once saw a very severe case of the independent and apparently CHEONIC BRONCHITIS. 153 quite uncomplicated form iu a young woman who had hig-h fever at times, aud wlio became much broken down physically. Course of the Disease. — The course of most chronic bronchial catarrhs Ls very protracted. The disease usually has frequent remissions and fresh exacerbations. The patient is tolerably well iu the pleasanter time of the year if he takes good care of himself, but in autumn and winter, or after exposiu-e to various noxious influences, the catarrh grows worse and the patient's symptoms increase. If the disease has lasted for years, we usually find symptoms in the lungs, like emphy- sema or chronic tuberculosis, or in the heart, like secondary dilatation and hyper- trophy of the right ventricle, which symptoms gradually become more severe. The details of these conditions are to be found in the appropriate sections. Diagnosis. — The diagnosis of chronic bronchitis is not difficult in itself, and may easily be made by considering the patient's symptoms and by judging of the result of the physical examination. We must always consider, however, whether the bronchitis is not a result or a complication of some other chronic disease. Therefore in every case of chronic bronchitis the heart and the urine must be carefiilly examined, as well as the lungs. Prognosis. — Chronic bronchitis is in most cases a very stubborn affection, which frequently shows improvement, but from which complete recoveiy is rare. The prognosis also depends greatly upon the patient's circumstances, and upon the possibility of his taking care of himself and avoiding all harmful exposure. In secondary bronchitis the question whether the bronchitis is capable of material improvement or not of course depends mainly upon the prognosis of the primary disease. The danger in primary chronic bronchitis comes from the final development of its sequela, especially from the gradual appearance of pulmonaiy emphysema, dilatation of the heart, etc. Treatment. — The only hope of success in severe cases in any method of treat- ing chronic bronchitis is in removing the patient completely, at least for a time, from the action of injurious influences. The favorable result of the baths and health resorts that are employed depends largely upon this, that patients enjoy in them complete bodily rest, and are far better protected from dust and the changes in the weather than at home. We must make the patient comprehend the neces- sity of this condition as the basis of any treatment. If he can not go to a suitable climate during the cold season, he must keep his room in all unpleasant weather, but at other times he may be permitted to stay in the open air. Fiu-ther- moi'e, the patient must be warned to avoid as completely as possible those harm- ful influences which his calling and manner of life entail, and among which especially is the bad air in our inns and restaurants. Food should be easily digestible, aud, in people inclined to corpulence, sparingly taken. Alcohol is to be permitted only in a moderate degree. We combat the tendency to constipa- tion, which is often present, by dietetic remedies, by taking fruit, especially grapes, prunes, etc. , honey, Graham bread, or by mild laxatives, like the bitter waters, Friedrichshall, Ofner, etc. If the circumstances of the patient permit and his condition requires it, we should send him south in the autumn iu order to avoid the evils of a northern winter. The rule is to send patients with a bronchial catarrh when there is much secretion to health-resorts with a dry climate— for example, to the western Riviera, San Remo, Bordighera, Mentone, Cannes, etc. The somewhat dry yet cooler climate of Meran, Gries, or Arco is suitable for patients with a stronger constitu- tion. Patients with dry bronchitis usually find themselves at their best in a warm but not too dry climate. If we wish to be sui-e of avoidmg the whiter's cold, we must choose Sicily, Egypt, or Madeira for a residence. Of the more 15-± DISEASES OF THE EESPIRATORY ORGANS. northern winter resorts we may mention here places on the eastern Riviera, Nervii, Spezzia, etc., except Venice, Pisa, or Rome. We must recommend especially, in bronchitis, a suitable summer residence outside of large and dusty cities. Any private country residence in a well-wooded and protected place is of advantage. If we wish to send patients to a bath, Marienbad, Eissingen, or Homburg are proper places for corpulent people who also suffer from digestive disturbances, while we may send weaker patients to Ems, Soden, Badenweiler, Ischl, or Reichenhall. Milk cures, whey cures, and grape cures are also prescribed in many cases of chronic bronchitis, the milk cure in particular for weak and anaemic individuals. A summer residence on the sea, best on the Baltic, is very serviceable for mauy patients with bronchitis. The inhalation treatment is much employed in chronic bronchitis, but we should not cherish too high hopes about its use. The best inhalations in dry catarrhs are simple steam, a two-per-cent. solution of common salt or bicarbonate of sodium. Ems water, etc. In cases with marked secretion, inhalations of oil of turpentine are most to be praised. The simplest way is to pour a teaspoonful of oil of turpentine into hot water and inhale the vapor as it arises. The so-called turpentine-pipe, however, is more convenient and more efficacious. This consists of a flask, which is flUed to the height of several inch&s with water and then with a layer of oil of turpentine or of oleum pini x>umilionis (P. G.), some two centi- metres thick. Two glass tubes, open at both ends, are passed through the cork. One, straight, tube extends down into the layer of water; the lower end of the other is free in the upper part of the flask. The outer portion of this last tube is long enough to be bent at an angle and forms the mouth-piece of the pipe which the patient sucks. He thus breathes the air which is filled with turpentine vapor. We have ti-eated many patients in this way, who, for a number of hoiu-s a day, " smoked " their turpentine-pipes. In treating chronic bronchitis the pneumatic method * was considerably em- ployed for a time ; that is, the patient was made to breathe artificially compressed ah', or to ex])ire into air of a less than atmospheric tension, by means of a movable pneumatic apparatus, as proposed by Waldenburg and others. Of late, however, this method of treatment has received less favor, inasmuch as actual results have fallen decidedly short of the benefit promised. In Ems, Reichenhall, and other places special pneumatic cabinets have been aw-anged, filled with compressed air, in which patients remain for varying lengths of time. The different alkaline mineral waters^^eltzer, Ems, Victoria, etc. — are next to be mentioned among internal remedies, which may also be used efficaciously at home. Tbe numerous expectorants, like ipecac and apomorphine, are especially valuable in dry bronchitis. In bi-onchial blennorrhcea we know empirically that the internal use of balsams causes a distinct diminution of the secretion. Oil of turpentine is the most active, and may be given internally in gelatine cap- sules, two or three capsules a day, or mixed with milk, in doses of ten or fifteen drops two or three times a day. Lepine, G. See, and other French physicians recommend terpiue as still more effectual. This is a derivative of turpentine, and is best employed in pills coutaining one and a half gi-ains (O'l), of which two or even more are to be taken three times a day. It may also be given in solution * Details of tho pneumatic treatment may be found in the following works : R. v. Vivenot, Jr., "Zur Kenntniss der physiologischcn Wirkuugen und der theropeutischen Anwcndung der ver- dichtetea Luft," Erlangen, 13U8. Waldenburg, " Die pneumntische Behandlung der Respirations- und Circulationskriinkheiton," Berlin, ISsO. Knautlie, "Ilaudbuch der pneumatiscbon Therupie," Leip- zig, Wigand, 1876. Sclmitzlcr, " Die pneumiitische Bebandlung d. Lungen- u. Ilerzkrankheiten," Wien, 1877 (40 Seiten). Oertel, " Ilandbuch d. respiratorischen Therapie" (v. Ziemssen's "AUg. Thorapie," ii, 4), Leipzig, Vogel, 1881. FCETID BRONCHITIS. 155 as follows : Terpine, 2 J drachms (grm. 10); alcohol, q. s. ad sol. faciundam; aq. dest., 6 ounces, 6 drachms (200 grm). Misce. Sig: Two or thi-ee tablespoonfuls daily. Balsam of copaiba and balsam of Peru are also used internally. We should be very sparing- of narcotics at first, but in severe cases we can not wholly dispense with them. [The iodide of potassium in doses of five to ten grains thrice daily is sometimes distinctly curative. An out-door life, free diet, moderate alcoholic stimulus, tonics, and woolen clothing do much to promote recovery.] Local applications to the chest in the form of embrocations, mustard plasters, dry cups, or cold wet compresses are to be used, especially with severe dyspnoea, or with pain and a feeling of oppression in the chest. Eegular cold sponging of the chest serves to harden and strengthen the patient. Warm baths are very well borne by many patients with chronic bronchitis. Sometimes, too, vapor baths, if taken with caution, may be of service, especially in strong and corpulent patients. In all secondary chronic catarrhs our chief attention, beyond the symptomatic treatment of the bronchitis, must be directed to the treatment of the underlying disease. If we succeed in once more regulating the heart's action where there is uncompensated heart disease, or in establishing diuresis where there is renal dis- ease, we may also in that way cause improvement in the existing bronchial catarrh. CHAPTER in. FCETID BRONCHITIS. (Putrid Bronchitis.) .ffitiology. — By putrid or foetid bronchitis we mean that form of bronchitis in which the secretion of the mucous membrane undergoes a putrid decomposition, and in which, consequently, the expectoration takes on a peculiar and extremely foul odor. The cause of foetid bronchitis is usually the entrance of the bacteria of puti'efaction into the bronchi by means of the inspired air. Only in rai-e cases does it arise from a pulmonary gangi-ene of embolic origin {vide infra). The opportunity for the agents of putrefaction to enter the bronchi with the inspired air is of course often given, but a foetid bronchitis naturally is excited only when they can remain there and increase. Their retention and their further development is chiefly favored, as we know, by diseased conditions which already exist in the bronchi. A great number of cases of foetid bronchial catai-rh there- fore develop secondarily upon other pulmonary affections of longer standing. Thus the expectoration may quite suddenly change and take on a fojtid character in the course of a chronic or rarely of an acute bronchitis or of phthisis. Bron- chiectasis {vide infra) greatly favors the development of this putrid change, for in it the retention and stag-nation of large amounts of secretion furnish the aid and occasion for it. If a putrid decomposition of the secretion begins in one part of the bronchial system, the further extension of the process foUows from direct infection. In rare cases putrid bronchitis also develops in lungs which were previously apparently sound — primary foetid bronchitis. Symptoms and Course; Anatomical Changes.— If a foetid bi-onchitis arises in the course of some other chronic pulmonary disease, its appearance may be marked by a sudden impairment of the general condition, by high fever, often associated with numerous chills, and by an increase of the thoracic symptoms, like pain and 156 DISEASES OF THE RESPIRATORY ORGANS. cough. The change in the expectoration, tlie peculiarity of whicli \va.s first accurately described by Traube, is characteristic. There is a repulsive, sweetish, putrid smell. The expectoration is usually quite abundant; the consistency is rather thin. On standing, the sputum shows a very marked division into three layers. The upper layer consists of a very frothy, muco-pui-uleut stratum, con- sisting in part of individual masses, from which a number of coarser or finer fibers float down into the middle layer. This middle layer consists of a dirty-green muco-serous fluid. At the bottom of the vessel is found the third layer, which is often the thickest, and is composed entirely of pus. It consists of pus-corpuscles which have sunk to the bottom, and is of a rather thin, greasy consistency. With the naked eye we generally recognize a number of little whitish-gray plugs and particles in it. These so-called " Dittrich's plugs," which are easily crushed under a cover-glass, are quite characteristic. !Microscop- ically, they consist of decomposed pus-corpuscles, detritus, and bacteria, and usually contain very many needles of fat acids arranged in bundles (see Fig. 21). We often find also in the sputum large masses of fungi, especially great bunches of twisted lep- tothrix fibers, which, by an uupracticed eye, may readily be mistaken for elastic flbei-s. Tlie latter are, of course, never found in the expectoration of a simple foetid bronchitis, but only in the deej)- Ftu.'ai.-Crystais of fat adds. Seated, destructive processes in the lung, like gan- grene. On chemical examination of the sputum, the ordinary products of ])utrefaction may be found — volatile fat acids, especially butyric and valerianic acids, also sulijhuretted hydrogen, leucine, tyrosine, etc. The breath of the patient, as well as the sputum, is very often foul-smelling, and so offensive that he becomes a burden to his associates. The signs which fajtid bronchitis gives on physical examination are those of an ordinary bronchitis. In a great number of cases we also find signs of con- solidation and contraction of the lung, of pleurisy, etc., which do not belong to foetid bronchitis as such, but are due to complications or sequelaj. The most frequent of these sequelaj is the development of a " reactive " lobular inflammation, a pure pneumonia, which follows a catarrh which has attacked the finer bronchi. These pneumonias frequently run into gangrene, so that we very often find a number of larger or smaller nodules of pure gangrene besides the ex- tensive foetid bronchitis in the lungs. In many of these cases the foetid bronchitis is certainly the pi'imarj^ process, and the development of the nodules of gangrene is sccondai-y ; yet we .shall see later that the reverse may also be true. Foetid bron- chitis and gangrene of the lungs run into each other so often, both clinically and anatomically, that there is no sharp line to be drawn between them. If the nodules ai'e superficial, and reach the pleura, the infection attacks this, and we have a purulent or even an ichorous pleurisy. The smaller and inedium-sizod lironchi are almost always found in a condition of cylindrical dilatation in old foetid bronchitis. Their miicous membrane is in- tensely inflamed, and often ulcerated superficially. On its surface we see in the cadaver the greasy purulent masses and the plugs which we find in the expectora- tion during life. Whatever may be the case with the general course of foetid bronchitis, its beginning is often quite sudden and acute, both in the primary and in the second- ary forms, as we have said. The patient is attacked with fever, which may often be quite high, and with a stitch in the side, and cough, and expectoration. Later, FCETID BRONCHITIS. 157 the characteristic peculiarities described above appear. The farther course of the disease is almost always chi'onic, lasting f(3r years, but subject to many variations. Very often manifest improvement, and even apparent recovery, takes place, until suddenly there is a new attack of fever and thoracic symptoms. The general condition and nourishment of the patient may be quite good for a long time, except during the periods of marked exacerbation of the disease. Patients with chronic foetid bronchitis often appear somewhat bloated, but also pale and slightly cyanotic. Peculiar clubbed thickenings of the terminal phalanges of the fingei-s gradually develop, as in many cases of bronchiectasis. Slight oedema of the lower extremities is also sometimes present. Symptoms referable to other organs may he wholly absent. We see most frequently disturbances of the stomach, loss of appetite, and nausea, which proba- bly comes from swallowing the foetid sputum. Patients also complain of occa- sional rheumatic pains in the muscles and joints, which may perhaps be due to an absorption of septic matter. In conclusion it mast be mentioned that in fortunately rare cases of foetid pulmonary disease pyogenic germs reach the brain by metas- tasis, and here give rise to purulent meningitis or cerebral abscess. The danger of the disease, apart from the exceptional occurrence just mentioned, lies in the possible extension of the process to the lungs and the development of pulmonary gangrene and its sequelae. We hai-dly ever find a simple foetid bron- chitis in the cadaver, but we almost always see other processes besides, which have been mentioned above — reactive pneumonia, pulmonary gangrene, etc. These processes develop very readily, and make rapid progress in old, decrepit persons, who live under bad external conditions, in whom putrid processes in the lungs are frequent. The diagnosis of foetid bronchitis is not difficult in itself, for tbe diagnosis of a putrid process in the lung may be made from the stinking sputum alone. It may be difficult to decide whether we have to do merely with a foetid bronchitis, or with a pulmonary gangi'ene also. Decisive indications of gangrene are derived from physical examination — dullness, bronchial respiration, and large, moist rales — and also the discovery of elastic fibers and fragments of parenchyma in the expectoration. The prognosis must be made with care in every case of foetid bronchitis. If the external circumstances of the patient are favorable, he may remain in toler- able health for years. We must always be prepared for the ajspearance of new exacerbations of the disease and of affections of the lung itself. Treatment. — The chief aim of treatment must he to bring- the putrid processes in the bronchi to a stand-still by the death of the agents of putrefaction. The difficulty of fulfilling this task lies in the impossibility of getting the disinfecting material to act on the bronchial mucous membrane in the necessary amount aud concentration. Nevertheless, we can, without doubt, at least relieve a foetid bron- chitis and keep it in check by the judicious use of inhalations. Inhalations of a two-per-cent. solution of carbolic acid are most useful, given for five or ten mui- utes several times a day. These, however, are sometimes not well borne if long continued, and they may excite mild symptoms of carbolic poisoning — like head- ache, malaise, and dark carbolic urine. We have often used with good results the " carbolic mask " recommended by Curschmann, a kind of respirator fastened in front of the nose and mouth, containing cotton in a special receptacle impreg- nated with carbolic acid, equal parts of carbolic acid and alcohol, or other remedies like turijentme or creasote. Many patients can wear these masks, with occasional interruptions, for many hours a day. Turpentine is most used next to carbolic acid. Turpentine can be used by inhalation and also internally. Likewise ter- pine and myrtol are often of decided benefit. We have very recently, in the 158 DISEASES OF THE RESPIRATORY ORGANS. clinique at Erlangen, liad good results from iuhalations of oleum pini pumilionis (employed as described on p. 154 for the Lnhalatiou of turpentine). Both inhala- tions and the internal exhibition of turpentine are of distinct value. We may also try acetate of lead internally, one or two gi-aius (grm. '05-0 10) in powder every two hour.s. In other respects all the general hygienic and sj^mptomatic method.s of treat- ment recommended for common chi-onic bronchitis are also useful iu foetid bron- chitis. The sputum should be disinfected by putting strong carbolic acid, etc., into the sputa-cup to lessen the bad odor. It is a very good plan to keep the car- bolic spray at work in the patient's room as often and as long as possible, or the air may be impi-egnated with oleum lyini pumilionis. CHAPTER IV. CROUPOUS BRONCHITIS. {Fibrinous or Fueu do-membranous Bronchitis.) Croupous bronchitis is a peculiar form of disease of the bronchial mucous membrane, of very rare occurrence, in which there is a formation of extensive fibrinous patches in the bronchi. Only that form of croupous bronchitis which occurs primarily in the bronchi is to be considered here, and not the secondary form, which on the one side is associated with diphtheria in the pharynx and larynx, and on the other with croupous pneumonia. The aetiology of the disease is as yet wholly unknown. From analogy with other well-known croupous inflammations of mucous membranes, we must look here for some noxious influence which destroys the epithelium, but up to this time we are entirely ignorant of its character. Individuals in youth and middle age, somewhere between ten and thirty years old, are the chief victims. Men are attacked somewhat moi-o frequently than women. The disease comes on either in persons who were previously healthy — the essential croupous bronchitis — or in those who have already sufFered from some other disease, especially some chronic pulmonary affection — the symptomatic, secondary croupous bronchitis. It is not certain whether the last-named cases can have the same etiological relation as the cases of pure primary fibrinous bronchitis. Fibrinous bronchitis has been ob- served in the course of tjqihoid fever. Symptoms and Course. — Primary fibrinous bronchitis occurs in two forms, acute find chronic. The acute form begins quite suddenly, with fever, cough, pain in the chest, and severe dyspnoea which speedily develojis. The fibrinous coagula, which alone render the diagnosis possible, appear in the expectoration either at once, or after the existence for some days of what is apparently simple catarrhal bronchitis. These coagula form complete casts of the bronchi, and are more or less branch- ing. They are of a whitish color and of quite a dense, elastic consistency. The main stem may be a centimetre thick, and from it the further ramifications branch, dividing dichotomously. The largest casts are ten or fifteen centimetres long. On section, we usually find a free lumen within, and generally recognize a definite laminated structure in the membrane. In many places they are enlarged and swollen. Microscopically, we find white blood-corpuscles in and upon the hyaline ground-substance of the casts, and also red blood-cor])usclcs, sometimes epithelial cells, and quite often the peculiar pointed octahedral crystals which are also found in the expectoration in bronchial asthma {vide infra). The so-called " spirals " CROUPOUS BRONCHITIS. 159 {vide infra) have also been found in the expectoration of fibrinous bronchitis. Chemically the casts consist of coagulated albumen. Their solubility in alkalies, especially in lime-water, is of therapeutic importance. On coughing, the patient usually raises a simple mucous or muco-purulent ex- pectoration beside the casts, and in this sputum the casts are imbedded. They are often fu-st discovered by pouring the whole amount of sputum into water, when they unfold and spread out. The expectoration also contains not infrequently a slight admixture of blood. The subjective symptoms of the patient may be very violent. The dyspnoea sometimes attains a high and alarming degree. It ceases when a large cast is ex- pectorated after a severe paroxysm of coughing. Such attacks may recur every day or two. In other cases, however, the subjective symptoms ai-e comparatively slight. Physical examination of the lungs gives little that is characteristic. In uncom- plicated cases percussion gives nothing abnormal, or at most the signs of an acute emj)hysema. Auscultation gives the ordinary signs of bronchitis, not char- acteristic in themselves, such as rhonchi, or moist rales. If a large bronchus is plugged, the respiratory excursions and the respiratory murmm- are almost en- tu'ely absent in the corresponding portion of the lung, but after the expectoration of a cast the murmur once more becomes audible. The duration of acute cases is sometimes only a few days, at most a few weeks. In favorable cases the fever, which at times is quite high, soon disappeai-s, the respiratory symptoms grow milder, the expectoration of the casts ceases, and there is a complete and permanent recovery. In severe cases, however, death often ensues with all the symptoms of suffocation. The acute form sometimes becomes chronic, but this is rare. The chronic form of fibrinous bronchitis may last for years. Usually the con- dition grows worse periodically, at varying' intervals of time, and at each exacer- bation casts are expectorated, while in the interval there is apparently merely a simple bronchial catarrh. Some observations ai-e also recorded in medical litera- ture of people who have expectorated these casts at intervals for years without any special distui-bance of then* health or their nutrition. In some cases other chi-onic pulmonary affections, like tuberculosis, finally develop. The pathological anatomy of fibrinous bronchitis is not yet satisfactorily known on account of the rarity of the affection. The changes in the lungs found at the autopsy of fatal cases have usually been complications, like pneu- monia, pleurisy, or tuberculosis, which stood in no direct relation to the fibrinous bronchitis. A loss of epithelium has been discovered in some cases in the parts of the bronchial mucous membrane that were attacked. Prognosis. — In all acute cases the prognosis should be guarded, for we know that about one fourth of the cases terminate fatally. The chronic cases, as has been said, are usually very protracted and are subject to frequent reciu'rences, but they differ from the acute cases in being much less dangerous. Treatment. — We make special use for inhalations of those remedies which, as we have said, are able to dLssolve the casts. We usually employ a two- to-five- per-cent. solution of carbonate or bicai'bonate of sodium, and above all lime- water, either pure or diluted with an equal volume of water. The internal administration of iodide of potassium, in doses of twenty to forty-five grains (grm. l'o-.3'0) a day, proves of advantage in many cases. Energetic inunction with mercurial ointment is sometimes of service. Expectoration of the casts may be aided in many cases by such expectorants as senega and benzoic acid, or by the timely use of emetics. We do not know any remedies which are able to pre- vent a return of the attacks in the chronic form. The treatment, except at the time of the attacks, is the same as in ordinary chronic bronchial catarrh. 160 DISEASES OF THE RESPIRATORY ORGANS. CHAPTER V. WHOOPING-COUGH. (Pcrlusfis. y'usitis convuhiva,) .ffitiology. — By the name " whooping-cough " we mean a specific disease of the mucous membi-aue of the air-i)assages, which is chiefly seen in children, and is characterized by a peculiar violent and paroxysmal cough. Sporadic cases are of almost constant occurrence in large cities, but the disease often apijears in epi- demic outbreaks. Epidemics of whooping-cough follow epidemics of measles with remarkable frequency. Whooping-cough is without doubt contagious, and therefore often attacks one child after another in the same family. Kindergartens, orphan a.sylums, and nuj'series aid very much in extending the disease. The contagious element seems to be connected with the an- expired by the patient, particularly ydi\\ the secretion from the mucous membrane expectorated after coughing. Childi'en are most sub- ject to an attack up to the age of six years; from that age the disposition to the dis- ease decreases rapidly with increasing years. Whooping-cough is seen, indeed, in adults, but it is quite rare, and almost always comparatively mild and rudimentary. The epidemic onset, the contagiousness, and the whole course of the disease favor the theory of its infectious nature. The presence of the organisms which are supposed to be the poison of the disease has not yet been certainly demon- strated, although many have claimed to discover characteristic organisms in the sputa of patients. These statements, however, all conflict, and lack well-attested and methodical proof. If a patient has once had the disease, he is almost inva- riably secure against a new attack. Symptoms and Course of the Disease. — Whooping-cough begins with the symp- toms of a catai-rh of the trachea and bronchi, which develops more or less rapidly, and which at first often shows nothing characteristic. We can at this period make a tolerably probable diagnosis only at a time when an epidemic is prevailing, or in case the child's associates have alreadj' been attacked with the disease. The cough is often quite severe at the beginning, but it does not yet come on in dis- tinct paroxysms. Examination of the chest shows nothing peculiar except a few rhonchi. There is often a coryza, with frequent sneezing, and there is sometimes a mild conjunctivitis. The child is restless and feverish, especially toward night. The temperature maj^ repeatedly reach 103° or 104° (39°-40° C.) in this initial fever. The duration of this first so-called catarrhal stage varies, but it usually lasts a week or ten days. The catarrhal stage gi-adually passes into the second, convulsive stage, without any sharp boundary. The cough becomes more violent, and comes on in the separate pai-oxysms of whooping-cough which are characteristic of the disease. We do not know the particular reason why the cough has this paroxysmal char- acter, but a nervous factor probably plays the chief part in it. The peculiarity of the attack consists in the violent, paroxj-smal fits of cough- ing, which arc from time to time interrupted by deep, long-drawni, loud, and shrill inspirations, due to the occurrence of a .spasmodic contraction of the glottis. Exceptionally there are cases without this loud whistling inspiration. The child becomes markedly cyanotic diu-ing the attack, the veins in the neck swell, and teal's come into the eyes. Ha3morrhage into the conjunctiva, nose-bleed, and in some cases hemorrhages into other organs, like the ear, the skin, and the brain,* • In one instance we observed the very rare occurrence of a hemiplegia during a paroxysm of whooping-cough. WHOOPING-COUGH. ICl often come on as a result of this stasis. Vomiting very often occurs either during a paroxysm or at its close. Involuntary evacuations of urine and faeces may also follow from the violent contraction of the abdominal muscles. Exceptionally we observe still more severe symptoms with a paroxysm: a complete spasmodic cessa- tion of respiration with immineut danger of suffocation, or sometimes general convulsions. The paroxysms vary with the severity of the disease, frequently appearing ten or fifteen times in twenty-four hours; sometimes with greater frequency — fifty times or more. They also occur at night as often or even oftener than in the daytime. They come on either spontaneously or from some special predis- posing cause. We may, for example, excite a paroxysm artificially by pressing on the larynx or by making the cliild cry. If there are several children with ■whooping-cough in the same room and a paroxysm attacks one of them, the others, as a rule, soon begin to cough too. Some prodromal symptoms often pre- cede the peculiar paroxysm, such as general iiueasiness, rapid respu-ation, or vomiting. At the end of a paroxysm many childi-en remain very feeble and exhausted, but others recover very rapidly, and are playing again quite briskly a few minutes after. In general the child feels quite well in the interval between the pai-oxysms, but the effects of the violent attacks of coughing may of course often be seen. Besides the occasional hasmorrhages into the conjunctiva, we find the eyelids somewhat swollen, their veins dilated and blue, and showing through the skin. A small ulcer is quite frequently formed on the frjenum of the tongue, the origin of which is to be referred to mechanical causes. The tongue is violently pro- truded in the severe paroxysms of coughing, and the fraenum is thus pulled or torn, or injured by the sharp lower incisors. Physical examination of the lungs shows nothing abnormal in uncomplicated cases except a few moist rales or rhonchi. Sometimes the rhonchi are wanting, or are present in small numbers only a short time before a paroxysm, but in other cases an intense diffuse bronchitis is developed, which often leads to the develop- ment of a lobular pneumonia {vide infra). Sometimes, but not always, there is an acute catarrhal inflammation of the bronchi, and especially of the posterior wall of the larynx. The fever, wliich is usually present in the first or catarrhal stage, is absent in the convulsive stage. The child is free from fever for the most part. We often find a slight rise of temperature up to 100° or 101° (38°-S8'5° C), but only toward night. Higher and more persistent fever points to the development of complica- tions, especially on the part of the lungs. The convulsive stage seldom lasts less than three or fom- weeks, and often much longer, up to three or four months. The paroxysms gradiiaUy become less frequent and less violent {stadium decrementi), until they finally disappear entirely ; but relapses and fresh exacerbations also occur in this stage. Finally, however, the disease, in uncomplicated cases, goes on to a permanent and com- plete recovery. Complications and Sec[Xiel89. — The severe results which sometimes follow whoop- ing-cough are probably partly due to the direct action of the sijeciflc causes of the disease, and partly to complications of a secondary nature whose origin is merely favored by the whooping-cough. The most important are complications in the lungs. A lobular, catarrhal pneiimonia often develops after a severe bronchitis which involves the finer bronchi. In such cases the respiration be- comes hurried and superficial, the fever higher, and the general condition bad even in the times between the paroxysms. On examination of the lungs, we hear numerous moist rales, especially over the lower lobes, and we can sometimes 1G2 DISEASES OF THE RESPIRATORY ORGANS. make out dullness on one or both sides if there is extensive pneumonic infiltration. Such cases are always vei-y protracted, and many children succumb, partly from the disturbance of respiration and partly from general weakness and inanition. Complications in other organs are much rarer. Among the most frequent are attacks of diarrhoea which exhaust the child's nutrition. Many observers have also mentioned the quite frequent occurrence of a croupous or diphtheritic inflammation in the phai^rnx and lai-ynx in the course of whooping-cough. Finally, a case uuder our own observation may here be mentioned, in which death occurred with severe nervous symptoms, convulsions, and coma. At the autopsy very numerous capillary haemorrhages were found in the brain. Pulmonary emphysema is the first thing to be mentioned among the sequelae of whooping cough. From the marked pressure which the severe and frequent outbursts of coughing exert from within upon the alveoli of the lungs, they gradu- ally become dilated. An acute lobular emphysema ("acute pulmonary infla- tion") is set up which sometimes passes into a typical chronic pulmonary emphy- sema (vide infra). Chronic bronchial catarrh may also remain for a long time after an attack of whooping-cough. A third important sequel of whooping-cough is pulmonary tuberculosis. The bronchitis and lobular pneumonia which occur during a whooping-cough some- times do not improve, especially in weak childi-en with a tubercular tendency. The fever continues high, the child grows thin, and constantly becomes more and more miserable. At the autopsy we find cheesy nodules in the lungs, cheesy bron- chial glands, and at times tuberculosis of other organs. These cases signify that when a tubercular infection is present, but is still latent, the whooping-cough acts as an exciting cause for the outbreak of the disease, or that a greater i-eceptivity to infection with tuberculai* poison is created by the whooping-cough. Mobius has lately reported the occurrence in a few cases of paralysis as a sequel of whooping-cough. This usually begins in the lower and extends to the upper extremities, and is apparently due to neuritis. The diagnosis of whooping-cough can not be made with certainty, as we have said, until the second or convulsive stage. It is easy then, however, since the characteristic attacks occur in no other affection of the lungs in like manner and with like frequency and duration. If we have no opportunity to observe the attack itself, and have to depend upon the description of the friends, the diagnosis is sometimes more uncertain. In such cases, however, certain signs are often present: the child has a bloated aspect, or we may find slight haemorrhages into the conjunctiva, or ulcers on the fraenum of the tongue, whicli make the diag- nosis highly probable. Under some circumstances we may also make the attempt to bring on the paroxysm artificially (vide sujira). The prognosis is favorable with the majority of children if they are previously strong and healthy. Very young children are in more danger than older ones. There is danger if secondary pneumonia develops, and if the general nutrition and strength of the child suffer. As soon as the diagnosis is certain we nnist call the attention of the parents to the probable long duration of the disease. Regard must also be paid to the possibility of the development of sequelae, especially in weak children suspected of tuberculosis. Treatment. — Since the disease Ls pi-otracted and is not devoid of danger, it is our duty, when an epidemic of whooping-cough prevails, to guard children from it as far as possible. If one child in a family is taken ill, the other children must be rigorously kept away from him. If circumstances permit, we should prefer to send them away to aiiother place free from whooping-cough. With regard to the treatment of the disease, we must first endeavor to fulfill general dietetic and hygienic indications. The child should breathe good, pure WHOOPING-COUGH. 1G3 air, and for this reason it is often advisable to transfer the patient to a larger room, ■with as much air and sunlight as possible. The atmosphere should not be too dry, and it is advisable to employ a spray of carbolized water occasionally, or to hang up sheets moistened with the same in the room. In good weather the child should be out of doors a large part of the time, provided fever has ceased. City children are to be sent, if possible, into the country. The food .should be good and nour- ishing, but dry and crumbly articles should be avoided, being apt to excite cough. Warm or lukewarm baths frequently prove very beneficial, particularly when there is considerable bronchitis, as they lessen the danger of a lobular pneumonia. The medicinal treatment of whooping-cough xhas not yet shown brilliant results despite the large number of remedies recommended. Internally, quinine, belladonna, and bromide of potash are most worthy of a trial. Quinine is given in powders of one and a half to eight grains (O'l to 0'5) several times a day, either in capsules or, in the case of smaller children, with chocolate. The earlier this remedy is employed the more prompt is said to be its beneficial influence. Lately the treatment of whooping-cough with antipyrine has been much recom- mended. Belladonna is prescribed in powders containing one twelfth to one sixth grain (O'OOo to 0"01) of the extract of belladonna, giving three to five such powders a day. This remedy has often seemed to the author to diminish the num- ber and violence of the paroxysms. The largest daily dose of sulphate of atropine to be given to children is one sixtieth of a grain (O'OOl), and even this amount demands in every case caution and watchfulness for the possibility of symptoms of poisoning, such as enlargement of the pupils and dryness of the mouth. Bro- mide of potash is employed in an aqueous solution in the dose of fifteen to forty- five grains per diem (1 to 3 grm.). Its benefit is probably due to its power to diminish reflex excitability. The same drug employed in an atomizer often has a palliative effect. If the paroxysms are very violent we may caiitiously administer small doses of morphine or codeia. Inhalations of chloroform and ether have also been recommended. The following mixture is a suitable one : IJ Chloroformi § j (grm. 30) ; iEtheris | ij (grm. 60) ; 01. terebinthinaj 3 ijss. (grm. 10). M. Sig. One or two teaspoonf uls to be poured upon a pocket-handkerchief for inha- lation. Finally, considerable success has attended the application of cocaine to the throat and larynx by means of a brush. A solution of ten to fifteen per cent, has a considerable influence in modifying the frequency and violence of the paroxysms. Michael advocates the daily insufflation into the nostrils of pow- dered benzoin. Inhalations of various antiseptic remedies have been frequently employed because of the infectioiis natiu'e of the disease. The practitioner must not exjject too much from them, however, althoug'h they sometimes act well. A one-per- cent, or two-per-cent. solution of carbolic acid is most frequently employed for inhalation. It may be given several times a day for periods of two or three minutes at a time. Next to this, turpentine and benzine are most to be recom- mended ; of these, twenty or thirty drops are poured upon a sponge previously moistened with hot water. [Farlow and others report marked success from spray- ing the upper air-passages with a two-per-cent. solution of resorcin.] For the treatment of the complications and sequelas of whooping-cough the reader is referred to the appropriate chapters of this book. 164 DISEASES OF THE RESPIRATORY ORGANS. CHAPTER VI. BRONCHIECTASIS. ( Bronchial Dilatation.) Dilatation of the bronchi is not a separate disea.se, but it i.s a result of various affections of the lungs and bronchi. Nevertheless, we will speak of it briefly in this connection since many cases of bronchiectasis present the appearance of quite a characteristic disease. We distinguish anatomically the cylindrical and saccular bronchiectases. Cylindrical bronchiectasis consists of a uniform dilatation of a bronchial tube, and occurs most frequently in the medium-sized, or rarely in the finer bronchi of one or more lobes of the lung. It is usually due to a long-continued bronchitis, and develops most frequently in cases of emphysema, and also in whoopLng- cough, measles, and sometimes in phthisis, etc. The primary process is probably always the atrophy which follows the eatai-i-h, and the diminished resistance of the bronchial walls thus occasioned. The dilatation of the lumen of the broucbes is produced gradually, partly by the traction of the thorax diu-ing inspiration, and still more by the increased pressure in the bronchi due to the frequent and violent fits of coughing, and finally, perhaps, by the constant pressure of tlie stagnating secretion. The diagnosis of cylindrical dilatation of the bronchi is only a probable one. We suspect that a bronchiectasis has formed if the conditions are fulfilled which we know lead to it. In the chronic bronchial catarrh of emphysema we judge that there is cylindrical dilatation of the bronchi if the secretion is veiy abundant and comparatively thin, and separates on standing in a sputa-cuiD. The dilatation is iisually emptied by a severe paroxysm of coughing, such as is apt to occur in the morning if the secretion collects in great quantity during the night. Physical examination usually gives numerous small and medium moist i-ales, especially in the lower lobes. The respiratory mm-mur sometimes loses its vesicu- lar character in marked cylindrical bronchiectasis, and has a more indefinite and tubular quality. Saccular bronchiectases are sphei-ical or oval dilatations which are confined to a definite portion of the bronchial tube. They may attain a diameter of .several centimetres. The bronchus passes suddenlj' or gradually into the dilatation, and it is often obliterated so that the bi-onchiectasis forms a completely closed cavity. The wall of a saccular bronchiectasis loses in great measm-e the character of a normal bronchial wall. As a rule it is atrophied to a high degree, the atrophy involving not only the mucous glands, but also the muscular fillers, the elastic elements, and even the cartilages, so that the bronchiectasic cavities seem lined with nothing but a thin membrane. In olher cases, however, we find hyper- trophic processes, which involve the connective tissue of the mucous membrane, and lead to band-like projections and swellings. Finally, ulcerative processes may develop on the inner surface of a bronchiecta.sis and attack the smroiuiding lung-tissue, and change the bronchiectasis to a typical ulcerating cavity. Only rarely, foi' example in emphysema, do we find a single saccular bron- chiectasis surrounded by tolerably normal lung-tissue. Its origin, tlien, is to l)e referi-ed to causes like those which have been given above for the nuich com- moner cylindrical bronchiectases. In the great majorit.y of cases we find saccular bronchiectases, singly or in large numbers, surrounded by indurated and con- tracted lung-tissue. They form one of the complications of "pulmonaiy con- traction ■' [fibroid phthisis], which is almost always associated with contraction of the pleura. Since Cori-igan's day we have with good reason looked upon this con- BRONCHIECTASIS. • 1C5 traction as the cliief cause for their origin. By the gradual shrinking and retrac- tion of the lung, which as a rule has become adherent to the costal pleura, a trac- tion is exerted upon the bronchial walls from without to which they gradually yield. Thus arises the frequent combination of pulmonary contractiou with the formation of bronchiectases. This combination is usually unilateral, and involves the whole lung or only one of the upper or lower lobes. This form has been described from a histological stand-point as a chronic interstitial pneumonia, and it has been believed possible to make a sharp distinction between it and the chronic tubercular processes in the lung. We often see the form of pulmonary contraction in question developing as a result of pleurisy. Laennec first advanced the opinion that in such cases the pleurisy was the primary trouble, and that from it an interstitial inflammatory process attacked the connective tissue of the underlying lung and led to contrac- tion and then to the formation of bronchiectases. In our opinion we must indeed recognize the manifold anatomical and clinical peculiarities of the combination of pulmonary contraction and formation of bronchiectases in question, but astio- logically we are unable to separate it from pulmonary tuberculosis (vide infra), at least in the great majority of cases. But on the other hand it can not be denied that extensive bronchiectasis is sometimes observed entirely independent of any tuberculous process. In these rare cases the bronchial dilatation seems to be a sequel in most instances of a severe antecedent chronic bronchitis. It is seen, for example, in workmen who are obliged to inhale a great deal of dust. There can be no doubt, however, that the process here finally extends to the lung-tissue, for upon autopsy the parenchyma between the various bronchiectasic cavities is usu- ally not normal, but transformed into a firm indurated tissue. As a rule the dis- ease is mainly limited to one side, involving perhaps the whole lung, or, if only a single lobe, usually the lower one. The symptoms caused by saccular bronchiectasis alone are derived in part from the result of physical examination and in part from definite pecidiarities of the sputum. If great bronchiectasic cavities lie near the chest-wall, they may give the same physical signs that we shall learn to recognize later in the description of tubercular cavities. Bronchiectases lying within the lung, however, are often devoid of definite physical signs, so that at most we may suspect them from other symptoms, like the peculiarities of the sputum. The more abundant the forma- tion of bronchiectases the more does the respiration lose its vesicular character and become harsh and finally bronchial. Inasmuch as there is usually a very considerable secretion of mucus, we generally iind, upon auscultation, abimdant medium and even coarse moist rales. The expectoration is, as a rule, very abundant, and it is often raised "by mouthfuls." On standing, it exhibits a distinct division into an upper layer of serum and a lower of pus. It usually has a stale, sweetish odor, but it may be foetid. The diagnosis of the extensive formation of bronchiectases La the lungs is usually quite easy. In order to avoid confounding it with chronic tuberculosis, the following should be especially considered : In bronchiectasis the patient does not present a true cachexia ; he is usually somewhat cyanotic and often pale at the same time. The terminal phalanges of the fingers are often clubbed, as in foetid bronchitis. Fever is usually absent, unless there are some special complications. The expectoration is more abundant and more distinctly stratified than is often seen in tuberculosis; and, most important of all, it contains, of course, no tubercle bacilli. Since bronchiectasis may give rise to a foetid bronchitis, and since, on the other hand, as we have said, foetid bronchitis itself often leads to the formation of bronchiectasis, we can understand the maiiifold relations and changes which the 16G DISEASES OF THE EESPIEATORY ORGANS. two forms of disease described may furnish. If ulcerative processes arise in the wall of a bronchiectasis, they may give rise to haemoptysis. The further course of bronchiectases depends, of course, upon the nature of the primary affection. The cylinch'ical dilatations which arise after a severe bron- chitis, as happens in whooping-cough, measles, or typhoid, may in many cases gradually get well; but recovery from saccular bronchiectasis by a process of obliteration, if it occurs at all, is exti-emely rare. Nevertheless, the course of the disease may be comparatively benign, since the affection often remains eircum- sci'ibed, and the patient's general strength and nutrition suffer comparatively little from it. Finally, of course, severe symptoms arise, either from in.sufficiency of the heart, when there is cyanosis, dyspnaa, or oedema, or as a result of emphy- sema, tuberculosis, gangrene, or extensive lobular pneumonia. The treatment is never directed against the bronchial tUlatation a.s such, but toward its causes or sequela;. The treatment of bronchiectasis, therefore, coin- cides with the treatment of chronic bronchitis, emphysema, foetid bronchitis, chronic tuberculosis, etc. CHAPTER' VII. STENOSIS OF THE TRACHEA AND BRONCHL 1. Tracheal Stenosis. .ffltiologfy. — Stenosis of the trachea may be caused either by dLseases in the vicinity of the trachea, or by diseases of the trachea itself. The fii'st-named mode of origin is the more frequent. To this are due all the stenoses of the trachea from compression. Enlargements of the thyroid gland from simple struma and new growths, aneurisms of the ai-ch of the aorta and of the in- nominate artery, tumors and abscesses in the anterior mediastinum, swelling of the lymph-glands at the bifurcation of the ti-achea, abscesses on the anterior sur- face of the cervical vertebrae, etc., may exert so great a pressure on the trachea from without that its lumen is made narrower. Besides the direct action of press- ure, in most cases, a gradual atrophy from the pressure and a softening of the rings of cartilage sometimes plays an important part, according to Rose, m the occurrence of stenosis. A collapse of the trachea may arise from this " flaccid softening," which may come on quite suddenly, and may cause many of the cases of sudden " scrofula death.'' Changes in the trachea itself leading to stenosis are quite rare. Cicati-icial stenosis as a result of syphilitic ulcerations is relatively the most frequent. New growths in the trachea are also to be mentioned, such as poljiji and carcinomata, the latter almost always having invaded the trachea from the adjacent parts. Very rarely acute and clu-onic inflammatory processes like perichondritis lead to a swelling of the mucous membrane sufficient to cause stenosis. In conclusion, we niay mention that stenosis of the ti'achea maj' be due to the presence of foreign bodies. Symptoms. — If the stenosis is .so extreme that there is a real hindrance to respi- ration, a very striking modification of the breathing occurs. It is diflicult and labored, and is performed only by the help of the accessory muscles. Both expi- ration and inspiration are lorotracted, long drawn, and accompanied by a loud stridor. In many cases inspiration is more difficult than expiration, so that there is accordingly a preponderating insj)iratory dyspnoea, and the number of respira- tions a minute is diminished. If the entrance of air into the lungs is incomplete STENOSIS OF THE TRACHEA AND BRONCHI. If;; in spite of the lengthening of the respirations, we see an inspiratni-y retraction of the lower part of the thorax, and sometimes of the throat and the supra-clavicular fossse. In tracheal stenosis the larynx, however, shows little or no to-and-fro movement on respiration. This fact is of value in diagnosis in distinguishing tracheal from laryngeal stenosis, for in the latter the respiratory movements of the larynx are quite well marked. We sometimes notice in the pulse during inspiration a marked fall in tension and in the height of the pulse-wave, the pulsus paradoxus. With the sphygmo- graph we can show still more plainly the changes in blood-pressui-e, which vary quite markedly with the respiration. The frequency of the pulse is usually a little increased, but sometimes it is diminished. The symptoms of the disease just described may form so characteristic a picture that we can recognize it at the first glance. More precise information as to the seat of the stenosis, or the accurate differentiatioji of tracheal stenosis from the very similar picture presented by laryngeal stenosis, demands a direct laryngoscopic examination of the lai-ynx and trachea, which, of course, is hardly practicable in a patient with a high degree of dyspnoea. 2. Beonchial Stenosis. Narrowing of a primary bronchus, which is the only form to be mentioned here, arises most frequently as a result of the presence of foreign bodies. These may enter the air-passages by means of a deep inspiration while eating, or during sleep. We know that foreign bodies get into the right bronchus, which is wider, somewhat more frequently than they do into the left. Stenosis of the main bronchi from pressure also arises from aneurisms of the aorta, mediastinal tumors, enlarged bronchial lymph-glands, etc. Stenosis of the left bronchus from the pressure of the greatly dilated left auricle has been observed in mitral stenosis. The symptoms are not equally distinct in all cases, and they depend upon the shutting off of the corresponding part of the Imig. The dyspnoea is usually veiy evident, especially in acute cases. The respiratory excursions are much less on the affected side than on the sound side. The percussion-note, indeed, remains clear, but the vesicular respiratory nuirmur disappears, and instead of it we some- times hear over the whole side a loud whistling or humming sound, the vibration of which can in some cases be felt by the hand applied to the chest-wall. The vocal fi-emitus is diminished on the affected side. A vicarious emphysema soon develops in the other lung. Lobular pneumonia frequently develops as a result of the entrance of foreign bodies into a bronchus, because the agents of inflammation have entered at the same time with these bodies, and, as the expectoration can be evacuated only with diiHoulty, and hence is more or less stagnant, these irritants can readily establish themselves in it. In stenosis from pressure the character of the disease may of course be modified in many ways by the primary disease. The prognosis and treatment of tracheal and bronchial stenosis depend entirely upon the nature of the primary disease. General statements as to treatment, therefore, need not be given here. A direct mechanical treatment of tracheal stenosis in appropriate cases, such as cicatricial stenosis, may be undertaken ac- cording to the different modes of dilatation above enumerated. The methods for removing foreign bodies from the larger air-passages belong to the domain of surgery. The employment of an emetic has met with distinct siiccess in such cases, but it is not without danger, for the foreign body may wedge itself into the glottis during the act of vomiting and result in the danger of instant suffocation. 168 DISEASES OF THE EESPIRATORY ORGANS. CHAPTER Vni. BRONCHIAL ASTHMA. (Xei'vous Aftlivia.) Bronchial asthma is a disease clinically well characterized, but setiologically it is probably not quite a distinct affection. Its chief symptom consists of marked paroxysmal attacks of dyspnosa. The cause of the dyspnoea is not to be sought iu any coarse factor that can be demonstrated anatomically, but it is probably due, at least in part, to some abnormal condition of nervous irritation. The chief theories as to the origin of the asthmatic attacks will be given further on. The disease is decidedly more common iu men than in women, and it is not very rare even in children. Symptoms and Course of the Disease. — " Nervous " bronchial asthma consists, in its purest form, of attacks of shortness of breath, which come on iu pei'sons who are otherwise quite well, with varjaug freqiiency and varying dui'atiou, partly from some special cause, and partly without any discoverable reason. In the intervals between the attacks the patients are completely well, and do not show the slightest signs of any disease of the respiratory or circulatory organs. The asthmatic attack either begins quite suddenly, or it is preceded for a shorter or longer r)eriod by prodromata. These consist in a general feeling of discomfort, in abnormal sensations iu the larynx or epigastrium, sometimes in remarkably frequent gaping, and often in a marked coryza associated with a good deal of secretion and frequent sneezing (compare the relation between many attacks of asthma and diseases of the nose, given below). The attack begins in most cases at night. The patient wakes up with an intense feeling of pressure and artxiety. Sometimes he complains of a feeling of pain in the chest. He has to sit up stiaight, and in severe cases even to get out of bed. He often hurries to an open wmdow in order to " get ah'." His expression is anxious; his skin becomes pale and cyanotic, and sometimes is covered with a cold sweat. The respiration, too is altered in a very peculiar and characteristic way. Both inspiration and expira- tion are almost always accompanied by a high-pitched whistling sound, audible at a distance. Both respiratory acts ai'e labored, requiring the aid of the accessoiy muscles. On inspii-ation, only the upper part of the thorax is elevated to any extent. We see in the neck the inspiratory contraction of the steruo-cleido- mastoids, the scaleni, etc. Still more striking, however, is the labored, panting, long-protracted ex])iration, during which the abdominal muscles are contracted to a board-like hardness. We therefore recognize the disturbance of respiration in asthma as essentially an expiratory dyspnoea. The frequency of respii-ation is in many cases normal, or even somewhat diminished, yet we have repeatedly counted thix-ty or forty respirations a minute. On physical examination of the lungs dui-ing the paroxysm, we find the per- cussion-note over them normal or even strikingly loud and deej) — the "box-tone." The lower boundary of the lung is usually found one or two intercostal spaces lower than normal. AVe accordingly have to do with an abiuu-mally low position of the diaphragm, with an acute emphysema. On auscultation, whistling and creaking sounds, which quite obscure the vesicular murmur, are heard over most of the lung, especially during the long expirations. In many places, indeed, the respiratoi-y murmur is entirely absent, or we hear only a low whistle on expira- tion. Toward the end of the paroxysm the noises become deeper and more boom- ing, and sometimes we hear a few moist rales. In brief paroxysms there may be scarcely any cough or expectoration. In BRONCHIAL ASTHMA. 169 most, particularly in the tedious, cases, there is, however, a scanty tough mucous expectoration. In this are found, beside the ordinary constituents of simple bronchitic sputum, larger or smaller numbers of very characteristic clumps. These may be yellow or greeiiish-yellow, or, on the other hand, gray. The yellow- ish clumps, which are usually very tough, and often consist of a clump of thi-eady matter, represent swollen and fatty-degenei'ated pus coi'puscles, between which are very frequently iutersj)ersed a considerable number of pointed octahedral crystals. These crystals were hrst described by Leyden in the sputum of asth- matic patients, and are usually termed asthma crystals (see Fig. 22). Chemically they are identical with " Charcot's crystals," -which are found in the leukajmic spleen, the bone marrow, and the semen, and thej' jirobably represent the phos- phoric-acid salt of a peculiar base (Schi-einer's base, CaHsX). As soon as the paro.xysms cease the number of crystals in the sputum usually begins to diminish rapidly, and it is often possible to observe in them evident tokens of disintegra- tion. Often, also, numerous ciliated epithelial cells are found, in addition to the crystals, in the yellow masses. The graj^ plugs in the sputum of asthmatic patients consist mainly of clumps of thi'eady mucus, and contain the pecuUar ''spirals" which were first described by Uugar and by Curschniann. Many of these spiral threads are visible to the naked eye, but others demand the micro- scope for their recognition, through which they are seen as brilliant forms com- posed entirely of various sized bands and thi-eads collected in spirals (see Fig. 22). Sometimes a brilliant central thread of small diameter is seen in the midst of the spiral. Around the spirals are found round cells, dj-ops of fat and myeline, epi- thelium, and, according to Lewy, frequently also numerous epithelial cells from the pulmonary alveoli. As to the precise way in which the spirals and their central thread, develop, the question is not yet settled, but it is certain that the spu-als represent casts of the minutest branches of the bronchi, and therefore indicate the existence of a peculiar disease of the terminal bronchial twigs (see below). It should be added that sometimes also the microscope reveals in the sputum crystals of oxalate of lime (TJngar) and of phosphate of lime (Lewy). The pulse is usually accelerated during the asthmatic pai'oxysm ; the bodily temperature is normal, or sometimes even subnormal. In asthmatic patients who have protracted attacks we have repeatedly seen a slight febrUe movement up to about 103° (39° C). The duration of the asthmatic paroxysm is very different in individual cases, as has aheady been said. Sometimes it lasts only a few hours, but sometimes Fig. 32.— Asthma crystals and Curschmann's spirals (a, central fiber). it lasts several days, and even weeks. The attacks of protracted asthma are not very rare. Marked exacerbations and remissions of the disease usually alternate 170 DISEASES OF THE RESPIRATORY ORGANS. in them. The frequency of the paroxysms in ordinary asthma also varies exceed- ingly. Sometimes they come on almost every night, and then there are long pauses of months and years, so that we can not make any general statements as to the course of the disease. Definite recoveries are quite rare ; they are most frequent in children. Although patients with the form of pure essential asthma which we have so far described seem perfectly well in the intervals between the attacks, there is also a symptomatic asthma. This is seen chiefly in patients with emphysema and chronic bronchitis. The term " symptomatic asthma," however, can be used only when the attacks actiially show the symptoms of pure asthma, and when the dyspnoea which occurs in them has no relation to the anatomical lesions present. In such cases it is often hard to decide whether the existing emphysema and chronic bronchitis are really the primary disease, or the result of the asthma. There is no doubt but that a secondary emphysema of the lungs may develop as a result of frequent and jjrotracted asthmatic attaclra. The attacks of dyspnoea, which come on in chronic affections of the heart and blood-vessels — cardiac asthma (vide infra) — depend upon other causes than the peculiar bronchial asthma, and should not be classed with it. Theories as to the Origin of Asthma.— .aEtiology — The peculiarity of the asth- matic symptoms has given rise to iiuiiierous theories as to the origin of asthma, yet none of them have obtained general recognition up to the present time. Many authors, like Weber, Storck, and Frautzel, seek the underlying cause of asthma in an acute swelling of the bronchial mucous membrane, as a result either of a sudden dilatation of the blood-vessels arising from nervous influences or of a very acute catarrh. Wintrich and Bamberger have advanced the theory that asthma consists in a tonic spasm of the diaphragm, by which the diaphragm is kept motionless in a fixed insijiratory position ; but it is at once plain that such a condition can at least not play the chief part in the occuri-ence of asthma, for we can usually feel the respiratory movements of the diapliragm quite plainly during the paroxysm. It should be stated that Riegel, who is the latest cliampion of the theory of diaphragmatic spasm, is of the opinion that there is not a com- plete tetanic spasm of the diaphragm, but merely a superexcitation of the phrenic nerve, and that the excursions of the diaphragm are not completely inhibited. The theory long ago advanced by Trousseau, the chief advocate of which of late is Biermer, is the most probable one, and is now generally accepted, namely, that the spastic nervous element, which is not wholly to be disregarded in any explanation of bronchial asthma, consists of a tonic spasm of the muscles of the smaller bronchi. The tonic contraction of the smaller bronchi explains the whistling sounds that are heard. A marked hindrance to respiration is set up which can be more easily overcome by the inspiratory suction of the thorax than by the expiratory pressure. Since the latter acts not only upon the alveoli, but also upon the lesser bronchi themselves, the closure of the bronchi upon expira- tion is still more marked. The air which is di-awn into the alveoli can conse- quently get out again only imperfectly, and this explains the expiratory dysp- noea, the emphysema that soon occurs, and the low position of the diaphragm. The acceptance of this theory of bronchial spasm also readily explains tlic often sudden onset, and just as sudden cessation, of the asthmatic attack. If we inquire further, however, into the cause of the occurrence of the bron- chial spasm, only a vei-y indefinite answer can be given; for little is said by answering that asthma is a neurosis of the vagus. Many facts make it very prob- able that the spasm is of reflex origin, at least in many cases. Leyden has expressed the suspicion that the irritation of the mucous membrane by the pointed crystals, which he discovered, gives rise to the spasm. It may be said in oppo- BEONCHIAL ASTHMA. 171 sition to this, however, that the "asthma crystals" are sometimes found in the sputum of patients with emphysema who have no asthmatic symptoms, and also that in asthmatic patients the severity and duration of the attacks stand in no constant relation to the number of the crystals. Nor can the above-pictured spirals be regarded as the cause of the paroxysms of asthma, since they likewise occur in other diseases of the minutest branches of the bronchi — for example, they are not very rare in croupous pneumonia. The fact lately corroborated by numerous observations by Voltilini, B. Frankel, Hack, and others, is very important— namely, that the asthmatic par- oxysm is sometimes of reflex origin, starting from some disease of the nasal mucous membrane. We find quite often, for instance, that asthmatic patients are suffering from chronic diseases of the nose, like chronic catarrh, nasal polypi, and especially the enlargement of the so-called erectile bodies of one or more turbinated bones, and that after their removal the asthma disapjieai-s. In this connection may be cited the noteworthy fact that many asthmatic patients have an attack brought on by certain odors, for example, at the smell of freshly roasted coffee, or of ipecacuanha. Trousseau, who suffered from asthma himself, always had an attack on smelling violets. It is doubtful whether a pure bron- chial asthma can have a reflex origin from other distant organs. The connection between asthma and diseases of the phai-ynx, or hypertrophy of the tonsils, is extremely probable in some cases, but the statements as to the occurrence of asthmatic paroxysms in diseases of the stomach ("dyspeptic asthma"), of the intestine, or of the female sexual organs, are to be taken only with great reserve. We usually have to do here with a confusion between pure asthma and other conditions of dyspnoea — nervous dyspnoea, conditions of cardiac weak- ness, etc. In a large number of cases — which seem to us to be most characteristic — the disease can be explained, in our opinion, only by the hypothesis of a peculiar primary disease of the bronchia] mucous membrane, particularly affecting the ter- minal twigs of the smallest bronchi, and whose special feature, somewhat like the spasm of the glottis in whooping-cough, consists in the occurrence of a refl.ex bronchial spasm. The whole type of the disease and the peculiarities of the ex- pectoration, the S]jirals, and crystals, furnish unequivocal testimony for this theory of asthma. Curschmann therefore claims that the anatomical basis of these cases is an exudative bronchiolitis. We think that " asthmatic bronchiolitis " is the most fitting name for such cases of asthma as are not found to be dependent upon disorders of the nose or similar causes. The observation, often made, that many asthmatic patients have attacks only when in certain places, and are quite free from them in othere, is very remarkable. They sometimes have an attack at every change of place. In conclusion, it may be mentioned that in some cases a distinct hereditary predisposition to asthma has been observed, and that asthma sometimes occm-s in families with a general neurotic tendency. Diagnosis.— This is usually easy if we pay careful attention to all the symp- toms and to the whole course of the disease. Other conditions which may lead to dyspnoea are of course to be excluded by a careful examination of the chest. Attacks of spasm of the glottis and of paralysis of the openers of the glottis are to be differentiated from bronchial asthma by the predominance of inspiratory dysimcea as well as by other signs. And in cardiac asthma and the manifold varieties of respiratory spasm and neurotic angina, such as are seen especially in 'hysteria, not only are the other attendant symptoms different from those seen in genuine bronchial asthma, but the very dyspncea itself is usually of quite another variety. 172 DISEASES OF THE RESPIRATORY ORGANS. Prognosis. — There is hardly ever any immediate danger to life even in the most intense asthmatic paroxysms, but permanent recovery is rare, siuce even after long intei-vals the attacks may finally return. The cliief danger ui severe and protracted cases lies in the development of a pulmonary emphysema with its fui'lhcr consequences. Treatment. — In every case of asthma the first thing to he thought of is whether there is not a definite cause whose removal may cure the disease. In this connection we should examine the nose carefully, since nimicrous observations have recently shown that a previously existing asthma may permanently disap- pear after the treataient of some nasal disease which may be present, like the removal of polypi, the destruction of the erectile bodies by the galvano-cautery, etc. If we can not satisfy the causal indication in this way, we should always try next a remedy which must pass for a direct specific against certain forms of asthma — iodide of potassium. In doses of twenty to forty-five grains a day (gi-m. l'5-3'0), which can be increased if necessary, this usually causes a rapid imiJi-ove- ment, which of course is not always, although it is frequently, perraauent. If iodide of potassium has been used in vain, we must turn to the other remedies which have been employed against asthma, although their action is often quite uncertain. We may mention here the nitrite of socUum (two parts in one hun- dred and twenty of water, two to three teaspoonfuls a day), and nitro-glycerine, which has an analogous action (twenty drops of a one-per-cent. alcoholic solution in six and a half ounces (grm. 200) of water, a tablespoouful two or three times a day) ; also quinine, bromide of potassium, belladonna, atropine, arsenic, etc. In some cases pneumatic treatment, such as the inhalation of compressed air, has been successful, and sometimes, too, electricity (galvanization and faradization of the neck), or hydrotherapj', has been claimed to give relief. Change of climate may be of distinct service. Many patients bear the sea-air well, while with others mountain traveling exerts a favorable influence. In severe cases a special symptomatic treatment of the attack itself is often necessary. Narcotics are without doubt the most effective, especially chloral and morphine. In severe attacks we can not avoid injections of mori)hinc, btit we must always be cautious in order that the patient may not form the habit of using this to excess. Germain See has lately sti-ongly advocated inhalations of pyridin. Of this, about one drachm (4 to 5 grm.) is shaken into a saucer and the fumes are inhaled three times a day for fifteen to thirty minutes. Inhalations of chloi-oform and ether are also much employed. Among other usefid remedies and devices we may mention mustard plastei-s to the chest and calves, putting the hands and feet into hot water, inhalations of nitrite of amyl, inhalations of turpentine or ammonia vapor; also the often-used fumigation with saltpeter paper — unsized paper dipped in a concentrated solution of nitrate of potassium and dried. The stramonium cigarettes to be had in most drug-stores ai-e much praised ; or the patient may smoke stramonium or belladonna leaves which have pre- viously been dipped in a solution of .saltpeter and then dried. Among internal reme- dies we may mention tincture of lobelia, formerly much used, and also the remedy lately employed by Penzoldt, the tincture of quebracho, a tablespoouful pure or in some nnicUaginous vehicle. [Potassic iodide is more likely to prevent recm-rence if it is given continuously, for several months at least, and it .should not be thrown aside as useless until it has been pushed to the limit of toleration without avail. A convenient form of administration is in saturated aqueous solution, a minim of which represents about a grain of the drug. The syrup of hydi-iodic acid may be substituted for potassic iodide in cases PULMONAEY EMPHYSEMA. , 173 of intolerance of the latter. Grindelia robusta, a drachm of the fluid extract thi'ee or four times a day, serves sometimes to prevent reciu'rence of attacks. Marked alleviation of the paroxysms is often obtained from the inhalation of fifteen to thu-ty drops of the iodide of ethyl.] SECTION TV. Diseases of the Lungs. CHAPTER I. PULMONARY EMPHYSEMA. (Alveola)- A'l-tafis. Incnascd I'vliime vf the Lunffn.) Nature and .Etiology of the Disease. — Pulmonary emphysema, the abnormal inflation of the lungs, is one of the commonest pulmonary affections. It either develops in separate x^arts of the lung, in which case it is subordinate to other pathological changes which co-exist in the lungs, or it involves almost the whole extent of both lungs, and then presents the symptoms of a characteristic aflfection, which it is usually easy to recognize. The essence of pulmonary emphysema, the condition from which most symp- toms are immediately derived, is the loss of elasticity in the lungs. If we com- pare the sound lung with its normal elastic force to a new and very tense rub- ber band, the emphysematous hxng must be compared to an old and lax band that is sfa'etched and pulled out. We therefore see why the emphysematous lung takes up a greater space than the sound one, for, on account of its lack of elasticity, it can no longer contract to its former volume. We may thus call emphysema a permanent inspiratory distention of the lung from which it can no longer return to its expiratory condition. If we open the thorax of a subject with normal lungs, they contract, as is well known, but the emphysematous lungs remain in theic inflated condition after the thorax has been opened. If we inquire into the factors which cause this loss of elasticity in the lung, we find that they are the same kind of influences which tend to diminish the elas- ticity of any other elastic body. As a rubber band, by mxich pulling and stretchmg, gradually gets longer and less elastic, so the lungs, as a result of then' abnormally frequent and sevei'e distention, gradually become inelastic and emphysematous. The normal traction of inspiration, which is continually making new demands on the elastic powers of the lungs, finally leads to a loss of elasticity in them. In advanced age most lungs become more or less inelastic. The lungs of an old man are like an elastic band, which has done its work for years but which has finally become yielding. We therefore class the emphysema of the lungs in old age rather among the states of involution such as develop in almost all organs in advanced life, than among special pathological changes. We distinguish, more- over, most of the lungs with senile emphysema from other emphysematous lungs by the fact that their volume as a whole is not increased, but is rather diminished below that of the healthy lung, since we find in them the extensive atrophic processes of old age. The condition becomes pathological, however, if the elasticity of the lung is deficient in earlier years and without exposui'e to the action of the special in- jurious influences which will soon be mentioned. In such cases of emphysema, 174 DISEASES OF THE RESPIEATORY ORGANS. developing in middle life or even in youth, the idea of a congenital weakness of the elastic elements in the lungs can not be set aside. It probably consists in a quantitative or a qualitative defect of the elastic tissue. Some observations seem to corroborate the statement that a disposition to emphysema may be present in several membei's of the same family. If a lung whose elasticity is previously subnormal can not persistently satisfy the ordinary demands upon it, a normal lung, on the other hand, also loses its elasticity if the demands made upon it are greater than it can perform. This is the reason why pulmonary emphysema is in part considered a disease arising from the occupation. We mean here not only those influences which lead to chronic bronchitis and thus later to emphysema (vide infra), but more especially the abnormal demands upon the lungs in all those callings which necessitate severe physical labor. We must not only regard the deeper and more rapid res- pii'atious, but also the increased pressm-e on expiration to which the lungs are often exposed in the raising of heavy weights, etc. This explains the great fre- quency of emphysema in the laboring classes, and also its gi-eatcr frequency in men than in women. Beside this, we must add that in certain callings, like glass- blowing and horn-blowing, the overstraining of the lungs is much more direct. In all such cases emphysema may be termed simply a premature exhaustion of the lungs. In very many cases emphysema develops as a result of other diseases of the lung, and especially as a result of chronic bronchitis. Dry catarrh of the middle and finer bronchi when of long duration leads, as a rule, to ijulmonaiy emphy- sema. The abnormal mechanical influences to which the lungs are thus exposed act both in inspiration and in expiration. Since the entrance of air to the alveoli is rendered more difficult bj- the swelling of the mucous membrane in the smaller bronchi, abnormally deep and strong inspirations are necessary, with a marked expansion of the alveoli, in order to draw a sufficient quantity of air into the alveoli. The alveolar walls are therefore exposed to an abnormal traction at each inspiration. On expLi-ation, a pressure from within, which is pei'haps even more injurious, acts on the alveoli. The ordinary expiration, which usually needs only the elastic power of the lungs, is not sufficient in chi-onic bronchitis to drive the air out of the alveoli through the narrowed bronchi. Thus arise the difficulty and delay in expu-ation which are present in clu-onic bronchitis, and which lead to the active participation of the muscles of expiration, the abdominal gi-oup of muscles. On forced expiration, however, the pressure does not act simply upon the contents of the alveoli, but much more upon the smaller bronchi tiiemselves. The channel of exit for the air from the alveoli, therefore, becomes still naiTower. Since the air can not escape, the pressure w-ithin the alveoli is raised by the efforts at expiration, and the alveolar wall is thus again abnormally expanded. Tlie cough, which is often present in chronic bronchitis, is a fm-ther factor, which acts in a precisely similar injurious fashion. The attacks of coughing begin with a forced contraction of the muscles of exjnration, which follows the closure of the glottis. Until the glottis opens, therefore, the lower parts of the lung especially are put under strong pressure. The air in them, which can not escape outward, is driven into the iipper parts of the lung, and there leads to expansion of the alveoli, and finally to emphysema. We accordingly see that a number of injurious influences co-operate in the gradual develoijment of emphysema from chronic bronchitis, and that, sooner or later, these influences have as their result the gradual dilatation of the lungs. Here, too, we must bear in mind the individual differences in the resisting power of the lungs. Couihtions precisely similar to those in chronic bronchitis occur in other dis- PULMONAEY EMPHYSEMA. 175 eases, and lead in like manner to pulmonary emiiliysema. We very often see the development of emphysema in severe and persistent whooping-cough. The worst factor here, besides the existing bronchitis, is the frequent paroxysms of coughing. We have already mentioned, in the description of bronchial asthma, both the acute emphysema, which occurs during the attacks, and the final development of a permanent emphysema. In conclusion, we must here consider a theory advanced by Freund, which would make the development of an emphysema dependent upon a " primary rigid dilatation of the thorax." It is indeed conceivable that from certain pathological changes in the costal cartilages, as Fi-eund claims, a thorax, which had become rigid in the position of inspiration, might exert a constant abnormal traction on the lungs, and so give rise to an emphysema. The occurrence of this hypothetical primary disease of the cartilages, however, has up to the present time not been established. It is rather considered by the majority of authors as a second- ary change, developing as a result of emphysema or else simultaneously with it. On the other hand, it is certainly remarkable that we sometimes observe in children the " emphysematous habit " of the thorax and neck, which will be more fully described further on, and that in fact in such childi-eu we can often discover early in life a beginning emphysema. Besides the already described essential or substantial emphysema, which is a special disease attacking both lungs uniformly, we distinguish a so-called vicarious or complementary emphysema. If, by any disease, certain portions of the lungs are incapacitated in their functions, the parts which remain healthy must then assume the whole business of respu-ation. They become excessively expanded on inspiration, and as a result they become emphysematous. Thus we see emphysema of the upper lobes in affections of the lower lobes. Emphysema of one limg is most frequently observed clinically when the other lung is extensively diseased, especially in unilateral chronic contractions of the lungs and pleurte, usually seen in tuberculosis. Vicarious emphysema may also be confined to quite small por- tions of the lung, but then it is merely of pathological and not of clinical interest. Pathological Anatomy.— As we have seen, the actual abnormality of the luno- in emphj-sema is not due to a pathological change, but to a change in its physical conditions. The loss of elasticity of the lung is shown iu its greater volume, in its lack of contractility, and in its persistence in a position of inspiration. The single alveoli are of course just as much expanded as the whole lung, but their walls show at first no histological changes. We have here, then, a condition which Traube has called " increased volume of the lungs," and has distinguished from the " pulmonai-y emphysema " proper. This distinction is without doubt justi- fied anatomically, but clinically it can not well be maintained. As the distention is constant, the alveolar walls can not withstand the constant traction and pressure. This leads to progressive atrophy of their tissue from pressure — that is, it leads to a real disappearance of the elastic elements of the lung. The atrophy be- gins quite gradually. The partition-walls of the alveoli are first perforated, and then they partly or wholly break down. The neighboring alveoli run more and more into one another, and thus finally arise alveolar ectasis and infundibular ectasis, which can be made out with the naked eye, and which may attain a diam- eter of five or ten millimetres or more. If single air-bubbles enter the interlobu- lar, interstitial, or subpleural connective tissue, which may happen perhaps in severe fits of coughing, we speak of an interstitial or interlobular emphysema, in distinction from the ordinary vesicular or alveolar emphysema. The tissue atrophy in the septa of the alveoli afi'ects not only the elastic tissue, however, but it also affects the branches of the pulmonary capillaries in the alveo- lar walls. The affection of the elastic tissue adds no new conditions to the dis- 1Y6 DISEASES OF THE EESPIEATORY ORGANS. turbed functions of the emphysematous lung, which we have just described. Tlie destruction and final atrophy of the pulmonary capillaries, however, is the second important factor in the patholog-j^ of pulmonary emphysema, for, with the destruc- tion of so great a part of the vascular area in the lungs, the outflow from the right side of the heart is considerably lessened. There must therefore necessarily be a stasis in the pulmonary arteries and the right side of the heart, and the right side of the heart can overcome the increased resistance only by increased work, and thus in every chronic pulmonary emphy.sema there finally arise a dilata- tion and consecutive hypertrophy of the right ventricle with their further conse- quences. Symptojis and Course of the Disease. General Course of the Disease. — Although a pulmonary emphysema may sometimes, as in whooping-cough, dcveloi^ ui a comparatively short time, still its course is always very chronic. In most cases the origin of the disease is quite gradual, as in all those cases in which an emphysema develops from a chronic bronchitis, an asthma, or as a result of some injurious occupation. The symp- toms gradually and insidiously associate themselves with those of the chronic bronchitis. The symptoms of emphysema usually begin in middle or advanced life, but marked emphysema may occur in youth and childhood. The disease always lasts for years, unless some [fatal] intercurrent disease arises. The objective and subjective symptoms are due either to the chronic bron- chitis, which very often co-exists, or to the emphysema it.self. Not only is the bronchitis, as we have seen above, very often the cause of emphysema, but, on the other haiid, the development of a chronic bronchitis is greatly favored by the circulatory disturbances in the lurLg associated with emphysema. Thus the two diseases, emphysema and chronic bronchitis, are closely connected clinically. Bronchitis causes its well-known symptoms — cough, expectoration, moderate dyspnoea, and a feeling of pressure in the chest. The bronchiectases, which are often gradually formed, especially in the lower lobes, may lend a peculiar stamp to the cough and expectoration (see page 16.5). Emphysema increases the patient's dyspnoea to a degree which can never be caused by chronic bronchitis alone. The emphysematous lungs soon become incapable of satisf\-iug any extraordinary demands of respiration. Many patients are only slightly conscious of the diffi- culty in breathing so long as they keep quiet, but wlienever they make a trifling physical exertion, go up-stairs, or take a little longer walk than usual, the dyspnoea comes on. The variations in the intensity and extent of the bronchitis correspond to the frequent and quite marked variations in the patient's feelings. These variations depend upon the condition of the patient, his external circumstances, and the possibility of his taking care of himself ; the change of seasons, too, has an influ- ence on him. In pleasant weather many patients live in tolerable comfort, but autunm and winter bring an increase of all their symptoms with the increase in their bronchitis. The last stage of the disease is characterized by the appearance of a disturb- ance of compensation in the heart. We have seen above that the cause of the impairment of the pulmonary circulation, and of the resulting hypertropliy of the right ventricle, is the closure of numerous pulmonary capillaries. A fm-ther reason for the impairment of the circulation comes fi'om the disturbance of res- piration itself, since the influence of the respiratory movements on the circulation is well Icnown. The "ppoarance of a marked distm-bance of the circulation may be deferred for some time by the increased efforts of the right ventricle. The PQLMONAEY EMPHYSEMA. 177 cyauosis of most patients is due solely to incomplete oxidation and to the blood- stasis which extends backward fi'om the right side of the heart into the veins of the body. Finally, however, the right ventricle becomes more and more feeble, the stasis in the veins increases, oedema of the extremities and transudation into the various cavities of the body ensue, and after long suffering the patient succumbs to dropsy. Emphysema is frequently combined in its later stages with other chi-onic dis- eases. Puhnonary emphysema with its sequelae is seldom found at the autopsy as a single lesion, but we discover in the cadaver co-existing disease of the heart, the blood-vessels, or the liidneys. Pulmonary tuberculosis is often a final devel- opment in emphysema, but it is usually of the chronic indurated form, and is not very extensive. Physical Examination. 1. Inspection. — In many patients we can detect the disease with considerable confidence at the first glance; we ai'e therefore justified in speaking of an emphysematous habit. The patients are usually quite well nourished, at least in the early stages of the disease, and are often rathei* corpulent. They appear plump or even somewhat bloated, and their faces are more or less markedljf cyanotic. The configuration of the neck and thorax is especially char- acteristic. The neck is usually short and compressed ; the sterno-cleido-mastoid muscles, which have to act as auxiliaries in inspiration, are tense and hj-per- trophied. The inspu-atory contraction of the scaleni ma3'' also be seen and felt. The veins in the neck are visibly dilated, and in severe cases are swollen to thicli blue cords, and we sometimes see in them evident undulating or pulsating move- ments. The thorax is rather short, but broad and strikingly deep— the "barrel- shaped thorax." The intercostal spaces are narrow, and the lower ribs move only a little downward. The epigastric angle is therefore obtuse, and sometimes becomes almost a straight line. The respiratory naovements are almost always accelerated in severe cases. Inspiration becomes short and labored. The excur- sions of single ribs are therefore slight, and the thorax is raised rigidly and more as a whole. Expiration is visibly prolonged. There may be a noticeable retrac- tion of the intercostal spaces on inspiration in the lower and lateral portions of the thorax. This characteristic form of the thorax in emphysema is regarded as a constant inspiratory position of the ribs, and corresponds to the permanent inspiratory dila- tation of tiie lungs. The peculiar rigidity of the thorax is probably due to the changes in the costal cai'tilages already described, which, according to Preund, are primary. In many cases the emphysematous form of the thorax gradually devel- ops in the course of the disease, but in other cases it seems to depend on some original predisposition {vide supra) to the disease. In conclusion, we must state that the above description corresponds to the typi- cal form of emphysema, from which we may have many deviations. In the para- lyzed thorax, for instance, we may meet with a high degree of essential emphy- sema of the lungs, which has often given rise to erroi'S in diagnosis. 2. Percussion. — Percussion gives very decided results in the diagnosis of pul- monary emphysema. We find the inferior border of the lungs one or two inter- costal spaces lower than under normal conditioi^s, corresponding to their perma- nent inspiratory inflation. Clear pulmonary resonance on the right front in the line of the nipple extends to the lower border of the seventh, and sometimes of the eighth rib. On the left front it extends to the fifth or sixth ribs, so that the cardiac dullness is lessened. The area of cardiac dullness can often not be made out at all ; or at most, on strong percussion, it is made out in a limited extent as relative dullness. The pulmonary resonance extends on both sides in the back to the first or second lumbar vertebra. This condition on percussion in emphysema, 12 178 DISEASES OF THE RESPIEATORY ORGANS. however, is frequently altered, because other conditions, like passive congestion of the liver, meteorism, and ascites, may be present at the same time, and push up the diaphragm. Thus the detection of emphysema by percussion i.s made decid- edly dillicult. Qualitative changes in the percussion-note may be entirely wanting in emphy- sema. The pitch is sometimes remarkably loud and deep — the "box-tone " [tym- panitic resonance] ; but in otlier cases, especially in the back, we find it somewhat raised. This may depend in part upon the poor vibratory conditions in the rigid chest-walls, but in other cases it is caused by the retention of an abundant secre- tion in the lower lobes. The detection of dilatation and hypertrophy of the right ventricle by percus- sion is in many cases uncertain, because the lungs cover the heart. A positive result can be obtained only by carefully defining the relative cardiac dullness. The frequent epigastric pulsations in emphysema, and also the marked undulating and pulsating movements in the jugular veins, ai'e to be regarded as quite certain signs of dilatation of the right side of the heart. 3. Auscultation. — The characteristic auscultatory sign of emphysema is the prolonged expiration. As a flabbj^ rubber band, when it is stretched and then let loose, no longer snaps back quickly and strongly, so the emijhysematous lung, when it has been stretched in inspii-ation, comes back again only slowly. We hear with it a somewhat aspirated, sonorous sound, which plainly exceeds the vesicular inspiratory sound in duration. The vesicular murmur itself often undergoes a modification in pulmonary emphysema. It sounds exaggerated, and very shuf- fling, or in other cases it is rougher and more indefinite. In a high degree of emphysema the vesicular respiration is sometimes very low^ and obscuie, because the inspu'atory current of air is reduced to a small amount in the lungr, which are already excessively dilated. In many cases we hear rhonchi beside the respiratory murmur, di-y whistling, buzzing, and creaking sounds on inspiration and expiration. If cylindi-ical bronchiectases have already formed, we hear, espe- cially over the lower lobes, numerous small and medium moist rales, but no sono- rous rhonchi. The rhonchi may wholly conceal the respiratory sounds. With a marked retention of secretion we sometimes hear nothing but a low, suj^pressed, rattling sound. In the heart the sounds are usually rather low, because it is covered by the lung. The "accidental systolic sound in emphysema" at the apex, described by some writers, we have heard much less frequently when the valves were intact than we should expect after the statements relatuig to it. The pulmonic second sound is, as a rule, mai-kedly accentuated, as a result of the stasis in the pulmo- nary circulation. The diminution of the expiratory pressure in emphysema may be measured with the manometer, or with Waldenburg's " pneumatometer." The normal expi- ratory pressure of 110 to 130 millimetres sinks in emphysema to 100 or 80 milli- metres. As we should e.xpect, the spirometer shows a diminution of the vital lung capacity, which can be readily explained. The normal lung capacity of about 3,500 cubic centimetres falls to 2,000 or 1,000 cubic centimetres. Other Symptoms in the LtJNas and in Other Organs. In regard to the other symjjtoms in the lungs we have only a little to add to what has already been said. The intensity of the cough naturally varies in individual cases according to the degree of the existing bronchial catarrh. Many patients are troubled by a dry cough, while others have abundant expectoration. There is nothing characteristic of emphysema in the composition of the latter. PULMONARY EMPHYSEMA. 179 All the kinds of sputa which are found in the different forms of chronic bronchitis are also found in pulmonary emphysema. The dyspnoea, whose predominant expiratory character we have already mentioned, increases in advanced cases to a most marked degree. Sometimes the increase shows itself by the appearance of distinct asthmatic attacks. These are often really to be regarded as a symptomatic bronchial asthma, of nervous origin, but, on the other hand, we must not overlook the fact that a temporary increase of the bronchitis, retention of secretion, and cardiac failure, may also excite attacks of dyspncea, which can not properly be termed asthma. Tiie important changes in the heart resulting from emphysema have already been described. The exhausted right ventricle can uo longer overcome the in- creased resistance in the pulmonary circulation. The difBculty of respiration is still greater, from the passive congestion of the pulmonary vessels. The skin be- comes still more cyanotic, and finally adema and general dropsy develop. The failure of compensation is evident by the lessening of the pulse, its increased fre- quency, and sometimes by its irregularity. The difficulty of an objective exam- ination of the heart in emphysema has been spoken of above. The appearances of blood stasis in the internal organs are shown especially in the liver and the kidneys. The liver is swollen, and its increase in size (the liver of passive congestion) can frequently be made out by percussion or palpation. The pains in the region of the liver, of which many patients complain, are per- haps sometimes due to the stretching of the capsule of the liver, but they ai-e prob- ably more often muscular pains excited by the frequent coughing. In tlie kidneys the effect of stasis is first shown by a diminished excretion of iirine. The urine is more scanty in amount, more concentrated, of a higher spe- cific gravity, and of a darker color. It generally gives an abundant sediment of ui-ates, and may contain a small amount of albumen. Microscopically, are dis- covered a few hyaline casts, and a few red and white blood-corpuscles. It is evi- dent that this diminished activity of the kidneys favDi-s the development of di-opsy. The spleen is not infrequently found congested at the autopsy. The evidence of this, however, is often uncertain during life, for percussion of the spleen is difficult on account of the emphysema, and palpation is difficult from the swelling of the body. Gastro-intestinal symptoms may be present in emphysema. The appetite seldom remains good throughout the disease. Many patients suffer from clu'onic constipation ; and more rarely there is a tendency to diarrhcea. Fever is not present in simple pulmonary emphysema. Every fever which exists for a long time depends on other complications, like severe bronchitis, pneumonia, or tuberculosis. Complications of emphysema with other chronic diseases are frequent. The old opinion that emphysema and tuberculosis, and emphysema and chronic heart disease, were antagonistic to each other is entirely false. These complications are not very rare. We may also mention the complication with general ai'terio- sclerosis and with chronic nephritis, especially the contracted kidney. Among acute chseases we must mention croupous pneumonia, which is not very rare in emphysema, where it must always be regarded as a dangerous combination. The diagnosis of emphysema can be made directly from the results of the physical examination, and usually presents no difficulties. It is obscure only when the patient is not examined till the final stage of dropsy. Then it may be very hard to avoid confusing it with forms of heart disease, like primary hyper- trophy, myocarditis, or mitral stenosis, or with contraction of the kidney. Prognosis. — Pulmonary emphysema of acute origin, like that resulting from whooping-cough and analogous affections, may be recovered from in many cases. 180 DISEASES OF THE RESPIRATORY ORGANS. but otliPi'wise, as regards the iinal curaljOity of the disease, the prognosis is wholly bad. The duration of the disease aud the inteusity of the symptoms are of course very different iu individual cases. Here almost everything depends upon the circumstances iu which the patient is placed. With sutficient care the disease may be tolerably well borne for many yeai-s, but without it the first symptoms of respiratory and cardiac insutHciency appear much earlier. Treatment. — Since emphysema itself is only slightly amenable to treatment, most of oui' therapeutic remedies are directed to tliat accompanying condition upon which the greater part of the symptoms depend — to the chronic bronchitis. If we succeed in improving this, or even in wholly removing it, we always obtain a distinct improvement in aU the patient's symptoms. The therapeutic remedies mentioned in the description of chronic bronchitis are therefore of frequent use in emphysema. In the first place, we must seek the best hygienic conditions for the patient, and remove liim from all injurious influences, such as dust, bad air, and work requir- ing physical exertion. In dry catarrh we should use the alkaline mineral waters, and when there is abundant mucous secretion the balsams, such as tuj-pentine intei-nally and by inhalation. The most valuable e.xpectorants are apomorphine, liquor ammonii anisatus, and senega. Their action, of course, too often fails of the desired result, so that we frequently have to change our remedies. When there is a troublesome cough, distui-bing the sleep, we can not dispense with nar- cotics, like morphine or Dover's powder. If severe dyspnoea comes on, we may try to obtain relief by mustard plasters to the chest, or by immersing the hands and feet in hot water. With asthmatic attacks we may try iodide of jiotassium, beside the other remedies mentioned for asthma. Here, too, we must finally resort to narcotics. We must carefully watch the condition of the heart, and use digitalis when there are signs of beginning disturbance of compensation aud the pulse grows small and irregular, and this drug may prove very useful. If symptoms of di'opsy set in, we may sometimes prescribe diuretic i-emedies, like juniper-tea, or acetate of potassium, besides digitalis. We aLso try to strengthen the heart by wine, camphor, benzoic acid, or other stimulants. Besides the purely symptomatic treatment thus described, the attempt has been made to meet the causal indications in emphysema, and esjiecially to aid the patient in expiration, and thus to improve the power of the lung to contract, where it is possible. To this end Gerhardt has recommended assisting expiration mechanically by compression of the thorax. This compression must be done methodically by another person,* about five or ten minutes every day, by the aid of both hands laid flat on the lower lateral portions of the thorax. The effect of this manipulation in diminishing the dyspnoea and making expectoration easier is in many cases very satisfactory. The employment of the pneumatic treatment has also become quite general, especially since the introduction of Waldenbin-g's portable ai)paratus. The expi- ration into rarefied air, which meets the causal indication, may procm-e great relief for the patient in many cases, and .sometimes, too, result in au iiu])rovement of the emphysema which can be demonstrated on physical examination. Inhcla- * Ono of my patients at the policlinio in Lcipsic made himself a very simple but very effect- ive apparatus for producing this compression of tlio thora.\ on himself by the aid of two small boards, which arc firmly fiustened together at one end by a long cord. These boards, which are fur- nished with a piece of wood at this end fitted to the wall of the chest, are laid flat on the two sides of the thorax so that their free ends can project for,ward some six inches or a foot, and serve a.s a one- anned lever. By pressing them together the patient himself can thus, without any strain, exert a con- siderable pressure on liis thorax with each expiration. PULMONARY ATELECTASIS. 181 tions of compressed air are also employed when there is severe bronchial catarrh. Still, too much must not be anticipated from pneumatic treatment. CHAPTER II. PULMONARY ATELECTASIS. ( Compression of the Lvmjs. Aplasia of the Lwnrja in Cases of Ki/phoscoliotit.) .ffitiology.— Atelectasis of the lungs is a condition directly opposed to emphy- sema. While in the latter the lungs are abnoi-mally inflated, in the former they are abnormally collapsed. The aii- has disappeared from the alveoli and lesser bronchi, and in the most advanced cases even from the larger bronchi. The atelec- tatic portions of the lung are not altered histologically, but are changed to a firm tissue, deprived of air — the so-called splenization or carnefaction. The atelectasis of the new-born is due simply to deficient respiration and to the consequent imperfect entrance of air into the lungs. In weak children, who die soon after bii-th, we often find the lower lobes wholly or in part in a foetal, unin- flated condition— that is, atelectatic. By artificial inflation we can readily expand the lungs to their normal extent. Acquired atelectasis occurs in two ways. We may mention, as the first and most frequent setiological factor, the plugging of the smaller bronchi. If a com- plete closure of a bronchus arises from the accumulation of secretion, as may easily happen in the narrow bronchi of children, the air can no longer enter, on inspira- tion, into that portion of lung supplied by the plugged bronchus. The air which is shut up in it is gradually absorbed by the blood. The adjacent parts of the lung expand, and the portion that is excluded from respiration collapses, leaving a circumscribed pulmonary atelectasis, usually rich in blood but devoid of air. Such atelectases, in greater or less number and extent, are very often found in the bodies of children who have suffered from severe bronchitis, especially after measles, whooping-cough, or diphtheria. Beside the direct action of the plugging of the bronchus, the weakness of the respiratory movements and the cough, condi- tional upon the general state of the disease, play a significant part. The second very frequent and impoi'tant cause of pulmonary atelectasis is com- pression of the lung. In all the diseases which diminish the space for the expan- sion of the lungs, the lungs are pressed together fi-om without to a greater or less extent, whereby the air is pressed out of them. Thus arise the atelectases from pressure in pleuritic eft'usion, hydrothorax, pneumothorax, in marked cardiac hypertrophy, pericardial effusion, and aneurism of the aorta. Atelectasis of the lower lobes also arises in the same way from great upward pressure on the diaphragm by ascites, meteorism, abdominal tumors, etc. That form of pulmonary atelectasis which arises from deformities of the thorax is of great practical importance. In severe kyphoscoliosis, the half of the thorax corresponding to the convexity of the vertebral column is much narrowed. The lungs are materially hindered in their expansion, and even in their growth, if the deformity occurs in youth. This is called ''aplasia of the lungs," a condition which may give rise to grave results {vide infra). Sjnuptoms. — In the majority of cases the appearances in atelectasis are subordi- nate to the symptoms caused by the primary disease. This is especially the case in most of the atelectases from pressure, although the most dangerous factor lies in the compression of the lung. The atelectasis of the lungs developing as a result of diffuse capillary bronchitis, 182 DISEASES OF THE EESPIRATORY ORGANS. especially in children, can of course not be detected by physical examination until it is of great extent. The respiration, in extensive formation of atelectasis, often shows a very striking and characteristic deviation from the ordinary tyjie, especially when the atelectasis develo^js in the lower lobes. It is accelerated and labored, and is perfonned chiefly by the iippei' and anterior portions of the thorax. In the lower poi'tions we see marked inspii-atoiy retractions, which are caused in part by the external pressure of the air, and in part correspond to the forced con- traction of the diaphragm. Physical examination can, of course, reveal abnormal conditions, especially dullness on percussion, only when the atelectasis is extensive. Dullnes.s, however, is usually hard to make out in children. Auscultation gives signs of existing bronchitis ; and sometimes, too, with more extensive consolidation, there is bron- chial respiration. In other cases, as may be easily seen, the respiratory muiinur is much diminished or wholly absent. As we can perceive, the physical signs of atelectasis are not really distinguishable from those of pneumonia, especially of lobular pneumonia. In fact, a sharp boundary between atelectatic nodules and nodules of lobular jjneumonia in the lung can not be drawn clinically. Aplasia of the lungs in kyphoscoliosis demands a special description, because it is of great practical significance. Many patients vvath kyphoscoliosis ma^' live for years without special respiratory disturbance. More careful observation, of cour.se, usually shows a somewhat labored and hurried respiration, but the patients have not paid much attention to it. In other cases the difHculty in breathing is more noticeable. The person affected is incapable of any severe physical exertion ; he always feels short of breath, and often suffers from cough and expectoration. In the cases first mentioned, howevei-, which for years have had little or no ti'ouble, disturbances in respiration sometimes come on quite suddenly. They maj' de- velop as a result of a mild bronchia! catarrh, and they also frequently arise without any special cause, and may attain a very threatening degree. The condition may improve, or it may lead to comparatively speedy death. Examination of the lungs diu'ing life usually shows nothing but the signs of an extensive bronchitis. By careful percussion we may quite frequently detect an increased area of cardiac dullness to the right. Sometimes a moderate oedema develops. In such cases the autopsy shows nothing as the cause of death but the changes in the lungs. The lungs are abnormally poor in air, small, and compressed, but in circumscribed portions, on the contrary, emphysematous and expanded. The right side of the heart in the great majority of cases is dilated and hypertrophied. There can scarcely be a doubt, therefore, that the cause of the onset of severe symptoms and the final cause of death is to be sought in the cardiac failure. Finally, it is worthy of mention that there is a frequent form of mild atelectasis in the lower lobes, which occurs in very sick and bed-ridden patients who usu- ally keep in one position — on the back — as in typhoid fever. On making such patients sit up we hear during the first inspirations exquisite crepitant rales over the lower lobes, which sometimes disappear after a few deep inspirations. Here we have to do with a mild atelectatic condition, with a temporary adhesion of the walls of the alveoli and smallest bronchi. The treatment of atelectasis coincides in great measure with the treatment of the primary disease, and is therefore to be looked for in the corresponding chap- ters. The prophylaxis of atelectasis, by constant attention to the respiration, is of great pi-actical importance. We should try to keep the patient from lying con- tinually on his back, and we should make him take deep inspirations. The timely use of tepid baths, with shower-baths, is a special preventive of the development of atelectasis, and it may bring about a recovery when atelectasis is already present. Tepid baths may also be used with care in the treatment of dyspnoea caused by PULMONARY CEDEMA. 183 kyphoscoliosis. The condition of the heart, however, deserves especial attention (stimulants and digitalis). The reader is referred to the consideration of the general treatment of circulatory disturbances under Heart Disease. In other respects the symptomatic treatment by expectorants, etc., is the same as in other chronic pulmonary affections. CHAPTER in. PULMONARY CEDEMA. iEtiology and General Pathology. — We have in'pulmonary oedema the exuda- tion of a highly albuminous fluid, usually somewhat hasmorrhagic, not only into the interstitial tissue, but also into the alveoli themselves. The danger of the condition is easily understood from the high degi-ee of dyspnoea which immedi- ately ensues from it. In fact, pulmonary oedema is in many cases a terminal symptom, which comes on in all forms of acute and chronic disease. Mauy pa- tients are said to die with the signs of pulmonary oedema, especially patients with heart disease, pulmonaiy and renal disease, and also with otlier affections of the most different kinds. In rare cases pulmonary oedema is a transitory symptom. Repeated attacks of it may occur, especially in heart disease and chronic renal disease, and for a time at least, the patient recover from them. Many erroneous notions formerly prevailed as to the particular cause of pul- monary oedema. The theory was especially wide-spread that arterial congestion in the lungs could excite an oedema, but through the experiments of Cohnheim and his pupils we now know that pulmonary oedema is to be considered the result of stasis. It takes place when the outflow of venous blood in the lung meets an obstacle which can no longer be overcome by the mechanical foi-ce of the right ventricle. The obstacle which plays the most significant part here, and which may occur in all possible forms of disease — of coui'se more readily in those mentioned above than in others — is the paralysis of the left ventricle. If the further progress of the blood is much hindered by this, the overfilling of the pulmonai-y circulation and a consequent pulmonary oederua will necessai-ily fol- low, in spite of the most vigorous action of the right ventricle. Every terminal pulmonary oedema depends upon this fact, that the left ventricle is paralyzed in its action sooner than the right. Inflammatory pulmonary oedema must be distinguished from the pure oedema from stasis just described. It is found in the vicinity of portions of lung infiJi- trated with pneumonia, it is usually of limited extent, and therefore it is of sub- ordinate importance as a cause of disturbances in respiration compared with the general oedema of stasis. In very rare cases, as we have seen, an apparently primary acute pulmonary oedema, with a speedily fatal termination, develops in men who were before that apparently perfectly healthy, and the autopsy gives no further explanation of its origin. We jirobably have to do in these cases with the sudden failure of the left ventricle. Symptoms. — Marked dyspnoea is the most striking symptom in pulmonary oedema. It is subordinate only when the patient is found in the death agony and is no longer fully conscious. In pulmonary oedema the respiration is huri-ied, labored, and rattling. All the accessory muscles of respiration are called into play. The patient usually sits 184: DISEASES OF THE RESPIEATOEY ORGANS. upright in bed. We see on his lips and cheeks a gradually and coustantly increasing cyanosis, and we .often heai* at a distance the moist rales in the larger bronchi. On examination of the lungs, the percussion is essentially noi'mal, if there is no other disease of the lungs. Sometimes the percussion-note is a little higher in pitch, and often it is slightly tympanitic. On auscultation, we hear everywhere many small and medium moist rales. If the jjatieut can still expectorate, he raises a large amount of frothy, sero-hamorrhagic sputum. The whole picture of the disease is so characteristic that the condition can scarcely be mistaken. Treatment. — Since in most cases pulmonary oedema is not so much the cause as a symptom of approaching death, our remedies against it are apt to prove pow- erless, but it must always be our duty, at least in all cases that are not absolutely hopeless, to try to relieve the pulmonary cu-culation. From the pathogene- sis of pulmonaiy oedema it follows that we must pay particular attention to the condition of the heart, especially of the left ventricle. Hence we should use energetic stimulants, especially subcutaneous injections of camphor or ether, every half hour or hour. Internally we give camphor, musk, wine, and strong cafe noir. Beside that, we apply strong ii-j-itants to the chest, such as large mus- tard plasters or hot sponges. Sometimes an actual improvement of the respira- tion, when it has already stopped, may be obtained by a bath with cold douching, where there is mai'ked general cyanosis. If the patient is on the whole strong and well nourished, venesection is sometimes of manifest benefit. Emetics, how- ever, accomplish little, and are even dangerous on account of the collapse which may readily come on after them. Aji energetic " derivation to the intestines," however, by senna, calomel, or enemata of vinegar, seems sometimes to be i-eally of service. Acetate of lead in large doses, one or two grains (grm. O'05-O-IO), in powder, evei'y hour, employed empirically by Traube, is deserving of ti-iai. In this way, especially in acute diseases like typhoid and pneumonia, we in fact sometimes succeed in averting the danger of pulmonary oedema by rapid and energetic action. In the cases of oedema occurring in incm-able chronic diseases of the heart and kidneys, the remedies employed are of coui-se unfortunately incapable of preventing death. CHAPTER IV. CATARRHAL PNEUMONIA. (Bronclio-piicuinonia. lobular Pneumonia.) wffiltiology. — Catarrhal pneumonia is not, like croupous pneumonia, a distinct and independent disease, but in the gi'eat majority of cases it is a secondary phenomenon, which may develop in the com-se of acute and chronic diseases of various kinds. It almost always follows bronchitis. The same process which produces catarrh of the bronchial nnicous membrane, in its fm'ther com-se in- vades the broncliioles and the alveoli, and here leads to catarrhal pneumonia. In every acute or chronic disease, of any severity, the conditions are favorable for the development of an inflammation in the bronchi, and subsequently in the pulmonary alveoli. Everywhere in the au'-passages. as well as in the cavities of the mouth and pharynx, saliva, mucus, etc.. readily collect if the patient is veiy ill. Expectoration is imperfect, and the constant doi-sal decubitus favoi-s the accumu- lation of secretion, especially in the lower lobes. The mouth and pharynx are harder to keep clean than under normal conditions. Fungi and bacteria collect in the secretion itself, as well as in the epithelium and particles of food which CATARRHAL PNEUMONIA. 185 are left in the mouth, and these excite and keep up processes of decomposition. The inflammatory agents, which ai-e carried into the air-passages with the inspired air, find everywhere favorable conditions for settling and further development. From the upper portions they are drawn farther downward. From the larger bronchi the process invades the finer bronchi, and finally leads to catarrhal pneu- monia. We must also bear in mind that many patients who are very ill have difficulty in swallowing. They get choked, and pai-ticles of food, with the germs of inflammation cluiging to them, are carried into the air-passages. That which a healthy person could easily cough uj) again remains there, is decomposed, and gives rise to bronchitis and lobular pneumonia. This is the explanation of the frequent development of lobular pneumonia in the course of diseases which are entirely dissimilar. We observe it especially in all patients vrith stupor, in severe typhoid, in meningitis, and also in cases of nerv- ous disease, where coughing and deglutition are impau-ed, as a result of bulbar affections. In all such cases lobulai" pneumonia is to be considered a complica- tion, and with reference to its origin deserves the name of inhalation pneumonia or deglutition pneumonia. We shall soon see that this form, under some circum- stances, may pass into circumscribed gangrene. Although the ajtiological factors just described, which come into notice in the development of lobular pneumonia, have nothing to do with the nature of the primary disease as such, there are, on the other hand, certain infectious diseases which from the beginning are exclusively, or at least mainly, localized in the air-passages. Among these are measles, whooping-cough, and also, to a cei-tain degree, diphtheria, small-pox, etc. In these diseases we very often see lobular pneumonia following bronchitis. In individual cases, of course, it is scarcely possible to decide how far the bronchitis is directly dependent upon the specific cause of the disease, or whether it is merely a complication such as might also occur in any other disease. Lobular pneumonia in diphtheria, and iu severe small-pox, is probably for the most part a deglutition or an inhalation pneu- monia, the occurrence of which in these diseases may be readily understood. In measles and whooping-cough, however, we may consider that the pneumonia is directly dependent upon the specific agents of the disease, although here, too, the other causes for the development of lobular pneumonia should be home in mind. The development of lobular pneumonia from broncliitis is most frequent, as we know, in children and old people. The frequency of catarrhal pneumonia in childhood depends in part upon the limited dimensions of the bronchi. Besides that, however, the diseases in which it is especially frequent — namely, measles and whooping-cough — are children's diseases. In old people its comparatively easy development is due to imperfect expectoration. The mild cases of primary bronchitis scarcely ever lead to lobular pneumonia, but sometimes in children, and less often in adults, a severe febrile bronchitis may occasion the formation of pneumonic foci. Here, iu Erlangen, the author has seen cases which can not be regarded otherwise than as isrimary catarrhal pneumonia. The inhalation of irritating chemicals may occasion lobular pneu- monia as well as bronchitis. Pathological Anatomy. — It is characteristic of catarrhal pneumonia that the inflammation is circumscribed, being limited to the territory of a small bronchus. Hence the name of " lobular " pneumonia, in distinction from or croupous lobar pneumonia. An atelectasis {vide supra) of the affected lobule, arising from the plugging of the bronchus leading to it, often, but not always, precedes the inflamma- tion. The inflammatory process itself consists of the exudation of a scanty fluid, which does not coagulate, and of numerous pus-corpuscles (white blood-corpuscles) 186 DISEASES OF THE RESPIRATORY ORGANS. into the lumen of the alveoli. The alveoli and smallest bronchi are completely filled by the pus-corpuscles. There are also more or less abundant red blood-cor- puscles. The vessels of the alveolar walls are very hypertemic. The alveolar epithelium is much swollen, and is often tlirowu off in quite large amounts, the " desquamative pneumonia." It is doubtful whether it also takes an active part in these changes by processes of division. The inflamed lobules are readily apparent to the eye and the touch by their Ann consistence, being devoid of air. Their color at first, from the blood contained in the inflamed part, is a dark red, but later it becomes more grayish. Their lobular boundaiy is usually easily recognized, but, by confluence of ad.iacent nod- ules, large portions of the lung, and even whole lobes, may become infiltrated throughout — generalized lobular pneumonia. Symptoms, — The primary catarrhal pneumonia vihicb not infrequently occui-s in adults usually begins with the same phenomena as a severe attack of acute bronchitis. The patient feels prostrated, has cough, dyspnoea, and pain upon that side which is chiefly affected. The fever is not very high, say 101° to 103° (38'5° to 39'5° C), and it does not follow any regular course. The expectoration is simply catarrhal, not bloody as in ci'oupous pneumonia. Upon physical examination are found moist rales, seldom marked bronchial breathing, and a dullness upon per- cussion which is usually only moderate, or else a tympanitic percussion-note over the diseased area. The illness may last two or three weeks, or even longer. There is never a crisis, the fever ending gradually by lysis. Most of the cases of catarrhal pneumonia develop, as we have already said, secondarily in the course of other affections, hence the symptoms are frequently over.shadowed by those of the other disease. There are often found at autopsy a few foci of lobular pneumonia in the lower lobes which gave rise to no clinical symptoms whatever. In other cases, however, the development of extensive lobular pneumonia is of the greatest clinical significance. The disturbance of respiration, dui-ing the patient's life, forms the most striking symptom of the disease, and lobular pneumonia is shown at the autopsy to be the immediate cause of death. The largest part of the fatal cases of measles and whooping-cough, and no vei-y small part of those of diphtheria, scarlet fever, typhoid, or small-pox, are due, in the last instance, to the disturbance of respiration dependent upon lobular pneu- monia. Since a diffuse bronchitis, extending into the finer bronchi, almost always pre- cedes the development of lobular pneumonia, and since it may also give rise in itself to marked disturbance in respiration, there is no sharp boundary to be drawn clinically between diffuse capillary bronchitis and lobular pneumonia. Only the experience, a hundred times repeated, that every extensive capillary bronchitis readily leads to lobular pneumonia, permits us to suspect the latter, with consider- able certainty, even if there is no direct clinical evidence of it. The type of lobular pneumonia seen in childhood is the most characteristic and the most important clinically. It is observed in measles and whooping-cough, and also in weak, atrophic, and rachitic childi-en. The increased frequency of respiration is most striking. The breathing is superficial, but labored, as is shown by the contraction of the auxiliary muscles of inspiration and the play of the nos- trils. We also notice inspiratory retraction of the lower lateral portions of the thorax as a result of the incomplete entrance of air. Tlie number of respirations a minute increases in children to si.xty or eighty, or even more. In most cases the child has a frequent and apparently painful cough. Expectoi-ation is entirely absent in small children. When it is present it shows no characteristic i^eculiari- ties different from ordinary catan-hal sputum. The general condition is always CATAERHAL PNEUMONIA. 187 bad. The child is restless, apathetic, and more or less stupid. Its face is usually pale, but often quite cyanotic. The pulse is very rapid, and in small children may attain a frequency of 140 to 180 a mmute. Fever is almost alwaj-s present. It shows no typical course, it is now remitting and now intermitting, and toward evening it perhaps rises to 104° or 105° (39'5°-40'5° C). The occurrence of such a high rise in temperature is not without value in the diagnosis of catarrhal pneu- monia. If in diffuse capillary bronchitis a high fever is present for some time, we may assume with considerable certainty that the formation of lobular nodules has already begun. Physical examination furnishes direct evidence of the affection of the lungs, but its results are for the most part to be referred to the diffuse bronchitis and not to the lobular infiltration. Auscultation gives the most valuable signs. We hear over the lungs, in a greater or less extent, numerous small and medium moist rales, often quite high-pitched. From these signs, strictly interpreted, we can diag'nosticate merely bronchitis, but we may suspect pneumonia with the greatest probability. With very confluent bi'oucho-pneumonia aviscultation sometimes gives bronchial breathing and bi'onchophony beside the rales. It goes without saying that little lobular nodules, surrounded by normal lung-tissue containing air, give no special signs on percussion. With numer- ous nodules running into one another, the percussion-note is duller, and there is sometimes tympanitic resonance. The dullness is often first to be made out over a stripe extending along the vertebral column — the so-called " stripe-pneu- monia." Course and Termination. — An attack of extensive lobular pneumonia is usu- ally quite protracted. Even in favorable cases the disease rarely lasts less than two or three weeks, and it may persist much longer. The course of the disease is apt to be irregular, relapses succeeding improvement. The chief danger of the disease lies in this tendency to a protracted course, extending over weeks and months. Many children finally die, not of the lobular pneumonia itself, but from the general weakness and emaciation following the tedious febrile disease. We must remember, however, that complete recovery may sometimes take place quite late in the disease. The " transition of catarrhal pneumonia to caseation and tuberculosis " is a clinical fact with which physicians have long been conversant. In fact, we often find true tubercular changes in the lungs of children who have died after a tedious illness, as a result of measles, whooping-cough, etc. There can, of course, be no real question, however, of an actual transition from one disease to the other. In such cases we have to do either with an acquired tubercular infection, which has found a favorable soil in an already diseased lung, or (what is probably more fre- quently the case) the disease of the lung has promoted the development of a pre- viously existing tuberculosis. It is usiially weak children, with a herechtary pre- disposition to tubercle, who succumb to tuberculosis as a result of the above-named diseases. The diagnosis of a developing tuberculosis is not always easy, since it is only rarely that marked phthisical changes — like dullness at the apex, cavities, etc., which can be made out by a physical examination — are found in the lungs. We can usually suspect tuberculosis only from the general conditions — emacia- tion, persistent hectic fever, hereditary predisposition, or some secondary tubercu- lar disease like meningitis, etc. — especially as absolute proof, from the detection of tubercle bacilli in the sputum, is only rarely possible in children. The transition of inflammatory lobular nodules to pui-ulent foci (abscesses), or nodules of gangrene, which sometimes happens, especially in small-pox, depends upon the specific malignant property of the agents of inflammation which have entered the bronchi. ISS DISEASES OF THE RESPIRATORY ORGANS. If the lobular nodules extend to the pleura, a secondary sero-fibrinous or even purulent pleurisy may develop. %. Treatment. — Since we have already mentioned the proper treatment, in our description of the various diseases in which secondary i)neumonia is especially prone to develop, we can now be brief. We have also laid repeated stress upon the possibility and the great practical importance of prophylaxis, which is self- evident from a just comprehension of the origin of lobular pneumonia. Besides keeping the cavities of the nose, the mouth, and the pharynx as clean as possible, tepid baths, with cool douching later, are the best means of preventing the devel- opment of lobular pneumonia, or of checking its further extension if possible. Cold packs are often used with advantage, but they are more disagreeable to many patients than baths. It Ls an advantage, which is indeed to be considered in the second rank in comparison with the improvement in respiration, that by both the bath and the pack the febi-ile temperature is at the same time reduced. In the treatment of the lobular pneumonia of children a wet pack including the whole body is the best remedy. A sheet is dipped in water, wrung out, and wrapped around the whole of the patient except his head and arms. Outside of this is to be placed a dry woolen blanket or a layer of oiled muslin. The temper- ature of the water employed should be 68° to 77° (16° to 20° R.). The higher the fever the colder should the water be, and the oftener, say every hour, must the pack be renewed. In milder cases and at night it may be allowed to remain for three or four hours. The beneficial influence of the pack is shown not only by the temperatiu'e, but still more by the respiration. If the breathing, despite this remedy, remains unsatisfactory, and the patient becomes more and more stupefied, the treatment must be changed to lukewarm baths of a temperature of 77° to 86° (20° to 24° R.), with douchings of colder water. It is sometimes advisable in severe cases to add to the water employed for bathing or for the wet j)ack a few handfuls of mustard. The stimulation thus exerted upon the skin is quite marked. Among external applications to the chest, beside mustard plasters and poul- tices, di'y cups are to be mentioned, which often do very good service in strong, older children, and especially in adults. We never need to use local blood-let- tings, however, in catarrhal pneumonia. Of internal remedies, expectorants are most used. Chief among these are ipecac, senega, and benzoic acid. This last is pai'ticularly useful in the lobular pneumonia of children. In strong children the abundant collection of mucus in the bronchi may sometimes be relieved by the administration of an emetic. We should be cautious in the use of narcotics. Stimulants fcamphor, wine) must be used in severe cases. Inhalations are quite valueless in lobular pneumonia, yet it is recommended to keep the air in the sick-chamber rather moist bj' hanging up wet towels, or by sprinkling with water. The room should also be as large and as well ventilated as possible. The general hygienic treatment is of the greatest importance. One of the most important duties, of which the physician must always be mindful, is to keep iip the patient's strength by sufficient and jiroper food. When convalescence sets in, complete restoration to health may be fur- thered by a suitable residence in the country. CROUPOUS PNEUMONIA. 1S9 CHAPTEE V. OBOUPOUS PNEUMONIA. {Lung Fever. Lobar Pneumo7iia. Fibrinous Pneumonia. Pleuro-pneumonia.) Ceoupous pneumonia is an acute febrile disease of the lungs, very sharply deBued both anatomically and clinically. It is one of the most impoi'tant and most common of the severe acute diseases. It is generally known among the laity by the name of "lung fever." Since secondary pneumonia may develop in the coiu'se of various other diseases, like typhoid, small-pox, or diphtheria, and may anatomically have all the signs of croupous pneumonia, but a?tiologically be quite distinct from it, we speak of this pneumonia as primary, genuine pneumonia, in opposition to the other forms. The physical signs and the disturbances of respiration are of com-se the same in primary pneumonia as in secondary. The whole typical picture of the disease, which is so sti-iking, is seen, however, only in genuine croupous pneumonia, of which we will make exclusive mention in what follows. .ffitiology. — The majority of pathologists have now become convinced, from a series of clinical observations, that the cause of pneumonia is to be sought in an infectious agent which enters the luug-s and there gives rise to the development of an inflammatory process. This conception of croupous pneumonia as an acute infectious disease, with which alone all the pathological appearances readily coin- cide, has been more and more verified by all the recent iuvestigations. The pre- cise germ of the disease has not yet, however, been fully determined. Friedlander, indeed, has almost invariably found in the pneumonic lung a special kind of micrococcus, or, to speak more correctly, bacillus, which, singly or in larger num- bei-s, is inclosed in a characteristic shell or capsule — "capsule coccus" — and on cultivation shows a peculiar " nail-like" gi-owth in the cultiu'e gelatine; but since quite similar cocci are also found under other conditions, there is no definite proof at present that they are really the pathogenic agents in pneumonia, particulaa-ly as the results of experiments upon animals have not been unambiguous. [Friedlander himself has now agi'eed that the capsule is simply accidental, probably due to imperfect staining or decolorization. Talamon has produced pneumonia in animals by the injection of the ovoid coccus in pure culture, but has obtained also a similar result with round cocci. Thus the question of the coccus of pneumonia is still undetermined.] A. Fraukel has lately obtained bj' means of pure cultivation from the lungs in pneumonia a lancet-shaped diplococcus, or, more correctly, bacillus, to which he ascribes an setiological significance. This bacillus appears to be identical with that sometimes seen in the saliva, even in that of healthy persons, and it is the cause of the so-called "sputum septicEemia" which can be artificially produced in animals, particularly in rabbits. Frankel's statements have been confirmed by Weichselbaum, so that the very frequent occurrence of Frankel's bacillus in lungs affected with pneumonia is indubitable, but an absolute proof that these bacilli are the genuine cause of crouxjous pneumonia has not yet been furnished. Sup- posing the infectious nature of pneumonia to be certain, all the other alleg-ed causes may of course be regarded as at most " predisposing causes." The old opinion, which is yet current, that pneumonia is due to catching cold, is to be received with great limitations, for croupous pneumonia is very frequently seen independently of any such influence. In a good many cases it will be found that an exposure to cold immediately preceded the commencement of the disease ; but in these instances the cold is probably to be regarded merely as that 190 DISEASES OP THE RESPIRATORY ORGANS. circumstance which promoted the occurrence of the infection, i)ossibly because of the resultant injury to the bronchial and pulmonary epithelium. This explains the fact that pneumonia is especially frequent in certain classes, for instance, among day-laborers and soldiei-s. With regard to the so-called " traumatic pneu- monia," the state of the case is similar to that of pneumonia due to cold. Patients from the classes who work hard physically sometimes assert that they were taken ill as a result of heavy lifting or of a blow on the chest, but in such cases the subsequent stitch in the side was probably not the result of the injury, but a symptom of the disease which had previously begun to develop. It is a noteworthy fact in favor of our conception of pneumonia as an acute infectious disease that it may be endemic ; which sometimes, though rarely, seems to be quite certain. Extensive endemics of pneumonia, usually of quite a malig- nant character, have been repeatedly observed in single buildings, especially in barracks or prisons, as well as in tenement houses and other localities. Pneumonia does not show a decided epidemic character. Iij a large popula- tion sporadic cases occur at any season, but, on the other hand, we may notice a striking increase of pneumonia at many times. Most attacks occiu- in the winter or spring months, without any necessary relation, however, between the frequency of pneumonia and the occurrence of especially bad, wet, or cold weather. Individual predisposition plays an unmistakable part in the disease, as we must suppose that it does in all infectious diseases. Like facial ei-ysipelas and acute articulai" rheumatism, pneumonia is one of those diseases which is jsrone to attack the same individual several times. There are persons who have had acute pneu- monia four or five or even more times in their lives. We can not afHrm with certainty that the liability to ijneumonia is due to a special bodily constitution. The strongest and most robust often fall ill with it, and, on the other hand, weak and delicate people, with a tendency to phthisis, are frequently attacked. Drunkards seem to have a special predisposition to the dis- ease, but of course it is exceedingly hard to give any definite statistics upon this ■ point. Pneumonia occurs at any time of life, most frequently in youth or middle age; but it is by no means rare in early cliildhood, and also in more advanced yeai's up to sixty or seventy. In general it is observed rather more often in men than in women. [Defective house drainage seems to be a predisposing cause of pneumonia in some cases. A careful inspection of the local sanitary conditions is desirable, esi^ecially where more than one case occui's in a house.] Pathological Anatomy. — The anatomical process in croupous pneumonia con- sists in the formation of a haemorrhagic, coagulable "fibrinous" or "'croupous" exudation into the pulmonary alveoli and the smallest bronchi. The develop- ment of the exudation usually extends over one or more lobes to their whole extent, and, as the alveoli and fine bronchi ai'e completely filled by the tough exudation, the spongy lung, filled witli air, is changed to a firm tissue, devoid of air, except as it is penetrated by the large bronchi. Since Laennec's day we distinguish three stages in the development of the pro- cess. In the first stage (stage of inflammatory engorgement, engoiiement) the lung is vei'y hyperamiic, dark red, and the air contained in it is even now much diminished, but not entirely absent. The alveoli are filled witli an abundant exudation, already haamorrhagic, but still fluid and not coagulated. In the second stage (stage of red hepatization) the coagulation of the exudation is coniplete, and the lung has become throughout of the consistency of liver. The hepatized lung shows a somewhat increased volume, and is strildngly hard. The surface of the section has a red and manifestly granular appearance, which is due CROUPOUS PNEUMONIA. 1